Home > Publications > Selected Cases > Selected Investigations Completed AprilSeptember 2003 > Case No. E.2003/01-02
Complaint against Isle of Wight Healthcare NHS Trust
Summary of Case
Mrs P complained that when her 80 year old mother Mrs F, was admitted to hospital on 19 December 2000 following a stroke, she was not given pain relief on admission and that there was a delay in performing a CT brain scan. Only after a scan was performed, on 28 December, was Mrs F given anti-clotting drugs.
Mrs P feared that the delay in performing the scan, and a lack of review during that period, meant that the opportunity was lost to improve her mother’s condition, and prevent her death: on 4 January 2001.
In January 2001 Mrs P complained to the Trust, but was dissatisfied with the response and requested an independent review (IR). On 27 July the Trust’s Convener referred Mrs P’s complaint back for further local resolution. Mrs P had a meeting with Trust staff, but later the Chief Executive wrote to her that an IR had been undertaken. The letter also implied that the complaints procedure had come to a close.
Findings
The Ombudsman’s investigation focused on three specific aspects of Mrs F’s care and treatment, and the Ombudsman took advice from two Professional Assessors. She found that although a decision had been made to request a scan on 19 December, a request form had not been completed until 27 December. The Trust’s own investigation had not discovered that, and the Trust had wrongly confirmed to Mrs P on two occasions that the scan was requested the day after Mrs F’s admission. Nevertheless the Ombudsman accepted her Assessors’ view that even if the scan had been performed sooner, it was unlikely that anti-clotting drugs would have been appropriate. She also accepted their conclusions: there was no evidence to suggest a failure to provide pain relief; the delay in performing the scan was reasonable; and Mrs F was reviewed appropriately. The Ombudsman did not, therefore, uphold Mrs P’s complaint about Mrs F’s care and treatment.
In relation to the handling of the complaint, the Ombudsman found that from the point when the Convener first wrote to Mrs P, the whole process had been confused. Although well-intentioned, those involved with the handling were unclear about what decisions had been taken and what stage of the NHS complaints procedure had been reached. Nearly three months after acknowledging Mrs P’s request for an IR, the Convener wrote to her that he needed to “fully investigate” her mother’s treatment. Investigation of complaints is not a Convener’s role: thus he had either acted beyond his role, or had not clearly explained the action he was taking. His letter was not explicit about whether the complaint was to be referred back for more local resolution, or whether the request for an IR was being turned down.
It was not helpful that the Trust had a practice of offering complainants a ‘rounding-off’ meeting after the Convener had refused an IR request. Mrs P took up the Convener’s offer to meet “an independent Consultant”. She asked the Convener to clarify what was meant by “independent”. However, the Convener then replied that Mrs P had already received an independent report from a clinical adviser, but that she could attend a meeting with members of Trust staff. This seemed to preclude the meeting with an external Consultant, which had previously been offered. Mrs P met Trust staff but there was some confusion about the purpose and status of the meeting: while Trust staff saw it as helping Mrs P come to terms with what had happened to her mother, Mrs P understood it to be part of the complaints process.
The Ombudsman criticised the Trust for not handling the complaint in accordance with national guidance and for adopting practices that were potentially confusing. This aspect of the complaint was upheld.
Remedy
The Trust apologised to Mrs P. Since the events complained of, it had taken action to improve the exchange of information between departments and was working towards introducing an automated request system for scans throughout the Trust: that would make it easier to ‘chase’ test requests, and would reduce the risk of requests or results being lost in transit. The Trust said that relevant staff and Conveners would comply with the national guidance on the complaints procedure, would have a clear understanding of their roles, and would cease to offer ‘rounding off’ meetings to complainants.
Previous < Contents > Next
Back to top
|
