An injustice that can never be put right: the loss of a much-loved family member

Good complaint handling needs to be at the heart of the new NHS. We are working with the Department of Health on the Clwyd and Hart review of NHS hospital complaints commissioned by David Cameron and with the NHS Commissioning Board to support the development of guidance on complaint handling for Clinical Commissioning Groups. We want to ensure that good complaint handling is embedded as the standard across the new NHS in England. Miss G’s story highlights the ongoing improvements required in the NHS for individuals with learning disabilities, a problem starkly set out in our 2009 report Six lives.

Miss G, a woman in her early 50s with learning disabilities  and a history of bipolar disorder, was diagnosed with gallstones and needed surgery.  She was admitted to a hospital run by a hospital trust. They could not operate  immediately due to inflammation and she was sent home until the operation could  be done. In the meantime, Miss G was unable to cope with the pain, and she was  sectioned to the psychiatric ward run by a care trust, because of her  behaviour. Her medical notes were not acquired by them and they would not  listen to her family. She did not have her operation for four months. Following  the surgery, she developed a bowel blockage, for which she had another  operation. Sadly, she died two weeks later. While these events took place, Miss  G was transferred back and forth between these two trusts, despite the fact  that they were in the same building.  

Miss G experienced unnecessary physical and mental suffering. If this period of poor care had not occurred, it is likely that Miss G’s death could have been avoided

Miss G’s brother and sister-in-law, Mr and Mrs A, complained  to us, supported by Mencap. We investigated and found that Miss G’s care had  not been properly co-ordinated or managed.   There was no evidence that the trusts had taken Miss G’s disabilities into  account when planning her care, although this was a legal obligation under disability  discrimination law. In particular:

  • Nursing records did not clearly say what care  was planned, what decisions had been made, or what care had been delivered.
  • Communication between nurses, doctors and other  clinical staff and with Miss G and her family was ineffective, and they did not  help her to understand what was happening. This meant distressing events were  made even more distressing for Miss G.
  • Neither trust made adequate use of community  learning disability services to make sure that Miss G had support for her  specific needs.
  • When Miss G missed appointments at the hospital  trust, they did not consider how to ensure that she attended her appointments.  This meant that her gallstones were untreated for over five months, which would  have made her feel unwell and in pain.
  • After surgery, nobody took account of her  specific needs, and she ended up very agitated and ‘running around’.
  • Doctors at both trusts failed to adequately  assess and manage Miss G’s condition after the second operation, and she  was transferred back to the care trust prematurely.
  • The psychiatrist at the care trust did not  ensure that her care was properly co‑ordinated and managed. Staff at the care  trust did not listen to the people who knew her best – the team that cared for  her and members of her family – or allow them to be involved.

These failings meant Miss G experienced unnecessary physical  and mental suffering. If this period of poor care had not occurred, it is  likely that Miss G’s death could have been avoided. Mr and Mrs A suffered  the loss of a much‑loved member of their family: an injustice that can never be  remedied. We upheld their complaints about both trusts.

Both trusts agreed to acknowledge and apologise for their  failings and to offer Mr and Mrs A compensation of £15,000. Both trusts  also agreed to put together action plans that described how they had learnt  from their failings and what they would do to stop them happening again.

Six months after the investigation was finished, Mencap told  us that Mr and Mrs A were very pleased with the action taken by the  hospital trust.

To find out more about our work on NHS complaints, read Listening and Learning.