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Selected Investigations Completed April - September 1998 > Part II, Case no. E.1733/97-98
Complaint against:
Guy's & St Thomas' Hospital NHS Trust
Complaint as put by Ms X
1. The account of the complaint provided by Ms X was that, after the delivery of her baby at St Thomas' Hospital (which is managed by the Trust) on 25 January 1996, she suffered gynaecological problems. Her general practitioner (GP) referred her to a consultant obstetrician and gynaecologist (the first consultant) at a different hospital, where she was told that she required surgery. In April Ms X had an appointment with another consultant obstetrician and gynaecologist (the second consultant) at the Trust. On 7 June 1996 the Community Health Council (the CHC) wrote to the Trust to complain about arrangements for the delivery of the baby and about the consultation with the second consultant. The Trust's director of midwifery services replied on 2 August, but Ms X remained dissatisfied. On 19 August the CHC wrote to the Trust saying that several concerns remained outstanding. The director replied on 9 October saying that she had nothing to add to her previous letter. On 4 November 1996 the CHC requested an independent review (IR) of the complaint but, after correspondence with the Trust's convener, by 22 December 1997 no decision on whether to hold an IR had been given. The CHC then wrote on Ms X's behalf to the Ombudsman.
2. The matter investigated was that the handling of Ms X's complaint and request for an IR was dilatory and inadequate.
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Investigation
3. The statement of complaint for the investigation was issued on 6 January 1998. The Ombudsman's staff interviewed the Trust staff involved. The comments of the Trust were obtained, and relevant papers were examined. CHC staff were interviewed, although their actions are not within the Ombudsman's jurisdiction.
Chronology
4. Dates of the key events and correspondence are set out below
25 January 1996 —Ms X's baby was delivered at St Thomas' Hospital.
18 March - A letter from the first consultant to Ms X's GP indicated that Ms X had sustained 'very bad tears' during the birth, and would need surgery.
9 April - At the request of her GP Ms X was seen by the second consultant, who wrote to the GP on 16 April describing the consultation and giving her views.
7 June - On Ms X's behalf the CHC complained to the Trust about her baby's delivery, and about the attitude and advice of the second consultant. The letter said that Ms X was shocked at 'the diverse opinion' the second consultant presented compared to 'the previous two consultants'.
11 June - The Trust's customer care co-ordinator (the co-ordinator) acknowledged the letter, and passed it to the clinical operations manager (the COM) for investigation and reply.
26 June - The second consultant wrote to the director of midwifery services (the director) with her response to the complaint.
28 June - The director, acting on behalf of the COM, wrote to the CHC saying that she hoped to be able to reply fully within the next four weeks.
2 July - A draft letter of reply to the complaint was prepared for the director's signature. A computer log managed by the co-ordinator recorded the reply as having been sent that day.
26 July - The director made minor changes to the draft letter of 2 July, and sent it to the CHC as her substantive response. She enclosed copies of the Trust's protocol on the management of labour, Ms X's birth plan and the second consultant's letter to the GP.
30 July - The CHC wrote to the Trust asking why they had received no response.
2 August - The CHC received a fax of the draft letter of 2 July from the Trust. The letter dealt with the issues about delivery and quoted the second consultant's comments at length. The CHC conveyed the information to Ms X. (Note: the CHC have said that they received no other copy of the letters of 2 and 26 July.)
19 August - The CHC wrote again in some detail to the Trust saying that Ms X remained dissatisfied, especially about inconsistencies in the explanations about the birth, and about the second consultant's advice and attitude. They said that they had not received the birth plan or the labour protocol.
21 August - The co-ordinator acknowledged the letter, and passed it to the COM. (Note: that is recorded on the computer log, but there is no record of any follow up action by the co-ordinator.)
26 September - The CHC wrote direct to the COM asking for a response
9 October - The director wrote to the CHC saying that she had reviewed the complaint (though she had not been able to speak to the second consultant, who had left the Trust) and had nothing to add to her previous letter.
