We issue today a public interest report about a failure by Aneurin Bevan Health Board to offer fampridine, a drug that may help to improve walking for some patients with multiple sclerosis, to eligible patients in its area.

Summary

We launched an investigation after Mrs X complained that the Health Board failed to offer her treatment with fampridine after its approval for NHS use in Wales.

We found that although fampridine was approved by the Welsh Government as an NHS funded treatment in Wales in December 2019, Aneurin Bevan University Health Board had still not put in place arrangements to offer fampridine to Mrs X, or any eligible patients in its area.  

During our investigation, we found evidence that the Health Board had estimated that there may be around 500 patients in its area who may be eligible for this treatment. The Health Board said it had been unable to offer the drug due to a lack of resources. It said that a business case for introduction of the drug was being developed, including the need to recruit suitable staff to ensure the safe roll-out of fampridine treatment.

The Health Board said that it was not able to refer patients to other health boards nearby, as they already had waiting lists for accessing fampridine within their own areas.  Fampridine is not NHS funded in England, so the Health Board stated there was no possibility of seeking an agreement to refer patients there for treatment.  

Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:

“Newly approved medicines should be offered within 60 days of approval by the Welsh Government. It is therefore concerning that fampridine is not being offered to any of the eligible patients within the Health Board’s area.

Even if the Health Board’s own Pre-Investment Panel approves the funding immediately, the Health Board has estimated another 3 to 6 months to recruit staff.  This means that the earliest fampridine could be offered to patients is the middle of 2024.  This represents over 4 years since the approval of fampridine as an NHS-funded treatment in Wales.

This delay is unacceptable. It has caused and continues to cause injustice to Mrs X, and other patients, who remain unclear as to when or if they will have access to this potentially life improving medication.”

Recommendations

We recommended that the Health Board should apologise to Mrs X and that it should urgently establish an action plan, with timescales, for the provision of fampridine. We also asked the Health Board to share our report with the Board or relevant committee who should oversee and regularly review the action plan to ensure that good progress is made and that the actions are completed. 

Aneurin Bevan University Health Board accepted our findings and conclusions and agreed to implement these recommendations.

You can read the full version of the public interest report into Aneurin Bevan University Health Board (202301069) here.

15/02/2024

Uncategorised |

The Local Government and Social Care Ombudsman (LGSCO) and the Housing Ombudsman Service (HOS) have launched their aligned Complaint Handling Codes which will result in better services to the public and make good practice in complaint handling clearer for local authorities and landlords.

They are launched on the day the LGSCO celebrates 50 years of remedying injustice, with 8th February marking the start of the Local Government Act 1974, which created a Commission to investigate administrative actions of local authorities.

The Complaint Handling Codes are an update of the existing Housing Ombudsman Code and the Local Government and Social Care Ombudsman’s Good Practice Guidance. They make good complaint handling easier for local authorities and landlords, while setting clear expectations for the public.

Both organisations consulted on a single Code in November 2023 which saw more than 150 councils, 250 landlords and 360 members of the public respond. In response to the consultation, and to recognise the different legal powers the organisations hold, they have produced two closely aligned Codes for complaint handling – one for council services outside of housing and one for landlords and housing authorities.

The Codes are based on unified principles and share many of the same approaches in key areas like response times. This approach follows that of the Scottish and Northern Irish Public Services Ombudsmen who have model procedures for different services under a set of unified principles.

Ms Amerdeep Somal, Local Government and Social Care Ombudsman, said:

“The Complaint Handling Codes mark an important step in improving standards and helping to give complaints management the priority status it deserves as part of local service delivery.

“We appreciate the feedback from the consultation and have come to a position of two individual codes that have a unified approach but recognise the different contexts in which our Ombudsman schemes work.

“50 years and still innovating! The LGSCO has a rich history of holding public services to account and helping to make things better for people using them. But by setting out clear advice and guidance, for the first time, on having an effective complaints process, it proves we are not resting on our laurels.”

Richard Blakeway, Housing Ombudsman, said:

“Our statutory Code promotes a positive complaints culture across the social housing sector and ensures residents do not experience a postcode lottery in complaint handling.

