The complainant, Mr D, had been removed from his GPs' list after a telephone conversation with the receptionist during which Mr D insisted that the surgery arrange blood tests for his daughter. Dr E that she had removed him from her list because of the distress experienced by the receptionist after her telephone conversation with him and aggression shown to staff members was regarded by the practice as a breakdown in the doctor-patient relationship. Mr D requested an independent review of his complaint. He was informed that the Convener was turning down his request because a review had no authority to reverse the practice’s decision to remove him from their list and that his daughter had been treated with all reasonable care by the general practitioners within the practice.
South of Scotland
Argyll and Clyde Acute Hospitals NHS Trust
Renfrewshire Emergency Medical Service
Borders General Hospital NHS Trust
Summary
Mrs C complained about the care and treatment that her father (Mr A) received from Dumfries and Galloway NHS Board (the Board) in A&E and in the clinical assessment unit at Dumfries and Galloway Royal Infirmary. Mr A arrived at A&E late in the evening on 2 December 2017. Early in the morning on 3 December 2017, Mr A was admitted to the clinical assessment unit. While in the clinical assessment unit, Mr A had a cardiac arrest and he sadly passed away. The cause of Mr A’s death was a ruptured abdominal aortic aneurysm (AAA).
Mrs C complained that Mr A’s symptoms were not investigated appropriately in A&E. Mrs C also questioned whether the Board’s record-keeping regarding Mr A’s care and treatment was appropriate.
We took independent advice from a consultant in emergency medicine, a consultant in acute medicine and a nursing adviser.
We found that the history and initial examination carried out in A&E were reasonable. However, we also found that the Board failed to perform an ultrasound scan or a CT scan of Mr A’s abdomen in A&E to confirm or exclude a diagnosis of an AAA. If a scan had been done in A&E this may have led to an earlier diagnosis of AAA, Mr A’s transfer to a hospital with a vascular surgical capability (vascular specialists treat disorders of the circulatory system) and the chance of his survival may have been greater.
We found that Mr A was not reviewed promptly by medical staff on his transfer to the clinical assessment unit when he was suspected to have an infection and the nursing documentation and cardiac arrest documentation were not completed reasonably.
In view of these failings, we upheld Mrs C’s complaint that the Board did not provide reasonable care and treatment to Mr A. We also found that the failings in care that our investigation identified could have and should have been established and acted upon during the Board’s own complaints investigation.
Mrs C also complained that the Board did not communicate reasonably with Mr A’s family. We found that Mr A’s family were not kept updated about his deteriorating condition, they were informed in a corridor that he had passed away and clear information was not given about the time of Mr A’s death.
In light of this, we upheld Mrs C’s complaint that the Board did not communicate reasonably with Mrs C and her family regarding Mr A’s care and treatment.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mrs C and her family:
| Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
| (a) and (b) |
The Board failed to perform an ultrasound scan or a CT scan of Mr A’s abdomen in A&E to confirm or exclude a diagnosis of an abdominal aortic aneurysm. Mr A was not reviewed promptly by medical staff on his transfer to the clinical assessment unit when he was suspected to have an infection. The nursing documentation and cardiac arrest documentation were not completed reasonably. There were failures to communicate reasonably with Mr A’s family |
Apologise to Mrs C and Mrs C’s family for the failure to perform a scan of Mr A’s abdomen in A&E, that Mr A was not reviewed promptly on his transfer to the clinical assessment unit, that the nursing and cardiac arrest documentation were not completed reasonably and that there were failures to communicate reasonably with Mr A’s family |
A copy or record of the apology. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance
By: 19 December 2018 |
We are asking the Board to improve the way they do things:
| Complaint number |
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|---|
| (a) |
The Board failed to perform an ultrasound scan or a CT scan of Mr A’s abdomen in A&E to confirm or exclude a diagnosis of an abdominal aortic aneurysm |
Medical staff in A&E should be aware of abdominal aortic aneurysm presentation and investigation
|
Evidence that the findings on this complaint have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions). Evidence that abdominal aortic aneurysm presentation and investigation has been included in A&E staff induction programme. Evidence that guidelines are in place for obtaining imaging when abdominal aortic aneurysm is suspected
By: 13 February 2019 |
| (a) |
Mr A was not reviewed promptly by medical staff on his transfer to the clinical assessment unit when he was suspected to have an infection
|
Patients admitted to the clinical assessment unit who are suspected to have an infection should be reviewed promptly by medical staff |
Evidence that the Board have reviewed the current system for the medical review of patients who are transferred from A&E to the clinical assessment unit and identified areas where this system could be improved
By: 13 February 2019 |
| (a) |
The level of nursing assessment and monitoring that Mr A needed was not recorded on his admission to the clinical assessment unit.
