We have today published a report into complaints concerning events that took place at University Hospitals of Morecambe Bay NHS Foundation Trust.  Our investigations were not into the care of the baby, but about the handling of complaints following this avoidable death.  The report has been published on our website and you can view it on the following link http://www.ombudsman.org.uk/reports-and-consultations/reports/health/four-investigation-reports-concerning-the-university-hospitals-of-morecambe-bay-nhs-foundation-trust

Our investigations found that the hospital did not answer the family’s questions openly and honestly and did not learn from what it found.  This is particularly unacceptable when an avoidable death was the cause of the complaints.  The fact that the early records were missing compounded the problem.  The complaints demonstrate that a lack of openness by the Trust and the quality of their investigations of these complaints caused a loss of trust and further pain for the family.

The results of these investigations reinforce the need for change in hospitals.  Cultural change is needed from the ward to the board.  Strong leadership is necessary to encourage openness and learning and must start with definitive action by hospital boards.  Our report ‘Designing Good Together’, published in 2013, set out what must change in hospital complaint handling, highlighting the need to overcome the defensive response of hospitals to complaints.

When serious untoward incidents happen there needs to be an independent investigation, which looks at the root cause of the complaint and the role of human factors.  We expect all service providers to adopt this approach to help them understand why mistakes happen and help improve services for everyone.

In 2010 my predecessor declined to investigate the Father’s first complaint.  In light of new evidence from the coroner’s inquest, we later accepted for investigation the elements of this original complaint that were still outstanding.  Although the decision made at the time, not to investigate, was lawful, with the benefit of feedback from the complainant and others, it is not a decision we would make today.  We recognise that had we investigated, this family might have had answers to some of their questions regarding what happened to their baby sooner than they did.  We are sorry for the impact that has had on the Father and his family.

Feedback from complainants has had a profound impact on our service.  We changed our criteria for investigating complaints last year and since February 2013 we have begun our consideration of any complaint about a death of a loved one that could have potentially been avoided with the presumption that it will be investigated.   

We have further changed our approach so that we can give more people our service and are now seeing the impact of this change - by December 2013, we had already completed four times more investigations than the previous year, 1,046 investigations, compared with 249.  Our vision is for complaints to make a difference and to help improve public services for everyone.

Yours sincerely,

Dame Julie Mellor, DBE

Parliamentary and Health Service Ombudsman