Ombudsman reveals wide range of public service failures across NHS in England and UK government departments
22 October 2015
Too many unresolved complaints are being taken to the Parliamentary and Health Service Ombudsman which could have been resolved by public services locally, meaning that people are left waiting longer for answers and that much needed service improvements are delayed.
A new Parliamentary and Health Service Ombudsman report published today has revealed the devastating impact that public service failures can have on individuals and how its investigations have resulted in the organisations putting things right for people.
The report is a snapshot of 192 case summaries of the 1,075 investigations of unresolved complaints the Parliamentary and Health Service Ombudsman (PHSO) completed investigating in February and March 2015.
It includes cases about delayed asylum claims, nursing home patients being wrongly charged thousands of pounds for their nursing home care, delays in diagnosis which meant that one woman was left with unrelenting facial pain for more than a decade, poor end of life care and poor treatment of sepsis, commonly referred to as blood poisoning.
People often take their unresolved complaints to the Parliamentary and Health Service Ombudsman because they want an apology, an explanation of what went wrong and to ensure the service improves for others. The report shows that far too many people are left waiting longer for answers and that much needed service improvements are delayed.
The report includes investigations which have resulted in a hospital trust apologising to a grieving daughter for the failings in its treatment of her father, who died from sepsis. The trust also took action to prevent the same thing from happening again, following the Parliamentary and Health Service Ombudsman's intervention. Another investigation resulted in a nursing home patient being refunded £102,000 in nursing home care costs he was wrongly charged.
Parliamentary and Health Service Ombudsman Julie Mellor said:
'Many people complain about public services out of a sense of public duty, because they don't want what happened to them or their loved one to happen to someone else.
'In many of the complaints we see, the organisation complained about has done the right thing to put things right. But too many people aren't getting the answers to what went wrong from the organisation they complained about.
'Complaints alert people to where problems are and should be welcomed by all levels of the organisation from the frontline to the board, so that much-needed improvements are made.'
The report contains 116 investigations about the NHS in England and the remaining 76 investigation summaries are about UK government departments and organisations such as the UK Visas and Immigration (UKVI), the Children and Family Court Advisory and Support Service (Cafcass) and HM Courts & Tribunals Service.
During February and March 2015, the Parliamentary and Health Service Ombudsman upheld 34% of the unresolved complaints it investigated. In cases where the complaints were not upheld, it is often because no failings were identified or because it found that the public service did the right thing to resolve the complaint.
When complaints are upheld, the Parliamentary and Health Service Ombudsman makes recommendations for organisations to put things right. These can include an apology from the organisation to the complainant, a financial remedy, action plans to ensure mistakes are not repeated, staff training, or changes to policy and procedures. More than 99% of the organisations comply with its recommendations.
Most of the summaries published are cases the Parliamentary and Health Service Ombudsman has upheld or partly upheld. These are the cases which provide clear and valuable lesson for public services by showing what needs to change to help avoid the same mistake happening again, including complaints about failures to spot serious illnesses and mistakes by government departments that caused people financial hardship.
The Parliamentary and Health Service Ombudsman investigates approximately 4,000 complaints a year and upholds around 37%.
Notes to editors
Today's report includes the following investigation summaries:
Father died after Newcastle Upon Tyne Hospitals NHS Foundation Trust failed to treat him appropriately for sepsis, commonly referred to as blood poisoning. The patient was admitted to hospital with signs of sepsis after a painful lump on his buttock. He was sent home without surgery or appropriate treatment. He returned to hospital three weeks later with intense pain in his foot. Clinicians found that the infection had spread, and he died a few days later. Our investigation found that the subsequent infection was linked to the first admission and that the lack of appropriate treatment when he was first in hospital compromised his chances of survival. Following our investigation the trust apologised to the daughter, who complained, paid her £2,000 in recognition of the impact of what went wrong and took actions to improve. (Full case summary on page 95 of the report).
A man who had taken an overdose, committed suicide shortly after being discharged from Great Western Hospitals NHS Foundation Trust, after Avon and Wiltshire Mental Health Partnership NHS Trust said he was not at risk of self-harm and did not give him information about how to get help if he suffered another crisis. Our investigation found that the mental health trust failed to adequately assess the patient and take into account his physical health or the previous overdose, or ask questions about these issues. It also failed to give him information on what to do should he suffer a crisis shortly after leaving hospital. His family's distress was compounded by inadequate complaint handling by both organisations. Following our investigation the mental health trust paid his family £1,000 and explained how it would prevent the service failings from happening again and improved its complaint handling. The acute trust apologised and paid £250 in recognition of the impact of its poor complaint handling and drew up plans to improve its service and complaint handling. (Full case summary on pages 114 and 115 of the report).
