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Selected Investigations Completed April - September 1999 > Information sheet
Information sheet
Roughly every six months the Ombudsman publishes a volume of recently completed investigations. This information sheet has been produced to coincide with the publication of the volume presenting reports of investigations completed between 1st April and 30th September 1999. Health matters for Scotland and Wales have been devolved to the Scottish Parliament and the Welsh Assembly. Accordingly the Ombudsman does not report on any Scottish or Welsh cases in this volume but will publish the relevant information to those bodies in due course. In the introduction to the volume the Ombudsman explained that he was publishing it for four main reasons.
- Accountability— to keep Parliament and others abreast of the way his work is developing
- Education— many educators use his case reports as teaching material, he is eager to encourage their use in that way
- Openness— publishing a wide selection of case reports helps to demonstrate that his office works to high professional standards and is completely impartial and objective
- Partnership— publishing reports in this way, as a working document for the National Health Service, professional and consumer-based organisations should support efforts to create effective partnerships between them.
The Ombudsman hopes those aims will be further promoted by this information sheet which he is giving a wide circulation including professional, patient and consumer organisations and all Community Health Councils in England.
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Themes from cases
Number of complaints
In the six months from 1 April 1999 the Ombudsman's office received 1450 complaints, slightly fewer than in the same period last year. More than 40% came from people who had not yet approached local health services with their complaint and given them the opportunity to resolve it. This illustrates a continuing dilemma for the Ombudsman's office. On the one hand, it is important that those who have a complaint against the NHS should be aware of the existence of the office. On the other hand, no useful purpose is served by stimulating a large volume of premature or inappropriate complaints.
Complex cases — clinical care and inter-agency services
The Ombudsman is now investigating cases of increasing complexity. Many are to do with clinically complex matters involving a number of people. Others concern the provision of care by more than one agency not of all which are within his jurisdiction. For this reason the Ombudsman's staff are forging ever-closer links with the Local Government Ombudsmen within whose remit come social services departments.
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Independent Review Panels
The Ombudsman is also dealing with a second generation of problems relating to the way in which Panel hearings are planned and managed. In recent months he has communicated his concerns direct to Regional Offices so that they can draw them to the attention of all lay chairs. With Primary Care Trusts coming into being next year, it would be a pity if lessons learned from his investigations over the past three years were not passed on to these new organisations.
Recommendations arising from the Ombudsman's investigations
Most of the reports upholding complaints made to the Ombudsman include recommendations, which are normally accepted by those complained against. A few practitioners, however, have declined to do so. The Ombudsman believes that a refusal to accept the outcome of a fair and rigorous investigation by his office is unreasonable. In the introduction to the last volume of completed cases (June 1999), the Ombudsman said that in future he would usually name those who refused to apologise for shortcomings identified by his investigations. The name of a general dental practitioner is the first such. The dentist did not agree to implement the recommendation made in the Ombudsman's report or to apologise for the shortcomings found. The case (E.544/98-99) is included in the published volume.
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Cases investigated
In the published volume fifteen completed investigations are presented in full and preceded by a summary, which outlines the main features of the case. The remaining investigations are presented in brief summary form. Below are one example of the former and four of the latter.
Case No. E.374/98-99
Salford Royal Hospitals NHS Trust
On 30 May 1997, Mrs Q found her brother, Mr N, a man with Down's Syndrome, unconscious and with a high temperature. He was taken to the A&E department of Hope Hospital where he was examined by an A&E registrar who considered several diagnoses, including meningitis, but did not record these in Mr N's notes. The registrar ordered blood tests and a CT scan and gave Mr N intravenous antibiotics. He discussed his findings and proposed management of Mr N with the A&E consultant but neither doctor recorded their discussion. The CT scan was clear and the registrar referred Mr N to a RMO. The registrar expected him to be seen urgently and to be admitted but did not record any clinical information at the time of the referral. Mr N was not seen until the evening. The RMO examined Mr N, concluded that he had a urinary tract infection, prescribed antibiotics and told the family that he could be discharged. The next day Mrs Q took her brother to Oldham Hospital where he was diagnosed with meningitis. He died a week later. Mrs Q was dissatisfied with the outcome of the later independent review of her complaint. The panel's report was critical of failures in communication, but concluded that Mr N's discharge was appropriate. Mrs Q complained to the Ombudsman. He upheld her complaints that inadequate records had been kept and that Mr N's discharge was inappropriate. He found that poor recording of information by doctors and an error in clinical judgment had resulted in the inappropriate discharge. He also found confusion among A&E and medical staff about the procedure for referring patients from A&E to the RMO, and errors and omissions in the record keeping of the majority of staff who dealt with Mr N. The Ombudsman's clinical assessors advised that despite the failure by A&E doctors to record their presumptive diagnoses, there was sufficient information in Mr N's medical records to indicate to the RMO that admission was required.
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Remedy
The Trust reminded all staff of the need for accurate and complete medical records. They also introduced a formal hand-over procedure for the referral of patients from A&E and agreed to put a protocol in place for staff concerns about the discharge of a patient. The Trust also undertook to review the staffing and organisation of the medical team and apologised to Mrs Q.
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Short summaries
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 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 Service 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 that Mrs X's care was satisfactory until 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 the care they received. The Trust agreed to review its guidance on the monitoring and recording of foetal 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.
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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. 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. The Trust agreed to remind staff of the need to fully document significant communications with relatives, and of the importance of establishing the facts before responding to complaints.
E.1821/98-99
A GP in the West Sussex Health Authority Area
On 25 December 1997 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 Mrs S was admitted to hospital, as she was then seriously ill. Mrs R complained that the second GP had failed to recognise the severity of Mrs S' symptoms, and failed to arrange 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.
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Further information
All volumes of the Ombudsman's completed investigations are available in hard copy from The Stationery Office bookshops and can also be found at www.ombudsman.org.uk. The website can provide details explaining how his staff deal with complaints and these are also available in leaflets. The address and telephone numbers are:
The Health Service Ombudsman for England
Millbank Tower
Millbank
London SW1P 4QP
Telephone: 0845 015 4033 (local call rates)
Text telephone: 0171 217 4066
Fax: 0171 217 4940
E-mail: phso.enquiries@ombudsman.org.uk
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