Selected Investigations Completed April - September 1999

Mrs A complained that when she and her husband attended the GP's surgery and told him that Mr A was suffering from diarrhoea and dramatic weight loss, the GP only took a blood sample and performed an rectal examination before diagnosing irritable bowel syndrome (IBS). She said that the GP did not take adequate account of Mr A's symptoms, did not refer him for further tests and gave no advice about returning to the surgery. Mr A was later admitted to hospital where a diagnosis of cancer was made. Soon afterwards he died at home. The Ombudsman did not uphold the complaint, finding that the GP had provided reasonable treatment to Mr A and had been reassured by a negative blood test result. However, the GP was reminded of the importance of completing a full entry in the patient's medical record and of the need for clarity in his communications with his patients.

E.2176/97-98

Doncaster Health Authority

The Ombudsman upheld complaints from Mr X that the Health Authority's convener inappropriately interviewed a potential witness and that a note written by Mr X's late sister was attached to the draft panel report contrary to Mr X's wishes. The Ombudsman decided that it was unnecessary for the witness to have been interviewed before a decision could be reached about the IR and that the convener unduly influenced the panel's decision not to subsequently call that witness to the panel hearing. Although the lay chairman said that the note written by Mr X's late sister was attached to the panel report as a result of a genuine misunderstanding, the Ombudsman considered that Mr X made his wishes absolutely clear. Although the Ombudsman knew that the Health Authority was formally responsible for the IR process, it was acknowledged that the actions of the lay chair were beyond its control.

E.30/98-99

A GP in the Portsmouth and South East Hampshire Health Authority area

Mrs X complained that when, during October and November 1996, her mother—a diabetic—became ill with stomach pains and sickness, her GP did not respond appropriately to requests to make home visits. The Ombudsman did not uphold that complaint. However, the Ombudsman did uphold to a limited extent her complaints that the GP failed to recognise the increasing severity of her mother's condition, to make arrangements for her referral to hospital and to monitor adequately her diabetes.

E.195/98-99

Chelsea and Westminster Healthcare NHS Trust

In December 1996, Dr B, who was pregnant, underwent a surgical procedure to insert a suture in the neck of her womb, to try to prevent a miscarriage. In January 1997 she had a spontaneous miscarriage. She had previously had two successful pregnancies after sutures were used. She complained that the procedure had not been performed adequately and that she had not been given adequate information about it beforehand. The Ombudsman upheld neither complaint.

E.299/98-99

Thanet Healthcare NHS Trust (now part of East Kent Hospitals NHS Trust)

Mrs C complained that the examination of a chest X-ray taken in May 1996 was inadequate, because it failed to detect the lung cancer from which her father, Mr D, died in March 1997. The complaint was supported by Mrs C's mother, Mrs D. The Ombudsman did not uphold the complaint, because he was satisfied that there was nothing on the X-ray to suggest the presence of cancer. However, he upheld a further complaint about the way in which the Trust (and in particular one of their conveners) handled complaints which Mrs C and Mrs D made about Mr D's care. It took over nine months for a decision to be made on a request for an independent review. That was totally unacceptable and largely due to a series of errors. The Ombudsman criticised the Trust for those failings, some of which appeared to be connected with the arrangements the Trust then had for handling such requests. By the time of the Ombudsman's report the new Trust had already taken steps to improve matters. They apologised to Mrs C and Mrs D. They also agreed to implement the Ombudsman's recommendation that they should conduct a review of the systems for considering, and monitoring the progress of, requests for independent reviews and make any changes considered necessary to ensure that such requests are dealt with efficiently and in line with national guidance on the NHS complaints procedure.