Nursing staff in the clinical assessment unit failed to complete Mr A’s vital signs chart |
Patients admitted to the clinical assessment unit should have their required level of nursing assessment and monitoring recorded.
Patients presenting with moderate pain and signs of shock should have their vital signs checked appropriately following admission to the clinical assessment unit |
Documentary evidence that the findings on this complaint have been fed back to relevant nursing staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).
Evidence that the Board have reviewed the current system for nursing assessment and monitoring of patients admitted to the clinical assessment unit and identified any areas where this system could be improved
By: 13 February 2019 |
| (a) and (b) | The documentation regarding Mr A’s cardiac arrest was unreasonable and this may have led to Mr A’s family being given unclear information about his time of death |
Cardiac arrest documentation should detail:
|
Evidence that the findings on this complaint have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).
Evidence that the Board have reviewed the current system for documenting cardiac arrests in the clinical assessment unit and identified any areas where this system could be improved
By: 13 February 2019 |
| (b) | Mr A’s family were informed in a corridor that he had passed away | Upsetting news should be communicated in a private and quiet area |
Evidence that the Board have reviewed the current system for breaking upsetting news in the clinical assessment unit and identified any areas where this system could be improved
By: 13 February 2019 |
| (a) | The Board’s own investigation did not identify the serious failings in the care provided to Mr A | The Board’s complaints handling system should ensure that failings (and good practice) are identified, and that it is using the learning from complaints to inform service development and improvement (where appropriate |
Evidence that the Board have reviewed why its own investigation into the complaint did not identify the failings highlighted in this report
By: 16 January 2019 |
The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:
| Complaint number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
| (b) |
There were failures to communicate reasonably with Mr A’s family:
|
The Board said that they had fed these failings back to the teams in A&E and the clinical assessment unit |
Evidence that the findings on this complaint have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions)
By: 16 January 2019 |
Feedback
Complaints handling:
Given that your complaint was received after 1 April 2017, the Board should have been adhering to the NHS Model Complaints Handling Procedure (CHP).
- on 4 January 2018, the Board said that Mrs C made contact with them by telephone to raise concerns about Mr A’s care and treatment.
- on 23 February 2018, a meeting was held to discuss the concerns. The Board state the complaint was closed on 26 February 2018 following the meeting.
The meeting was held 36 working days after Mrs C contacted the Board to make the complaint. The CHP states that meetings should be held within 20 working days of receiving the complaint wherever possible. It is not clear from the records available to me why this meeting was not held within 20 working days of the complaint being received. I have drawn this to the Board’s attention.
Summary
Mr C complained about orthodontic treatment he received over a number of years to address crowding in both his upper and lower jaws. After he lost one of his upper front teeth due to an injury and infection, the decision was taken to move the remaining upper front tooth across the centre of his mouth to fill the gap, whilst also moving the other teeth to resolve the crowding issues.
Mr C was initially told that the treatment was expected to take between 18 and 24 months. However, after around two and a half years of treatment, his original orthodontist left the practice. The subsequent orthodontist was concerned about the appropriateness of the treatment plan and referred Mr C to an orthodontic consultant after identifying a deterioration of Mr C's bone structure and tooth roots. The decision was taken to cease treatment due to the risk of further damage. Mr C was left with the tooth in the centre of his mouth. A veneer was then required to make the tooth appear more normal.
