The Parliamentary and Health Service Ombudsman has published a report containing a snapshot of summaries of the complaints it has investigated over a two month period, during which it upheld 41% of the complaints it investigated.

The report contains summaries of 163 investigations, showcasing the wide range of cases the Ombudsman service investigates about the NHS in England and UK government departments and their agencies such as the UK Border Force, the Driver and Vehicle Licencing Authority and HM Courts &Tribunals Service.

Included in the report are cases about breaches of cancer waiting times, families resorting to putting their family in private care following unsafe discharges from A&E on Christmas Day, people wrongly losing their permanent status to reside in the UK because of poor advice and people going into debt due to incorrect benefit advice.

The report published today by the Ombudsman service contains summaries of 163 complaints it completed investigating in October and November 2014. During this period it made final decisions on a total of 618 complaints and upheld 41% of these complaints. In cases where the Ombudsman service doesn't uphold complaints, it is often because no failings were identified by the Ombudsman service or because the Ombudsman service found that the public service did the right thing to resolve the complaint, which the Ombudsman service then explains to the complainant.

Approximately 80% of its investigations are about the NHS in England as opposed to UK government departments and their agencies. During this two month period, most of its NHS investigations were about hospital trusts, followed by GP practices and then mental health trusts. 

Parliamentary and Health Service Ombudsman Julie Mellor said:

'These cases show the impact that service failure can have on individuals and their loved ones.

'These case studies - which are a snapshot of our work - show the wide range of unresolved complaints we look at, many of which should be resolved by the organisations locally, without people having to refer the complaint to us.

'Good complaint handling has to start from the top, and leaders will recognise the valuable opportunities complaints provide to really improve the service they are delivering.

'Many people complain about public services to enable lessons to be learnt because they don't want the same thing to happen to somebody else.'

Today's report includes the following case summaries:

• A patient with dementia was left on a trolley in A&E for more than 33 hours and then left in an assessment unit for 42 hours. The Ombudsman service's investigation found that the patient had to wait in both departments far too long and nurses did not provide an appropriate care plan for him and that University Hospital of North Staffordshire NHS Trust's response to the complaint gave no reassurance that the failings would not happen again. Following the Ombudsman service's investigation, the trust acknowledged and apologised for its failings and agreed to explain what action it has taken or proposes to take to ensure that there is learning from what happened. (Full case summary on page 141 of the report).
• A family could not be with their mother in her final hours although she was just the other side of a curtain, on a hospital bed at University Hospitals Birmingham NHS Foundation Trust. Her family were only allowed to see her 45 minutes after she had died. The Ombudsman service's investigation found that there were failings in how staff communicated with the patient's children and how they treated them and that the trust's complaint handling fell short of the expected standards. (Full case summary on page 81 of the report).
• Paramedics left frail woman in her 80s home alone with inadequate support although she was suffering with sickness and diarrhoea and had soiled herself. The Ombudsman service's investigation found that the patient should have been taken to hospital by East of England Ambulance Service NHS Trust. She was not able to use a commode without help so it was inappropriate to leave her alone. The failure to take her to hospital sooner caused her avoidable distress, discomfort and loss of dignity. (Full case summary on page 144 of the report).
• A hospital trust did not follow cancer waiting times and kept a patient waiting far too long with possible prostate cancer symptoms. When he was eventually diagnosed with cancer, he faced a further wait and paid to receive private treatment. The Ombudsman service's investigation found the cancer waiting time targets were breached by a significant margin and that the patient suffered great distress and worry for several months as a result of the delay which led him to seek prompt private treatment. University Hospital Southampton NHS Foundation Trust paid him £5,000 in recognition of the money he spent on private treatment because of its delays. It also prepared an action plan to address the shortfalls in the service. (Full case summary on page 152 of the report).
• A family had no choice but to place a vulnerable man with dementia in private care over Christmas, after he was unsafely discharged from A&E on Christmas Day. (Full case summary on page 65 of the report).
• A man received £1,000 following a delay by the DVLA in reinstating his driving licence, after he was diagnosed with early-onset dementia. The DVLA revoked his licence as soon as it found out his diagnosis, however once it received more information from a consultant stating that he was fit to drive, it took seven months longer than it should have done to reinstate the licence. The Ombudsman service's investigation found that the explanations and advice the DVLA gave about the revocation were very poor. (Full case summary on page 9 of the report).
• A failure by Jobcentre Plus to tell a man about benefit rules led him into debt. The complainant wanted to separate from his wife and move into a council property. He told Jobcentre Plus he was doing this but it failed to tell him that unless he sold his previous property, he would lose entitlement to income support when it was due to be reviewed after 26 weeks of the change. When it was discovered some months later, his income support was stopped and he had to move back into his marital home. He could not afford to rent the council property without his benefit payments and he was unable to get his wife to sell the marital home, and so had to move back into his marital home. The Ombudsman service's investigation found that he suffered significant stress and inconvenience. (Full case summary on page 12 of the report).
• UK Visas and Immigration's incorrect advice led to a woman from New Zealand wrongly losing her permanent status to reside in the UK. Following the Ombudsman service's investigation, her permanent status to reside in the UK was reinstated. This was after she was advised by the UKVI to apply for the wrong type of visa when returning to the UK from New Zealand. (Full case summary on page 27 of the report).
• The UK Border Force paid a company more than £12,000 after it damaged several sacks of bran during a routine inspection of a lorry in Dover. The company supplies cereals to manufacturers in the UK and Europe. The lorry from Poland was stopped at Dover and UK Border Force officials carried out a search. They used sticks to probe the contents of the sacks which damaged the packaging to the extent that the contents could no longer be used and had to be destroyed. (Full case summary on page 29 of the report).

