Wed, 20/07/2022 - 12:00

We laid 16 decisions before the Scottish Parliament this month.  For more information, please click the link below.

Download the Ombudsman's overview (PDF, 390KB) or read it online (link is external).  Media enquiries can be made by email or via our online form.

A 65-year-old man died after doctors failed to notice serious abnormalities on his X-ray, an investigation by the Parliamentary and Health Service Ombudsman has revealed.  

The investigation comes a year after a landmark report by the Ombudsman highlighted failings in how X-rays and scans are reported and followed up in the NHS.  

Mr B, who was admitted to University Hospitals Birmingham NHS Foundation Trust in May 2019, had been unwell for several days. He was admitted to hospital suffering from abdominal pain and vomiting. An X-ray of his abdomen was taken, which two doctors said did not show any apparent abnormalities.

The following day the man’s condition deteriorated. He suffered a heart attack and died. A PHSO investigation found the Trust failed to notice a blockage in his intestine on the X-ray. Because of this failure, Mr B did not receive treatment that could have saved his life. 

Speaking on this case Ombudsman Rob Behrens said:  

“The case of Mr B highlights the devastating impact mistakes like this can have. If the Trust had picked up the abnormalities on his X-ray sooner, Mr B could still be with his family today. 

“As the NHS faces the challenge of rebuilding after the pandemic, it must not lose momentum in improving the way X-rays and scans are handled during a patient’s care.”  

The Ombudsman's report, Unlocking Solutions in Imaging: working together to learn from failings in the NHS, identified areas of concern including not only ignoring national guidelines when treating patients but also a culture of not learning from past mistakes. He said opportunities to spot serious health conditions earlier were being missed. 

Progress has been made by the NHS in implementing recommendations made by the Ombudsman in his report. These include improving digital reporting capabilities around X-rays and scans and the updating of guidance on the roles and responsibilities of clinicians. 

However, Rob Behrens has said more needs to be done to protect patients from serious harm. He said:  

“Attention and buy-in from the NHS’s senior leaders is crucial if we want to see sustained and meaningful change in how X-rays and scans are managed during a patient’s care. We need more collaboration across clinical specialties, looking at the whole patient journey once a scan has been carried out.

"I want to see the NHS treating complaints as a source of insight to drive improvements in patient care. Not learning from mistakes will mean missed opportunities to diagnose patients earlier. In the most serious cases, like that of Mr B, it will mean a death which should never have happened.” 

After an extensive period of research and development, the new Ombudsman’s Office website www.tiesibsargs.lv was launched on July 20. The new website is not only more accessible to people with disabilities, but also more user-friendly for every visitor of the website. The website was developed in cooperation with digital accessibility experts and users.

Ombudsman Juris Jansons: “We are happy, because we can proudly say that we are changing with the times. After a 7-month long intense developing process, we have now put our website up for your evaluation and judgement. This has been busy time for our team. In cooperation with specialists, we have paid close attention to ensuring that the website is user-oriented, intuitive, as well as compliant with modern-day requirements. It is important to me, as an ombudsman, that everyone can find the information they need and use it to defend their rights.”

The website development was carried out in accordance with the Directive of the European Parliament and of the Council on the accessibility of websites and mobile applications of public sector bodies, which requires all websites of national and local authorities to comply with accessibility requirements. Accessibility is an inclusive practice that contributes to a successful interaction between people and the digital environment – regardless of the user’s digital literacy, availability of technologies, health condition or other circumstances.

To make the website user-friendly, user habits needed to be analysed in detail. Therefore, one of the main steps in the production of the website was the development and analysis of user profiles, simulation of scenarios, and identification of risks.

Ruta Siliņa, Head of the Communication and International Cooperation Division: “Sometimes legal terms can be very complex and specific. For the sake of the bigger picture, we tried to find a balance between the use of correct legal terms and the best interests of users by including descriptions and explanations of areas of law in the website. A resource database has also been introduced, which will be a great opportunity to search, find and publish information in a more convenient manner. In the future, this will allow the website to be much more active and, simultaneously, more structured.”

The website of the Ombudsman’s Office was developed in cooperation with Turn Digital, digital accessibility experts and users.

El Defensor del Pueblo, Patxi Vera, se ha reunido con representantes del Sindicato de Técnicos en Cuidados Auxiliares de Enfermería (SAE).

El encuentro tuvo lugar ayer día 21 de julio en la sede de la Institución. Desde SAE, se ha trasladado a la Institución la situación en la que se encuentra este colectivo en sus reivindicaciones ante el Gobierno de Navarra, como son la falta de regulación y reconocimiento de la carrera profesional del Técnicos en Cuidados Auxiliares de Enfermería y, por otro lado, el desacuerdo con la aplicación de la Ley 6/2018 de 3 de julio por la que se decide el encuadramiento de todo el colectivo perteneciente al nivel E en nivel D, al que ellos pertenecen.

En el encuentro han estado presentes, por parte de SAE, Begoña Ruiz (Secretaria Provincial del Sindicato), Ana Isabel Chasco y Oscar Moreno. Por parte del Defensor del Pueblo asistieron también Carlos Sarasíbar (Secretario General) y Susana Galilea (Jefa de Gabinete).