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Failings in NHS and poor government complaint handling highlighted in new report by Parliamentary and Health Service Ombudsman

The Parliamentary and Health Service Ombudsman has published 161 summaries of investigations it carried out between April and June this year.

The Ombudsman Service investigates complaints about the NHS in England and UK government departments and their agencies, such as the Child Maintenance Service and the DVLA. The summaries published today include 35 governmental cases and 126 are healthcare.

The cases investigated included several complaints about incorrect discharges from hospitals, failings in diagnosis of cancer and another complaint concerned poor case handling from the Child Support Agency.

One complaint investigated concerned Barking, Havering and Redbridge University Hospitals NHS Trust where a man died following a liver biopsy. The investigation found he had an inadequate care plan, was incorrectly discharged from A&E and biopsy consent was not properly obtained. He was not properly monitored, cared for and given inappropriate medication after the biopsy, and the Trust lost clinical records.

In another case a man attended a Bedford Hospital NHS Trust A&E with nausea, vomiting and not opening his bowels for three days. The following day he was admitted to hospital where surgery found he had a complete loss of blood supply to his small bowel. We found the Trust inappropriately discharged the man from A&E.

Other cases investigated concerned diagnosis of cancer. In one case, a woman who had surgery at Wirral University Teaching Hospital NHS Foundation Trust was told she had cancer in her stomach and bowel and would need cancer treatment and further tests, but staff did not arrange these. She then saw a surgical consultant, who said there was no cancer whatsoever. Five weeks later the surgical consultant told her she did in fact have cancer.

One of the Parliamentary cases shows the huge impact the Child Support Agency  now the Child Maintenance Service had on a women's mental health, causing her to attempt suicide because its poor case handling meant she struggled for seven years to get it to act properly.

Parliamentary and Health Service Ombudsman Julie Mellor said: "These investigations highlight the devastating impact failures in public services can have on the lives of individuals and their families.

"A shocking case that stood out was that of a one-day-old baby who suffered permanent brain damage at Barts Health NHS Trust in London because a nurse and two doctors made serious mistakes during a blood transfusion.

"We are increasingly concerned about patients being discharged unsafely from hospital. Unplanned admissions and readmissions are a massive cost to the NHS.

"We are publishing these summaries so public services, MPs and members of the public can see the different types of complaints we look into, our findings and recommendations. I hope this will give people with concerns about the service they have received the confidence to come to us to complain. We also want to provide valuable lessons for public services, and show how complaining makes a positive difference to them."

This second tranche of cases summaries contains almost twice as many case summaries as the previous release in August (which covered February and March).

The link to the case summaries is here.


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Relevant forthcoming events:

Masterclass: Nurse Led Discharge
Friday 7 November 
Hallam Conference Centre

Root Cause Analysis: 2 Day Intensive Training Course
Tuesday 20 January — Wednesday 21 January 
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Complaints Handling, Investigating, Resolving and Learning
Wednesday 11 February 
ICO Conference Centre




29 October 2014


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