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

17Case StudyTrust failed to update amputeeson service improvementsMany of the cases we investigated in2007-08 illustrated serious failings atlocal level. In the case of Mrs Y acomplaint about the prosthetic serviceprovided to amputees by her PrimaryCare Trust was upheld by an IndependentReview Panel. The Trust agreed to makeseveral changes to its procedures, butthen failed to keep Mrs Y informed abouttheir implementation.The need for local leadershipImproved local resolution of NHScomplaints will not come about withoutstrong leadership at a senior level in Trustsand General Practices. Board members,chief executives and senior practitionersneed to create a culture that welcomescomplaints and actively seeks to resolvethem, dealing with people fairly and beingwilling to learn from mistakes and servicefailures. Many of the cases of poorcomplaint handling that we investigateshow why this strong, focused localleadership is so necessary to driveimprovements. In each of these cases,strong local leadership, a culture ofopenness towards complaints and adetermination to put things right couldhave prevented distress to those involved.In the case of Mrs G we recommendedcompensation by the Trust and theHealthcare Commission following thepoor handling of a complaint about thecare and treatment of her daughter, whodied after surgery. We found that theTrust’s response to the Commission’srecommendations was inadequate, andthat its actions had caused Mrs G tosuffer further distress.Mrs Y, an amputee, was concerned about the prosthetic serviceprovided on the Isle of Wight, to the extent that she felt her carehad been seriously compromised. Her concerns included a lack ofprosthetic expertise, the lack of a consultant-led multidisciplinaryteam, and the availability of information, protocols or guidelinesaround treatment options. She made a complaint to the Isle ofWight Primary Care Trust (the Trust), which ended with anIndependent Review Panel in January 2005. The Panel found thatMrs Y’s complaint was justified and made several recommendationswhich the Trust agreed to implement. The Trust told Mrs Y thatit was committed to implementing the recommendations. It alsocarried out a Prosthetic Services Review.Mrs Y complained to the Ombudsman that although shehad contacted the Trust on a number of occasions, it had notadequately communicated with her about how it wouldimplement the Panel’s recommendations, and had given her noofficial reassurances that appropriate changes to the servicewould be made. She hoped that her complaint would lead toimprovements for amputees with complex needs living on theIsle of Wight.We fully upheld Mrs Y’s complaint. The Trust accepted it hadnot kept Mrs Y formally informed and updated about theimplementation of the Panel’s recommendations. Furthermore,Mrs Y’s complaint to the Trust had been made personally, andthe Trust had wrongly assumed that she had been kept updatedabout progress by the Artificial Limb User Group.The Trust gave us a copy of the Prosthetic Services Review reportand the Prosthetics Action Plan, which our advisers consideredcontained useful recommendations. The Trust also acknowledgedthe need to commission specialist mainland services for complexcases, such as that of Mrs Y, and told us that a meeting had beenheld with the staff of a specialist centre in Bournemouth.Arrangements for Mrs Y to be seen there were also progressing.The Trust agreed to apologise to Mrs Y for the failings we hadidentified, and to arrange a meeting with her to address anyremaining concerns that she had.We also investigated the case of Dr R,a GP who retired on health groundsafter a poorly handled investigation bytwo Trusts of a complaint against her.We recommended substantial financialcompensation by way of remedy, andshe received a total of £25,000.40