the IR panel acted inappropriately in:
- meeting Mrs Z without a clinical assessor, to discuss matters relating to clinical judgment;
- failing to address adequately one of its terms of reference, about communication between doctors and with the family; and
- producing its draft report without taking full account of advice from two clinical assessors
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Investigation
3. The statement of complaint for the investigation was issued on 23 April 1997. The Commissioner obtained the comments of the Trust and relevant documents, including Mr Z's medical and nursing records, were examined. The Commissioner's staff took evidence from Mrs Z, her niece, staff of the Trust, two members of the IR panel—the independent lay chairman and the representative of North Nottinghamshire Health Authority (the purchaser representative)—and its two clinical assessors. Mrs Z was told that her complaint could in part concern action taken before 1 April 1996 solely in the exercise of clinical judgment. Such action is outside the Commissioner's jurisdiction.
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Complaint (a)
Inadequate communication
Mrs Z's evidence
4. Mrs Z explained that her husband had an operation for cancer at the King's Mill Centre (which is managed by the Trust) and was readmitted a few weeks later on 29 May 1995, as he had become unwell. A consultant surgeon had performed the operation but a consultant physician was also involved as he had been seeing her husband for some time about his diabetes. Mrs Z said that there were failures in communication: the surgeon and the physician did not liaise adequately about her husband's care and treatment, and they did not keep her informed. She was convinced that had the communication been better it would have been discovered earlier that her husband was terminally ill and he could have returned home sooner where she could have nursed him in comfort (she is a nurse). As it was, she was not told that the cancer had spread until 4 July, five days before her husband's death. He returned home on 7 July.
5. She said that the physician would say that her husband's problem was surgical and the surgeon that it was his diabetes. After first complaining to staff on the ward she approached the Trust's senior complaints and litigation officer (the complaints officer) on 26 June. The complaints officer promised to arrange a meeting involving the surgeon, the physician and Mrs Z but, although the complaints officer later told Mrs Z that she had spoken to the physician, the meeting did not go ahead. Mrs Z thought that was because the complaints officer could not persuade the surgeon to attend.
6. Mrs Z had four meetings with the physician and saw the surgeon once. She was told by ward staff that if she wanted to see the physician she would have to wait for a ward round, as individual appointments could not be made. She felt that she was regarded as a nuisance when she asked for information. When she met the surgeon, by chance, he said that he would meet the physician to discuss her husband's treatment. She did not believe that such a meeting ever took place. The family had been concerned that the cancer had returned but the doctors did not seem to accept that that was possible.
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Documentary evidence
7. Reports of ultrasound scans on the following dates include:
(28 June)'Liver is enlarged with mixed echo pattern throughout suggestive of multiple secondary deposits [of cancerous tissue]...' (3 July)'The liver shows widespread abnormality in keeping with [spread of cancer]'
8. The surgeon wrote in Mr Z's clinical notes on 2 June:
'Odd picture I think he will just slowly pick up Let me know if you want me to see him again...'
and on 26 June:
'...Nothing quite fits here—suspicious of [secondary cancers], but [test results] could be due to the septicaemia...'
A senior house officer in the physician's team wrote on 29 June:
'Abdominal scan to confirm [spread of cancer to liver]'
and on 30 June
'Awaiting... scan.'
9. A further entry in the clinical notes, made on 4 July after the physician's ward round, says;
'Ultrasound scan [points to secondary cancer] discussion with [Mr Z and his] wife Diagnosis/prognosis explained Refer to [surgeon] ? Refer to [another doctor] for chemotherapy'
10. Notes made by the complaints officer, include:
(dated 26 June but since confirmed as likely to relate to 29 June)'[After talking to Mrs Z] I telephoned [the physician] he informed me [:]'...
- [Mr Z] has had [a] scan the previous day [which] has shown [secondary cancer]
- [the surgeon] is to see [Mr Z] again to discuss palliative care.'
(4 July) 'I telephoned [Mrs Z's] niece to enquire what progress had been made in reaching a diagnosis She informed me that [the physician] had confirmed the diagnosis that day...'
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11. The Trust's notes of a meeting on 19 October (after Mr Z's death) attended by Mrs Z, her niece, the physician and the surgeon include:
'...On 28 June a scan indicated widespread [secondary cancers], and the family are concerned that they were not informed of this for several days. [Mrs Z] had been told that his scan was clear. A further scan was performed on 3 July which confirmed the cancer [The surgeon] explained that the motive for not informing the family earlier was that they wanted to be sure and did not want to cause any unnecessary upset.'