E.470/98-99

Two GPs in the Southern Derbyshire Health Authority area

Mr and Mrs Y complained to the Ombudsman that they were removed from their GP's list in December 1996 because of their ethical objections to vaccination. They said that the practice had put unreasonable pressure on them to have their child vaccinated and had failed to take sufficient account of the family's cultural and ethical beliefs in the consideration and management of their primary health care needs. They complained that Mrs Y was removed from the list shortly after the practice became aware of her pregnancy. The Ombudsman did not uphold the complaints. However, he criticised the doctors for not explaining that the family's removal was due to the family's failure to attend pre-arranged appointments with health care professionals. That failure led Mr and Mrs Y to believe that their beliefs were the cause of their removal from the practice list. The Ombudsman also criticised the doctors for failing to ensure that Mrs Y knew how to make arrangements for ante-natal care.

E.553/98-99

Three GPs in the Croydon Health Authority area

Mrs X complained that a GP did not adequately investigate and manage her thyroid condition or problems with her hands. She also complained that in November 1997 she and her family were unfairly removed from the practice's patient list without being given an appropriate explanation or having proper account taken of her representations. The Ombudsman did not uphold the complaints about Mrs X's treatment. As for the family's removal from the practice's list, the Ombudsman found that on the whole the practice had acted reasonably. However, one of the GPs had raised Mr and Mrs X's expectation that they might continue as a patients; and, given that, the practice should have explained why that expectation could not be met before they wrote to the Health Authority asking for the family to be removed. To that limited extent the Ombudsman upheld the complaint.

E.668/98-99

A GP in the County Durham Health Authority area

Mrs A experienced severe abdominal pains in the early hours of 1 April 1997. A GP visited her at between 8.30 and 8.45am, prescribed painkillers and said he would arrange an urgent outpatient appointment. Later that day Mrs A was admitted to hospital, where she was found to have generalised peritonitis. She died on 9 April. Mrs A's son complained that the GP did not make a sufficiently thorough assessment of her condition or take adequate steps to relieve her pain. The Ombudsman found that the GP responded appropriately to the call about Mrs A, and that there were no grounds for considering that he should have suspected peritonitis when he visited her. However, he did not perform all the tests which a GP might reasonably have done in the circumstances; nor did he take full account of the distress Mrs A was experiencing. To that extent, the Ombudsman upheld the complaint. He did not uphold the complaint about the steps the GP took to relieve Mrs A's pain.

E.743/98-99

A General Practitioner in the South Staffordshire Health Authority area

The Ombudsman did not uphold complaints from Mr and Mrs T that on, 11 October 1997, Mrs T's GP failed to examine her fully during consultations at his surgery in the morning and at her home in the afternoon. Later that day Mrs T, who was expecting twins, suffered a placental abruption and was admitted to hospital on the advice of a midwife. The Ombudsman did not uphold a complaint that the GP had failed to arrange for her to be admitted.

E.762/98-99

Homerton Hospital NHS Trust

Mr W complained that staff at the A&E department failed to assess his mother adequately when he took her there on 1 July 1997 and she was sent home. She had been suffering from breathing difficulties, a high temperature and coughing. She had been sent home from a previous visit to A&E less than 24 hours earlier. Several days later she was admitted to the hospital, where she died. However her deterioration and death could not have been predicted from her condition on 1 July, and she had been treated reasonably then based on the information the locum doctor had. Although the Ombudsman criticised the standards of records made by one of the A&E doctors, he did not uphold the complaint. The Trust are to consider auditing locums' record-keeping and arrangements for providing relevant feedback to locum agencies.

E.820/98-99

The Dudley Group of Hospitals NHS Trust

Mrs D, who was 28 weeks pregnant, complained that inadequate steps were taken to monitor her and her baby when she attended Wordsley Hospital with reduced fetal movement in December 1997. The Ombudsman found that the care given to Mrs D was appropriate, and he did not uphold the complaint. Mrs D also complained about her care and treatment when she attended the hospital three days later. On that occasion Mrs D suffered a concealed placental abruption and was told that her baby had died. She insisted on going home that evening and was asked to return the next morning so that the baby could be delivered. Mrs D complained that she had not been given sufficient priority; that staff had allowed her to go home before the results of blood clotting tests were available and that it was unreasonable of staff to put the onus on her to return to the hospital in the event of further problems. The Ombudsman upheld Mrs D's complaint about the blood test results but he did not uphold her other complaints. He did, however, note that Mrs D was not asked to complete a self-discharge form when she insisted on going home. The Trust agreed to ensure the proper use of the forms in future. Back to top

