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

Parliamentary and health service ombudsman annual report 2007-0818Case StudyInadequate responseto recommendationsMs G was 42 when she had a stroke in February 2002 and wasadmitted to hospital. She had a pulmonary embolus (a blood cloton the lung) and was prescribed Warfarin (an anticoagulating drug)which was stopped after six months. Tests were carried out todetermine her blood clotting levels and to search for a patentforamen ovale (a hole in the heart).After review as an out-patient, Ms G was discharged from carebut was readmitted in August 2002 and was found to haveanother pulmonary embolus. She was referred for an MRI scanwhich was due to take place in March 2003 but, before thishappened, she moved house. She was subsequently diagnosedelsewhere as having pulmonary hypertension and a large patentforamen ovale. She was transferred to Papworth Hospital fortreatment but died shortly afterwards.Ms G’s mother, Mrs G, complained in November 2003 about thefailure to diagnose pulmonary hypertension at an earlier stage.Mrs G had a meeting with Trust staff in April 2004, but this failedto resolve matters. In September 2004 Mrs G complained to theHealthcare Commission, which took clinical advice from aConsultant Cardiologist, who found a number of failings in thecare provided to Ms G.In April 2006 Mrs G again complained to the Commission, whichsaid that the Trust had complied with most of its recommendations,but asked it to respond on the issue of the review of guidelinesfor management of pulmonary embolism. The Trust sent a furtherreply to Mrs G in June 2006 which made no acknowledgementor apology for the failings identified by the Commission.Mrs G complained to the Ombudsman in September 2006.The complaints investigated by the Ombudsman were thatthe Trust had failed to respond adequately to the Commission’srecommendations following its investigation, and the Commissionhad refused to take any further action despite that failing bythe Trust.We found that the Commission had carried out an appropriateinitial review of Mrs G’s complaint, but that the Trust’s responseto the Commission’s recommendations was inadequate. TheCommission had failed to properly consider Mrs G’s subsequentcomplaint about the Trust’s response. The Trust’s actions hadcaused Mrs G to suffer distress and delay in receiving theexplanation and response to which she was entitled.As a result of the Ombudsman’s recommendations, the Trustmade a payment of £500 to Mrs G in the light of the seriousfailings in its complaint handling and to recognise the additionaldistress caused to Mrs G following the Commission’s review.It acknowledged and apologised for the failure of care towardsMs G. It also acknowledged other failings in the conduct of thecase and offered explanations for these. The Commission wroteto Mrs G to apologise for the failings identified by our report.41