A new report finds that too many people who complain to the NHS are not getting the answers they deserve when things go wrong.
This snapshot of investigations by the Parliamentary and Health Service Ombudsman shows the devastating consequences families suffer when complaints are not resolved locally.
The 133 cases in the report were investigated between July and September 2015 and include 93 complaints about the NHS.
Incidents of avoidable death, delayed cancer diagnosis, mistreatment of patients with mental health problems and poor end of life care are among the upheld NHS complaints in the report.
These are the cases which provide clear and valuable lessons for public services by showing what needs to change to help avoid the same mistake happening again.
In one case, an NHS trust had missed opportunities to prevent a woman committing suicide after she was discharged from hospital despite a history of depression and previous attempts to take her own life. The trust also failed to apologise properly or learn from its mistakes when the woman’s family complained.
The report also details the case of a pregnant woman who lost her baby in the latter stages of pregnancy after a trust had failed to carry out a scan that could have diagnosed the problem and probably saving the baby’s life. She was treated with a lack of care and compassion during the subsequent delivery of her stillborn child, according to the report.
Parliamentary and Health Service Ombudsman Julie Mellor said: “The NHS provides excellent care for patients every day, which is why it is so important that when mistakes are made they are dealt with well.
“These cases bring home all the suffering patients and their families experience when things go wrong, particularly when complaints are not handled effectively at a local level. Families have been left without an explanation as to why their loved ones died, mistakes have not been admitted, which means that much needed service improvements are being delayed.
“We are sharing these cases to help the NHS and other public sector organisations recognise and value the importance of complaints in helping to improve services.”
The Ombudsman investigates approximately 4,000 complaints a year and upholds around 37%. When it upholds complaints it makes recommendations for the organisation to put things right if they have not done so already. Most of the summaries published are of complaints upheld or partly upheld.
Another investigation found that a woman had died an avoidable death after two GPs failed to diagnose and treat her correctly after she had developed deep vein thrombosis. She was admitted to hospital nine days later then died. The trust delayed responding to her husband’s complaint.
In another case, a two year old child with Down’s syndrome and leukaemia was admitted to hospital for chemotherapy but was then given anaesthetic for a follow up operation even though he had an infection. The child subsequently died. The Ombudsman found that the doctor should have known it was a risk to operate on the child in his condition.
The report includes 40 complaints about other public bodies such as the Home Office’s border law enforcement, Border Force; the organisation that represents children in court cases, Cafcass; the Job Centre and Her Majesty’s Courts and Tribunal Service (HMCTS). Delays, poor decisions and complaint handling were common findings in all the cases in the report.
Phil McCarvill, Deputy Director of Policy, NHS Confederation, said: “More than ever before, the NHS is actively encouraging those who use services and its own staff to come forward with any concerns about patient care – and it does listen. It is essential that we continue to learn from these incidents and improve care for all those who use the NHS. When things do go wrong it is crucial that the family receives an apology, an explanation and a clear understanding of what lessons have been learned.”
Read the full report.