E.822/98-99

St George's Healthcare NHS Trust, Tooting

In October 1996, Mr A's dentist asked a consultant in restorative dentistry at St George's Hospital for an opinion on treatment which the dentist had provided. The consultant saw Mr A several times and provided advice to the dentist, who continued to treat Mr A. The consultant also provided minor treatment for him. Mr A complained to the Ombudsman that the consultant failed either to provide an appropriate opinion or to use study models the dentist had provided. The Ombudsman did not uphold either complaint. The consultant provided a diagnosis and treatment plan which were appropriate to the clinical circumstances. However, the Ombudsman criticised him for not explaining clearly to Mr A or the dentist why he was reluctant to provide information which might be used in a medico-legal context. There were good clinical reasons for not using the study models, and the consultant had explained that to Mr A.

E.1025/98-99

Bedford Hospital NHS Trust

In June 1997 Mrs E's 70 year old father had a hip operation, after a cycling accident. He did not recover from the operation as quickly as Mrs E, who was a nurse, had expected, and she thought he had developed an infection. She raised her concerns with staff several times and asked them to take a chest x-ray and urine sample to screen for infection. Three weeks after the operation Mrs E's father was diagnosed as having pneumonia, and he died 11 days later. The Ombudsman did not uphold Mrs E's complaint that staff had failed to recognise and act soon enough on her father's symptoms. However, he was critical of one aspect of Mrs E's father's care. He found that the request for a urine sample, which would have determined whether infection was present a few days after Mrs E's father's operation, was not followed up. The Trust have reviewed their documentation to make clear when tests have been requested and when the results of those tests are obtained.

E.1037/98-99

Four GPs in the East Lancashire Health Authority area

Mrs X complained that there was inadequate communication about her husband's deteriorating condition among four GPs from the practice with which he was registered, who saw him on five occasions between 27 June and 25 July 1997. She also complained that there was inadequate communication between the GPs and a GP from an out-of-hours service and delay in referring Mr X to hospital. This resulted in a delayed diagnosis of his bilateral subdural haematoma and, as a consequence, lengthy neuro-surgery and a protracted recovery. The Ombudsman did not uphold Mrs X's complaint. Mr X presented with a general headache and nausea to begin with. As his condition deteriorated the GPs carried out appropriate examinations, arranged blood tests and then an appointment with a neurologist and discussed hospitalisation as an option pending that appointment. There was nothing to alert the GPs to a developing bilateral subdural haematoma. The out-of-hours GP arranged Mr X's admission on 27 July after a marked deterioration in his condition. The GPs had satisfactory systems for communication about patients within the practice and with the out-of-hours service. Mr X's problems in hospital were due to the difficult bilateral nature of his condition rather than any delay in his admission. (See also E.1249/98-99.)

E.1110/98-99

East Yorkshire Hospitals NHS Trust

Mr X, who had been receiving treatment for deep vein thrombosis, complained that at a clinic appointment in July 1997, a consultant failed to examine his leg and take proper account of his symptoms. Mr X also complained that the Trust gave him conflicting and inadequate explanations of the consultant's actions. The Ombudsman upheld the complaint about the consultant's actions only to the limited extent that he should have examined Mr X's leg and considered pain relief. However, in the overall context of the consultation, which was for the purpose of arranging further tests, the consultant acted appropriately. The Ombudsman upheld the complaint that the Trust's explanations were contradictory. The Trust agreed to remind their staff of the need to provide clear, comprehensive and accurate accounts which covered the relevant issues when responding to complaints.

