Warren Cox
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Summary report of an investigation by the Health Service Ombudsman of a complaint made by Mencap on behalf of Mr and Mrs Cox in relation to their late son, Mr Warren Cox.
Complainants:
Mr and Mrs Cox
Aggrieved:
Mr Warren Cox (Mr and Mrs Cox’s late son)
Representative:
Mencap
Complaint against:
Harold Road Surgery (the Surgery)
A GP employed by South East Health Ltd
(the Out of Hours GP)
East Sussex Hospitals NHS Trust (the Trust)
Healthcare Commission
How the Health Service Ombudsman investigated
What the Health Service Ombudsman found and investigated
Background
Mr Warren Cox was a 30 year old man with severe learning disabilities. His parents described him as a very happy and contented young person with a great sense of humour and a love for everyone. He lived at home with his parents who were his carers. Mr Cox had very little speech, but he could make himself understood to his family.
In September 2004 Mr Cox became unwell with abdominal pain. He had difficulty sleeping and had a bad epileptic seizure. His parents contacted their local Surgery, and the GPs who visited Mr Cox and spoke to his parents on the telephone diagnosed a viral infection. Around 1.30am on 25 September 2004 Mr Cox’s parents became increasingly anxious about their son because his abdomen was very swollen and they telephoned the Out of Hours GP. He visited and said Mr Cox should go to hospital for an X-ray. Mr Cox’s parents were reluctant to take Mr Cox to hospital at that time of night because they were worried they would have to wait until the X-ray department opened and this would make it hard for them to care for their son properly. Subsequently, Mr Cox’s parents telephoned the Out of Hours GP again and he arranged for an ambulance to take Mr Cox to hospital urgently.
At the Trust an intestinal obstruction was diagnosed. Various examinations and tests were performed and Mr Cox had an X-ray of his abdomen. Shortly after he returned from the X-ray department, around 90 minutes after he reached the Trust, Mr Cox vomited and unexpectedly his heart stopped and he stopped breathing. Sadly, attempts to resuscitate him were unsuccessful.
A post mortem showed that Mr Cox had died from inhaling vomit into his lungs and that his bowel had stopped working due to inflammation of the lining of his abdomen.
The complaint
Mr Cox’s parents complained that their son should not have died. They said that if the GPs from the Surgery, the Out of Hours GP and staff at the Trust had acted differently and with more urgency, he would have survived. They believed their son had been treated less favourably for reasons related to his learning disabilities.
Mr Cox’s parents were also dissatisfied with the way their complaint had been handled by the Surgery, the Trust and the Healthcare Commission. They felt the NHS complaints process had failed them and they had not had answers to their questions about the service provided for their son.
What should have happened
The NHS staff who looked after Mr Cox should have been mindful of the overall standard governing their work. This standard is made up of two components: the general standard which is derived from general principles of good administration and, where applicable, public law; and the specific standard which is derived from the legal, policy and administrative framework and the professional standards relevant to the events in question.
In Mr Cox’s case, legislation and policy about disability and human rights, in particular the Disability Discrimination Act 1995, the Human Rights Act 1998, Valuing People: A New Strategy for Learning Disability for the 21st Century (2001) and Once a Day: A Primary Care Handbook for people with learning disabilities (1999) were especially relevant to the overall standard. In terms of professional standards, the doctors and nurses should have followed the standards set out by their regulatory bodies.
The responses to Mr Cox’s parents’ complaint should have followed the National Health Service (Complaints) Regulations 2004.
How the Health Service Ombudsman investigated
The investigator met Mr Cox’s parents to gain a full understanding of their complaint. It was important to carefully consider their recollections and views. Evidence about what happened to Mr Cox and how his parents’ complaint had been handled was considered. Further enquiries were made of the Surgery, the Out of Hours GP and the Trust.
Several professional advisers provided expert clinical advice to the Health Service Ombudsman. They were: two GPs; a consultant gastroenterologist; a consultant surgeon; an accident and emergency consultant; a hospital nurse; and a learning disability nurse.
Mr Cox’s parents, their representative and the bodies complained about had the opportunity to comment on the draft report, and their comments were carefully considered before the final report was issued.
What the Health Service Ombudsman found and concluded
The investigation of the complaint against the Surgery
Mr Cox’s parents complained that GPs at the Surgery failed to diagnose their son’s condition and failed to carry out further investigations when it was clear he was in pain and distress. They said the GPs did not listen to them when they expressed concern about Mr Cox’s condition and when they suggested he had appendicitis. They believed the GPs treated their son less favourably for reasons related to his learning disabilities. Mr Cox’s parents were also dissatisfied with the way the Surgery handled their complaint.
The Health Service Ombudsman was advised that diagnosing acute appendicitis is very difficult, especially when a person is unable to communicate the detail about their symptoms. Also, she was advised that although the GPs did not reach a definitive diagnosis this did not necessarily mean their actions were unreasonable. She found that, although the GPs could have considered more proactive management, they were not at fault for taking a conservative approach to Mr Cox’s care and treatment. The Health Service Ombudsman found that, in the circumstances, the GPs acted reasonably in their responses to Mr Cox’s parents’ concerns about their son and in their examinations of him.
