Home > Publications > Selected Cases - Health >
Selected Investigations Completed April and July 2000 > Foreword II
This report contains reports on investigations completed by my office between 1 April and 30 July 2000. In the foreword to the volume covering investigations completed between 1 October 1999 and 31 March 2000 (HC 541-1) I explained that the new format of that volume was designed to offer easier access to information. I am grateful to all those who commented upon it: many of the suggestions made have been incorporated into this volume.
This volume contains a letter that invites readers to tell me whether the revisions to the new format are helpful, the use they plan to make of the publication, and how they think it might be improved. Comments and suggestions will be very welcome.
I hope that publishing reports of investigations in this way continues to provide material for teaching and training, to assure the public and health professionals of the office's commitment to thoroughness and impartiality, and to provide a working document for all those who are involved in promoting good practice.
Part one of this volume contains information about the thirty-five investigations about health services in England that were completed in the period. (I report separately to the Scottish Parliament and the National Assembly for Wales on cases arising in those countries). Eleven are presented as short reports outlining the key features of the case: the rest are presented in the form of brief summaries. Part two consists of the full text of the eleven investigations reported in short form in part one.
Themes from cases
The thirty-five cases reported here arose mainly from events during 1999. They cover many issues, arising from in-patient and out-patient hospital care, family health services, the work of NHS conveners and the conduct of independent reviews.
I investigate very few complaints, compared with the number dealt with by the NHS, let alone the number of consultations or operations. It is dangerous, therefore, to draw conclusions from them about the state of the NHS in general, or to try and identify trends in care or complaints management.
That said, themes do emerge from investigations. I know that several of the external advisers who support my work say that they identify problems in the course of an investigation which lead them to 'just check' that the same problem does not feature in their own organisation! They also identify good practice and take that knowledge back with them.
There are three such themes to which I draw attention: the support and supervision of doctors in training and others with delegated responsibilities; record keeping and handling patient complaints.
Support and supervision of doctors in training
I report the outcome of three investigations (cases E.924/99-00, E.1476/99-00 and E.1004/98-99). They all involve occasions when junior medical staff should have called on a more senior member of staff for advice. This was not the single determining factor in the shortcomings identified in any of these cases; but it was a feature of all of them. There are many reasons why someone might not seek the support of a senior colleague: pressure of work on both, an error of judgment as to apparent urgency, or simple availability. But it is clear from these reports that there were communication barriers between senior and junior medical staff, and that these adversley affected the care of patients.
Record keeping
Poor record keeping is a feature of many of the complaints that I investigate. In one case (E.704/99-00) it did not, in fact, lead to serious consequences; but things could have been different. Although the notes made by a GP about the care of a patient were only very brief, and not immediately available to the practice nurse when she needed them, appropriate arrangements were made to care for the patient. In view of what was something of a 'near miss' the GP agreed to review record keeping arrangements.
A second case (E.2291/98-99) highlights a different aspect of record keeping. Here I criticise nursing staff for not recording concerns raised with them by a patient's relatives. Relatives are often well placed to observe departures from 'normal', but their comments are not always taken seriously or recorded. In this case, information about relatives' concerns might have influenced the management of the patient's care.
Handling complaints
Nine of the investigations reported between April and July 2000 are to do with handling complaints, and all but one of the complaints was upheld. Some reveal alarmingly poor practice on the part of some NHS bodies and review panels.
I see many complaints that are handled very well. But those I report here illustrate some basic misunderstandings about the role of NHS trusts and conveners in the second stage of the complaints procedure (E.2143/98-99) and serious delays in the process (E.2043/99-00). Early and careful consideration of a complaint helps both the patient and the staff complained against.
Michael Buckley
Health Service Commissioner for England
(Ombudsman)
Previous < Contents > Next
Back to top
|
