Poor complaint handling contributed to concerns that something had gone wrong

Summary 1099 |

A trust delayed responding to a complainant's concerns and gave mixed messages about whether an investigation was ongoing or not. This led to fears of a cover up.

What happened

Mrs Y was admitted to hospital with end stage heart failure. A decision was made that she should not be resuscitated in the event of a heart attack.

One week later, Mrs Y's condition worsened and she was given a 5ml dose of morphine. This slowed down Mrs Y's breathing and, despite attempts to reverse the effects of the morphine, she never regained consciousness. Mrs Y died later that day from heart and kidney failure.

Mrs Y's daughter, Mrs G, complained that the family had not agreed with the decision not to resuscitate her mother; that a heart monitor was not used; and that an incorrect dose of morphine led to her mother's death. She also complained about the attitude of staff on the ward.

What we found

We partly upheld this complaint. The Trust gave Mrs Y appropriate care and treatment. The dose of morphine it gave her was a standard dose and slowing down breathing is a known side effect. The reason for giving Mrs Y morphine should have been noted in the records, but it was still appropriate to provide it as she was dying and in discomfort.

There were, however, faults in the way the Trust dealt with Mrs G's complaint. It did not follow up on actions that were agreed, particularly in relation to a member of staff's attitude, or inform Mrs G of the actions it had taken. It delayed responding to her and wrongly told her that its investigation into her concerns was ongoing, when in fact it had closed her case.

Putting it right

The Trust acknowledged and apologised for the failings in its complaint handling and took action to address these.

Health or Parliamentary
Organisations we investigated

North Middlesex University Hospital NHS Trust


Greater London

Complainants' concerns ?

Did not apologise properly or do enough to put things right

Did not put recommendations into practice



Recommendation to learn lessons or draw up an action plan