Trust response
12. In his comments to the Commissioner the Trust's chief executive said:
'The investigation of the complaint indicated that there had been a good level of communication between the doctors and a high level of communication between them and the family. Unfortunately, it appeared that despite the communication that had taken place, the family were not able to be reassured by this.'
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Evidence of Trust staff
13. The physician, under whose care Mr Z had been admitted, said that although he frequently saw relatives during ward rounds, nursing staff should have been aware that other appointments could also be made to see him if necessary. He met Mrs Z approximately six times while her husband was in hospital. Consultants would not usually see relatives as often as that. Mrs Z had been convinced that her husband's cancer had recurred and her main concern had been that the physician was hiding that diagnosis from her. He had said that he did not know what was wrong and explained what was being done. At first there was no evidence of cancer. The rapid development of the cancer along with the patient's diabetes made a diagnosis difficult. He was careful not to say that the Mr Z had cancer in case that was wrong. However, the Mrs Z's expectations were high and she persisted in saying that doctors were hiding their diagnosis. He understood why Mrs Z might have felt that the staff treated her as a nuisance: staff were guarded because she appeared to be continually threatening to complain.
14. He had several telephone conversations and meetings with the surgeon about Mr Z's treatment, and about the difficulties they were having in satisfying Mrs Z's requests for information when there was nothing new to tell her. He could not recall a proposal for a joint meeting with Mrs Z. He was sure that he would have informed Mr Z of the diagnosis as soon as it was known.
15. The surgeon said that staff usually suggested that relatives saw him during a ward round. Mrs Z could have seen him then or telephoned his secretary (as she did several times). Her husband had been admitted to the physician's ward and the physician was primarily responsible for his care. However, after Mrs Z telephoned the surgeon's secretary he went to see her in the physician's ward. She did not appear to understand that it was not appropriate for him to persist in seeing another doctor's patient. He had met her at length at least twice. He had told her several times that there was a possibility of secondary cancer being discovered, but that at the time he was not able to make a diagnosis. He tried to explain that he did not know why Mr Z was so ill. The diagnosis was not made until shortly before he died.
16. He considered that the crux of the complaint was that Mrs Z had confused the lack of a diagnosis with a lack of communication. It had become clear with hindsight that although she appeared to understand his explanations, she had not done so. He might have told Mrs Z that he was going to speak to the physician; the two doctors had spoken several times. Although he had agreed to attend such a meeting he had not met Mrs Z with the physician before her husband died. He had believed that was because Mrs Z did not want to meet the doctors.
17. The complaints officer said that she met Mrs Z and her niece on 26 June 1995, when they told her that they were not receiving adequate information about Mr Z's diagnosis and prognosis. Mrs Z said that staff were not being open with her and that the physician had told her that he could not comment on a diagnosis as that was a matter for the surgeon. The complaints officer had said that she would arrange for them to meet the physician, but that she would also seek some up-to-date information from him and would then telephone Mrs Z's niece.
18. On 27 June, the complaints officer telephoned the Mrs Z's niece who told her that the surgeon had visited the patient the previous evening and had spent half an hour talking to Mrs Z. The complaints officer believed that Mrs Z and her niece must by then have had the information they needed and so did not pursue their request for a meeting. She also spoke to the physician, probably on 29 June (see paragraph 10). He told her that there were diagnostic difficulties, although an ultrasound scan the previous day suggested that Mr Z had secondary cancer. The physician said that the surgeon would see Mr Z and discuss palliative care. On 4 July she telephoned Mrs Z's niece again to ask whether there had been a definite diagnosis. Mrs Z's niece said the physician had confirmed a diagnosis that day (but did not say what the diagnosis was) and that options for future care, including hospices, were being discussed.
19. A senior house officer in the physician's team said that after the patient was admitted Mrs Z kept asking if his cancer had returned. He had been reluctant to confirm that when there was no proof. It was for the surgeon to make any such diagnosis. He had tried to respond helpfully to her frequent requests for information, but she seemed to be unhappy with many aspects of her husband's care and, eventually, to be complaining about all the staff.
20. The chief executive believed that the complaint about communication had arisen due to differing perceptions on each side. The doctors had done all they could do to convey information, but Mrs Z might have perceived a lack of communication because the message was not what she wanted to hear. He considered that there had been good liaison between the clinicians. However, the Trust were developing training in communication for clinicians, and developing better teamwork for those working with terminally ill patients.