We took independent advice from an orthodontics adviser on the treatment that Mr C received from the initial orthodontist. The adviser considered the treatment plan was unusual. As such, the adviser would have expected there to be evidence of discussions with restorative dentists, because restorative work would be required after orthodontic treatment was complete in order to make the moved teeth appear normal. However, this did not take place.
The adviser was also critical of the quality of the records, which were unreasonably abbreviated and lacked evidence that alternative treatment options were discussed with Mr C, potentially making the consent he gave for the treatment plan invalid. The notes also failed to confirm whether a previously identified infection had resolved before orthodontic treatment was commenced, meaning this could not be ruled out as a factor in the bone structure and tooth deterioration Mr C experienced.
For these reasons, we considered that the treatment fell below a reasonable standard and we upheld the complaint.
Further to the clinical failures, we also identified concerns with the orthodontist's complaints handling and communication, both with Mr C and the SPSO. Throughout the complaints process, the orthodontist missed 11 deadlines for response, sometimes by a number of weeks or months and often without contact to explain the delay. The orthodontist also failed to provide all of the information requested on a number of occasions.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Orthodontist to do for Mr C:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
|
The orthodontic treatment provided to Mr C fell below a reasonable standard, as did the subsequent complaints handling |
Apologise to Mr C for the failing identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance |
A copy or record of the apology
By: 25 July 2018 |
We are asking the Orthodontist to improve the way they do things:
|
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|
|
The orthodontic treatment provided to Mr C fell below a reasonable standard, as did the subsequent complaints handling |
All treatment should be provided to a reasonable standard. Records should be detailed, complete, and clear; all treatment options and predicted outcomes should be fully discussed with a patient before commencing a treatment plan and details of this should be documented; valid consent should always be recorded; complaints should be responded to in a reasonable timescale |
To ensure appropriate professional development, details of this complaint and the learning needs identified as a result should be included in the Orthodontist's Personal Development Plan which is submitted to the General Dental Council under their 'Enhanced CPD guidance'. A copy of this should then be submitted to SPSO
By: 27 August 2018 |
Summary
Mr C complained about the care and treatment provided to him by the board after he was diagnosed with prostate cancer. His prostate cancer was considered low risk and the plan was for active surveillance, which involves having a PSA test (prostate specific antigen: a marker in blood tests which can indicate prostate problems) three to four times a year, and an MRI scan six months after diagnosis. However, Mr C complained that he was not given a PSA test until nearly a year after his diagnosis, and the MRI scan was not organised in a timely manner.
We took independent, professional advice from a urologist. We found that the board failed to:
- arrange follow-up appointments;
- arrange PSA tests that required to be undertaken;
- check that PSA tests were undertaken as intended;
- make adequate and timely arrangements for an MRI scan which took
Mr C’s special needs into account; and - provide Mr C with information that might have enabled him to make alternative arrangements to get the necessary tests done.
Given these failings, we upheld this aspect of Mr C's complaint.
Mr C also complained that the board failed to communicate appropriately with him regarding the monitoring of his prostate cancer. We found that when Mr C was diagnosed the need for regular PSA testing and the MRI scan were not communicated to him or his GP appropriately. We also found that when Mr C was contacted regarding the MRI scan, the information he was given did not answer all of his questions, nor was he fully informed of his options. We upheld this aspect of Mr C's complaint.
