PHSO

Listening and Learning:

The Ombudsman’s review of complaint handling by the NHS in England 2011-12

The importance of explaining decisions properly

The NHS failed to give accurate and complete information to Miss R who was grieving for her father. A formal investigation by the Health Service Ombudsman was the only way that Miss R was able to get the information she sought.

Mr R had a triple bypass operation in June 2008 at a hospital run  by Plymouth Hospitals NHS Trust (the Trust). Over the next week he remained in  hospital while his condition deteriorated and he developed complications with  his breathing and circulation. Tests showed nothing obviously wrong with Mr R’s  heart. Nine days after the bypass surgery, surgeons carried out exploratory  surgery and found nothing. Sadly, Mr R died later that day.

No post mortem examination was carried out. The doctors certified  Mr R’s death as being caused by inadequate circulation and multiple organ  failure caused by pneumonia. Mr R’s daughter, Miss R, complained in writing,  asking the Trust how her father acquired pneumonia. The Trust told her that  they could not comment on whether or not Mr R had contracted pneumonia.

We formally  investigated Miss R’s complaint and found that the management of Mr R’s  illness was reasonable. However, despite having good reasons for the two causes  of death the doctors recorded, the Trust failed to explain this to Miss R when  she complained. We found that because she did not receive an explanation, Miss  R’s distress at her father’s death was exacerbated. The Trust agreed to  apologise to Miss R and pay her £250 in compensation.