Lack of bystander activation shows that localization exterior tochromosome territories is not sufficient to up-regulate gene expression Céline Morey, Clémence Kress and Wendy A. Bickmore 2009 19: 1184-1194 originally published online April 23, 2009 Genome Res. This article cites 34 articles, 19 of which can be accessed free at: Receive free email alerts when new articles cite this article - sign up in the box at the
Remedy in the nhs: summaries of recent cases .pdfRemedy in the NHSSummaries of recent cases Remedy in the NHSSummaries of recent cases Session 2007-2008 Presented to Parliament pursuant to Section 14(4) of the Health Service Commissioners Act 1993 (as amended) The House of Commons London: The Stationery Office Crown Copyright 2008 The text in this document (excluding the Royal Arms and otherdepartmental or agency logos) may be reproduced free of chargein any format or medium providing it is reproduced accurately andnot used in a misleading context.
The material must be acknowledged as Crown copyright and thetitle of the document specified.
Where we have identified any third party copyright materialyou wil need to obtain permission from the copyrightholders concerned.
For any other use of this material please write to Office of PublicSector Information, Information Policy Team, Kew, Richmond,Surrey TW9 4DU or e-mail: [email protected] 2 Remedy in the NHS June 2008 Remedy in the NHS June 2008 4 Remedy in the NHS June 2008 As Health Service Ombudsman, I conduct confirm my own approach to recommending independent investigations of complaints about remedies when I have upheld a complaint.
NHS providers and practitioners: the final stage inthe complaints procedure. My investigations are In terms of putting things right, the Principles are: carried out in private but I occasional y publishanonymised summaries of selected cases.
• If possible, returning the complainant and, where appropriate, others who have suffered This is the first in what wil be an ongoing series similar injustice or hardship to the position of published summaries about NHS complaints they would have been in if the that I have investigated. My aim in publishing maladministration or poor service had not these summaries is to promote better and more consistent complaint handling in the NHS and todemonstrate how I expect the NHS to put things • If that is not possible, compensating the right when things have gone wrong.
complainant and such others appropriately.
The cases have been chosen as apt il ustrations of • Considering ful y and seriously al forms of good or poor practice in putting things right remedy (such as an apology, an explanation, when they have gone wrong. They il ustrate the remedial action to prevent a recurrence, or variety and scope of my investigations about the NHS and the types of remedies secured as aresult. Some of the cases focus specifical y on • Providing the appropriate remedy in each case.
complaint handling (by the provider, thepractitioner, the Healthcare Commission or a In some cases, a complainant might receive combination of two or more of these). Others financial compensation for direct financial loss.
involve failings in service provision – ranging from Mrs G (page 33) feared her daughter's life was in poor record keeping and poor communication danger fol owing poor care and treatment for her with patients, relatives and carers to more serious eating disorder in an NHS unit. Mrs G took out a clinical failings and, in one case, an avoidable loan to pay for private treatment for her daughter. In response to my recommendations,the Trust agreed to reimburse Mrs G the cost of The cases also il ustrate my ‘Principles for the private treatment and the interest paid on Remedy'.1 These Principles (which fol ow on from my ‘Principles of Good Administration'2) set outmy views on the Principles that should guide how Financial compensation for non-financial loss may public bodies provide remedies for injustice or also be an appropriate remedy in some cases. For hardship resulting from their maladministration or example, in the case of Dr D (page 15), the poor service. As wel as explaining how I think complainant received financial compensation in public bodies should put things right when they recognition of the fact that the Trusts' poor have gone wrong, the ‘Principles for Remedy' also Remedy in the NHS June 2008 complaint handling resulted in her early I have also included in this digest examples of retirement and significantly disrupted her cases where I have engaged a regulator (pages personal and family life. In this case the 15 and 39), whether that is the Healthcare complainant was a GP, il ustrating that the Commission or Monitor, in taking forward my Ombudsman can investigate complaints about recommendations. In the case of Mrs J, I decided the NHS from clinicians as wel as those from to involve Monitor, the body which authorises patients or carers.
and regulates NHS Foundation Trusts, because Iwas highly critical of the nursing care provided by Many of the cases in this col ection highlight the the Trust but was not satisfied that the Trust had value of a sincere and timely apology and a ful y learnt the lessons from the events which wel -reasoned explanation for what went wrong.
prompted my investigation. Through the In the case of Mrs N (page 21) I found that she involvement of Monitor, I was assured that was not given sufficient information about the there would be an appropriate review of the potential scarring she would have fol owing Trust's progress in learning lessons from the surgery, and therefore the validity of her consent complaint. In this way, the regulator can work was undermined. This was a case where financial effectively with the Ombudsman to achieve compensation could have been an appropriate remedy for the injustice suffered, but Mrs N wassatisfied with an apology and an assurance that The wider backdrop to this publication is the lessons had been learnt and that action would be changing landscape of complaint handling. A taken to prevent a recurrence.
new system for handling health and social carecomplaints is due to come into place in For those complained about, there can be April 2009 and a pilot of the new arrangements reputational risks of complaints to the began in April this year, with support and advice Ombudsman. Where appropriate, I wil not from this Office. The changes also put my role, hesitate to draw attention to those NHS and that of the Local Government Ombudsman, providers and practitioners involved so that poor into sharper focus and give them greater service is identified and lessons learnt.
prominence. This publication is therefore part ofan ongoing dialogue with the NHS about what One case which I wish to highlight is that of the Ombudsman expects of service Dr Mrozinski (page 37). He refused to take part commissioners, providers and complaint appropriately in the local complaint handling handlers under the new system.
process and refused to pay the financial redress Irecommended for the complainant in recognition I responded jointly with the Local Government of the unnecessary distress he had caused her.
