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Ombudsman says NHS bosses 'not responding properly' to errors

Published 22/10/2015

The majority of the complaints related to NHS trusts
The majority of the complaints related to NHS trusts

Serious errors by NHS hospitals - including a woman left with "unrelenting" facial pain for 12 years and a father who died of blood poisoning - have been published in a review by the Parliamentary and Health Service Ombudsman (PHSO).

The PHSO said too many people suffered a "devastating impact" because NHS and other bosses did not respond properly when things went wrong.

The report is a snapshot of 192 case summaries of the 1,075 investigations that were all concluded by PHSO in February or March this year.

Most cases - 116 - involved the NHS, with UK Visas and Immigration (UKVI), the Children and Family Court Advisory and Support Service (Cafcass) and HM Courts and Tribunals Service also the subject of investigations.

One example involved the Isle of Wight NHS Trust and a patient referred to as Mrs L. She first complained of "severe and unrelenting" facial pain in 1997, but was repeatedly refused an MRI scan until 2012. The MRI identified the source of the problem and she received surgery which ended the pain.

The Ombudsman found the trust's actions "contributed to Ms L's unnecessary suffering during that period" and secured an apology and a payment of £750 compensation.

In another case, involving Newcastle Upon Tyne Hospitals NHS Foundation Trust, a man suffering a painful lump on his buttock was sent home with antibiotics but within three weeks was back with pain in his foot.

Doctors found the initial infection had spread and he died from blood poisoning two days later.

His daughter disputed the trust's claim that the two admissions were unrelated and took the case to the PHSO which found the "lack of appropriate treatment when he was first in hospital compromised his chances of survival".

The trust apologised to the daughter and paid her £2,000 compensation.

At the South Lincolnshire Clinical Commissioning Group (CCG), health bosses claimed they were responsible for only a portion of a pensioner's care home costs and invoiced his daughter for £102,000. The CCG was forced to refund these costs by the PHSO and has promised to pay for the man's continuing care.

In another case, Sheffield Children's NHS Foundation Trust was forced to pay £500 in compensation to a couple after it told them that if they used a herbal cream on their son's eczema instead of prescribed drugs, they would regard it as a " safeguarding issue".

Ms P and Mr Q's son was under the care of a consultant dermatologist, who said the unpreserved herbal cream was more likely to become contaminated with bacteria and cause infection.

He told the couple that if their son became ill again and they refused to follow medical advice, it would be a child protection issue. In another case, a woman who fractured her ankle paid for a private appointment after her own NHS trust told to put her feet up and gave her an appointment for two months' time.

If she had followed the NHS advice, she would have lost the use of her ankle. Following the PHSO's investigation, Milton Keynes Hospital NHS Foundation Trust reimbursed the woman the £323.50 she paid for the private appointment.

In a further case, a man who had taken an overdose committed suicide shortly after being discharged from Great Western Hospitals NHS Foundation Trust.

Avon and Wiltshire Mental Health Partnership NHS Trust had said he was not at risk of self-harm and did not give him information about how to get help if he suffered another crisis.

The PHSO report also detailed how the Passport Office put the wrong photographs in two passports and then failed to give a full apology and explanation to the father after he complained.

A refugee also suffered an unnecessary three-year delay on his asylum claim after he went to his home country temporarily to attend the funerals of family members who had died suddenly.

Ombudsman Julie Mellor said: "In many of the complaints we see, the organisation complained about has done the right thing to put things right. But too many people aren't getting the answers to what went wrong from the organisation they complained about.

"Complaints alert people to where problems are and should be welcomed by all levels of the organisation from the frontline to the board, so that much-needed improvements are made."

Anna Bradley, chair of Healthwatch England, said: "The Ombudsman's findings are worrying, but sadly not surprising. Our research shows that three in five people who complain about health and social care services feel their complaints are not properly addressed.

"While it's encouraging that many organisations are taking action on complaints to put things right, too many are still failing to do so, meaning patients are left in the dark for too long and mistakes aren't learned from."

Richard Lloyd, executive director of consumer group Which?, said: "It's shocking to see complaints not being resolved, particularly when our research shows people are reluctant to complain because they don't feel confident that action will be taken.

"The Government needs to reform the broken complaints system in public services to prevent serious failings."

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