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Findings (a)
21. Mrs Z believes that the physician and the surgeon did not communicate with each other sufficiently about her husband's treatment, and that that was why there was no firm diagnosis of the secondary cancer earlier. According to the physician and the surgeon Mrs Z's belief was unjustified. The evidence suggests that the consultants followed the common practice, when an inpatient may require treatment in two specialities, of one consultant (in this case the physician) taking the lead and liaising with the other (in this case the surgeon): Mr Z had been admitted to a medical ward, under the care of the physician, rather than to a surgical ward. I have not seen any evidence that the two consultants were reluctant to work together or of administrative failings in their contact with each other. While they may not have had as much contact as Mrs Z would have liked, that in itself is not evidence that their liaison was inadequate. However, the apparent misunderstanding about whether she was to have a meeting with both of the doctors contributed to her belief that there was a particular difficulty. The consultants had to make a judgment about the amount of contact they needed to have to diagnose Mr Z's illness, and that judgment has a significant clinical element which takes it outside the Commissioner's jurisdiction. I therefore make no finding on whether the doctors communicated adequately with each other.
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22. Mrs Z was also concerned that the doctors did not communicate sufficiently with her, particularly to let her know that her husband's condition was terminal. She had several meetings with the physician and at least one meeting with the surgeon while her husband was in hospital. That seems to reflect a willingness on the part of those doctors to keep Mr Z's family informed about his condition. The records suggest that a firm diagnosis of cancer was not made until shortly before the patient's death, and that for a long time, as the doctor told Mrs Z, they simply did not know what was wrong and had to pursue various possibilities. The doctors were cautious and, after the first evidence of cancer in the scan on 28 June, waited for a second scan before giving a diagnosis to Mrs Z and her husband. Once the second scan had been done they informed the Mrs Z and her husband of the situation. I recognise that many patients and relatives would not want to be given a diagnosis of cancer unless that was certain, but I am surprised by the decision not to tell the family about the result of the first scan, when Mrs Z had already made it clear that she saw cancer as a possibility and that she was very anxious to have as much information as possible. With hindsight it clearly would have been better if she had been told then. However, I also recognise that such a decision is a fine judgment, and that doctors can also be criticised for imparting diagnoses prematurely. I do not, therefore, find that the doctors acted maladministratively in this regard and I do not uphold this aspect of the complaint.
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Complaint (b)(i)
Panel discussion on clinical matters without a clinical assessor Terms of reference
23. The IR's terms of reference included:
'to consider:
'(i) the clinical treatment provided to [Mr Z]'
'(ii) communications between the consultant medical staff concerned with [the patient's] care and with his family'.
Chronology of panel meetings
24. The panel, comprising a lay chairman nominated by the regional office of the NHS Executive, the Trust's convener and the purchaser representative, met as follows:
20 August 1996—First (unminuted) meeting, attended by the lay chairman, the convener, the purchaser representative and the Trust's business manager.
19 September—Second meeting (minuted), attended by the lay chairman, the purchaser representative, the business manager, Mrs Z and her niece.
9 October—Third (unminuted) meeting, attended by the lay chairman, the convener and the business manager.
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Evidence of Mrs Z and her niece
25. Mrs Z said that she received a letter from the business manager proposing a meeting with panel members. Mrs Z's niece said that she telephoned the business manager to ask if a clinical assessor should be present as she understood that to be a procedural requirement. He said that there was no need for an assessor, as it would be an introductory meeting; she took it that clinical matters would not be discussed at the meeting.
26. At the meeting, the lay chairman explained at the outset that she was not qualified to discuss clinical matters. Scans and test results were then displayed and the purchaser representative and the business manager discussed them in detail. Mrs Z did not think they should have done that without a medically qualified person present but did not object at the time as she was not sure about the procedure. Mrs Z's niece said that initially they were very pleased to have been given explanations, for the first time, which left them feeling that the doctors had done all they could for the patient. However she later had doubts about the correctness of what had happened. She would have prepared different questions if she had known that clinical matters were going to be discussed.
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Statutory directions and national guidance
27. The Directions to NHS Trusts on the hospital complaints procedure include in Article 26:
'(3) Before the panel determines to adopt a procedure for dealing with a complaint it shall consult the assessors.
