A man’s death could have been avoided if the Calderdale and Huddersfield NHS Foundation Trust had operated on his twisted bowel, the Parliamentary and Health Service Ombudsman (PHSO) has found. Mr A, an otherwise healthy 71-year-old man, died when his twisted bowel tore following serious failings and multiple delays in his treatment at the Trust.

Mr A went to the emergency department at Calderdale Royal Infirmary (CRI) on Christmas day in 2017 with constipation and abdominal pain. The hospital identified the risk of his bowel tearing and that he needed surgery. Mr A was transferred to Huddersfield Royal Infirmary (HRI) hospital the same day. 

On 27 December, staff at HRI performed an investigation and recorded the same risk of perforation in clinical notes. Similar conclusions were drawn in a further examination on 30 December. However, it was not until the New Year, on 1 January 2018, a week after M A’s initial visit to A&E, that HRI recognised a need for urgent surgery. This was planned for 2 January but was then cancelled and rearranged for 3 January. As a result of the delays, Mr A’s condition worsened, his bowel perforated and he sadly died on 4 January after his organs failed. 
Miss A, Mr A’s sister, complained to the Trust. In its response the Trust said that its care and treatment was appropriate and that Mr A had been managed cautiously. 

Miss A took her complaint to the Ombudsman because she was not satisfied with the response to her complaint and she wanted the Trust to acknowledge its

failings. She said her brother would have wanted to improve services so that the same mistakes would not happen again. 

The Ombudsman found that the Trust failed on more than one occasion to follow national guidance and act on the results of its investigations into Mr A’s condition. The Ombudsman also found that the delay in operating led to his avoidable death.

Rob Behrens, the Parliamentary and Health Service Ombudsman, said:

This case shows why the guidelines exist and the tragic consequences when they are not followed. 

'By carrying out our recommendations and putting an action plan in place the Trust can improve its service to ensure this never happens again.’

Miss A said:

Thanks to the Ombudsman, we have some justice for my brother and his tragic avoidable death has been highlighted.

‘He deserved better than the inadequate treatment and original response to my complaint provided by HRI.

‘My brother should still be here today but he would have been happy to know that changes had been made so the same thing won’t happen to anyone else.’

David Birkenhead, Medical Director at the Calderdale and Huddersfield NHS Foundation Trust, said:

We are always very sorry when our care falls below the standards we expect to deliver. We have apologised and have agreed to the Ombudsman’s recommendations to

develop an action plan to prevent a recurrence. 

‘Again, we would take the opportunity to send our apologies to the family.’

The Trust has agreed to the Ombudsman’s recommendations to develop an action plan to address its failings and outline how it will prevent them happening in the future. As part of this process the Trust has committed to carry out training on the guidelines for surgeons and improve processes for monitoring high risk patients. It has formally apologised to Miss A in recognition of the injustice its failings have caused.

Read the Case Summary.

3/01/2020

El Defensor del Pueblo (e.f.), Francisco Fernández Marugán, valora positivamente la respuesta recibida desde la Secretaría de Estado de la Seguridad Social en la que se comprometen a realizar un estudio para modificar la Ley General de la Seguridad Social y equiparar el Servicio Social de la Sección Femenina y el Servicio Militar a los efectos de alcanzar el período de cotización que  permita el reconocimiento de jubilación anticipada.

En su escrito, la Administración ha comunicado que, en el momento en que sea posible, realizará el citado estudio para, atendiendo a las características del Servicio Social Femenino computar dicho período en los mismos supuestos y con los mismos requisitos que contempla el ordenamiento jurídico respecto al cómputo del período de prestación del servicio militar obligatorio o de la prestación social sustitutoria.

En la actualidad, el tiempo de servicio militar o prestación social sustitutoria computa a efectos de cubrir los periodos de 33 y 35 años de cotización que se requiere para las modalidades jubilación anticipada y para los 33 de la jubilación parcial pero no se considera como cotizado para acreditar el período de quince años que, con carácter general, se requiere para acceder a la jubilación ordinaria.

El pasado mes de noviembre, el Defensor admitió a trámite la queja de una mujer que cuestionaba que no se había contabilizado el tiempo dedicado a la prestación obligatoria en el Servicio Social Femenino para acreditar el periodo mínimo de cotización exigido para acceder a la jubilación anticipada y parcial, y exponía su disconformidad con la norma al considerarla discriminatoria.

Prestación obligatoria para muchas mujeres

Entre los años 1937 y 1978 muchas mujeres de entre 17 y 35 años se vieron obligadas a realizar este servicio ya que era requisito indispensable para tomar parte en oposiciones y concursos, obtener títulos académicos, acceder a un puesto de trabajo remunerado, unirse a una asociación, obtener el pasaporte o el carné de conducir.

A pesar de ello, la Ley de Seguridad Social no reconoce ningún efecto al tiempo que las mujeres dedicaron a este servicio y sin embargo, en el caso de los hombres sí se considera a efectos de cómputo de tiempo trabajado el servicio militar o prestación sustitutoria.

En los últimos años, algunos tribunales ya han reconocido que ambos servicios deben ser equiparados dada la similitud que tenían. Por este motivo, el Defensor del Pueblo solicitó información a la Secretaría de Estado de la Seguridad Social sobre la posibilidad de modificar la Ley de la Seguridad Social para igualar ambas prestaciones.

