Complaint about Pennine Acute Hospitals NHS Trust and the Healthcare Commission
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Complaint about care and treatment after two operations were cancelled and about poor complaint handling
Background to the complaint
Mr V was being treated by Pennine Acute Hospitals NHS Trust (the Trust) for sleep apnoea (a condition where the patient stops breathing during sleep) and a Consultant Surgeon (the Surgeon) put him on a waiting list for examination under anaesthetic. On 13 September 2002 he attended for the surgery, but was sent home. This was because the anaesthetist deemed him to be a high risk and required that he undergo a formal pre-operative assessment, including an echocardiogram, and because he would need a High Dependency Unit (HDU) bed. By the time Mr V was discharged, he had been without food or drink for about 20 hours.
On 4 October 2002 Mr V attended for pre-operative assessment, but his medical notes were unavailable. He said he tried to tell the staff about the tests that were required but they did not listen to him. When Mr V attended for the rearranged operation on 14 October, staff identified that he had not undergone the required tests. An echocardiogram was carried out but, as an HDU bed was not available, the operation was cancelled. On 11 November Mr V saw the Surgeon, to discuss the problems he had faced, but felt rushed and the issue of relisting his surgery was not resolved. Mr V’s progress continued to be monitored, and in April 2003 a ‘watch and wait’ policy was adopted in respect of his future treatment.
Complaint to the Trust and to the Healthcare Commission
In November 2002 Mr V complained to the Trust. In reply, the Trust explained why the operations had been cancelled and apologised for the inconvenience and anxiety caused. In March 2003 Mr V complained to the Trust, via his representative. He wanted to know why he was kept at the Trust on 13 September for so long; why staff had ignored what he told them about the tests required by the anaesthetist; and why he waited so long on 14 October when similar staff had dealt with him on 13 September. Mr V also complained about the Surgeon’s attitude during the November consultation, which had left him feeling unimportant and angry. The Trust’s response did not cover all the issues.
A local resolution meeting took place in October 2003, but Mr V remained unhappy. The Trust issued their final response in March 2004, apologised for their complaint handling, said that the complaints system was being externally reviewed, repeated their previous explanations and said they could do nothing more. The Trust told Mr V that he could request an independent review (but not that he had to do so within 28 days of the local resolution ending). After a review had been requested on 29 July, the Trust told Mr V’s representative that it was too late for him to request one.
Mr V complained to the Healthcare Commission (the Commission). Its recommendations to the Trust included that they give Mr V a more detailed explanation for the October cancellation, and tell him about the steps being taken to improve their complaint handling. No further action was taken on the complaint about the Surgeon. Mr V was dissatisfied with the information later provided by the Trust.
What we investigated
In August 2006 Mr V complained to the Ombudsman seeking explanations for the failings he had experienced, and financial redress for the impact that pursuing his complaint had had on him.
We investigated the Trust’s cancellation of Mr V’s operations and his subsequent care; the events that occurred at the pre-operative assessment; and their complaint handling. We also investigated Mr V’s complaint that the Commission had not investigated all his concerns and had ignored his evidence.
We looked at all the relevant documentation, and took clinical advice from an experienced Surgeon.
What our investigation found
We found that it was unreasonable that Mr V had waited so long at the Trust in September 2002 before being told that his operation had been cancelled, and that the delay could have been avoided if his medical records had been reviewed earlier. The Trust apologised to Mr V for this failure and improved their systems as a result. The anaesthetist did not record his decision that Mr V was a high risk, and why. If Mr V was a high risk and needed an HDU bed, the Trust had failed to organise this before admission. The lack of an adequate record of why the operation was cancelled and the failure to get a statement from the anaesthetist meant that the Trust could not provide a clear reason for the cancellation.
It was unreasonable that Mr V’s medical records were unavailable for the pre-operative assessment (the Trust have since improved their systems). The Trust said that the lack of medical records had no impact on the quality of the assessment and Mr V’s ongoing care, but also said this meant no echocardiogram was performed, leading to the cancellation of the October operation. These views were contradictory and we criticised the Trust for their unclear explanations. There was a lack of planning before Mr V’s October admission, and a delay in telling him that the operation had been cancelled.
It was not possible to determine what occurred at the consultation with the Surgeon. As he had previously apologised to Mr V for the communication breakdown, we did not investigate the matter further.
The Trust’s complaint handling was poor. Their responses to Mr V were delayed and did not fully answer his concerns. He had difficulty contacting staff to discuss his complaint and there was confusion about the review. The Trust misunderstood Mr V’s complaint, believing it was mainly about system failures, whereas he wanted to know why he was a high anaesthetic risk. If the Trust had given Mr V clear explanations about that the complaint may not have reached the Ombudsman. In summary, the Trust’s failings significantly impacted on Mr V’s life in terms of distress and inconvenience and we upheld his complaint.
The Commission failed to obtain independent clinical advice on Mr V’s complaint, although it raised clinical issues. It failed to scrutinise the Trust’s explanations, and so unfairly presumed that they had given Mr V an adequate and accurate account of his care and treatment. Mr V’s concerns that the Commission’s decision letters were unfair and biased were understandable. It would have been better for the Commission to have confirmed with Mr V the complaint to be investigated (the Commission now does this). Its review focused on the changes in practice at the Trust rather than on the facts of the complaint. Furthermore, the lack of clinical advice affected the quality of explanation given to Mr V and the appropriateness of its recommendations. We found that the Commission’s complaint handling was maladministrative, and denied Mr V an independent review of his complaint. We upheld the complaint.
We concluded our investigation in July 2007.
Outcome
The Trust and the Commission agreed to implement the following recommendations:
- The Commission and the Trust were to apologise to Mr V for the failings we identified.
- The Trust were to pay £250 to Mr V in light of the serious failings in their complaint handling; and to report back to the Ombudsman on how the lessons learnt from this case have been fed into their practices and procedures.
As the Commission was already working with the Trust to improve their complaint handling, no further recommendations were necessary.
Principles of Good Complaint Handling
The Principles of Good Complaint Handling were not referred to in our report but this case summary serves to illustrate the following Principles:
- ‘Being customer focused’ (ensuring people can easily access the service dealing with complaints; listening to complainants to understand the complaint and the outcome they are seeking).
- ‘Being open and accountable’ (providing honest, evidence-based explanations and giving reasons for decisions; keeping full and accurate records).