Finally, Mr C complained about the board's handling of his complaint. We found that Mr C's complaint to the board had been incorrectly logged as a concern rather than a complaint. We also found that communication with Mr C throughout and after the complaints process had been poor. We upheld this aspect of Mr C's complaint.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mr C:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
|
(a), (b), & (c) |
The Board failed to provide appropriate monitoring following a diagnosis of prostate cancer; failed to communicate appropriately; and handled Mr C’s complaint unreasonably |
Apologise to Mr C for failing to provide appropriate monitoring following a diagnosis of prostate cancer; failing to communicate appropriately; and handling his complaint unreasonably The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance |
Copy or record of apology By: 20 June 2018 |
We are asking the Board to improve the way they do things:
|
Complaint number |
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|---|
|
(a) |
The Board failed to provide appropriate monitoring following a diagnosis of prostate cancer | Prostate cancer patients on active surveillance should be properly and appropriately monitored |
Evidence of a review of current systems to monitor prostate cancer patients on active surveillance, which includes an assessment of the reliability and effectiveness of these systems and any improvements to be made as a result of the review Evidence that there has been a review of all prostate cancer patients on active surveillance to ensure they are being actively followed up By: 15 August 2018 |
| (a) | There was a failure to make adequate and timely arrangements for a scan which took Mr C’s needs into account | There should be a system in place to accommodate patients with special needs such as claustrophobia who are required to undergo scanning |
Evidence that a system has been put in place to make arrangements for patients with special needs such as claustrophobia to undergo scanning and that this system has been communicated to all the relevant staff By: 15 August 2018 |
| (b) | When Mr C was diagnosed with prostate cancer it was not communicated to him that he would need three monthly testing and scanning after six months | Patients on active surveillance for prostate cancer should have the follow-up requirements clearly explained to them |
Evidence that this has been considered and a system is in place to ensure that patients on active surveillance for prostate cancer have the follow-up requirements clearly explained to them By: 15 August 2018 |
| (b) | When Mr C was contacted regarding scanning, the information he was given did not answer his questions, nor was he fully informed of his options | Clear information should be given regarding options for scanning, and staff should make efforts to ensure they are answering all of a patient's questions |
Evidence that this has been fed back to the relevant staff in a supportive way that encourages learning By: 4 July 2018 |
| (c) |
Mr C’s complaint was handled unreasonably |
Complaints should be accurately logged and responded to in line with the complaints handling process |
Evidence that this has been fed back to the relevant staff in a supportive way that encourages learning
By: 4 July 2018 |
| (c) | Communication with Mr C during and after the complaint process was poor | Communication with complainants should be pro-active, and complainants' requests for contact should be returned |
Evidence of a review of the communication during and after the complaints process in this case, including an assessment of why staff failed to return Mr C's requests for contact and what action will be taken to avoid this recurring in the future By: 15 August 2018 |
Feedback
Points to note
The Board could consider raising awareness of their clinical staff about the current options of Healthcare in Europe for patients.
Summary
Mr C, who works for an advocacy and support agency, complained on behalf of Mr A about a number of issues relating to Mr A's discharge to a nursing home following an admission to Newton Stewart Hospital. First, Mr C complained about the length of time it took clinicians to tell Mr A that an operation to help with a complex medical condition was not going to be possible for him despite it being initially proposed. Had Mr A known that the operation would not be possible, Mr C said Mr A would not have allowed himself to be discharged to the nursing home. Instead, when Mr A was discharged, he believed that he would be able to return home after a short time in the nursing home following the operation. Second, Mr C said that Mr A had not been given the option to return home with a funded care package before being discharged to the nursing home. Third, Mr C said that board staff had failed to explain clearly to Mr A the financial repercussions of his discharge to the nursing home before discharge and then, given his mental health issues, unreasonably failed to arrange an advocate for him to help him throughout the discharge process. Finally, Mr C said that Mr A's time in the nursing home should be considered as NHS continuing care because he was waiting for an NHS funded operation.
We took independent advice from a consultant in care of the elderly and considered guidance on choosing a care home on discharge from hospital and on hospital-based complex care (ongoing hospital care) in place at the time of the complaint. We found that when Mr A was discharged, he did not need hospital care and so it was reasonable to discharge him given his clinical needs at the time. Given this, we also found that the board's decision not to pay the nursing home charges was made in line with the guidance on ongoing hospital care. In relation to the time it took the board to reach a decision about Mr A's operation, the advice we accepted was that the operation was specialist and complex and so it was reasonable for the decision to take as long as it did. However, we identified a number of significant failings about the way Mr A was discharged.