Most of the summaries published are cases the Ombudsman service has upheld or partly upheld. These are the cases which provide clear and valuable lesson for public services by showing what needs changing so it can be avoided in the future. They include complaints about failures to spot serious illnesses and mistakes by government departments that caused financial hardship.

The Parliamentary and Health Service Ombudsman makes formal decisions on complaints which haven't been resolved locally by the NHS in England or by UK government departments and their agencies, such as the Department for Work and Pensions, the DVLA, the Passport Office and the Highways Agency.

The Ombudsman service investigates approximately 4,000 complaints a year and upholds around 37%.

Notes to editors

1. For more information please contact press office Steven Mather on 0300 061 4324 or email steven.mather@ombudsman.org.uk or contact senior press officer Marina Soteriou on 0300 061 4996 or email marina.soteriou@ombudsman.org.uk
2. In 2014-15 approximately 79% of the Parliamentary and Health Service Ombudsman investigations were about the NHS in England and 21% were about UK government departments and their agencies.
3. In October 2014, the Ombudsman service completed 327 investigations. Of these 252 were about the NHS in England and 75 were about UK government departments and its agencies.
4. In November 2014, it completed 291 investigations. Of these 233 were about the NHS in England and 58 were about UK government departments and their agencies.
5. During this two month period, the Ombudsman service upheld 60 cases, partly upheld 193 and did not uphold 321. The remaining investigations were either resolved before the formal investigation ended or closed because for example the complainant did not wish to pursue it further or because the organisation complained about, offered to do further work to resolve the complaint locally.
6. Case summaries are published on the Ombudsman service's website, and can be searched by entering key words such as cancer, diagnosis and death, as well as by organisation, for example the name of a hospital trust and by location.
7. This is the fourth report of case summaries the Ombudsman service has published. The first batch was published in August 2014.

Contact: Marina Soteriou

Phone: 0300 061 4996

Welcome to SPSO News. In his overview, the Ombudsman highlights:

• how SPSO reports are being used to inform parliamentary debate; and
• this month's investigation reports.

Quick links:
Complaints Standards Authority Update
SPSO Training

This month we are laying two reports before the Scottish Parliament, both about the NHS. We are also laying a report on 68 decisions about all of the sectors under our remit.  These can be read on our website at www.spso.org.uk/our-findings.

Case numbers
Last month (in May), we received 444 complaints. We determined 444 complaints and of these we:

• gave advice on 238 complaints
• considered 144 complaints at our early resolution stage
• decided 62 complaints at our investigation stage

We made a total of 144 recommendations.

Overview

Parliamentary Committees
This month SPSO were invited to give evidence at four different parliamentary committee sessions on a range of issues.