“We welcome the positive engagement with the Code and its aims during our consultation, and it is crucial this is translated into action on the ground. It is essential for landlords prepare for the statutory Code and this includes a robust self-assessment being submitted to the Housing Ombudsman.

“Landlords should see the release of this Code as an opportunity to reflect on their complaint handling and to make improvements where necessary to deliver better services to residents.”

The update to the Housing Ombudsman’s Code will be statutory and apply from 1 April. The Local Government and Social Care Ombudsman’s Code has today launched with information to support councils who want to be early adopters.

In 2024 LGSCO will invite a group of pilot local authorities to develop a good practice guide which will support councils to implement the Code. Councils should start to adopt the Code soon after this, if they haven’t already done so, and once it has incorporated learning from the local authority pilots, LGSCO will start considering use of the Code as part of its investigation processes.

Article date: 08 February 2024

The Times Health Commission has today published a report into the state of health and social care in Britain. The report identifies failings within the NHS and suggests how to reform and improve the service.

It includes recommendations from professionals across the industry, with Ombudsman Rob Behrens explaining how the culture of the NHS should be improved to prevent patient safety being put at risk.

Commenting on the publication of the report, Ombudsman Rob Behrens said:

"The final report of the Times Health Commission presents a stark but depressingly familiar portrait of a health system under strain amid growing workforce pressures. Once again, we see evidence of the human cost of delivering care in increasingly difficult circumstances for patients, families, carers and staff themselves.

I welcome the recommendations made by the Commission. The move away from highly adversarial clinical negligence practices echoes calls I made last year in our report about avoidable deaths, ‘Broken trust: making patient safety more than just a promise’. This is essential to bridge the gap between patient safety ambition and the current state of play on the challenging NHS frontline.

The recommendation to give my Office powers to investigate issues without the need for people to complain about them is also very welcome. I have long called for these powers as a way of creating a fairer system that enables us to intervene early on critical issues such as failings in mental health services. We know that people who live in challenging circumstances, such as those living in long-term inpatient mental health care, are very unlikely to bring complaints to the Ombudsman. But without these powers we cannot investigate potential issues before they become a crisis.

The golden thread running through this report is, once again, the need for honesty, transparency and compassion across the board, from those delivering care to policy makers and health leaders. Cultures of blame and cover-ups cost lives. Never has the importance of learning from mistakes at all levels been so pivotal to the future of the NHS."

Ensuring children’s rights and needs are met by public service complaints procedures in Scotland

January 2024 -  Consultation on Draft Child Friendly Complaints Handling Principles

Our consultation on the draft Child Friendly Complaints Handling Principles (PDF, 125KB) is now open, and we are accepting responses until 1 March 2024. The purpose of this consultation is to gather responses on the current drafts, to ensure they are clearly communicated and easy to understand. This consultation is also a legal requirement, as we will be looking to amend our Statement of Principles to include the Child Friendly Complaints Handling Principles in the next few months, following parliamentary approval. 

The consultation is open to all, but we are particularly looking for responses from:

• Anyone under 18
• Anyone with caring responsibilities for someone under 18
• Public services and third sector organisations who work with people under 18 or have an interest in promoting their rights 

The consultation questionnaire only takes about 10 minutes to complete. It can be found here: Consultation on Child Friendly Complaints Handling Principles

June 2023 - Pilot of Draft Child Friendly Complaints Guidance

Following an extensive co-design project with a wide range of children, young people, and other stakeholders, we have now launched a pilot of a draft version of the new approach to handling complaints involving children. This consists of two key guidance documents - the Child Friendly Complaints Handling Principles, and a Child Friendly Complaints Handling Procedure.

The purpose of the pilot is to test the new approach in a real world setting, to ensure it achieves the goal of meeting children's rights and needs, and to identify any changes required or improvements that may be beneficial. The pilot is open to any public body under our jurisdiction, to trial and test the new process at a scope and scale that they feel is appropriate and manageable, with the SPSO available to support that implementation and answer any questions that may arise during the handling of a complaint.

If your organisation would like to learn more about the draft guidance, or would like to take part in the pilot, please contact us at ISE-CSA@spso.gov.scot and we will be happy to help.