A nursing home patient was refunded more than £102,000 in nursing home care costs after investigation found that he had been wrongly charged for his own care, which was not in keeping with the National Framework for NHS Continuing Healthcare. South Lincolnshire Clinical Commissioning Group apologised, refunded the patient the fees and agreed to continue to meet his care costs, following our investigation. NHS continuing healthcare is a package of care arranged and funded solely by the NHS for individuals who are not in hospital and have been assessed as having a "primary health need", which means that their main or primary need for care must relate to their health. NHS continuing healthcare is free, unlike social and community care services provided by local authorities. (Full case summary on page 103 of the report).
Trust delayed properly investigating unrelenting facial pain for twelve years. The patient repeatedly asked for an MRI scan after going to Isle of Wight NHS Trust with severe facial pain in 1997, but was only given an MRI scan in 2012. Our investigation found that the hospital should have carried out an MRI scan in 2000, after conservative treatment didn't resolve the pain. The MRI scan diagnosed the cause of her facial pain and she had surgery which resolved the pain.Following our investigation the trust apologised for the delay and explained to the patient what action it had taken to help prevent it from happening to future patients. It also paid her £750 in recognition of the pain and distress the delay caused. (Full case summary on page 143 of the report).
A man who had a history of schizophrenia, who was not warned by his GP of the side effects of taking stop smoking medication, suffered a relapse of schizophrenia. Following our investigation the GP practice in north Yorkshire, acknowledged and apologised for the failings and paid the patient £500 in recognition of the impact of what went wrong. (Full case summary on page 137 of the report).
A children's hospital treated parents' decision to use a herbal cream on their son's eczema instead of the cream prescribed, as a child protection issue. Following our investigation Sheffield Children's NHS Foundation Trust apologised to the boy's parents for the mistakes and for the distress caused and paid them £500 in recognition of the impact of what went wrong. (Full case summary on page 105 of the report).
A woman, who fractured her ankle, paid for private healthcare advice after she was given faulty advice from an NHS trust. If she had followed the NHS advice she would have lost the use of her ankle. Following our investigation Milton Keynes Hospital NHS Foundation Trust reimbursed her the £323.50 she paid for the private appointment. (Full case summary on page 131 of the report).
The Passport Office put the wrong photographs in two passports and then failed to give a full apology and explanation to the father after he complained. Following our investigation the Passport Office apologised and paid the father £50 in recognition of the impact of what went wrong. (Full case summary on page 72 of the report).
A refugee suffered an unnecessary three year delay on his asylum claim after he went to his home country temporarily to attend the funerals of family members who died suddenly. Following our investigation UK Visas and Immigration apologised and paid him £200 in recognition of the impact of what went wrong. (Full case summary on page 20 of the report).
The report includes the following investigation summaries of complaints not upheld:
A GP practice in the West Midlands took appropriate action when removing a patient from its list, after he was verbally abusive and raised his hand in the practice manager's face. The incident happened after the GP the patient was due to see was on sick leave and he refused to see a different GP, demanding to speak to a manager. Our investigation found that the practice acted in line with the relevant regulations. (Full case summary on page 147 of the report).
A GP practice in Cumbria appropriately stopped a patient from driving over concerns that he did not meet the vision requirements of the Driver & Vehicle Licensing Agency (DVLA). (Full case summary on page 212 of the report).
In 2014-15 approximately 79% of the our investigations were about the NHS in England and 21% were about UK government departments and their agencies.
In February 2015, we completed 428 investigations. Of these 334 were about the NHS in England and 94 were about UK government departments and organisations. In March 2015, it completed 647 investigations. Of these 479 were about the NHS in England and 168 were about UK government departments and organisations.
During February and March 2015 we upheld 94 complaints, partly upheld 268 and did not uphold 612. A further 101 were either resolved before the formal investigation ended or closed because for example the complainant did not wish to pursue it further or because the organisation complained about, offered to do further work to resolve the complaint locally.
Case summaries are published on the our website, and can be searched by entering key words such as cancer, diagnosis and death, as well as by organisation, for example the name of a hospital trust and by location.
This is the sixth report of case summaries published. The first batch was published in August 2014.
For more information contact Marina Soteriou on 0300 061 4996 or email firstname.lastname@example.org or Steven Mather on 0300 061 4324 or email email@example.com