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Selected Investigations Completed April - September 1998 > Part II, Case no. E.571/97-98

Part II - Full Texts of Selected Investigations

Case No. E.571/97-98 - Outpatient consultation unreasonably refused and dilatory handling of complaint

Matters considered: Patient unreasonably refused consultation at pacemaker clinic; failure to reply to complaint

Complaint against: Guy's & St Thomas' Hospital NHS Trust, London

Complaint as put by Mr J

1. The account of the complaint provided by Mr J was that when his father, who was 98 years old, attended an appointment at the pacemaker clinic (the clinic) at Guy's Hospital (the hospital) on 4 November 1996, he was turned away because his name did not appear on the list of patients for that day. On 9 November his pacemaker failed and, after painful emergency treatment, he had to be fitted with a replacement on 13 November.

2. On 20 November Mr J complained to the Trust, who manage the hospital, about the failure to see his father in the clinic; on 27 November he was told that an investigation into his complaint had begun. Although he wrote to the Trust on four further occasions, by October 1997 he had still not received a substantive response to his complaint.

3. The matters investigated were that:

(a) when Mr J's father attended the clinic on 4 November he was unreasonably refused a consultation; and

(b) the Trust's handling of Mr J's complaint was dilatory and inadequate. In particular, despite reminders, they failed to provide a substantive response to his complaint for nearly 11 months.

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Investigation

4. The statement of complaint for the investigation was issued on 28 November 1997. The Ombudsman's investigator interviewed Mr J, his father and the Trust staff involved. The comments of the Trust were obtained; and relevant papers were examined. Staff at the nursing home where Mr J's father lives, and the general practitioner (the GP) who provides a service to the residents, were also interviewed, although their actions are not the subject of investigation.

Complaint (a)
Unreasonably refused a consultation.

Evidence of Mr J and his father

5. Mr J said that his father had received an appointment letter asking him to attend the clinic. Mr J had not attended with his father, but soon afterwards his father had told him that the clinic staff had refused to see him as he did not appear to be on the list of patients to be seen that day. When interviewed by the Ombudsman's investigator (over a year after the incident) Mr J's father could not remember who had accompanied him to the clinic or what had happened that day.

Trust documentary evidence

6. In comments to the Ombudsman, on behalf of the chief executive, the director of quality and nursing wrote:

' ... when it was found that Mr J's father was not on the list he was asked to wait for a few minutes so that his pacemaker could be checked. According to clinic staff, [he] refused to wait and left the clinic before his pacemaker could be checked.'

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Clinic records

7. The appointment letter received by Mr J's father, generated by the computerised patient administration system (PAS) and dated 23 July 1996, says:

'An appointment has been arranged for [Mr J's father] to attend [the clinic] on Monday the 4th November 1996 at 2.30 p.m.'

Evidence of nursing home staff

9. The matron at the nursing home where Mr J's father lives said residents passed appointment letters to staff so that arrangements could be made for transport. She could find no record of the appointment having been changed, and was confident that any change would have been noted in the diary.

10. The deputy matron said she thought that the home had arranged transport for Mr J's father on 4 November. She said that when patients were taken to hospital by car, it was not unusual for the driver to remain with them while they waited. She did not know who had accompanied Mr J's father.

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Evidence of Trust staff

11. The chief technician said that she had been on duty at the clinic on 4 November 1996. It was a busy clinic with nine patients. In the absence of a clinic clerk she was receiving the patients as they arrived. She could not remember clearly when she became aware that Mr J's father (and a person whom she assumed was his son) were waiting, but thought it was about 2.30 or 3.00 pm. The other man called out to her, asking why he had been kept waiting. He then approached her, and she asked for the appointment card or PAS letter. Instead he handed her a letter from a GP requesting an appointment, on which the time and date of the appointment had been written. (Note: I have been unable to identify such a letter. When interviewed the GP said that he had not written to the hospital asking for an appointment for Mr J's father. It had been a routine follow up, organised by the hospital). The chief technician rang the appointments clerks to see if there was any reason why Mr J's father's name was not on the list, but they could offer no explanation. She returned the letter to the man saying 'Sir, you are not on the list'. At this point he began to get angry, although Mr J's father remained calm. She tried to explain that if he would wait a few moments she would get his records and arrange for him to be seen. It was not the practice to turn patients away, but she did not consider it appropriate to give Mr J's father priority over other patients who were on the list.

