Our statutory role and how we considered this complaint
We make final decisions on complaints that have not been resolved by the NHS in England and UK government departments and some UK public organisations. We do this independently and impartially. We are not part of government, the NHS in England or a regulator. We are neither a consumer champion nor arbitrator.
We are accountable to Parliament and our work is scrutinised by the Public Administration and Constitutional Affairs Committee.
We look into complaints where an individual believes there has been injustice or hardship because an organisation has not acted properly or fairly, or has provided a poor service and not put things right. We normally expect people to complain to the organisation first so it has a chance to put things right. If an individual believes there is still a dispute about the complaint after an organisation has responded, they can ask us to look into the complaint.
When considering a complaint we begin by comparing what happened with what should have happened. We consider the general principles of good administration that we think all organisations should follow. We also consider the relevant law and policies that the organisation should have followed at the time.
If the organisation’s actions, or lack of them, were not in line with what they should have been doing, we decide whether that was serious enough to be maladministration or service failure. If we find that service failure or maladministration has resulted in an injustice, we will uphold the complaint.
However, if we do not find that the injustice claimed has arisen from the service failure or maladministration we identified, we will only partly uphold the complaint.
Alternatively, if we do not find service failure or maladministration then we will not uphold the complaint. If we find an injustice that has not been put right, we will recommend action. Our recommendations might include asking the organisation to apologise, or to pay for any financial loss, inconvenience or worry caused. We might also recommend that the organisation takes action to stop the same mistakes happening again.
We investigated Mr Hart’s complaint by listening carefully to what he told us about what happened to Averil and about his experience of how his complaint was handled.
We considered the evidence he provided to inform our investigation. We studied Averil’s clinical records and interviewed key staff responsible for her care. We also considered statements made by some of those staff. We looked at evidence about the way each of the organisations handled Mr Hart’s complaint.
We established what should have happened by referring to relevant standards and guidance. Key ones are listed in the annex. We also took advice from clinical advisers.
Our investigation was conducted by a team of investigators including Dr Bill Kirkup – Lead Associate Investigator.