We found that the board failed to take all reasonable steps to ensure Mr A was in a position to make an informed decision about the move to a nursing home and that an opportunity for discharge home was missed. Staff failed to explore with Mr A the option of discharge home with a care package in a reasonable way, and failed to provide clear written information to Mr A about his discharge, particularly around the financial implications of the move. Staff also let Mr A retain an over-optimistic view about the potential of an NHS-funded operation to improve his health when clinicians considered this was unlikely. Finally, we found that the board should have offered advocacy services to Mr A given his mental health problems to support him during a complex and uncertain time with extremely significant implications.
We upheld two of Mr C's complaints and made a number of recommendations to address the issues identified.
Redress and Recommendations
What we are asking the Board to do for Mr A:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
|
(a) and (b) |
The Board failed to take all reasonable steps to ensure Mr A was in a position to make an informed decision about the move to a nursing home, in line with the guidance, and an opportunity for discharge home was missed |
Cover the costs of the nursing home fees Mr A has paid for the time he was in the nursing home on production of an invoice or receipt (or other evidence it was paid). The resulting payment should be made by the date indicated: if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment |
Evidence of payment By: 22 January 2018 |
|
(a) and (b) |
The Board failed to take all reasonable steps to ensure Mr A was in a position to make an informed decision about the move to a nursing home, in line with the guidance, and an opportunity for discharge home was missed |
Apologise to Mr A for failing to ensure he was discharged in a reasonable way and, in particular, in a position to make an informed decision about the move to a nursing home. The apology should comply with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance |
A copy or record of the apology By: 22 December 2017 |
We are asking the Board to improve the way they do things:
|
Complaint number |
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|---|
|
(a) and (b) |
Staff failed to follow elements of the guidance on choosing a care home on discharge from hospital and hospital-based complex clinical care to ensure Mr A was discharged in a reasonable way |
Staff should comply with the relevant guidance when arranging discharge |
Evidence the guidance has been raised with relevant staff, and that staff are complying with the terms of the guidance. This could be via an audit, undertaken regularly, to evidence compliance By: 22 January 2018 |
|
(a) and (b) |
Staff failed to provide clear written information in line with the hospital-based complex clinical care guidance about discharge to Mr A to ensure Mr A was discharged in a reasonable way |
Staff should ensure information is provided as part of the hospital based complex clinical care guidance |
Evidence that the process relating to the provision of information has been reviewed to ensure it complies with guidance By: 22 January 2018 |
|
(a) and (b) |
Staff failed to offer advocacy service to Mr A to ensure he was in a proper position to make an informed choice about his discharge |
Staff should ensure patients are offered advocacy services where appropriate |
Evidence Mr A's complaint has been raised with the staff responsible for advising advocate services in his case in a supportive way; and to staff involved in advising advocate services in cases such as this By: 22 December 2017 |
Summary
Ms C, a support and advocacy worker, complained on behalf of Ms B about the care and treatment provided to Ms B's son (Mr A) when he was admitted to Balfour Hospital (the hospital) following a road traffic accident. Ms C said that when Mr A arrived at the hospital his spine was not x-rayed despite him reporting pain in his back, and that when Mr A was later transferred to another hospital it was found that he had a spinal fracture. Ms C also complained that a wound to Mr A's leg was not cleaned appropriately and said this led to infections.
We took advice from an emergency consultant and an orthopaedic surgeon. We found multiple significant failings in the care and treatment provided to Mr A. These included a failure to examine and x-ray Mr A's spine; a failure to obtain
x-rays of Mr A's neck, chest and pelvis; a failure to assess and clean a wound in Mr A's arm in a timely manner; a failure to administer antibiotics in a timely manner; and a failure to administer appropriate pain medication. We also found that the treatment provided was not appropriately documented in the medical records. However, we determined that Mr A's leg wound was appropriately cleaned and therefore did not uphold this aspect of Ms C's complaint.