12. She rang the senior chief technician who agreed to see Mr J's father. When she went to tell him that, Mr J's father also became agitated and both gentlemen were demanding immediate treatment. By the time the senior chief technician arrived about five minutes later they had both left. She and the senior chief technician then made a note of events on the pulling sheet as they recognised the importance of recording what had happened and of alerting the appointments staff that Mr J's father needed another appointment urgently. She said that it was not uncommon for patients who were not on the clinic list to attend. However such patients were not turned away. At the time there were problems with booking clerks. Booking arrangements were much better now. (See also 11 April in paragraph 20.)

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13. The senior chief technician said that the chief technician had telephoned him saying that there was a patient in the department who was upset because he was not on the clinic list. He went to the clinic about ten minutes later and the patient had gone. He asked the chief technician to record her comments on the pulling sheet, and he then added his own. He said that when the incident occurred there was no regular receptionist for the clinic. Usually a clerk was present but that was not the case that day. If an appointment was cancelled after the appointment letter had been printed by PAS, the patient's name would automatically be removed from the pulling list. That could cause confusion if the patient did not receive a letter confirmimg the cancellation.

14. The complaints manager (the manager) confirmed that information held within the computer system showed that, on 23 July 1996, an appointment had been made for Mr J's father for 4 November. That appointment was cancelled on 27 July, and a new appointment made for 27 January 1997. She did not know why the appointment had been cancelled. A letter should have been generated by the PAS and sent to Mr J's father about that change, but it was not possible to tell whether that had happened. (Note: There is no evidence that Mr J's father received such a letter.)

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Findings (a)

15. Clinic staff were not expecting Mr J's father at the clinic that day. The chief technician believed that that might have been because he had just been referred by his GP. In fact the Trust had sent Mr J's father an appointment letter for that date but it appears that some months earlier they had changed that appointment. The Trust should have written to Mr J's father about that. It is not possible to say now whether a letter was sent but went astray, or whether the Trust failed to send one. However, staff confirmed that there had been problems with booking clerks and that it had not been uncommon for patients to attend who were not on the list provided. That suggests that the fault may well have been with the Trust. I recommend that the Trust review the present booking arrangements to check the frequency and causes of any similar problems at the clinic and take any necessary action to prevent such problems recurring.

16. The notes made at the time by the chief technician and senior chief technician convince me that they tried to remedy the situation by arranging for Mr J's father to be seen. I can understand why he might have become irritated and refused to wait; it is most regrettable that he was put in that position. However, I am mindful that the complaint under investigation was whether Mr J's father was unreasonably refused a consultation and therefore I do not uphold the complaint as put.

Complaint (b)

Handling dilatory and inadequate

17. Mr J complained that, despite protracted correspondence with the Trust, he did not receive a reply to his complaint.

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Guidance and standards

18. The Patient's Charter gives the right 'To have any complaint about NHS services investigated and to receive a full and prompt written reply from the chief executive.'

19. The Trust's standards for managing complaints, at the time of the complaint, state that:

'Complainants will receive a written reponse 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.'

'Register the complaint.

'Acknowledge [it] within 2 working days.'Refer [it] to the appropriate clinical operations manager for investigation within 2 working days.

'Monitor [its] progress against set Patient Charter standards.'

'Investigate the complaint.'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.

'Ensure all correspondence is copied to the customer care co-ordinator.'

