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Selected Investigations Completed April - September 1998 > Summaries
(Listed in alphabetical order of the name of the NHS body complained against. Complaints against GPs listed under "GP", in alphabetical order of the Health Authority or Health Board Area).
E.1047/97-98
Bassetlaw Hospital and Community NHS Trust, Worksop, Nottinghamshire
When Mr X was admitted to hospital for surgery in September 1994, he was asked to sign a form acknowledging that he was responsible for the costs of his treatment, although it was being funded by the NHS under an arrangement with his fundholding GP. He later tried to take legal action for negligence against the Trust: but they said that he had been a private patient. The Ombudsman upheld Mr X's complaint that the administrative arrangements had been ambiguous, which had led to unnecessary uncertainty about legal liability for the costs of his care. The Trust agreed that no future patient in a similar position would be asked to sign such a form and to indemnify Mr X for any additional costs incurred because of the maladministration identified.
E.1214/97-98
Bay Community NHS Trust (formerly Lancaster Priority Services NHS Trust)
The Ombudsman did not uphold Miss A's complaint that she had not been given sufficient information prior to and during a visit by a community mental health nurse in June 1996. The Ombudsman upheld Miss A's complaint that the nurse gave her misleading information (although inadvertently) when she asked him what information was held about her on a database. The Ombudsman did not uphold her complaints that the Trust gave her misleading information about the disclosure of information and that the Trust's handling of her complaint was dilatory or inadequate.
Back to top E.1484/97-98
Buckinghamshire Health Authority
Mrs X wrote to the Authority in June 1997. She expressed dissatisfaction with the care a GP had given to her husband. In reply the chief executive mistakenly and insensitively offered condolences to her (though her husband had not died) and refused to take any further action on her complaint that the GP had failed to exercise reasonable clinical judgment. The chief executive said that she did not consider Mrs X's letter had amounted to a complaint. The Ombudsman upheld Mrs X's complaint and criticised the Authority for failing either to refer the letter to the convener or to seek clarification of Mrs X's wishes. The Authority apologised for offering inappropriate condolences and agreed to ensure that in future the NHS complaints procedure would be complied with.
E.685/97-98
Epsom Health Care NHS Trust, Surrey
Mr Z, who has diabetes mellitus, attended Epsom District Hospital on a number of occasions during the first half of 1996 in connection with an infected wound on his heel. He was referred subsequently for an X-ray at another hospital and diagnosed as suffering from osteomyelitis (an infection of the bone). The Ombudsman did not uphold a complaint that insufficient steps were taken to diagnose and treat the infection.
E.461/97-98
Forest Healthcare NHS Trust, London
The Ombudsman upheld Mr X's complaint that the Trust had not provided him with an adequate explanation for the delays his mother-in-law had experienced before being seen by two different doctors in the Accident and Emergency (A and E) Department of Whipps Cross Hospital in May 1996. The Trust have since opened an assessment and admissions unit which should allow assessment and treatment to start for patients while a bed is found on a main ward. The Ombudsman did not uphold Mr X's complaint that a consultant did not attend an independent review (IR) panel, as she had not been invited to attend until the morning of the IR panel meeting. He upheld Mr X's complaint that the Trust did not provide the IR panel with relevant information on A and E attendances. The Trust agreed to take measures to ensure that requests for information from both complainants and IR panels were dealt with promptly and accurately.
Back to top E.1101/97-98
Milton Keynes Community NHS Trust
In February 1997 Mrs X applied to join a new scheme for provision of an electrically powered indoor/outdoor wheelchair (EPIOC) by the Trust. Following a number of training sessions she failed a 'driving' test and the EPIOC she had been using was withdrawn immediately. The Ombudsman upheld her complaint that the Trust failed to provide adequate information, since it had not been made sufficiently clear that if she failed the test the EPIOC might be taken away. However his view (and that of the clinical assessors who advised him) was that it was not unreasonable for the Trust to insist that all users should pass a test before being issued with their own EPIOC. The Ombudsman did not uphold Mrs X's complaints that the training she had received in the use of the EPIOC was inadequate and that she had been inappropriately left without a wheelchair.
