Annual Report 2007-08 - the Parliamentary and Health Service ...

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16Case StudyComplaint about cancertreatment was not properlyhandledIn 2000 Mrs S’s husband was diagnosed with prostate cancer andhad radical surgery. Although the surgery was performed privately,the majority of his pre- and post-operative care was provided bythe University Hospitals of Morecambe Bay NHS Trust (the Trust).Serious post-operative complications necessitated furtheroperations and a long stay in hospital. Mrs S considered that herhusband had been poorly advised about treatment options andshe complained to the Trust. An Independent Review Panel (thePanel) considered her complaint and made severalrecommendations, some of which related directly to the clinicalpractice of the Consultant Urologist responsible for Mr S’s care.Mrs S complained to the Ombudsman that the Trust had notdone more to resolve her complaint prior to the Panel, and hadfailed to inform her of the action it had taken, or planned to take,to implement the Panel’s recommendations.We upheld Mrs S’s complaint. She did not receive an adequateresponse to her complaint in a timely manner. The Trust did notoffer her a meeting to discuss her concerns, and failed to bring thelocal resolution phase of the NHS complaints procedure to an endto allow her to escalate her complaint. It also allowed all aspectsof Mrs S’s complaint to be investigated under the NHS complaintsprocedure, when it knew that some of her concerns about theConsultant’s practice needed to be reviewed through a differentprocess. The Trust failed to give Mrs S details of the action it hadtaken, or planned to take, to implement the Panel’srecommendations, or reassure her that it was taking appropriateaction to implement them. She was left feeling that she had noother recourse than to approach the Ombudsman and theGeneral Medical Council to resolve her complaint.The Trust agreed to apologise to Mrs S for the failings we hadidentified and to send her details of the action taken toimplement the Panel’s recommendations that did not relate to theConsultant’s personal practice. It also agreed to use the case as alearning opportunity to assist it when considering what parts ofa complaint should be investigated under the NHS complaintsprocedure, and to make a payment to Mrs S of £500 in recognitionof the worry and distress its poor complaint handling had caused.38
Parliamentary and health service ombudsman annual report 2007-08In the case of Mrs S, we found that thehospital where her husband was treatedfor prostate cancer failed to give anadequate and timely response to hercomplaint about his care. It also failedto inform her of the action it had takenin response to the recommendationsfrom an Independent Review Panel.A new approach to NHS complainthandlingThe Ombudsman has argued forimprovements in the NHS complaintsprocedure for many years and is pleasedto see the changes that will beintroduced from April 2009.Under the existing three stage system,the second stage is provided by thereview function of the HealthcareCommission, with a possible thirdstage when a case is referred to theOmbudsman. The new system will haveonly two stages: a complainant whoremains dissatisfied after a case has beenconsidered locally will be able to refer thecomplaint straight to the Ombudsman.These reforms should reduce delays forboth the complainant and the NHSservice provider, and deliver more timely,responsive and effective outcomes. Weare working closely with the HealthcareCommission to bring about a smoothtransition to the new system.A further objective of the new systemis to achieve greater alignment betweenthe NHS and the social care system.We are working closely with the LocalGovernment Ombudsmen to make surethat there is a fully integrated approachto complaints that cross boundariesbetween health and social care (seeInjustice in Residential Care, page 53).The new system will also enable patientswith complaints about primary careproviders (GPs, dentists, opticians andpharmacists) to complain directly to thePrimary Care Trust if they choose, ratherthan to the service provider. We knowthat for many patients, complaining toa practitioner with whom they have anexisting relationship can be difficult.The importance of local resolutionIn the short term we expect to seean increase in the number of enquirieswe receive and cases we accept forinvestigation under the new arrangements– and we are planning for that. In thelonger term we will want to see areduction in the number of complaintsreferred to us as a result of improvedcomplaint handling at local level.Complainants often comment to usabout the length of time it has takento get to the end of the existing NHScomplaints procedure. In many of thecases we investigate, delay is identifiedas a particular cause of complaint. It isnot uncommon for us to investigateevents that occurred two or three yearsago, because the cases have taken thatlong to reach the Ombudsman afterconsideration by the NHS.Our experience, supported by researchcommissioned by the Department ofHealth for its consultation paper MakingExperiences Count, makes clear thatcomplainants want their cases to beresolved quickly and close to source.Clearly, timely and effective localresolution of complaints should be theguiding principle for all bodies withinthe Ombudsman’s remit.39
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