Nearly three quarters of hospital investigations into complaints about avoidable harm and death claimed there were no failings in the care given, despite the Parliamentary and Health Service Ombudsman's investigations of the same incidents uncovering serious failings.

The wide-ranging review of the quality of NHS investigations into complaints about avoidable harm or death by the Parliamentary and Health Service Ombudsman, found that inadequate hospital investigations are leaving distraught patients and families without answers and delaying much-needed service improvements.

The report published today reveals that hospitals are not investigating serious incidents properly because they often do not gather enough evidence, use inconsistent methods and do not look at the evidence closely enough to find out what went wrong and why.

The Parliamentary and Health Service Ombudsman, which investigates complaints which have failed to be resolved by the NHS locally, launched the review because it found a wide variation in the quality of investigations carried out by the NHS into complaints about avoidable death and harm.

The review reveals that some investigations carried out by the NHS into complaints about avoidable harm and death are not being carried out by someone sufficiently removed from the incidents complained about.

Only half (52%) of the investigations about avoidable harm and death carried out by the NHS where a clinician reviewed what had happened, used a clinician who was independent of the events complained about, the review uncovered.

The review was based on interviews with hospital staff, a survey of NHS complaint managers and a review of the unresolved NHS complaints brought to the Parliamentary and Health Service Ombudsman. It found that:

• Nearly three quarters (73%) of cases where the Parliamentary and Health Service Ombudsman found clear failings, hospitals claimed in their earlier investigations of the same incident that they hadn't found any failings.
• Hospitals failed to class more than two thirds (20 of 28) of avoidable harm cases as serious incidents, meaning that they were not properly investigated.
• A fifth (19%) of NHS investigations were missing crucial evidence such as medical records, statements, and interviews.
• More than a third (36%) of the NHS investigations which recorded failings did not find out why they had happened, despite more than 90% (91%) of NHS complaint managers claiming that they are confident they could find out answers.

As a result, people often have no choice but to bring their complaints to the Parliamentary and Health Service Ombudsman to try to get answers about what happened to them or a loved one and so that hospitals acknowledge the distress caused and demonstrate that they have learnt lessons and improved the service.

Parliamentary and Health Service Ombudsman Julie Mellor said:

'Parents and families are being met with a wall of silence from the NHS when they seek answers as to why their loved one died or was harmed.

'Our review found that NHS investigations into complaints about avoidable death and harm are simply not good enough. They are not consistent, reliable or transparent, which means that too many people are being forced to bring their complaint to us to get it resolved. 

'We want the NHS to introduce an accredited training programme for staff carrying out these investigations as well as guidance on how they should be done, so the public can be confident that when someone is needlessly harmed it has been thoroughly investigated and answers provided, so that action can be taken to prevent the same mistakes from happening again.'

Cases highlighted in the report include:

• The parents of a baby girl, who was left with permanent brain damage due to errors with a blood transfusion, had to wait three years to find out what happened to their child. The Parliamentary and Health Service Ombudsman found that the NHS's investigation was carried out by a close colleague of the paediatrician in charge the day the mistake happened.
• In another case a young mother had her life cut short because of serious failings by a hospital trust to carry out tests to diagnose breast cancer and begin treatment. The Parliamentary and Health Service Ombudsman's investigation found that the trust failed to fully investigate the case and did not acknowledge the extent of the failings or the impact on the patient.

• The death of a 36-old-man, who was not diagnosed with a heart condition when he went to A&E with sudden, severe, chest pains, could have been avoided. The Parliamentary and Health Service Ombudsman's investigation found that the hospital trust repeatedly failed to give his parents answers before claiming to his parents that they were unable to provide answers.

The review found that even when a hospital trust finds failings in the care provided as a result of a complaint, it does not always take action to prevent the same mistakes happening again.

The hospital visits and survey of NHS managers found that frontline staff do not understand the important of learning from investigations because discussions about what improvements should be made are trapped at meetings with senior managers, who then fail to discuss them with those who provide the care.