E.965/97-98
The Royal Marsden NHS Trust, London
The Ombudsman upheld a complaint that, when Mr X was treated for impotence in January 1997, his treatment was inappropriately observed by doctors not involved in delivering it. The Ombudsman said that the practice of visiting doctors "tagging on" as part of the treatment team was not acceptable, and if it was essential for several doctors to see the patient at the same time then they should have been introduced. The Trust agreed to review written information given to patients about the implications of team working (ie the number of doctors present at consultations) and the Trust's educational role. They also agreed to audit standards on the number and relevance of staff present and on introducing staff to patients. The Ombudsman also found that the Trust's handling of Mr X's complaint was inadequate in that the explanations offered for the presence of the doctors were inaccurate. He upheld a complaint that the convening process was dilatory. The delay was caused by sick leave and the convener's absences abroad. The Trust agreed that, if similar spells of absence by the convener were likely, they would consider arranging for another convener to act.
E.1746/96-97
St Helens and Knowsley NHS Trust
The Ombudsman investigated the way the Trust handled a complaint made by Mrs X. In August 1996 she alleged that a member of staff had assaulted her. She made a written complaint to the Trust in February 1997 after learning that no court proceedings would be taken. The Ombudsman considered it reasonable for the Trust not to invoke the complaints procedure immediately after the incident (when the police were investigating and the alleged perpetrator had been suspended) or after her written complaint, (since disciplinary action was being considered). However, in accordance with national guidance, the Trust should have given Mrs X the same level of information as if the matter had been dealt with through the complaints procedure. The Trust told her that an internal inquiry had been carried out to determine whether there was a case to answer for disciplinary action, and that staff had been interviewed by Trust management who had obtained statements. However during the Ombudsman's investigation no statements (except that of the alleged perpetrator) or any record of an inquiry could be found in the Trust's files. Personnel matters, such as consideration of disciplinary action, are outside the Ombudsman's jurisdiction. However, the Ombudsman found unless such consideration was thorough and well documented, the principle of giving the complainant the same level of information as under the complaints procedure would not be satisfied. The Ombudsman criticised the Trust for the misleading account they gave of their investigations.
Back to top E.1395/97-98
St Albans and Hemel Hempstead NHS Trust
Mrs X complained that, after the traumatic delivery of her baby in August 1996, midwives failed to respond adequately to her need for psychological support, particularly her request for counselling. The Ombudsman concluded that the midwives reached a reasonable assessment of her needs given their observations of her behaviour, and her account of her problems and needs at the time. The Ombudsman found that there was some confusion about the arrangements for mothers to see their midwifery records. The Trust agreed to develop a written policy about that; and to review the range of services they provide for post-delivery support. The Ombudsman did not uphold the complaint.
E.1867/97-98
Southampton University Hospitals NHS Trust
The Omubudsman upheld a complaint that the Trust failed to safeguard Mrs Y's maternity folder, containing scan photographs of her children, when she was admitted to Princess Ann Hospital to give birth to her second child in December 1996. The investigation found that staff may not have carried out proper enquiries when Mrs Y first discovered her folder was missing. The Ombudsman noted that the Trust had since formalised the procedure for the handling of maternity folders.
E.1422/96-97
South Warwickshire Combined NHS Trust (formerly South Warwickshire Mental Health Services NHS Trust)
In March or April 1996, Mrs X's mother, who was a patient in a community unit managed by the Trust, sustained a fractured neck of femur which was not diagnosed for some four to six weeks. The Ombudsman upheld Mrs X's complaint that insufficient attention was paid to her mother's complaints of pain. The Ombudsman's professional assessors concluded that communication among the multi-disciplinary team caring for Mrs X's mother was ad hoc rather than structured, and that there was no clear mechanism for co-ordinating actions arising from multi-disciplinary team reviews. The Trust agreed to review their practices to make sure that all documented care needs were appropriately and promptly addressed and to establish a clear method of communicating the conclusions of team meetings to physiotherapists unable to attend. The Ombudsman also upheld a complaint that Mrs X was given conflicting accounts of an incident in which her mother was sat on the floor. The Trust agreed to remind all staff dealing with complaints to be clear and precise in their responses. The Ombudsman found, too, that in considering Mrs X's request for an independent review, the Trust's convener exceeded his role by conducting further investigations himself rather than referring the complaint back to the Trust for further local resolution.
W.87/97-98
East Glamorgan NHS Trust Rhondda Health Care NHS Trust
Mr Z complained that he was not given adequate information to enable him to locate a genito-urinary medicine clinic at which he had an appointment with a dietician in September 1997. The clinic was run by East Glamorgan NHS Trust on a hospital site managed by Rhondda Health Care NHS Trust. Mr Z sought reimbursement of the costs he had incurred. The Ombudsman did not uphold the complaint, or recommend any reimbursement, as he found that Mr Z was given sufficient information when the appointment was made; and the clinic was adequately, if not prominently, signposted. Both Trusts agreed to consider whether any action could reasonably be taken to improve the signposting; and Rhondda Health Care NHS Trust agreed to remind their staff of the need to ensure that the hospital reception desk was never left unattended.
