A damning review has concluded that patients who complain about their treatment in NHS hospital are being badly let down by “appalling” investigations.
A report by the Parliamentary and Health Service Ombudsman (PHSO) found that over a third of investigations carried out into avoidable injury or deaths in hospitals were “inadequate”.
Concerns from patient groups
Dr Katherine Rake, who heads up the patients’ group Healthwatch England, has called for the NHS complaints system to be completely overhauled in the light of the report’s findings. Dr Rake said that the findings released by the Health Ombudsman were “worrying, but sadly not surprising”.
Some of the families who were spoken to during the review spoke of feeling belittled or misled by hospital staff. They also said staff wouldn’t give them straight answers, or listen to their worries. Patient campaigning groups condemned the review findings as “worrying”, and said that they suggest that the NHS is not learning the lessons of hospital scandals.
Thousands fail to follow up NHS complaints
Research carried out by the PHSO indicates that many thousands of people are being failed by the NHS every year, yet fail to report it because they believe that making a formal complaint will make no difference.
Healthwatch England led calls for a total overhaul of the complaints system. Dr Rake called for a system which makes sure that every incident is fully investigated and that the lessons are learned each time. She also called for those affected to be treated with dignity and respect.
The Ombudsman looked into 150 complaints concerning situations where patients had suffered avoidable harm or had died because of failures in care standards.These could be down to medical negligence or genuine accidents.
The investigation found that 28 out of the 150 cases should have been designated as a Serious Untoward Incident (SUI). This designation allows doctors to learn from previous incidents and avoid similar mistakes in the future. In the overwhelming majority of these cases (71%), the hospital concerned did not label the incident as an SUI.
Julie Mellor, the Parliamentary and Health Service Ombudsman said that the quality of NHS investigations varied significantly. She also said that investigations were not carried out when they should have been, and even when investigations were carried out, they did not get to the root cause of any failings.
It is clear from these figures that the NHS has to do something to improve the quality of investigations, but also needs to be clearer about when an investigation is necessary.
One of the cases highlighted by the report concerned a 77 year old man who was admitted to hospital. Once on a ward his condition got rapidly worse, and he died two days later from a serious infection.
The patient’s daughter, who was unhappy with care standards, complained to the Head of Nursing. She investigated, but did not speak to any of the clinical staff involved. The Ombudsman investigated the case and found that doctors and nurses had not realised just how ill their patient was. The Ombudsman’s report stated that it was unable to say whether the death could have been avoided, but identified many missed opportunities for better chances of recovery and more timely interventions.
A major review is underway into the entire NHS complaints procedure and these are just interim findings. A full review and related report will be released at a later date.
A full review into the complaints process was announced in the wake of the Francis Review, which looked into the scandal at the Mid Staffs Hospital, in which at least 1200 patients are thought to have died because of poor care standards.
A spokesperson for the Ombudsman said that the final report would demonstrate that the quality of NHS investigations into complaints regarding avoidable harm vary in quality, and more often than not are “appalling”.
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