E.1192/98-99

Burnley Healthcare NHS Trust

The Ombudsman upheld a complaint made by Mrs Y about a delay by the convener in deciding whether to grant her an independent review panel (IRP). Mrs Y requested an IRP on 3 February 1998; on 23 June the convener wrote to her requesting clarification of her complaint. Mrs Y provided a letter of clarification on 22 July but at the time of her complaint to the Ombudsman, 11 September 1998, she had not received a response from the convener. In his response to the complaint the chief executive of the Trust stated that Mrs Y's complaint was justified and he explained action taken by the Trust to avoid recurrence of such delay in the convening process.

E.1210/98-99

North Bristol NHS Trust (formerly Southmead Health Services NHS Trust)

Mrs X was admitted to hospital for the birth of her third child in March 1998. Her previous two children had been born at home, and she had wanted the same for her third child. However after indications that the baby might be at risk, she agreed to be admitted to hospital for closer monitoring. Labour was induced. Her baby needed resuscitation at birth and is brain damaged. Mr and Mrs X complained that there had been inadequate monitoring of the baby by hospital midwives and that the midwifery records were inadequate. The Ombudsman found Mrs X's care was satisfactory until a point about an hour after medication was given to induce labour, but for approximately the next two and a half hours monitoring was inadequate: for example no attempt was made to monitor the baby's heart rate or Mrs X's vital signs. When more checks were done, the baby's heart rate was very low and the birth was imminent. The couple's disappointment and distress at the need to attend hospital seemed to have affected their relationship with the hospital midwives, and ultimately the care they received. The Ombudsman upheld the complaints both about monitoring and about the adequacy of the records. The Trust agreed to review its guidance on the monitoring and recording of fetal and maternal well-being following induction and prior to onset of labour; and, to provide training for staff in dealing with difficult situations. The Trust agreed to ensure that all midwives should attend documentation workshops. The Trust apologised to Mr and Mrs X.

E.1249/98-99

A GP in the East Lancashire Health Authority area

Mrs X complained that a GP from a GP out-of-hours service failed in July 1997 to tell the practice with which he was registered about her husband's deteriorating condition and delayed his referral to hospital. This resulted in a delayed diagnosis of her husband's bilateral subdural haematoma and, as a consequence, lengthy neuro-surgery and a protracted recovery. The Ombudsman did not uphold Mrs X's complaint. The GP carried out an appropriate examination on 19 July, referred Mr X to his GP practice and ensured that the practice received a detailed note of the consultation. There was nothing on 19 July to alert the GP to a developing bilateral subdural haematoma. On 27 July, the GP appropriately arranged hospital admission because of a marked deterioration in Mr X's condition. Mr X's problems in hospital were due to the difficult bilateral nature of his condition rather than any delay in his admission. (See also E.1037/98-99.)

E.1318/98-99

Manchester Health Authority

Mr P complained that the handling of his case against a GP by the Health Authority and its convener was dilatory and unsatisfactory. The Ombudsman upheld the complaint to a limited extent. The Ombudsman found that there was an unnecessary delay in Mr P's request for independent review being passed to the convener by the Health Authority. He noted that the Health Authority had already taken action to ensure that such requests are passed immediately to the convener. The Ombudsman also considered that the convener should have advised Mr P of his right to appeal to him about the convener's decision that one aspect of his complaint should be referred back to the GP. (See also E.1996/98-99.) Back to top

E.1396/98-99

A GP in the Bradford Health Authority area

The Ombudsman partially upheld a complaint that a GP was impolite to a patient at a minor surgery appointment in June 1997. However, he did not uphold a complaint that the GP unreasonably refused the patient treatment. At the surgery, the patient's friend (who was interpreting for him) criticised previous treatment the GP had given. A heated exchange occurred between the GP and the friend. Because of the breakdown in communication, the GP would not have been able to be sure that the patient properly understood and accepted the reasons for the particular surgery proposed. He could not operate without informed consent. The Ombudsman considered that the GP had acted reasonably in not carrying out the operation, but regretted that the GP had allowed himself to be drawn into the heated exchange. That had been a little imprudent. The GP apologised.