Key events and correspondence

20. I have set out below a chronology of the main events and correspondence:

20 November 1996 - Mr J sent his complaint letter to the Trust's chief executive.

27 November - The Trust's customer care co-ordinator (the co-ordinator) wrote to Mr J, confirming receipt of his letter and informing him that the matter had been passed to the clinical operations manager (the COM) for investigation. The letter was passed to the COM, for reply direct to Mr J.

21 January 1997 - Mr J wrote to the co-ordinator enquiring about progress.

24 January - The co-ordinator asked the COM to look into the matter urgently, and wrote to tell Mr J that.

11 February - The administrative manager for cardiology passed the results of her investigation of Mr J's complaint to the deputy directorate manager of the cardiothoracic centre (the deputy manager).

26 February - The Trust received a further letter from Mr J asking for a reply to his complaint.

27 February - The co-ordinator wrote to Mr J apologising for the delay, and informing him that the COM had again been asked to look into the matter urgently. The co-ordinator passed the letter to the COM.

7 March - The deputy manager noted, on a copy of Mr J's first complaint letter, that she telephoned him at 5.20 pm and told him that a written reply would follow.

19 March - Mr J wrote to the chief executive complaining that the deputy manager had told him that she had not received his original letter, and that he had still not received a reply. A copy of his letter was passed to the COM.

21 March - The co-ordinator contacted the personal assistant to the COM requesting that she get someone to look into the matter urgently.

26 March - The co-ordinator replied to Mr J, on behalf of the chief executive, saying that the matter had again been passed to the COM. She apologised again. The co-ordinator wrote to the COM, detailing the history of the complaint handling and asking for an urgent response.

11 April - The deputy manager drafted a letter to Mr J, saying that 'an administrative error had occurred in not adding [his father's name] to the clinic list for 4 November.' She also said that the Trust had since created a post of pacemaker co-ordinator to ensure that incidents of that sort did not occur in future. (Note: Mr J did not receive that letter, and no copy was sent to the co-ordinator at that time - but see 16 October.)

22 April - Mr J wrote again to the chief executive.

25 April - Mr J's letter was passed to the COM.

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29 April - The co-ordinator passed another copy of Mr J's letter to the COM asking for it to be dealt with urgently.

9 May - The co-ordinator wrote to Mr J, on behalf of the chief executive, apologising for the delay and informing him that the matter had again been passed to the COM for her attention. She also wrote to the deputy manager asking when a reply was likely to be sent to Mr J.

26 June - Mr J first complained to the Ombudsman that he had had no reply.

11 July - The Ombudsman's staff made enquiries of the Trust about the lack of a reply. We were assured that action would be taken.

15 July - The Ombudsman's office informed Mr J that the Trust had promised to respond, and asked him to await the outcome.

9 October - Mr J wrote again to the Ombudsman, complaining that he had still not received a response from the Trust.

16 October - In response to a telephone call from the Ombudsman's Office, the Trust said that a substantive response had been sent to Mr J on 11 April. A copy of that letter was supplied. A record made by the co-ordinator says that the deputy manager told her that she had told this office earlier that a letter had been sent to Mr J but that she would send a copy. However, she is recorded as having told the co-ordinator that the department had been in the middle of a move and it was possible that she forgot to send the letter. The co-ordinator received a copy of the letter for the first time.

Trust evidence

21. In comments to the Ombudsman, on behalf of the chief executive, the director of quality and nursing said that a response letter had been sent to Mr J in April 1997 but that:

'There was an inexplicable delay and confusion in responding to this complaint, the Trust accepts that this aspect of the complaint is justified.'

23. The complaints manager (the manager) said that the computer reports detailing outstanding responses had not been produced regularly at the time of Mr J's complaint, due to the pressure of work with other aspects of the complaints procedure. She had now assumed personal responsibility for the production of the reports, which were now provided regularly to the COMs.