The first session was on Tuesday 2 June with the Health and Sport Committee where we were able to highlight the case relating to palliative care that we published in our May compendium about the need to be clear whether or not someone is receiving active treatment or palliative care. As well as noting this case, our written evidence (PDF, 554KB) and our oral evidence both also highlighted the low numbers of palliative care cases that we see, in particular in relation to hospices. We did, though, note our wider experience of end of life care for elderly patients in acute settings.  We particularly highlighted the need to involve more the people who have most information about patients, their carers and families, in discussions and decisions around end of life care - especially where there are capacity issues.  Most importantly, we recognised the communication skills and the support required by NHS staff to be able to communicate early and well with families about end of life care and also to help families have these difficult conversations in a society where we find it hard to talk openly about death and dying.

On Tuesday 9 June, we spoke in front of the Justice Committee in relation to the draft Apologies (Scotland) Bill. We highlighted from the cases that we see that saying sorry is what many people want most, and the power an apology can have if done well to repair relationships. We recognised the special importance of being able to do this when there are ongoing relationships and there isn’t ‘choice’ about where to go to receive services. Paul McFadden, Head of CSA, noted:

‘From a very early point in the journey of many of the complaints that we see, it is clear that, if a simple, timely and human or empathetic apology had been given, the complaint would not have escalated. The failure to make that apology results in a breakdown of the relationship between the individual citizen and the public body, which then escalates, builds and exacerbates the situation—it grows arms and legs.’

For this reason, we offered our broad support for the Bill. In our experience, there continues to be a common misconception that saying sorry is automatically an expression of negligence. We know from speaking to staff and delivering our training on apology that there continues to be a culture of fear around apologising.  The proposed legislation has the potential to help create a safe space for public bodies to say sorry. Our written evidence for this session is also available on the Scottish Parliament website (PDF, 174KB).

On Wednesday 10 June we attended the Education and Culture Committee in relation to the complaints process for complaints about additional support needs. On the same day we also gave evidence to the Local Government and Regeneration Committee regarding the health and social care integration agenda and the range of complaints routes that a service user might have to pursue depending on what aspect of their care they were raising concerns about.

In both sessions we highlighted the need to ensure that complaints processes are as streamlined as possible to ensure the best access possible. In his evidence to the Education and Culture Committee, which can be read in full on the Committee’s webpage, Jim Martin said:

‘The direction of travel in Scotland is to reduce complexity and to make it as easy as possible for people using the system to complain and to have their complaint resolved as quickly and as well as possible. If we present people with a complex landscape, they will go to the wrong place, go round in circles, get tired, drop out and not pursue their rights.’

In summary, these evidence sessions gave us a strong platform to highlight three of our core messages – the need for good communication in order to deliver good care, the benefits that flow from having the capacity and support to be able to apologise early and do it well, and finally the need for easily accessible complaints processes where the barriers to complaining are removed.

Read my overview and summary of this month's investigation reports in PDF (102KB) or via the links below.

'Given the importance of the timing of surgery, I am concerned about the potential impact of the Board's bed management criteria. While I appreciate that there can be fluctuating pressures on resources, particularly bed availability, I am not satisfied by the evidence that the failure to prioritise Mr C was reasonable given his clinical need. In addition to the clinical effects the delay had on Mr C, it was also clear to me that the delay was extremely distressing for Mrs C who continues to be concerned about its impact on Mr C's post-operative recovery.'
Hospital transfer, care of the elderly
Highland NHS Board (201304732)
View a summary of this case and download the full report on the SPSO website

'Whilst the risk of [the side effect] occurring is very small, given the GMC's guidance that patients must be told about recognised serious adverse outcomes, even if they are rare, I consider that the surgeon should have warned Mr C of this potential adverse outcome. There is no clear evidence to demonstrate this was done or indeed that discussion took place about other major structures close to the operative area being at risk of injury with possible significant consequences.'
Consent; record-keeping
Greater Glasgow and Clyde NHS Board (201401527)
View a summary of this case and download the full report on the SPSO website

Complaints Standards Authority

Local government
The Local Government Complaints Handlers Network met most recently on 12 June 2015.  Issues considered by the network included good practice in dealing with complainants who have mental health issues, learning from complaints, the peer review of annual complaints reports and solutions to complaints handling issues through the complaints surgery.

Building on the positive outcomes of annual complaints reporting for 2013/14 which produced the first ever baseline of complaints performance information for the sector, the network will soon be looking at performance in the year 2014/15.  This information will be compared with the baseline data and will be used to benchmark for improved performance across the sector.  