'(4) Where the panel or a member of the panel interviews any of the participants for the purpose of discussing matters relating to the exercise of clinical judgment at least one of the assessors shall be present at the interview.'
28. NHS Executive guidance on the procedure defines, in Appendix 4, the role of the lay chairman as including: '...to take the chair at meetings and lead its work'
'...to agree with the panel and its assessors the way in which the latter will meet with Mrs Z...'
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Documentary evidence
29. The notes of the panel's meeting with Mrs Z and her niece on 19 September include:
'[Earlier] tests had not indicated the cancer Ultrasound scans had shown cancer
'[The lay chairman] felt that having looked through the notes and having read the report of the clinical assessor, the treatment that [Mrs Z's] husband received had been satisfactory It was possible for cancer to not be detected at the end of May and to reappear at the end of June.'
30. Mrs Z wrote to the lay chairman after the meeting: 'Thank you for your frankness and sincerity.
'However, we are concerned as to why the explanation of the treatment was not given to us at any earlier stage of our complaint!'
31. The report of the IR panel includes, under the heading 'Review Process': '...It was agreed that initial reports from the [assessors] should be sought prior to the meeting [with Mrs Z] in order to give panel members an insight and to help in their discussion with [Mrs Z].'
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Trust response
32. In his initial comments to the Commissioner the Trust's chief executive wrote:
'...it is clear that the intention of the meeting was to obtain a first-hand account of the complaint. It was not intended to discuss matters of clinical judgment, although matters of fact relating to [Mr Z's] care, and the opinion of one of the clinical assessors, as expressed in his report, were passed on.'
In later comments he added: 'The Independent Review process was the first one convened by the Trust
'The guidance was new, and those involved in dealing with the Review had little previous experience.
'Clearly much of the organisation of the process was led by the Lay Chairman, supported by Trust staff who were very keen to avoid compromising the independence of the process.
'The [Commissioner's] investigation has highlighted several important lessons for the Trust and confirmed the need to ensure that it keeps a closer eye on how the process of the Review is being managed....'
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Other evidence
33. The business manager said that his role in the IR was secretarial. He wrote to Mrs Z that the panel wished to meet her, but could not recall any subsequent telephone conversations. At the first panel meeting, members had discussed the merits of having an assessor at the meeting with Mrs Z. The lay chairman had said that was not necessary. He attended the meeting with Mrs Z to take notes. He did not take an active role. There was a discussion during which the lay chairman and the purchaser representative told Mrs Z that, judging from the assessor's report already obtained, her husband's treatment seemed to be satisfactory. Scans and x-rays were also available and the purchaser representative explained to Mrs Z how scans detected cancers.
34. The purchaser representative said that at the first meeting it had been decided that she and the lay chairman should meet Mrs Z; it was also thought appropriate to invite the Trust's medical director to the meeting. However, by the time of the second meeting, with Mrs Z and her niece, the lay chairman had decided that the Trust's medical director should simply be available if needed. The discussion at the meeting was mainly between Mrs Z and the lay chairman. However, x-rays were available and, as she was a qualified radiographer, she went through them with Mrs Z and the meeting strayed on to clinical matters. With hindsight, she believed that an assessor should have been invited. Even at the time she had been uneasy at the lack of a clinician.
35. The lay chairman said that at the first meeting it was decided that the panel needed the opinions of the assessors before meeting Mrs Z. However by the time of the meeting the panel had only one of the reports. The meeting with Mrs Z had two purposes: to give Mrs Z the opportunity to put her main complaints to the panel and to enable an independent view of her husband's clinical care to be given to Mrs Z. The purchaser representative explained the assessor's report to Mrs Z, who seemed satisfied. The business manager just took notes. With hindsight, and in the light of the Directions on the NHS complaints procedure (paragraph 27), of which she was not fully aware until later, the lay chairman realised that she should have taken greater control of the panel's proceedings: that included making sure that a clinical assessor was present at the meeting with Mrs Z.
36. One of the clinical assessors (the first assessor) said that he was not invited to meet anyone when dealing with the complaint. He thought that unusual. His secretary had telephoned the Trust to verify that he was not required to attend any meetings. He had no contact with the other assessor and did not see his report. The second assessor said he would have expected to meet Mrs Z if she remained dissatisfied. As he heard nothing from the Trust after submitting his report he assumed Mrs Z was satisfied. He thought he had seen the first assessor's report but could not remember when.