E.1402/98-99

Guy's and St Thomas' Hospital NHS Trust

Mr B complained that in August 1996 hospital staff did not tell him clearly whether his consent was required before his wife's ventilator could be turned off. He also complained that he was misinformed that his wife's ventilator would be left on. The Ombudsman did not uphold the complaints. It appeared that Mr B did not fully understand certain events, and the complaints were, to a degree, based on a false premise: his wife's ventilatory support was in fact switched off after she had died. However, Mr B's confusion was compounded by inaccurate information provided by the Trust. The Trust agreed to remind staff of the need to document fully significant communications with relatives, and of the importance of establishing the facts before responding to complaints.

E.1488/98-99

A GP in the North and Mid Hampshire Health Authority area

Mr T's wife was discharged from hospital in March 1998, with a diagnosis of hiatus hernia and inflammation of her gullet, following tests which included an endoscopy. She died of cancer several weeks later. The Ombudsman did not uphold Mr T's complaint that the GP's diagnosis and treatment of his wife's condition after her discharge was inadequate. He found that the GP had assessed Mrs T's condition appropriately when he saw her or spoke to her, taking into account her history and the information provided by the hospital. Any GP would have believed that cancer or other significant disease had been ruled out.

E.1573/98-99

GPs in a practice in the Brent and Harrow Health Authority area

Mr G complained that, when he visited the practice's Saturday emergency surgery in April 1998, the doctor refused to treat him or refer him for specialist treatment for pain from sciatica, but told him to wait for his routine appointment with a second GP at the practice. The Ombudsman did not uphold the complaint. The GP had reviewed Mr G's current medication but did not prescribe any more as she understood that he did not want more tablets. The GP asked him to wait for the referral, because to consider one then would have delayed the emergency surgery, and in any event he would have to wait some time for an appointment with a specialist. Mr G also complained about the response made by the second GP to his request for a referral to a specialist. The Ombudsman upheld the complaint only to the extent that, while the second GP had made the referral promptly, because of an administrative error, the letter was sent to the wrong hospital.

E.1730/98-99

A general dental practitioner in the East Norfolk Health Authority area

Mr A complained that a bridge fitted by a dentist in September 1997 was not of a suitable design for the conditions in his mouth, since it came out twice within eight months of being fitted. The Ombudsman did not uphold the complaint. He found that Mr A's dental treatment had been of a reasonable standard, and that the bridge was of a suitable design. However, the dentist accepted that the bridge had not lasted as long as she had anticipated and she had not made clear to Mr A that this type of bridge could debond. She agreed to reimburse him the amount he had paid for the bridge.

E1767/98-99

Bury Health Care NHS Trust

The CHC complained about the handling of a complaint put to the Trust by their client. A request for IRP was first made on 17 July 1998. The Trust did not pass it to the convener but attempted further local resolution. A second request was not passed on until after the chief executive had obtained a statement of outstanding concerns from the complainant. The convener did not act in accordance with the directions and guidance on the implementation of the NHS complaints procedure but attended a meeting with the complainant and Trust staff to discuss the case. At the meeting the medical and nursing directors agreed to investigate a number of new concerns. The convener did not, however, personally investigate those matters. The convener took clinical advice from the Trust's medical director although the director had been involved previously in the investigation. The convener apologised for making comments about a clinician not employed by the Trust. The Ombudsman upheld all aspects of the complaint except the matter of the convenor's investigating concerns not previously put to the Trust.