When ombudsman staff spoke to hospital staff, they did not find any consistency about the level of training of NHS investigators. Some hospitals had a list of trained investigators while others did not use trained investigators but said that incidents were investigated by 'the appropriate person'. 

Complaints about potential avoidable death make up around 20% of the NHS complaints the Parliamentary and Health Service Ombudsman investigates. Since 1 January 2015 to 1 December 2015 it investigated 536 cases about potentially avoidable deaths and upheld around half of these, a total of 264. Overall for health cases it upholds around 40% of complaints.

Kiel (SHL) – Immer öfter haben Bürgerinnen und Bürger Probleme, die Sprache ihrer Sozialbehörden zu verstehen. Insbesondere der Schriftverkehr wird durch zusammengesetzte Fachwörter, verschachtelte Sätze oder unvollständige Begründungen sowie fehlende Erklärungen unnötig verkompliziert. Die Bürgerbeauftragte für soziale Angelegenheiten Samiah El Samadoni und der Landesvorsitzende des SoVD Schleswig-Holsteins Wolfgang Schneider haben daher mit der heutigen Fachtagung einen ersten Anstoß gegeben, um im Dialog mit den Sozialbehörden Verbesserungen zu erzielen.

Ombudsman News 48/2015

The Parliamentary Ombudsman and the Commissioner for Health welcome this new development

Last August, in line with the provisions of the Ombudsman Act, the Parliamentary Ombudsman, Chief Justice Emeritus Joseph Said Pullicino asked the Speaker of the House of Representatives, the Hon. Anglu Farrugia to refer a report on complaints regarding medicines for the treatment of Hepatitis C, to the House Health Committee. Despite earlier lengthy correspondence, the Department of Health was not in agreement with the Ombudsman’s recommendation presumably for financial reasons, to provide treatment to patients suffering from Hepatitis C.  The Ombudsman and the Commissioner for Health considered such failure to be in breach of the Social Security Act.

While not all the patients who have been diagnosed with Hepatitis C especially alcoholics and those who abuse drugs may not be eligible for the newly available treatment (Harvoni Regime and Rebavirin) unless they are free from their habit for quite some time, there are however a number of other patients who would benefit greatly from this new treatment which is declared to cure as much as 95% of the patients.

This Office continued to be in touch with the Department of Health and last Monday the Ombudsman and the Commissioner for Health, Mr Charles Messina had a meeting with Hon. Chris Fearne, Parliamentary Secretary for Health.  Hon. Fearne informed the Ombudsman that the new treatment has been approved and the medicines will be procured, so that those cases who fall within  specific criteria and as a result are declared urgent would be given this treatment which costs approximately €75,000 per patient, free of charge from the Government Health Service.  Hon. Fearne emphasised that the amount of doses which Government will procure will be over and above those which were donated by the manufacturers through the personal intervention of H.E. Marie-Louise Coleiro Prece, President of the Republic. Hon Fearne also assured the Ombudsman that, henceforth, those patients who become eligible under the set criteria would be given the treatment straight away. There will be a committee of Consultants to vet the medical files to ensure that all the selected patients satisfy the criteria.

This Office understands that the established criteria for treatment with the newly available medicines has been drawn up in agreement with the specialists involved in the treatment of such patients.

During this meeting the Ombudsman reminded the Parliamentary Secretary for Health that there is also pending the availability of Glargine Insulin to Type 2 diabetics. Such insulin is currently only available to Type 1 diabetics. There is also an issue with the supply of adequate number of Haemoglucotest (HGT) blood testing sticks in line with recognised need for the proper treatment of diabetes to those over the age of eighteen who are certified to require to test their blood sugar levels more than twice a day.  Hon. Fearne confirmed that these two issues are under consideration with a view to be hopefully available as indicated next year.   However he also added that another new treatment is being introduced i.e. Gliptins, and it is possible that the patients in question will be adequately controlled by this new treatment and may not therefore necessarily need to have the Glargine Insulin.

The Ombudsman and the Commissioner for Health welcomed this new development which augurs well for better resolution of such issues as they arise from time to time.