Back to top E.962/97-98
A GP in the Bury and Rochdale Health Authority area
In May 1996 Mrs X became ill. Her husband telephoned the family doctor, described Mrs X's symptoms and asked him to visit her at home. The GP told Mr X that his wife's symptoms were not so serious as to justify a home visit and that an emergency appointment would be kept open for her that morning. Mr X later rang the surgery to say that he intended to seek medical help elsewhere. The next day Mr X called another doctor who visited and diagnosed pneumonia. The Ombudsman did not uphold Mr X's complaint. His professional advisers were of the view that the GP's actions were appropriate and in line with the symptoms described to him by Mr X. The Ombudsman also concluded that had Mrs X attended the emergency appointment she would have been seen earlier than if the GP had made a home visit, and 24 hours earlier than when she was seen by the second GP.
E.1778/97-98 / E.1779/97-98
GPs in the Gateshead & South Tyneside Health Authority area
Mrs Y was successively removed from the lists of two GP practices to which she had been allocated following her removal from the list of a GP with whom she had been registered for two and a half years. Mrs Y complained that she had been removed despite having had no contact with either of the surgeries involved. The GP of one of the practices said that he had removed Mrs Y from his list because she had failed to attend surgery for a new patient check. Mrs Y maintained that the practice nurse had agreed to see her at home. A nurse at the other practice told Mrs Y that a doctor had the right to remove a patient without giving a reason. The Ombudsman found that in the first complaint the GP had made no attempt to explain to Mrs Y why he had found it necessary to remove her from his list; and in the second, that the GP concerned consciously decided not to give Mrs Y a reason for his actions citing advice from his professional association. Both practices have now adopted a policy of providing patients with reasons when they are removed from the list.
E.99/97-98
Gateshead and South Tyneside Health Authority
The Ombudsman upheld a complaint that, when considering the case for an independent review of Mrs X's complaint, made in August 1997 about her removal from her GP's list of patients, the Authority's convener had mistakenly concluded that, as a GP had a right to remove a patient from his list, nothing would be gained by taking the matter further. The convener also failed to consider whether the GP had taken all practical action to resolve Mrs X's complaint.
E.1246/97-98
A GP in the St Helens and Knowsley Health Authority area
Mrs X complained that when she telephoned her daughter's GP in March 1997, he failed to take sufficient account of the information given to him or to make a sufficiently thorough assessment of her daughter's condition when he refused to visit. The Ombudsman, after taking advice from two external professional assessors, found that, although it would have been advisable to speak to the patient herself, the GP knew her medical history well and reached a correct diagnosis and prescribed the appropriate treatment. He did not uphold the complaint.
Back to top E.118/97-98
A GP in Wirral Health Authority area
Mrs X complained about the actions of her husband's GP in September 1996 when she telephoned to ask for a home visit. She believed that the GP failed to make a sufficiently thorough assessment of Mr X's condition to put herself in a position to decide whether to visit. The GP did not visit and Mr X died two days later. The Ombudsman found that the GP had not failed in her assessment of Mr X's symptoms as put to her, and he did not uphold the complaint.
S.122/97-98
Two GPs in the Fife Health Board area
The Ombudsman did not uphold complaints from Mrs Y about the attitude of a practice nurse and a GP in September and October 1996 respectively. However he upheld Mrs Y's complaint about the practice's handling of her complaints as he found that explanations given about the purpose of a proposed meeting were misleading, the matter could have been handled more appropriately and Mrs Y did not receive an adequate written response to her complaints. The GP who dealt with the matter apologised for those shortcomings and the practice agreed to ensure that in future complaints were fully answered and that the purpose of any proposed meeting was made clear at the outset.
S.51/97-98
Two GPs in the Lothian Health Board area
Mr X complained that despite his late father's worsening condition in April and May 1996, the GPs failed to refer him back to the hospital where he had previously been treated for cancer and that they failed to ensure that he received adeqauate pain relief. The Ombudsman, after taking advice from two external professional assessors, found that the GPs' actions were appropriate and responsible, and he did not uphold either aspect of the complaint. Previous < Contents > Next
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