E.1821/98-99

A GP in the West Sussex Health Authority area

On 25 December Mrs R contacted the on call service about her daughter, Mrs S, who was suffering from severe diarrhoea and vomiting. Mrs S had recently been diagnosed as having an enlarged liver caused by excessive alcohol consumption. A first GP visited, examined Mrs S and took her pulse and blood pressure. He prescribed medication and told the family to call the doctor again if the vomiting continued. The next day Mrs R considered that her daughter's condition had deteriorated so she called the doctor again. A second GP visited but said that Mrs S had improved. After a third GP called on 29 December the woman was admitted to be hospital, as she was then seriously ill. Mrs R complained that the second GP had failed to recognise the severity of her daughter's symptoms, and failed to make appropriate arrangements for her admission to hospital. The Ombudsman did not uphold the complaints. He considered that the second GP had examined Mrs S appropriately, and his assessment of her condition then and the advice he gave was sound. Mrs S's condition had been significantly different when she was later found to need hospital admission.

E.1992/98-99

A GP in the Wolverhampton Health Authority area

Ms C, who is a police officer, complained about the inappropriate attitude and manner of a GP towards her when she called him out to treat one of his patients in September 1998. Ms C said that the GP was agitated and shouted at her. The Ombudsman upheld the complaint. He found that there had been a breakdown of communication between the GP and Ms C, and that the GP had lost his patience with Ms C. Although there had been some provocation, in that Ms C apeared to question the GP's clinical judgment, the Ombudsman found that the GP's behaviour was inappropriate. The GP agreed to apologise to Ms C.

E.1996/98-99

A GP in the Manchester Health Authority area

In May 1997 Mr P complained to the Health Authority about the outcome of a consultation with the GP. The Health Authority forwarded his complaint to the practice and Mr P spoke to the practice manager on several occasions. He did not receive a written response from the GP and after three months asked the Health Authority to investigate that. In September the GP wrote to the Health Authority about Mr P's concerns but that letter went astray and in early October, the Authority's convener again asked the GP to make a full response to Mr P. The GP wrote to Mr P suggesting a meeting, but he insisted on a written reply. Subsequently, the GP wrote to Mr P but his letter was brief and only dealt with some of Mr P's concerns. Mr asked for a detailed and comprehensive reply and on 14 December the GP said he would reply when he returned from holiday in December. The Ombudsman upheld Mr P's complaint. He found that the practice had no written complaints procedure in place and the GP and his staff had little idea how complaints should be handled in accordance with the NHS complaints procedure. The GP apologised and agreed to produce a written complaints procedure as a matter of urgency and make all staff aware of its requirements. (See also E.1318/98-99.)

ANNEX 1

Date investigation report issued and NHS Authorities/Areas involved

Case Ref. No.	Report issued	NHS body/family health services practitioner involved
E.1019/97-98	05/08/99	St Helens and Knowsley Hospitals NHS Trust
E.1394/97-98	06/09/99	The Royal Hospitals NHS Trust (now part of Barts and The London NHS Trust)
E.289/98-99	30/09/99	Southport & Ormskirk Hospital NHS Trust (now West Lancashire NHS Trust)
E.374/98-99	04/10/99	Salford Royal Hospital NHS Trust
E.544/98-99	18/06/99	Dental GP in the Southampton & South West Hampshire Health
E.678/98-99	11/08/99	GP in the Barnsley Health Authority area
E.681/98-99	30/09/99	The Radcliffe Infirmary NHS Trust (now part of The Oxford Radcliffe Hospitals NHS Trust) Oxford
E.860/98-99	08/09/99	Ashford & St Peter's Hospital NHS Trust
E.926/98-99	24/08/99	The Medway NHS Trust
E.1125/98-99	30/09/99	GP in the Herefordshire HA area
E.1316/98-99	17/08/99	East Sussex, Brighton & Hove Health Authority
E.1321/98-99	18/06/99	Herefordshire Health Authority
E.1635/98-99	09/08/99	Nottingham Healthcare NHS Trust
E.1925/98-99	21/05/99	Chase Farm Hospitals NHS Trust (now Barnet & Chase Farm Hospitals NHS Trust)
E.2449/98-99	23/09/99	GP in the Avon Health Authority area

Last updated: 9 January 2006