24. In a written statement the COM stated that Mr J's complaint would have been logged by her personal assistant and passed to the deputy manager, who was responsible at that time for drafting replies to letters of complaint about non-clinical matters. She could not recall whether she saw all the correspondence relating to Mr J's complaint, as her assistant was authorised to deal directly with complaints correspondence.

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25. The COM acknowledged that there had been unacceptable and indefensible delays in responding to a straightforward complaint letter. At that time the directorate was very busy, and there were a large number of complaints relating mainly to delays in treatment. In addition the directorate was planning for and organising a major transfer of services from the Guy's Hospital site to St Thomas' Hospital during the summer of 1997. At a time when the directorate was facing a heavy workload the deputy manager had been absent for a number of weeks due to injury. As a consequence, the management and speed of response to complaints was not as efficient as it should have been. Given the high number of complaints and her desire to respond as soon as possible, she had waived the requirement that she should see all responses before they were sent. That did mean, however, that she was reliant on copies of the final response being forwarded to her office, which had not always been done promptly. There appeared to have been a further breakdown in procedure, in that no copy was sent to the directorate of quality and nursing.

26. The COM was not able to offer an explanation as to why the Trust's response dated 11 April was never received by Mr J. She regretted the difficulties he had experienced in trying to get a reply from the Trust.

27. The deputy manager said that she first became aware of Mr J's complaint in February 1997. She had been absent on sick leave during November and December, and had continued to need time off in January and February. In her absence Mr J's letter had been passed to the administrative manager, who sent a memo to her dated 11 February (paragraph 20). She could not remember what had prompted her to telephone Mr J on 7 March. She could not explain why he did not receive her letter of 11 April, although a number of temporary secretaries had been employed then and it was not uncommon for letters not to be received. It was a very busy time as the department was moving to another site. She said that, when she learned that Mr J had not received the reply of 11 April, she had sent him another one, but she could not remember when. She could not remember any information to add to that in the records. She accepted that the Trust's investigation had not got to the bottom of what happened.

28. As part of a separate investigation the Ombudsman's investigator interviewed the chief executive about the Trust's complaints procedure. He said that at the time of Mr J's complaint there was no routine reporting system to inform him of individual cases or alert him to delays and problems. At that time he had not been involved in responses to individual complaints. Now either he, or a designated executive director, oversaw all complaints and signed all final responses. Monthly meetings were now held with the clinical directorates to follow up on the process and any issues arising out of the substance of complaints.

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Findings (b)

29. The handling of this complaint was appalling. Mr J made a comparatively straightforward, non-clinical, complaint on 20 November 1996. No attempt was made to send him a reply until 11 April 1997. As its writer now acknowledges, that reply did not get to the bottom of things; worse still it incorrectly implied that Mr J's father's name should have been on the list for 4 November when in fact it appears that the problem stemmed from the cancellation of that appointment by the Trust. Furthermore, while a reply was drafted in April 1997, I do not believe that it was sent - Mr J never received it, nor was a copy received by the co-ordinator. Even though this office contacted the Trust in July 1997 and we were assured that action would be taken, Mr J had still not received a reply by October.

30. Why was the complaint handled so badly? The co-ordinator dutifully contacted the COM and wrote to Mr J after each of his four reminder letters, but no system operated to ensure that the delay would come to the attention of a sufficiently senior officer to ensure that action would be taken. While I accept that the COM and her staff were under considerable pressure, this case demonstrates clearly how failure to deal promptly and properly with a complaint not only does an injustice to the complainant, but also actually creates more work for Trust staff in the long run. I have been told that now more monitoring of progress of complaints is done by senior staff and the chief executive signs all replies. I recommend that he reviews the complaints system to make sure that similar problems cannot be repeated and that complaints are dealt with thoroughly and expeditiously.

Conclusion

31. I have set out my findings in paragraphs 15-16 and 29-30. The Trust have asked me to convey - as I do through my report - their apologies to Mr J and his father for the shortcomings I have identified and have agreed to implement the recommendations in paragraphs 15 and 30.

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Last updated: 12 January 2006