Fernández Marugán celebra el compromiso del Gobierno de estudiar el cambio normativo que permita asemejar el Servicio Social Femenino y el Servicio Militar a efectos de la jubilación anticipada.

The Office of the Public Defender of Rights has launched a four-year plan focused on human rights protection. The Plan will allow the ombudsman to focus even more strongly on particularly vulnerable groups, such as children, people with disabilities and people whose freedom has been restricted.

The Plan to Expand the Human Rights Activities of the Public Defender of Rights was launched on 1 December 2019 and will continue until 31 December 2023. The Plan is part of Human Rights Programme financed from the 2014-2021 Norway grants through the Czech Ministry of Finance. As part of implementation of the Plan, the ombudsman will conduct research and issue recommendations concerning the protection of the rights of children, persons with disabilities and institutionalised persons and will also develop new methods of work to ensure more effective protection of human rights.

For example, a handbook will be prepared for follow-up visits to facilities detaining persons subject to restricted personal freedom. The aim of these visits is to verify whether and how the facility complies with the ombudsman’s recommendations. The handbook will address the scope and focus of the visits, i.e. for example deciding whether the follow-up visit should focus only on verifying recommendations, or whether it should also respond to new findings, etc. It will also focus on the methodology of evaluating compliance with the recommendations.

At least two recommendations per year will concern protection of children’s rights, where many systemic issues persist that could not have been addressed so far due to lacking resources. This includes, for example, an analysis of how many children from foster care end up in institutional care, and why. Another task will be to draw up materials comprehensible to children, concerning their rights and solution of life situations they might encounter.

Research activities will focus, for example, on portrayal of people with disabilities in the media. The objective will be to educate the media on how people with disabilities should be portrayed in order to respect their dignity and avoid further strengthening of the existing stereotypes.

The Plan will also include several seminars and workshops for staff members of the relevant facilities, social workers and non-governmental organisations.

Maladministration on the part of Flintshire County Council resulted in years of “persistent and intrusive” disruption to a resident from an unlicensed car wash, an Ombudsman investigation has found.

Mr R (anonymised) suffered “significant injustice” after being exposed to unacceptable levels of noise and water spray over a five-year period, according to a new report issued today by the Public Services Ombudsman for Wales.

The report finds that Flintshire County Council failed to take timely and appropriate action to deal with the car wash, which was causing Statutory Nuisances of noise and chemical and water spray. It also concludes that the Council failed to give due consideration to Mr R’s right to quiet and peaceful enjoyment of his home, as set out in the Human Rights Act 1998.

Commenting on the report, Nick Bennett, Public Services Ombudsman for Wales, said:

“It’s concerning that, despite identifying in 2014 that the car wash was causing a Statutory Nuisance, the Council did not open an appropriate case file until 18 months later and did not serve an Abatement Notice for a further 13 months. When the car wash continued to operate and cause the Statutory Nuisance, in contravention of the Abatement Notice, the Council took no further action.

“It is also worrying that despite the Council being aware from at least 2012 that the car wash did not have appropriate planning consent, it held almost no planning records from before August 2018. The lack of records coupled with inaction over the five years preceding this date suggests that the Council did not adequately consider whether to take enforcement action against the car wash, which amounts to maladministration.

“My investigation found that the Council failed to respond to and escalate complaints appropriately. There was also an absence of clearly established ownership of responsibility for dealing with the situation at senior level, as well as a total disregard for the difficulties faced by Mr R, which severely affected his health and well-being. The Council was informed of this and yet failed to act over a prolonged period of time.

“Consequently, there was no appropriate investigation of the complaint and Mr R and his landlord received no meaningful response to their concerns until my office intervened, which was completely unacceptable.”

Flintshire County Council has agreed to a number of recommendations including providing a full and meaningful apology to Mr R and his landlord, and to offer financial redress of £3,500.

Court of Justice of the European Union

PRESS RELEASE No6/20

Luxembourg, 22 January 2020

Judgments in Case C-175/18P

PTC Therapeutics International Ltd v European Medicines Agency(EMA),

And C-178/18P MSD Animal Health Innovation and Intervet International v European Medicines Agency(EMA)

The Court confirms the right of access to documents contained in the file of a marketing authorisation application for a medicinal product

An objection to such access must explain the nature, purpose and scope of the data whose disclosure would undermine commercial interests

In the judgments in PTC Therapeutics International v EMA (C-175/18P) and MSD Animal Health Innovation and Intervet International v EMA(C-178/18P), delivered on 22 January 2020, the Court of Justice was required to examine, for the first time, the question of access to European Union documents submitted in the context of marketing authorisation (MA) applications. In this instance, it dismissed the appeals brought by, on the one hand, PTC Therapeutics International and, on the other, MSD Animal Health Innovation and Intervet International against thejudgments of the General Court1dismissing their actionsfor annulment of the decisions by which the European Medicines Agency (EMA) had granted access to documents containing information submitted in the context of the procedure relating to MA applications for medicinal products.

Full press release here: https://curia.europa.eu/jcms/upload/docs/application/pdf/2020-01/cp200006en.pdf