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Findings (b)(i)
37. The Directions and guidance leave considerable freedom to panels to decide on how to proceed. However, as the lay chairman has acknowledged, the way this panel went about its work was clearly wrong in not consulting the assessors on the procedures to be followed and not involving either of them in the meeting with Mrs Z. Given the terms of reference it was inevitable that any meeting with her would turn to matters of clinical judgment—as it did. Calling in the Trust's medical director to assist, as originally intended, would have been inappropriate for an independent review panel. While the purchaser representative appears to have made an excellent attempt to fill the vacuum, that cannot be an adequate substitute for having a clinical assessor present: indeed given the nature of Mrs Z's concerns and the two different specialties involved I consider that the lay chairman should have consulted the assessors about whether both needed to be present. I uphold this complaint.
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Complaint (b) (ii)
Failure to address one term of reference adequately Documentary evidence
38. The panel's findings on the second of the terms of reference (paragraph 23) (about communication) were:
'In respect of [Mrs Z's] concerns regarding communication, Panel Members were concerned that [Mrs Z] and her family had not been able to fully understand [her husband's] diagnosis and treatment, and had not been reassured by conversations with the staff involved in [his] care.
'It was of concern to Panel Members that other aspects of communication with [Mr Z's] family were received after [his] death, which had caused the family much upset.'
39. The first assessor's report contained only the following about communication:
'As so frequently happens the major problem throughout has been that of communication, rather than inadequate treatment.'
40. The second assessor's report contained only the following about communication: 'Clearly, there have been problems of communication throughout between Mrs Z and the medical and nursing staff which is regrettable It would appear that the medical and nursing staff may have failed to recognise [Mrs Z's] obvious concerns Had they done so, they may have saved [her] some distress...'
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Mrs Z's evidence
41. Mrs Z said that the panel did not look into communication with her family and between doctors, as it was supposed to. She believed that the paragraph in the panel's findings which referred to her inability to understand her husband's treatment and diagnosis was demeaning and distressing. The point was not that the family could not understand, but that they were denied facts which they repeatedly sought. It was impossible for them to understand what they had not been told.
Trust response
42. In his comments to the Commissioner the Trust's chief executive wrote:
'The panel had access to the correspondence and the case notes. They also spoke to [Mrs Z] and her niece. The panel's report addressed the issue of communication and identified that inadequacy was identified in as much as [Mrs Z] and her family remained less than appropriately informed.'
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Evidence of panel members and assessors
43. The first assessor said that he did not feel competent to make a judgment on communication within the hospital although, in his opinion, relationships with the family were mismanaged. He had intended his report to be critical of the Trust in that respect. The second assessor believed he had dealt fully with the communication aspect of the complaint in his report.
44. The lay chairman believed that although Mrs Z's distress at the time might have contributed to communication problems, the panel had come to the conclusion that communication with the family should have been much better. Staff should have had a more caring approach to patients and their relatives, and the report's finding was intended to be critical of the Trust not Mrs Z, though she could see that that might not be obvious. It had seemed that the purchaser representative's explanation of Mr Z's care and treatment was the first that had been given to her. Differences in interpretation might have been because the report had been drafted by a third party, the business manager. She accepted that it would have been helpful if more detail had been given.
45. She had not been able to make a judgment about the adequacy of communication between doctors in the case as she had never met them. The papers alone were insufficient to point to a conclusion. She accepted that the issue of communication between doctors in the terms of reference was not covered at all by the panel.
Findings (b)(ii)
46. The lay chairman has confirmed that the panel did not look into part of one of the terms of reference at all: the issue of communication between doctors. I criticise that serious omission, which left one significant element of the complaint unanswered.
47. However, even the issue of communication with the family led to a finding which Mrs Z found to be demeaning and distressing. She, not without some justification, read it as implying that problems in communication between the doctors and herself occurred because of her inability to comprehend what they were saying. The lay chairman has acknowledged that that, unintended, interpretation is possible. Since the panel did not interview the doctors (and as is clear from this investigation, full details of communication between doctors and the family was not available from documents) it is difficult to see how the panel could have had adequate evidence to make any finding on communications with the family. They attempted to do so but expressed it very badly. I uphold the complaint.
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Complaint (b)(iii)
Panel produced draft report without advice from two assessors Evidence of Mrs Z
48. Mrs Z received a letter dated 10 October 1996 from the business manager saying that the panel had drafted their report but had not yet received the second assessor's report. Although it later turned out that the second assessor agreed with the first, that was a matter of luck. She wondered what the IR panel would have done if the second assessor's report had not come to similar conclusions. Mrs Z said that, in view of the fact that the whole process had not kept to prescribed timescales from the outset, shortness of time should not have been a valid reason for producing the draft report that way.
