Part 4 - Complaint about Good Hope Hospital NHS Trust (the Trust) (now Heart of England NHS Foundation Trust) and the Healthcare Commission (the Commission)
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Complaint about the care and treatment of a woman who was later found to have pulmonary hypertension and who died following surgery, and a complaint that the Commission did not address the Trust’s failure to follow the Commission’s recommendations
Background to the complaint
Ms C was 42 when she had a stroke in February 2002 and was admitted to hospital. She had a pulmonary embolus (a blood clot on the lung) and was prescribed Warfarin (an anti-coagulating drug) which was stopped after six months. Tests were carried out to determine her blood clotting levels and to search for a patent foramen ovale (a hole in the heart which would allow blood clots to travel from the right side of the heart to the left side and from there to the brain thus causing a stroke). This test was performed initially using a transthoracic and subsequently a transoesophageal echocardiogram (an ultrasound test that can provide information about the structure and function of the various areas of the heart).
After review as an out-patient, Ms C was discharged from care but was readmitted in August 2002 and was found to have another pulmonary embolus. She was referred for an MRI scan which was due to take place in March 2003 but, before this happened, she moved house.
She was subsequently diagnosed elsewhere as having pulmonary hypertension and a large patent foramen ovale. She was transferred to Papworth Hospital for treatment but died shortly afterwards.
The complaint to the Trust and the Commission
Ms C’s mother, Mrs C, complained in November 2003 about the failure to diagnose pulmonary hypertension at an earlier stage. She questioned whether the earlier commencement of specialist treatment for Ms C might have prevented her death. The Trust could not find Ms C’s medical records. Mrs C had a meeting with Trust staff in April 2004, but this failed to resolve matters.
In September 2004 Mrs C complained to the Commission which took clinical advice from a Consultant Cardiologist, who found a number of failings in the care provided to Ms C. In December 2005, the Commission asked the Trust to provide explanations of those aspects of Ms C’s care and to change clinical procedures. The Trust responded in February 2006.
In April 2006 Mrs C complained to the Commission, which said that the Trust had complied with most of its recommendations, but asked them to respond on the issue of the review of guidelines for management of pulmonary embolism. The Trust sent a further reply to
Mrs C in June 2006 which made no acknowledgement or apology for the failings identified by the Commission.
What we investigated
Mrs C complained to the Ombudsman in September 2006. The complaints investigated by the Ombudsman were that:
- the Trust had failed to respond adequately to the Commission’s recommendations following its investigation; and
- the Commission had refused to take any further action despite that failing by the Trust.
We had access to all relevant documentation including Ms C’s medical records and the complaints correspondence. We took clinical advice from a consultant cardiothoracic surgeon.
What our investigation found
We found that the Commission had carried out an appropriate initial review of Mrs C’s complaint that identified failings by the Trust and made appropriate recommendations.
We found that the Trust’s response to the Commission’s recommendations was inadequate. They had failed to acknowledge the failure in care and to explain the reasons for it. Neither had they accepted the Commission’s recommendation that reporting procedures or guidelines needed to be reviewed.
We found that the Commission had failed to properly consider Mrs C’s subsequent complaint about the Trust’s response.
We found that the Trust’s actions (through mislaying papers and not responding appropriately to the Commission’s recommendations) had caused Mrs C to suffer distress and delay in receiving the explanation and response to which she was entitled.
The investigation concluded in July 2007 and we upheld Mrs C’s complaint that the Trust failed to respond adequately to the Commission’s recommendations and that the Commission failed to properly consider her subsequent complaint about the Trust’s response.
Outcome
As a result of the Ombudsman’s recommendations the Trust made a payment of £500 to Mrs C in the light of the serious failings in their complaint handling and to recognise the additional distress caused by their responses to Mrs C following the Commission’s review.
The Trust also:
- apologised for the loss of records and explained that they had introduced a tracking system for physical documents, an electronic patient record for clinical data and were moving towards all patient documentation being accessible electronically;
- produced an amended template for recording and reporting echocardiograms to help ensure that clear diagnosis is obtained;
- reviewed their guidelines for the management of pulmonary embolism and implemented those recommended by the British Thoracic Society;
- offered an explanation of the criteria that would have led to onward referral for Ms C, an acknowledgment of the fact that a referral could have been made earlier and an apology that the process was so protracted. They said that training was to be provided to staff to increase awareness of symptoms of pulmonary hypertension and the need for onward referral;
- explained the procedure surrounding transoesophageal echocardiogram tests and the reasons for delays in scheduling the MRI scan for Ms C. They said that transoesophageal echocardiograms that do not provide clear results would be discussed at regular meetings and that transoesophageal echocardiogram results would be audited for quality of data and accuracy of interpretation. A lead consultant for this work had been identified and staff training had led to British Society of Echocardiography accreditation; and
- acknowledged and apologised for the failure of care towards Ms C.
The Commission wrote to Mrs C to apologise for the failings identified by our report.
