Complaint about Taunton and Somerset NHS Trust (now Taunton and Somerset NHS Foundation Trust) and the Healthcare Commission
Jump to
Complaint about the handling of a complaint regarding the alleged abuse of an older person following a hospital admission and about the Healthcare Commission’s review
Background to the complaint
In February 2005 Mrs C, aged 79, was referred to Musgrove Park Hospital, having been unwell for a few weeks. She was extremely weak, unable to stand without assistance and her feet were very swollen and painful, owing to a related gout condition. She was diagnosed with bilateral hydronephrosis (swelling of both kidneys owing to a backup of urine); and bilateral nephrostomies (insertion of a tube through the skin into the kidney to provide urine drainage) were performed the next day. A suspected malignant lump was also found within Mrs C’s pelvic region. However, she contracted an infection and she was considered too weak to undergo further investigation.
Over the next eight days Mrs C told her husband, Mr C, of several instances of poor treatment by staff: being refused help to use the commode; being ordered out of bed; being scolded for leaning on her bed for support; and being orally harangued and roughly handled by a member of staff during the night. After that last incident, Mr C contacted the Patient Advice and Liaison Service, and the ward Matron then met with Mrs C the same day and agreed to speak to the staff concerned. The Matron turned down Mrs C’s daughter’s request to stay the night. Mrs C died early the next morning.
Complaint to Taunton and Somerset NHS Trust and to the Healthcare Commission
In March 2005 Mr C complained to Taunton and Somerset NHS Trust (the Trust); his letter focused on what he described as at least three instances of ‘deliberate abuse’ towards Mrs C. In April 2005 the Trust replied, apologised for the distress caused, and said that the care afforded to Mrs C had been below standard and that the Matron and Ward Sister were working to improve, and then maintain, standards. Mr C was unhappy with the response, including the involvement of ward staff in investigating the complaint, and remained so following a meeting with the Trust in May 2005.
In June 2005 Mr C complained to the Healthcare Commission (the Commission). Its report was issued in November 2005, and made four recommendations to the Trust. Mr C said that the Commission had failed to address the complaint that his wife had been abused. Correspondence between Mr C, the Commission and the Trust continued (Mr C also met with the Trust again in March 2006). In September 2006 the Trust apologised for the fact that they had, in breach of their Employee Relations Policy, not involved the Human Resources department in considering the complaint. In November 2006 the Commission issued its second report, confirming that finding, and said that it saw no scope for further action.
What we investigated
Mr C then complained to the Ombudsman. Our investigation looked at both the Trust’s and the Commission’s handling of Mr C’s complaints. In his complaint to the Ombudsman Mr C said that the lack of resolution to his complaint continued to cause him considerable distress and that ‘I have the lasting memory of unnecessary suffering inflicted on my wife by those who were paid to care for her’. He also referred to the time taken and expense incurred in pursuing his complaint.
During the investigation we considered evidence provided by Mr C as well as relevant documentation from the Trust and the Commission. We took clinical advice from a Senior Nurse.
In reaching our findings on this complaint we took into account the Trust’s complaints policy. We also considered the Department of Health’s guidance to support the implementation of the National Health Service (Complaints) Regulations 2004 and their March 2000 guidance No secrets: guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse (this latter guidance set out the requirement to have such a policy backed up by training for staff).
What our investigation found
We found that, despite the Department of Health’s guidance, the Trust had no policy in place, in 2005, for managing concerns related to adult protection/vulnerable adults.
We found that the Trust’s involvement of the Matron and other ward staff in the investigation of Mr C’s complaint complied with their internal complaints policy.
We found that the Trust had been responsible for delays in their handling of Mr C’s complaint and in their responses to the Commission.
We found that the Commission failed to confirm its understanding of the complaint with Mr C and did not, as a result, identify his main complaint: that the Trust had not properly addressed the complaint about abuse.
We found that the Commission did not consider the appropriate national guidance in investigating Mr C’s complaint as it did not identify the lack of, or question the Trust about the existence and use of, a policy for managing concerns related to adult protection/vulnerable adults.
We found that the Commission wrongly investigated Mr C’s complaint about the Trust’s failure to follow their Employee Relations Policy despite it being a staff disciplinary matter and not, therefore, within the remit of the NHS complaints procedure. By doing so the Commission caused confusion and further delay.
The investigation concluded in April 2008. We upheld the complaints about both the Trust and the Commission. Mr C was caused distress and inconvenience by the failure to consider his complaints fully, properly and within a reasonable timescale.
Outcome
As a result of the Ombudsman’s recommendations the Trust:
- wrote to Mr C to apologise;
- agreed to provide the Commission (in its regulatory role) with evidence about their performance against response times for complaints (the Trust having reorganised their complaints department since 2005). The Commission would also monitor performance going forward and information arising from that would be copied to Mr C and the Ombudsman;
- developed an action plan to ensure the implementation of their Adult Protection/ Vulnerable Adult Policy (which was agreed by the Trust’s Board in December 2007); and
- put funding in place for a new post of Adult Protection Supervisor.
As a result of the Ombudsman’s recommendations the Commission:
- wrote to Mr C to apologise; and
- paid him £150 compensation for the distress caused by its failures.
Principles for Remedy
The Principles for Remedy were not referred to in our report but this case summary serves to illustrate the following Principles:
- ‘Putting things right’ (apologies and compensation).
- ‘Seeking continuous improvement’ (using the lessons learnt from complaints to ensure that maladministration or poor service is not repeated; recording and using information on the outcome of complaints to improve services).