December 2022

The SPSO is currently working on a new approach to handling complaints that involve children. We are doing this by working with children & young people from a range of backgrounds, and from across Scotland, to co-design this new approach and ensure it is a system fit for purpose. We have also enlisted the help of a wide range of parents, advocates, and professionals that work with children in the public sector, to test and refine the approach and ensure it will work in a practical setting. We would like to extend our sincere gratitude and thanks to everyone who has helped us in this work so far.

We now have a first draft of a guide that will ultimately be implemented by all public bodies under our remit. This guide will set out how existing complaints processes can be adapted when a child or young person is involved. It will aim to ensure that their rights under the UNCRC are met throughout the complaints process and that their concerns are handled in a way that they have told us meets their needs.

We had initially planned to carry out a public consultation around now, aiming towards publishing the guide under our model complaints powers and requiring all relevant public bodies to have their own version in place by 1 April 2023. Following feedback from our engagement and testing work, we have decided to carry out a more targeted pilot first.

The pilot will focus on key services provided to children and young people, such as schools, social work services, and children’s health services. The aim of this work will be to test the new approach in practical settings, both to ensure it results in the right outcomes for children, and that it is efficient, practical and workable for the public sector bodies managing the process.

We will still hold a full public consultation before publication of the final guidance, but this will now take place after the pilots are complete and any changes made. We are still in the process of refining the pilot, and will provide further updates on the timeline and launch when we have definite dates. We will also be aiming to share further details of the approach before the 1 April 2023, so that all relevant bodies, including those not involved in the pilot, will have a better understanding of what to expect.

If your organisation would like to be involved, or you would like further information about what your involvement might entail, please contact us at CSA@spso.gov.scot and we will do our best to help.

July 2022

The SPSO is being funded by the Scottish Government to develop a child-friendly way for public bodies to handle complaints. On 25 April 2022 we launched our two-year project to develop and implement new guidance for the public bodies we work with.

Children and young people are users of a wide range of Scottish public services, including schools, children and families social work, and health visitor services. Many of these focus on wellbeing, health and development. Children have the right to complain if they are unhappy with those services.

We are developing guidance that will cover complaints about public services:

• made by children and young people themselves
• made on behalf of children and young people with their permission (e.g. by their parents, carers or third-party advocates), and
• concerning children and young people (e.g. made by their parents, carers or third-party advocates without permission or input from children and young people).

Project aim

Co-design and implement a public sector complaints service that meets children’s rights and needs, working in co-operation with children and young people, public bodies and wider stakeholders

It is important that complaints handling processes both enable children and young people to exercise their rights, and ensure those handling complaints hear and respect children and young peoples’ views and voices. Taking a co-design approach that hears those voices from the outset will help ensure young people have a real impact in shaping the new guidance.

Timescales

We will be running design workshops with a wide range of people over the next few months.  If you would like to take part in our workshops, or if you have any questions about the project, please contact us by emailing CSA@spso.gov.scot.  

Downloads

• Child Friendly Complaints update June 2023 (PDF, 150KB ) 
• Child Friendly Complaints update December 2022 (PDF, 91KB)
  • Child Friendly Complaints announcement July 2022 (PDF, 215KB)

The safety of mental health patients is being put at risk when they leave inpatient services, leading to a continuous revolving door of care and discharge, England’s Health Ombudsman has warned.

In a new report that examines issues in transferring people with poor mental health out of inpatient and emergency care, the Ombudsman has called on the Government to take urgent action, including strengthening and bringing forward reforms to the Mental Health Act.

The Ombudsman found a range of issues such as

• families not being updated or informed about a patient’s discharge from hospital care
• poor record keeping
• lack of communication and joint working between the multiple teams caring for a patient
• failings in assessing requests to leave hospital.

This can lead to poorer outcomes for that patient, including increased risk of suicide. Without proper support in the community, people can become stuck in a revolving door in and out of inpatient services.

The report comes after the Parliamentary and Health Service Ombudsman (PHSO) analysed over 100 cases involving people with a mental health condition and failures in their care.

It highlights six cases involving failures in the planning, communication, or care of a person with a mental health condition being transferred from inpatient services or emergency departments back into the community.