4 November - The CHC wrote to the Trust requesting an IR.
21 November - The convener wrote to the CHC requesting copies of the reports which the 'other two consultants' had compiled (see 7 June 1996).
19 December - The CHC replied to the convener, and enclosed a copy of the letter (which it referred to as a report) of 18 March from the first consultant. They suggested that a statement from a third consultant, then treating Ms X, might be helpful if an IR was held.
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10 January 1997 - The convener wrote to the CHC saying that the information he had was insufficient. He was unable to make a decision about the IR 'without the reports the two other consultants compiled on [Ms X]'s medical condition as [he needed] clarification'.
30 January - The CHC wrote to the convener saying they had already sent a report from the first consultant and asking him to confirm that the other information he required was a report from the third consultant (see 19 December 1996).
7 February - The convener replied saying that reports from the first and third consultants were not those which he required. He quoted the reference to two previous consultants in the CHC's letter of 7 June.
25 March - The CHC officer wrote to the convener apologising that the information in the letter of 7 June had been 'slightly misleading'. She explained that 'the two other opinions' were in fact those of the GP who had referred Ms X to the first consultant, and of the first consultant herself. The CHC officer hoped that the first consultant's report would be sufficient clarification.
14 April - The convener wrote again to the CHC, asking what was meant by 'slightly misleading'. Two consultants were mentioned in the CHC's original letter and he could not make a decision until he had received 'the reports from both consultants'.
17 April - The CHC officer wrote explaining again that the letter was misleading in that one of the 'consultants' referred to was in fact the GP. She asked the convener to telephone or fax her if he needed further information, rather than continue to send letters. It was in everyone's interests to reach a decision about an IR as soon as possible.
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1 May - The CHC received a letter from the convener saying that the CHC's delay had prevented a decision being made about the IR, and asking for the GP's report.
15 May - The CHC replied that there was no GP report, but that they had asked for the GP's records and the referral letter.
25 July - The CHC forwarded copies of the GP's records to the convener.
18 August - The convener acknowledged the CHC's letter of 25 July saying that he looked forward to receiving a copy of the GP's referral letter.
4 September - The CHC wrote to the convener to say that the letter had been hand written, and no copy had been kept.
15 September - The convener wrote to the CHC that he would write again when he had discussed the matter with a lay chair.
7 November - The convener sought advice from a midwifery adviser and a medical adviser.
17 November - The midwifery and medical advisers were sent additional information which they had requested.
21 November - The CHC enquired about the progress of the IR request.
5 December - The midwifery adviser sent her report to the convener.
22 December - The CHC wrote on Ms X's behalf to the Ombudsman, and on 6 January this investigation began.
28 January 1998 - The medical adviser sent his report to the convener.
26 February - The convener wrote to the CHC with his decision that the complaint be referred back to local resolution.
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CHC evidence
5. In their letter to the Ombudsman the CHC said that Ms X was extremely upset and frustrated with the way her complaint had been handled by the Trust, both at local resolution and at the IR stage. They were particularly concerned: because over a year after the request for an IR no decision had been reached; because before making a decision the convener carried out further investigation by asking for medical reports; and because they could only communicate with the convener by letter, which caused further delay.
Guidance and standards
6. The Patient's Charter gives the right 'To have any complaint about NHS services investigated and to receive a full and prompt reply from the chief executive.'
7. The Trust's standards for managing complaints, at the time of the complaint, state that:
Local resolution
'Complainants will receive a written response to their complaint within 20 working days of [its] receipt ... by the Quality and Nursing Directorate.'A holding letter should be sent to all complainants, informing them of any delay ... within the 20 working days.
'The maximum time for the final response will be 28 working days.'
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They also state that all complaints were to be sent to co-ordinators in the quality and nursing directorate. Their responsibilities included referring the complaint to the appropriate COM for investigation within 2 working days, and monitoring its progress against Patient Charter standards. The COMs' responsibilities included to:
'Prepare a response letter and sign on behalf of the chief executive within 20 working days. If there is to be a delay, then a holding letter should be sent ... informing of the progress of the investigation.'
