Complaint about the Healthcare Commission
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Remedy for a flawed investigation and poor service
Background to the complaint
In November 2002 Mrs S fractured her femur. She was admitted to St George’s Healthcare NHS Trust (the Trust) and underwent a dynamic hip screw procedure (insertion of metal plate and screws into the leg in order to allow healing of the fractured upper thighbone). In January 2003 the Trust X-rayed the fracture; Mrs S says she was told ‘it had mended ok’. A further X-ray was taken in February; the doctor was said to be pleased with the fracture. In March Mrs S decided to have private physiotherapy; in connection with that she paid privately for an X-ray. It showed the fracture had not united.
Complaint to the Trust and to the Healthcare Commission
In November 2003 Mrs S complained to the Trust. She asked why no one had pointed out that the fracture had not healed and why the X-rays had not picked up that the fracture had not mended. The Chief Executive replied in January 2004. He said his Consultant Orthopaedic Surgeon had said that fractures unite once they are healed and that X-rays sometimes suggest fractures have healed when they have not. Dissatisfied with that response, Mrs S wrote to the Trust’s Convenor. The Trust’s final response of March 2005 reiterated the Consultant’s previous advice about X-rays.
Before Mrs S received the Trust’s final response, she complained to the Healthcare Commission (the Commission). The Case Manager reviewed her complaint and sent her a decision letter on 8 July 2005 saying that he had referred her complaint back to the Trust, and asked them to obtain an independent orthopaedic opinion on her X-rays. (The Trust were unable to do that because Mrs S’s complaint had been discussed by the whole orthopaedic team. The Commission agreed to obtain an independent opinion instead.)
In February 2006 the Commission asked a Consultant Orthopaedic Surgeon (the Clinical Adviser) if the Trust’s explanations to Mrs S were ‘accurate and adequate’. The Case Manager sent a second decision letter to Mrs S on 11 April, saying that Mrs S had received correct and appropriate surgical treatment, but that he had concerns about how the Trust had communicated with her and supplied information to her. The Case Manager said that the Clinical Adviser had ‘commented that he believed [the X-rays] were suggesting a good progress regarding healing of the bone but sometimes a computerised tomography (CT) scan may be needed to rule out any abnormality in the healing process’. He concluded the Trust had ‘responded appropriately with regard to the interpretation of your x-rays’. Mrs S replied that her concerns had not been addressed; she asked for confirmation of whether her X-rays did, or did not, show a break. The Commission agreed to review its previous decision and sought clinical advice from a second Clinical Adviser.
A final decision letter was sent to Mrs S in April 2007 by the second Case Manager, who relayed the second Clinical Adviser’s opinion that fractures of the type Mrs S had suffered took about three months to heal solidly but sometimes took a lot longer. He said the second Clinical Adviser had explained that an X-ray taken in December 2002 showed ‘the fracture remains in excellent position’ and that the X-ray taken in January 2003 showed ‘the position of the fracture remained the same. He noted that … one would not expect the fracture to be healed at this point. He stated that the reason for the X-ray was to see if the fixation remained secure and the fragments remain the same [sic] position relative to each other’. The second Case Manager said a further X-ray taken in February 2003 ‘confirmed the results were the same as shown on the film taken on January 15 2003’. He stressed that Mrs S’s fracture had healed appropriately.
The second Case Manager conveyed to Mrs S the second Clinical Adviser’s advice about: the visibility of fractures and fracture healing on X-rays; why X-rays might not show breaks; and CT scans. He also informed her that the fracture had been clearly visible on all the X-rays reviewed by the second Clinical Adviser. He said ‘in the opinion of the adviser, the reason for taking the films had been to check the position of the fracture and only secondarily (at that early stage) to assess healing … the reason you were advised that things were going well … was because they were, but this related to the maintenance of the fracture position’. The second Case Manager concluded that there was nothing further that the Commission could do (or that the first Case Manager should have done), and proposed to take no further action.
What we investigated
Mrs S complained to the Ombudsman in May 2007 that after two reviews by the Commission she had still not received answers about whether the Trust’s X-rays showed a break, or why the Trust failed to identify that her fracture had not mended. She also complained that the Commission’s reports contradicted each other, and was unhappy about the length of time the reviews had taken. Mrs S said the delays had prolonged the inconvenience and distress she had suffered.
We investigated the Commission’s handling of Mrs S’s complaint, to assess whether its investigation process was flawed, its service poor or its decision wholly unreasonable. We also looked at whether it took an unreasonably long time to review her complaint.
During the investigation we examined all the relevant documentation and obtained specialist advice from a Consultant Orthopaedic Surgeon.
What our investigation found
The Commission’s decision letter of April 2007 included a detailed interpretation of the Trust’s X-rays, and stated that Mrs S’s fracture was visible on them all. We therefore disagreed that the Commission had failed to answer her questions about whether or not the X-rays showed the break. Neither did we agree that the Commission’s reviews had failed to address why the Trust did not identify that Mrs S’s fracture had not mended: the same letter confirmed that the X-rays would not have been expected to show that it had healed, and that she was told things were going well (in January and February 2003) because they were. The second Clinical Adviser provided clear and detailed advice about the course of healing of fractures and about the interpretation of the X-rays, and correctly identified that the fracture had mended appropriately.
However, we criticised the Commission’s conclusion that there was nothing further that it could do, or that the first Case Manager should have done. The Commission should have obtained its own clinical advice at the outset in response to Mrs S’s complaint (rather than first asking the Trust to do so). That failure meant that her concerns were not resolved at the earliest opportunity, and so prolonged the inconvenience and distress she suffered. The Commission’s decision letter of 11 April 2006 did not give Mrs S a clear answer about whether her X-rays showed a fracture. Furthermore, having previously identified that the Trust needed to take further action to address her concerns about the X-rays, the Commission now concluded that the Trust had responded appropriately. We therefore found that the decision letters of 8 July 2005 and 11 April 2006 appeared contradictory. The Commission took an unreasonably long period of time (29 months) to complete its reviews and provide Mrs S with a response that addressed her concerns.
In summary, the Commission’s investigative process was flawed and its service was poor, and these failings amounted to maladministration. Furthermore, the Commission did not demonstrate it met the standards of behaviour expected of it, as outlined in the Principles of Good Administration (‘Being customer focused’ – keeping to its commitments, including any published service standards; ‘Being open and accountable’ – giving information that is clear, accurate and complete; and ‘Putting things right’ – putting mistakes right quickly and effectively).
We partly upheld Mrs S’s complaint and concluded our investigation in June 2008.
Outcome
At our recommendation, the Commission agreed to:
- apologise to Mrs S for the failings we had identified; and
- pay her £200 as compensation in recognition of the inconvenience and distress its delay in resolving her complaint had caused her.
Principles of Good Administration
The following Principles of Good Administration were referred to in this case summary:
- ‘Being customer focused’ (keeping to commitments, including any published service standards).
- ‘Being open and accountable’ (giving information that is clear, accurate and complete).
- ‘Putting things right’ (putting mistakes right quickly and effectively).