NHS
Our work continues towards bringing forward changes to the NHS complaints handling arrangements. This includes liaising closely with key stakeholders to examine the present arrangements and to consider opportunities for improvement.  For example, we recently met with Tayside NHS to consider the issue of how complaints from prisoners are handled within a prison heath centre.  We will continue to work closely with our NHS partners as we work towards developing a model complaints handling procedure (CHP) for the NHS, which takes account of the framework of the Patient Rights (Scotland) Act 2011, is based on the current guidance while prioritising the early resolution of complaints, and places a requirement on service providers to learn from complaints.  More information will be provided in our following updates.

Housing
The next meeting of the Housing Complaints Handlers Network will be held in July.  We would like to remind all attendees that as part of the meeting we will consider the quarterly performance information of members against the requirements of the SPSO complaints self-assessment indicators for the housing sector (PDF, 188KB). We ask that attendees prepare their complaints performance information from the first quarter of 2015/16 in advance of the meeting so that we may move quickly towards benchmarking performance within the network.

We are encouraged that interest in this network continues to grow.  Further information on the role of the network, including details of how you may join can be obtained from anne.fitzsimons@tollcross-ha.org.uk. 

Further education
The Further Education Complaints Advisory Group is making excellent progress as it works towards driving up the standards of complaints handling and learning from complaints across the sector.  It met most recently on 8 June 2015 when the issues discussed included the use of the ‘online complaints handling tool’, a review of the successful workshop event held in May, complaints categories and key performance indicators, measuring customer satisfaction with the complaints process and the impact of complaints on the quality of learning, teaching and support services across the sector. A small working group will consider the current categories of complaints used across the sector in more detail with a view to identifying opportunities to standardise across the sector.  The group will also review the current approach to measuring satisfaction with the complaints procedure with a view to identifying and sharing good practice across the sector.

We would encourage any colleges that wish to join the Further Education Complaints Advisory Group to contact us at CSA@spso.org.uk and we will pass your details on to the Chair of the group.

Higher education
We encourage all higher education institutions to contact us directly at csa@spso.org.uk for advice on performance reporting, the compliance requirements of The Scottish Higher Education Model Complaints Handling Procedure or for generalist advice on complaints handling.

For all previous updates, and for more information about CHPs, visit our dedicated website www.valuingcomplaints.org.uk.  You can also contact the CSA directly at CSA@spso.org.uk
 

Forthcoming SPSO Training Events

Bookings are now open for the first ever SPSO Conference

Thursday 8 October 2015
COSLA conference centre, Edinburgh
Complaints processes generally concentrate on ‘putting it right’ for the consumer. Using the intelligence that can be derived from complaints, how can we ensure we ‘get it right’ next time for everyone else? How do we ensure that our complaints processes and responses are fit for purpose and allow us to identify where there is learning and meet the needs of the consumer?

Keynote speakers from SPSO, public and private sector organisations will talk about their real-world challenges in changing organisational culture, embedding potential learning and improving future practice. A series of workshops and ample networking opportunities will enable delegates to meet with colleagues across the public sector and beyond.

Who Should Attend?
Those with lead responsibility for monitoring and improving organisational performance;
Managers with responsibility for Organisational Learning from Complaints and Feedback;
Quality Assurance Managers;
Complaints and Customer Service Managers; and
Organisations with an interest in consumer redress.

Where and when?
9am - 4pm, COSLA conference centre, Edinburgh (near Haymarket train station)
Price: delegate rate £150 pp, including refreshments and conference materials

For booking forms or further information, please contact us at training@spso.org.uk

Booking now open:
Complaint investigation skills (stage 2 of the model CHP): 1 day open course
Our next open training course for staff handling second-stage complaints (Investigation Skills) is on Wednesday 9 September 2015 in central Edinburgh. This is open to staff from all sectors under the SPSO’s jurisdiction. Full course details are available on the SPSO Training Unit website.

Course price (per course): £180pp - to apply, please email training@spso.org.uk 

For more SPSO course information, please visit the SPSO Training Unit website: www.valuingcomplaints.org.uk/training-centre/

We also have a flyer available which details all of the training available from SPSO in 2015 (PDF, 40KB)
 

Jim Martin, Ombudsman | 17 June 2015