Independent review
'The convener should ... not take longer than 20 working days ... to decide whether to set up a panel and to inform the complainant of that decision.'
Trust evidence
8. In comments to the Ombudsman, on behalf of the chief executive, the director of quality and nursing, wrote that the Trust did not provide a full written response within the 20 working days, but sent a holding letter explaining that that was because of the depth of investigation needed. She added that the CHC's letter was misleading and that much of the delay was centred on establishing the facts. An additional convener had recently been appointed and support to the convener had been re-organised.
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Local resolution
9. The co-ordinator said that it was part of her role to monitor the progress of complaints. She produced regular reports of all outstanding complaints. Those were forwarded to the COMs. She was sure that she had been told that a reply had been sent, which had led to the entry of 2 July on the computer log as the date of a reply. She was, therefore, surprised to learn from the CHC on 30 July that they had not received a response. She contacted the COM's office on 1 August and was told that the reply was ready but had not been sent yet. She was faxed a letter, dated 2 July, which was forwarded to the CHC on 2 August. She later received a copy of a letter dated 26 July, which differed slightly from that dated 2 July.
10. The complaints manager said that revised procedures were now in place, which ensured that all draft responses were seen by her before being forwarded to the chief executive's office for signature. The sending of a response was not entered onto the computer system until a copy of the letter had been received in her department.
11. The director said that she first became aware of the complaint on 2April 1996. Ms X's GP had telephoned her. He said that Ms X had received a report from the first consultant indicating that she had sustained serious gynaecological damage, and that he would like a second opinion. The director arranged that with the second consultant. The director later spoke to Ms X's partner on the telephone. He said that the second consultant's opinion was unacceptable. The director said that she had discussed the matter with staff before the formal letter of complaint was received. She obtained comments from the second consultant and used them in the response to the criticisms. She considered that the letter of 26 July was a detailed response to the points raised. She was not aware at the time that the CHC had not received that letter, and could offer no explanation as to why that might have happened. She had not been aware that the co-ordinator had asked for a copy of the reply. She acknowledged that the wrong letter had been supplied to the co-ordinator, but could not say why that had happened.
12. The director said that when she received the second letter of complaint she tried to contact the second consultant but had been unable to do so. She thought that the second consultant might have been on holiday, and that that had accounted in part for the long delay in replying. She said that, with hindsight, her reply to the second letter of complaint should have been fuller.
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Request for IR Evidence from CHC
13. The CHC officer said that her first contact with the case had been when Ms X rang on 19 July 1996 asking about progress. It was difficult to appreciate fully the details of a case when one had not been involved from the beginning. She accepted that the reference to two consultants' views in the original letter of complaint was misleading, and that she should have sought clarification sooner from Ms X. She also accepted that the CHC could have progressed some things more quickly but felt that it would be unfair to blame them entirely for the delays and difficulties. She had found the convener's letters unhelpful.
Evidence of Trust staff
14. The convener said that he believed it was important to obtain the reports from the two consultants referred to in the CHC's letter of 7 June 1996. That was both to inform his own decision and to provide as much information as possible to clinical advisers. He felt that because of the need to be fair to both complainant and Trust, it was necessary to obtain the reports even though that delayed his decision.
15. He was confident that he had expressed his request clearly in his letters, and could not understand why there should be any difficulty complying with it, if the documents existed. He had been suspicious from an early stage that there was some problem with them. He elected not to accept the CHC's invitation to telephone, taking the view that it would potentially create further opportunities for his request to be misconstrued. He suspected that the CHC's misleading reference to two consultants' reports was an attempt to make the Trust take the matter seriously. He had become concerned that each time the CHC wrote they presented a different account of what documents were available. Although he had received a copy of the first consultant's letter to the GP at an early stage he had not realised that that was one of the 'reports' to which the CHC was referring. He only found that out later. He thought that the CHC had been obstructive.
16. In separate interviews both the co-ordinator and the complaints manager said that they had been aware of the delay in obtaining the reports which the convener had requested. They had encouraged him to telephone the CHC, but he had remained firm in his view that that was not appropriate.