In 2018, PHSO published Maintaining Momentum: driving improvements in mental health care, which highlighted a range of issues around mental health care including inappropriate transfers and aftercare. Six years on, and the same failings around transfers and aftercare are still happening, putting patients at risk.

Ombudsman Rob Behrens said:

“The overwhelming majority of professionals in mental health services are hard-working and demonstrate their commitment and care on a daily basis. However, the stories in our report show the human tragedies that happen when mistakes are made and how important it is for people to speak up and make complaints so that they don’t happen again.

“Delaying the transfer of someone out of hospital can cause harm, but so can inappropriately discharging people too soon. Too often, the focus is on transferring patients out of inpatient services quickly. No doubt this is at least partly due to the huge strain the NHS and mental health services are under. But the priority must always be patient safety. We know that unsafe transfers can have devastating consequences, such as patients being stuck in a re-admission cycle and, tragically, suicide.

“We need to see a holistic, joined-up, person-centred approach. Crucially, patients, their families and carers must be listened to and involved with decision-making.

“Mental health patients are among the most vulnerable in our society and I urge the Government to act on the recommendations in this report to keep them safe and prevent these same failures from happening again. The lack of progress on the Mental Health Act is deeply disappointing, we must see that strengthened and prioritised.”

The report shares the story of 22-year-old Tyler Robertson, an electrician from Hebburn.

Tyler was experiencing low mood and had expressed suicidal thoughts to his family. He later told the police about his suicidal thoughts and was taken to an emergency department within the South Tyneside and Sunderland NHS Foundation Trust.

Tyler was discharged that same day, but his family and carers were not involved in the discussion. A risk assessment was carried out by a team from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, but the Ombudsman found that the clinicians should have actively approached the family for information and the level of risk may have been different had the family been consulted.

Tyler was also asked by that team to self-refer and given information for support organisations, but the contact details were out of date and while he tried to call, he could not get in touch with most of them. Guidance says staff should have initiated contact with the support groups on his behalf.

Sadly, Tyler killed himself in July 2020, less than six weeks after leaving the hospital. The Ombudsman could not say that the failings directly led to his death, but the uncertainty around this is an injustice to his family.

Those involved in the care of Tyler have complied with the Ombudsman’s recommendations which included apologising to his family, acknowledging their failings and creating an action plan to prevent this from happening again.

Tyler’s mum Nicola, 43, described her son as outgoing and bubbly, a gym-enthusiast who loved going on holidays. Following his death, Nicola set up Suicide Affects Families and Friends Everywhere (SAFFE), a support group for people who have lost someone to suicide.

Nicola said:

“Tyler was the class clown at school and in public he was always laughing, but it was just a mask. At home, we saw his struggles. He had never been diagnosed with a mental illness, but he had problems with his mental health from a very young age where he was either very happy or very down.

“Losing Tyler was devastating. You just don’t expect to lose your kids. It feels as if we don’t live now, we’re just existing. If he had got the right help, he might still have taken his life, but he might not have, and the not-knowing is awful.

“People say time makes it easier, but I don’t think it does. The longer I don’t have him, the more I miss him. Nothing will bring Tyler back, but I would like to think that sharing his story could stop this from happening again or at least help another family in the same situation.”

The Ombudsman has urged the Government to take action by strengthening the bill for a Mental Health Act and prioritise pushing it through Parliament.

He also made several other recommendations including requiring a follow-up check within 72 hours for people discharged from emergency departments, and that the views of patients and their support network are listened to and actively taken into consideration when planning transitions of care.

Lucy Schonegevel, Director of Policy and Practice, Rethink Mental Illness, said:

“Someone being discharged from a mental health service, potentially into unsafe housing, financial insecurity or distanced from family and friends, is likely to face the prospect with anxiety and a sense of dread rather than positivity. Mistakes or oversights during this process can have devastating consequences.

“This report puts a welcome spotlight on how services can improve the support they offer people going through the transition back into the community, by improving communication and the ways in which different teams work together to provide essential care.

“Learning from the lived experience of people severely affected by mental illness and their carers is key, but we also need Government to deliver on its commitment to bolster the workforce so staff are less stretched, and bring forward long-overdue reform of the Mental Health Act to improve the standard of care offered to people when they’re at their most unwell and vulnerable.”