We had further concerns that the board's own investigation into Ms C's complaint failed to identify the serious clinical failings in this case and made recommendation regarding this.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Ms C:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
|
(a) |
The Board failed to provide Mr A with appropriate clinical treatment in view of his presenting symptoms |
Provide a written apology to Ms B and Mr A for failing to provide Mr A with appropriate clinical treatment in view of his presenting symptoms. This apology should be copied to Ms C |
Copy of written apology which complies with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance By: 27 September 2017 |
We are asking the Board to improve the way they do things:
|
Complaint number |
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|---|
|
(a) |
There were a number of significant failings in Mr A's care, including failure to:
|
The Board should provide a reasonable standard of trauma care, with adequate staff training and effective systems in place to support this |
Evidence that the Board have carried out a significant event review in to this case, with the findings made available to Mr A's family By: 22 November 2017 Evidence that the Board has reviewed their systems and staff training for the initial management of seriously injured patients (including review of the competencies and training for consultants who are expected to lead the assessment and resuscitation of patients with major trauma) By: 22 November 2017 |
|
(a) |
The Board's own investigation did not identify or address the serious failings in the care provided to Mr A |
The Board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement |
Evidence that the Board have reviewed why its own investigation into the complaint did not identify the failings highlighted in this report By: 25 October 2017 |
|
(a) & (b) |
There was a failure to appropriately document the treatment provided in the medical records |
All treatment should be appropriately documented in medical records |
Documentary evidence that this finding, and what action will be taken to ensure medical records are adequate in the future, has been shared and discussed with relevant staff. This could include, for example, minutes of discussion at a staff meeting or copies of internal memos, emails or notes of feedback given about this complaint By: 27 September 2017 |
Summary
Ms C complained on behalf of her son (Mr A) about the care and treatment he received following a road traffic accident. Ms C said Mr A had suffered a serious injury to his arm in the accident, which had required two operations. Following surgery, Mr A was transferred for a third operation to another NHS board.
Ms C said she was told following the third operation that Mr A's original surgery had not been properly performed and had had to be revised. She was told that the original surgery had damaged a nerve in Mr A's arm and that he had developed a life-threatening infection.
Following her complaint to the board, Ms C and her son met the board. Ms C said the board would not explain why Mr A's first operation had been incorrectly carried out. Ms C also believed that her son's infection had been caused by a failure to clean his wounds correctly and that the board should have identified this sooner.
We took independent medical advice from a consultant orthopaedic surgeon on the standard of care provided to Mr A. The adviser said that the board's position that Mr A's operations had been properly performed and his nerve left in the correct position was not logical. Mr A had as a consequence suffered further damage to his nerve. The adviser noted that Mr A's wounds were heavily contaminated and at high risk of infection. However, the cleaning of his wounds and provision of antibiotics to prevent infection were carried out to a reasonable standard. Overall, we found the board had failed to provide Mr A with a reasonable standard of care and treatment. We were highly critical of board's failure to acknowledge that Mr A's surgery had not been carried out correctly, resulting in damage to the nerve in his arm.
We also found that the board's handling of Ms C's complaint was inadequate as it did not properly acknowledge the failures in care, despite the board being aware of these at the time. We found that the board had failed to handle Ms C's complaint in an open and transparent manner and failed to address the concerns of the family properly.
Redress and Recommendations
The Ombudsman recommends that the Board:
- carry out a significant event analysis ensuring that Surgeon 1 reviews the findings of Operation 3; and
- provide evidence that Surgeon 1 has reflected on the failings identified in this report as part of their appraisal process;
- review their complaints investigation in light of the comments from the Aviser and provide Ms C with a full explanation for the findings of Operation 3; and
- review their handling of Ms C's complaint in order to identify areas for improvement and ensure compliance with the 'Can I help you' guidance.
- apologise unreservedly in writing to Ms C and Mr A for the failings identified in this report.