19 August 2015

A new Parliamentary and Health Service Ombudsman report shows the impact public service failures and poor complaint handling in the NHS in England and UK government departments can have on the public.

The report contains 121 summaries of complaints which are a snapshot of those investigated between December 2014 and January 2015 about the NHS in England and UK government departments and their agencies. The report includes the cases of three people whose deaths could have been avoided, nine asylum seekers who waited years for a decision on their application, multiple examples of inadequate end of life care and seven cases of poor care during pregnancy and maternity.

During this period the organisation made final decisions on a total of 556 complaints, of which 201 were upheld or partially upheld and 300 were not upheld.

Cases of avoidable death from the report

The investigations into the avoidable deaths that feature in the report found that lives could possibly have been saved if doctors and nurses had taken more time to act in line with guidance and good practice, and if they had provided better care to their patients.

The organisation investigated a total of 58 cases of avoidable death during the two month period which the report covers and upheld or partially upheld 29 of those.

  • A man in the West Midlands with learning disabilities died of multi-organ failure after a series of failures in care and a lack of consideration for his rights as a disabled person. He needed special bowel treatment as a result of his disability, but when he developed a kidney impairment and a blocked bowel the doctors and nurses at the nursing home did not treat him in line with established good practice and he died. His sisters received £10,000 in compensation. Read the summary here.
  • A man from the East Midlands died of a bladder infection a week after he was admitted to hospital in North Lincolnshire and Goole for a routine bladder operation. The hospital trust not only failed in its care that led to the man's death, they also made his daughter wait excessively for a response to her complaint. Read the summary here
  • A man from the South East who died after developing a blood clot on his lungs, which GPs had failed to identify. The man's problems began when he was sent home from hospital after fracturing a bone in his leg. His condition rapidly deteriorated, his leg swelled and he developed chest symptoms. Three GPs failed to identify the risk of developing blood clots and he died hours after the third GPs visit. His wife was awarded £15,000 in compensation. Read the summary here

Parliamentary and Health Service Ombudsman Julie Mellor said:

'Often people complain to us because they don't want someone else to go through what they or their loved one went through. This report shows the types of unresolved complaints we receive and the human cost of that poor service and complaint handling.

'Many of the complaints that come to us should have been resolved by the organisation complained about.

'Complaints provide an opportunity for learning and improvements and should be embraced at all levels of the organisation from the Board to the frontline.'

Immigration case from the report

The report also includes nine immigration cases the organisation investigated where it found that UK Visas and Immigration (UKVI), part of the Home Office made asylum seekers wait years for a decision on their application for asylum. We either upheld or partially upheld each of these cases.

Most of these could have been avoided if UKVI communicated better with applicants, responded to letters and kept better records.

  • A woman waited six years from 2008 to 2014 for a decision to be made on her asylum application before granting her leave to remain in the UK. We found that the delay was unacceptable and that the documentation the UKVI held on her case were poor or incorrect. Read the summary here

Cases of failures in end of life care

Failures in end of life care are a strong theme in the case summaries. Incidents of poor end of life care could have been minimised if doctors and nursing staff had taken care to follow guidelines and best practice.

  • A man went to a hospital in County Durham and Darlington NHS Foundation Trust where doctors misdiagnosed him with cancer when he had a blood clot on his lung. They then misdiagnosed him a second time with pulmonary fibrosis. During this time his blood clot remained untreated and he died in hospital a week later. The investigation found that given his condition even a correct early diagnosis is unlikely to have saved his life. However, the substandard treatment given to him meant his family could not prepare for his death in the way he would have wanted, which compounded their grief. Read the summary here
  • A woman in her twenties had been diagnosed with terminal cancer, but her palliative care was badly managed at a hospital in East Sussex. She suffered unnecessary levels of pain and sickness at the end of her life as a result, which was also very distressing for her family. Read the summary here
  • A man was misdiagnosed with pneumonia by a trust in the North West when he had lung cancer. The doctors should have picked up these symptoms but didn't. When lung cancer was eventually diagnosed the man only lived for another three weeks. Neither he nor his family had time to prepare for the end of his life, something they could have done if the correct diagnosis had been made in the first instance. Read the summary here

Pregnancy-related cases

The report also included nine cases related to shortcomings in care during pregnancy or maternity, seven of which were held or partially upheld. These could have been avoided by following established guidelines. In the year 2014 to 2015, we investigated 36 other pregnancy-related complaints.

  • A woman giving birth was not given adequate pain relief during a painful labour in Kent. After she had given birth she developed a uterine infection and was not offered pain relief during that either, despite the fact the woman was visibly distressed. Read the summary here
  • A pregnant woman with epilepsy wanted a home birth but she was told by midwives in Cumbria it would not be safe because of her condition. This advice was based on incorrect assumptions and they failed to seek the opinion of a consultant obstetrician. This caused the woman to be stressed during the pregnancy. Read the summary here

Approximately 80% of its investigations are about the NHS in England and 20% are about UK government departments and their agencies.

Almost half of all complaints about the NHS in England were about or partially about dissatisfaction in how complaints were handled.

Notes to editors  

  1. For more information please contact Steven Mather on 0300 061 4324 or email steven.mather@ombudsman.org.uk or Maria Mansfeld on 0300 061 4267 or email maria.mansfeld@ombudsman.org.uk
  2. The Parliamentary and Health Service Ombudsman makes final decisions on complaints which haven't been resolved locally by the NHS in England or by UK government departments and their agencies, such as the Department for Work and Pensions, the DVLA, the Passport Office and the Highways Agency.
  3. The remaining investigations 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.
  4. Case summaries are published on the Ombudsman service's 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.
  5. This is the fifth report of case summaries the Ombudsman service has published. The first batch was published in August 2014.