17. The complaints manager said that it was due to an oversight that clinical advisers had not been appointed until November 1997. Now advisers were appointed as soon as a case was referred to the convener. Handling of IR requests had been improved—the process had been centralised at Guy's Hospital and staff had been relieved of other duties to set up a computerised system.
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18. The chief executive said that he supported the convener's view that it was necessary to see the medical reports before reaching a decision about the IR. He considered that the CHC had been dilatory in taking so long to establish exactly what documents existed. He felt that it was difficult to know to what extent Trust staff should have intervened while the convener was handling the case, as they had been criticised previously for becoming too closely involved. At the time of this complaint there was no routine reporting system to inform him of individual cases or alert him to delays and problems. Additional conveners had now been appointed to share the workload. Now he monitored the progress of cases himself through a monthly report and regular meetings with the complaints manager.
Findings
Local resolution
19. The CHC received a reply to the initial complaint on 2 August: just under two months after the complaint was made. That was longer than the target of 20 working days (though a holding letter had been sent and the complaint was comparatively complex). However, there was unacceptable confusion about the sending of that reply. The letter, covering the main points, eventually received by the CHC was a faxed copy of a draft of 2 July. That date was entered on the Trust's computer system as the date of reply. A final reply was in fact not signed until 26 July, though for some unknown reason that letter was never received by the CHC. It was only when the CHC contacted the Trust again that any reply was received. The arrangements for sending the reply and recording its dispatch plainly were maladministrative; and, but for that, the reply might have been received rather sooner, and the attachments would have been included.
20. I accept that efforts to contact the second consultant may have justifiably delayed the reply to the CHC's letter of 19 August, though in that case it would have been better if the CHC had been informed. While the second consultant's departure complicated matters, it did not justify failing to respond to the specific concerns raised. I note that revised complaints systems are in operation and I look to the Trust to keep them under review to make sure that similar problems cannot arise. I uphold this aspect of the complaint.
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Request for IR
21. It took over 15 months for the convener to make his decision: when the target was 20 working days. Such a delay is completely unacceptable. While I acknowledge that not all the responsibility for that delay lies with the Trust, the majority does. The CHC's letter had referred to the opinions of two other consultants. I do not think it unreasonable for the convener to wish those to be taken into account—though that might appropriately have been dealt with by a referral back to local resolution at an early stage. Rather leisurely correspondence between the convener and CHC followed the convener's request for copies of the consultants' 'reports'. Eventually the CHC's letter of 25 March explained that their original letter had been 'slightly misleading' and that the opinions to which they had referred were those of one consultant and Ms X's GP, not two consultants. The convener had already been provided with a copy of the first consultant's letter and the CHC suggested that that might be adequate. Although the CHC must accept responsibility for their original incorrect letter and the initial effort required to clarify the situation, the letter of 25 March should have enabled the convener to proceed. I cannot see why he persisted in asking for consultants' 'reports' after that point. The original CHC letter had referred to opinions not reports and the letter of 25 March had corrected the original misleading statement. The CHC were clearly content to proceed on the basis of the letter from the first consultant which they had already provided. If they did not feel the need to provide evidence from the GP in support of the complaint, I cannot see why the convener should insist upon it. I cannot see any good reason why the convener could not then have made a decision, having taken appropriate advice, within a further month. Instead he insisted on having information from the GP. The GP's records were provided in July, but it still took a further seven months for the convener to reach a decision, partly because of a delay in obtaining clinical advice. In my view at least two thirds of the delay, ten months, was attributable to the Trust. The convener thought the CHC were obstructive: I would understand if they thought that he had been. Sadly the person who suffered in this most unhappy saga was the complainant. I recommend that the Trust regularly monitor the response times of their conveners and consider what action can be taken to prevent decisions taking significantly longer than the target time. I uphold the complaint.
Conclusion
22. I have set out my findings in paragraphs 19-21. The Trust have agreed to implement my recommendation in paragraph 21 and have asked me to convey—as I do through my report—their apologies to Ms X for the shortcomings I have identified.
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