The Health Service Ombudsman concluded that no one could say for certain whether different or more urgent action by the GPs would have resulted in a different outcome for Mr Cox. However, she found no evidence of service failure by the GPs and no evidence that they treated Mr Cox less favourably for reasons related to his learning disabilities. Also, she found no maladministration in the way the Surgery handled Mr Cox’s parents’ complaint.
Therefore, the Health Service Ombudsman did not uphold the complaint against the Surgery.
The investigation of the complaint against the Out of Hours GP
Mr Cox’s parents had not previously complained to the Out of Hours GP. However, the Health Service Ombudsman exercised her discretion and accepted their complaint for investigation because it was important to consider the whole story about Mr Cox’s care and treatment. Mr Cox’s parents complained that the Out of Hours GP who saw their son on the night he died did not tell them how seriously ill he was and delayed calling an ambulance. They believed that, had he acted more urgently, their son might not have died. They said the Out of Hours GP did not listen to what they had to say and treated their
son less favourably for reasons related to his learning disabilities.
The Health Service Ombudsman found that the Out of Hours GP provided a good standard of care, took appropriate note of Mr Cox’s parents’ concerns and acted promptly and appropriately when he heard that Mr Cox had deteriorated.
Mr Cox’s parents thought the ambulance took too long to arrive. However, the Health Service Ombudsman found that the Out of Hours GP had called for an urgent ambulance immediately after he had spoken to them for the second time and the ambulance had arrived within half an hour. Furthermore, it was clear that the Out of Hours GP could not have predicted Mr Cox’s rapid deterioration and, therefore, his actions were appropriate in the circumstances. The Health Service Ombudsman found no evidence that the Out of Hours GP treated Mr Cox less favourably for reasons related to his learning disabilities.
The Health Service Ombudsman found no evidence of service failure by the Out of Hours GP and, therefore, she did not uphold the complaint against him.
The investigation of the complaint against the Trust
Mr Cox’s parents complained that their son should have been treated with greater urgency when he reached the Trust. They were dissatisfied with specific aspects of his care and treatment, including the actions of doctors, nurses and a radiographer. Mr Cox’s parents felt strongly that inappropriate action by the staff meant they were denied the opportunity of being with their son when he died. They said he had received less favourable treatment for reasons related to his learning disabilities. They were also dissatisfied with the way the Trust handled their complaint.
The Health Service Ombudsman found that doctors and nurses at the Trust had acted reasonably in the way they assessed Mr Cox. Staff performed appropriate examinations, arranged appropriate tests and investigations, and instigated appropriate treatment. She found staff could not have predicted that Mr Cox’s heart would stop and he would stop breathing because there was no indication that he would collapse so suddenly. Also, in the circumstances, staff acted appropriately and in line with professional guidelines in asking Mr Cox’s parents to leave the area where he was being resuscitated.
The Health Service Ombudsman found no reason to believe that Mr Cox would have survived if different or quicker treatment had been provided by staff at the Trust. She identified some areas where the care and treatment provided could have been better, for example the management of pain and communication with Mr Cox’s family, but found the overall standard of care and treatment was in line with prevailing standards. She found no evidence that staff at the Trust treated Mr Cox less favourably for reasons related to his learning disabilities. Furthermore, she found no maladministration in the way the Trust handled Mr Cox’s parents’ complaint.
Therefore, the Health Service Ombudsman did not uphold the complaint against the Trust.
The investigation of the complaint against the Healthcare Commission
Mr Cox’s parents were dissatisfied with the way their complaint was handled by the Healthcare Commission.
The Health Service Ombudsman found failings in the way the Healthcare Commission reviewed Mr Cox’s parents’ complaint. She concluded that these failings amounted to maladministration which led to an injustice because the Healthcare Commission had denied Mr Cox’s parents a proper independent review of their complaint and unreasonably delayed resolution of the complaint.
The Health Service Ombudsman upheld the complaint and recommended that the Healthcare Commission should apologise to Mr Cox’s parents for the failings identified.
The Healthcare Commission accepted this recommendation.
Was Mr Cox treated less favourably for reasons related to his learning disabilities and was his death avoidable?
The Health Service Ombudsman found no evidence that Mr Cox was treated less favourably by any of the bodies complained about for reasons related to his learning disabilities. She found no service failure or maladministration relating to the care and treatment Mr Cox received from any of the bodies complained about. On that basis she found that Mr Cox’s death did not arise in consequence of any service failure or maladministration. Therefore, she could not conclude that his death was avoidable.
The Health Service Ombudsman said that in reaching her conclusions she had seen nothing in any of the evidence which suggested that Mr Cox’s parents were in any way to blame for the death of their son. She said she had no doubt that at all times they acted in what they understood and believed to be his best interests.
The complainants’ response
Mr Cox’s parents were dissatisfied with the outcome of the investigation. They expressed their strong belief that the actions of the GPs at the Surgery led to delay in diagnosing their son’s condition and that the Out of Hours GP failed him.
