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Selected Investigations Completed April 2001July 2001 > Foreword
Three times each year my office publishes details of the cases it has investigated. This volume contains reports of the 47 cases completed between 1 April and 31 July 2001. Some of the more significant cases appear in the form of a short report; the others appear as summaries of the matters investigated and of my findings. Of the 24 short reports, six also appear in their full text version in a companion volume. They relate to matters which may be of particular interest, or complexity, or both.
The investigations completed covered a very wide range of services, clinical specialties, and complaints during this period. I would like, however, to draw attention to two groups of cases which I believe illustrate issues that may have general application. The first group involves care provided in Accident and Emergency Departments; and the second illustrates continuing difficulties with ensuring adequate investigation of, and response to, complaints.
Care provided in Accident and Emergency Departments
Four of the investigations reported in this volume provide examples of decisions made by relatively inexperienced clinical staff, and which contributed to shortcomings in care. In the first (E.1649/99-00), a decision to refer a patient to a specialist team was based on a mistaken diagnosis and led to an unacceptable delay in providing treatment – the urgency of the situation was not appreciated. A second case (E.2178/99-00) illustrated the fact that an adequate medical history can be crucial in reaching an accurate diagnosis. Two further cases (E.2360/99-00 and E.156/00-01) involved failures to seek urgent support from specialist colleagues. These failings were not the sole reason for the shortcomings in the care provided to the patients involved; but they certainly contributed to them. They underline the need for adequate support and supervision of more junior clinical staff, to which I also drew attention in my last Annual Report.
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Investigating and handling complaints
Eleven cases described in this volume involve complaints about the way in which a complaint was handled by NHS bodies. Several illustrate something that arises frequently in my experience – a poorly handled complaint amplifies the dissatisfaction and distress of people who have concerns about the care provided to them or their family.
Regrettably, the cases that appear here suggest that some of the problems I have commented on in the past continue to arise. I criticise trusts that fail to pass requests for independent review to conveners (E.460/00-01, E.2242/98-99), conveners who fail to take clinical advice when considering a request for independent review (E.1446/00-01, E.2495/99-00), and independent review panels that fail to base their views on the evidence available (E.2171/99-00, E.1353/99-00). Two cases (E.763/00-01, E.1008/00-01) made clear the important role of conveners, and the responsibility they have for making sure that the matters to be considered are clear, and for contributing to a review process that is fair and as impartial as possible. Failures to identify and interview key witnesses feature in this volume (E.206/99-00, E.1353/99-00). Although neither trusts nor independent review panels can require current or former members of staff to provide evidence, complainants are right to expect that reasonable efforts will be made to identify and contact relevant witnesses. In my experience, NHS staff rarely decline to help. Finally, two further cases underline the need for effective complaints procedures and handling in the family health services (E1372/00-01, E.2506/99-00).
I hope the cases described here provide useful points for discussion and education. Comments upon this and all the office’s publications (they all appear on our website – www.ombudsman.org.uk) will be very welcome.
Michael Buckley
Health Service Commissioner for England
(Ombudsman)
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