National guidance
49. The NHS Executive's guidance on implementation of the NHS complaints procedure includes:
(paragraph 7.12) 'The panel has a duty to keep responsible records, bearing in mind the possibility of a future investigation by the Ombudsman...'
(paragraph 7.30) 'The panel may find it helpful to provide the complainant and any person(s) complained against with the opportunity to check a draft report for factual accuracy before it is issued formally in its final form. The assessors' reports should be made available in time for their preliminary circulation with the panel's draft report...'
Documentary evidence
50. In a letter to Mrs Z reporting progress, the business manager wrote on 10 October:
'...The panel have now completed the drafting of their report [they] have not yet had the opportunity of considering the report of one of the independent clinical assessors, and feel that they must take into account information contained within this before issuing their final report.'
51. Mrs Z wrote in reply: '...[Your letter] leaves me puzzled to understand how the panel can have completed the draft report it clearly raises questions about their impartiality!'
52. A reply from the business manager on 18 November included: 'In order to inform you of the probable delay, and the fact that it would not be possible to issue the final report in accordance with the time scale of the new procedure, it was agreed that I should write to you to indicate the current state of affairs'
'[The information gathered] was considered sufficient to draft a report with the intention of amending this once the second assessor's report had been received.'
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Evidence of panel members and Trust staff
53. The business manager said that after preparing a first draft of the report he suggested to the lay chairman that the physician and surgeon, as the staff complained against, should have the opportunity to meet the panel. Instead, it was decided that the draft report would be sent to them asking if they wished to comment on it. He thought the draft report had not been sent to Mrs Z because of timescale pressures.
54. The lay chairman said she could understand why Mrs Z might have felt aggrieved that the panel had drafted their report before receiving the second assessor's report. That had been due to time limits. It was always intended to alter the report if the second assessor did not reach the same conclusions as the first. She did not recollect making any decision about whether the draft should be sent to Mrs Z or the doctors. Her interpretation of the guidance was that if a draft report was to be sent out, it should be sent to all parties. She was also surprised that the panel's first and third meetings had not been minuted. She agreed that it would have been helpful both to the panel and the Commissioner if minutes had been taken.
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Findings (b)(iii)
55. There is no dispute that the panel prepared a first draft report without the benefit of the opinion of one of the assessors. The lay chairman says that it was their intention to amend the report if necessary before a final version was issued. Although not ideal, I see nothing wrong in preliminary drafting after one assessor's report is received, so long as the preliminary draft is changed as necessary on receipt of the other assessor's report, and before any draft report is issued. The guidance clearly implies that a draft report should not be circulated without both assessors' reports. That is where things went wrong here, when the draft was issued to some of those involved (but not Mrs Z) with the report of one assessor. However I have no reason to believe that the report would not have been changed had the second assessor's opinion been different from that of the first, and the only injustice to Mrs Z from this particular failing seems to have been to weaken further her confidence in the IR process.
56. Two of the three panel meetings were not minuted despite the guidance that panels should keep responsible notes in case of investigation by the Commissioner; that lack hampered this investigation. The lay chairman has since said that she would have approached differently her task of managing this IR panel if she had been more aware at the time of the requirements placed upon her. I uphold this part of the complaint.
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Conclusion
57. I turn now to the question of a remedy for the shortcomings I have found. While the significant procedural failings potentially affected the way both parts of the terms of reference were considered, Mrs Z's concerns about the outcome of the IR focus on the second (about communication) as do mine. The element of that about communication between doctors was not covered at all and the conclusion on the element about communication with the family was expressed very poorly. Although the Commissioner's investigation covered both those elements, the fact that his jurisdiction does not extend to matters of clinical judgment before April 1996 prevented me from reaching a firm conclusion on the first element. Since the IR has never dealt with that element there is nothing to prevent that point from being considered now. I recommend that the Trust make arrangements for that, making sure that both the consultants concerned are appropriately involved and that independent clinical advice is taken.
58. I have set out my findings in paragraphs 21, 22, 37, 46, 47, 55 and 56. The Trust have asked me to convey through my report—as I do—their apologies to Mrs Z for the shortcomings I have identified and have agreed to implement my recommendation in paragraph 57.
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Short text of this investigation
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