Ombudsman to the proposals for a new system.
Such lack of insight and defensive behaviour We specifically welcomed the emphasis on deserve to be highlighted. I wil not hesitate to effective complaint handling at local level; use the sanction of publicity and draw effective local leadership; a major cultural shift Parliament's attention to such behaviour. It by the NHS from a defensive application of contrasts sharply with the cases I see where staff process to a welcome for the learning from providing NHS services respond openly and complaints and a will to resolve them; the need promptly to concerns.
for an outcome-based approach to complaints; 6 Remedy in the NHS June 2008 and effective governance arrangements across complaint about health and social care and have all organisations to underpin and support this more such cases in the pipeline.
approach, and ensure that learning fromcomplaints is shared across the NHS and In the short term, I recognise that the changes social care.
will result in an increase in the number ofenquiries made to our Office and the number of There is one other aspect of these proposals investigations we undertake. We do not, that has my strong support: that is, the direct however, expect to take on the same number of path from local resolution – if that should fail – complaints for investigation as the Healthcare to an independent Ombudsman.
Commission has done. As evidence, I note thatwhen the Scottish NHS complaints system Currently, the second stage of the NHS moved to a similar model (at the time of the complaints procedure is provided by the review introduction of the Healthcare Commission in function of the Healthcare Commission, with a England), the number of investigations increased, possible third stage when a case goes to the but not unmanageably so. The Scottish Public Ombudsman. (Review by the Local Government Services Ombudsman accounts for this by the Ombudsman actually constitutes the fourth focus, during the transition stages, on effective stage in the social care complaints process.) The local resolution, coupled with the disincentive changes which are planned for April 2009 will of a referral to the Ombudsman, with the mean a simpler system that is less drawn out for potential for adverse publicity which an both the complainant and the service provider.
Ombudsman's finding can bring.
The regulator, the Care Quality Commission, willbe able to focus on its core business of The focus on more effective local resolution is a regulation and inspection, without the key to making the new system work in practice. I additional demand of complaint handling which would like to play my part in assisting NHS sits uneasily with its primary role. And a strategic bodies to prepare for the changes. My ‘Principles alliance between the Ombudsman and the of Good Administration' set out the sorts of regulator will ensure that any recommendations behaviour I expect when public bodies deliver the Ombudsman may make for systemic change public services; my ‘Principles for Remedy' flow are complied with, and followed up in the from the ‘Principles of Good Administration' inspection regime.
and, as noted above, set out my views on howpublic bodies should approach providing I am working closely with the Local Government remedies. I have also recently issued for Ombudsmen to make sure that there is a fully consultation my ‘Principles of Good Complaint integrated approach to the complaints that cross Handling'.3boundaries between health and social care. Wehave already issued our first joint report into a This latest set of Principles will set out forcomplainants and bodies in jurisdiction what the Remedy in the NHS June 2008 Ombudsman expects by way of good complaint culture. Is this an organisation which understands handling. The same six Principles will underpin and practises learning from complaints? this document, as they do its two predecessors,but apply them in the complaint handling As with al our Principles, those on complaint handling wil not be a checklist to be appliedmechanical y. I am not in the business of Getting it right wil be about getting the right providing a manual of how to stay on the right leadership, governance and culture – ownership at side of the Ombudsman. Rather, I am providing athe top of the organisation; about equipping and framework of Principles. I expect public bodies to empowering decision makers on complaints; use their judgment in applying those Principles to about focusing on outcomes not processes; and produce reasonable, fair and proportionate about signposting to the Ombudsman in the right results in the circumstances. I wil adopt a similar way at the right time.
Being customer focused wil be about providing I hope that my framework of Principles wil prove an accessible complaints service, with help to useful to complaint handlers without tying them make complaints for those who need it: a service to precise and possibly unsuitable templates.
that is simple, speedy, joined-up with other Over time I wil use my experience of them to providers, flexible, sensitive and tailored to feed back to the NHS lessons about both good people's needs – not ‘one size fits al '.
and bad practice in complaint handling.
Being open and accountable wil be about Final y, I did not think it was necessary to spel publicising complaints procedures clearly and out the value of complaints in this foreword; the wel ; about keeping proper records of complaints; cases speak powerful y for themselves about the and about giving reasons for decisions.
individual and public benefit of effectivelyresolved complaints. However, I do want to do Acting fairly and proportionately wil be about more to tel the NHS about the Ombudsman's decisions being reviewed by someone other than role in the complaints system, and to encourage the original decision maker; about natural justice better and more consistent complaint handling – to al the parties; and about not using practice across the NHS. This document is a key sledgehammers to crack nuts.
part of that ongoing process.
Putting things right wil be about remedy. Notonly apologies and explanations – important asthey are – and not only changes to prevent arecurrence – important as they are, as wel , but,as we have seen, financial remedies where they are justified and appropriate.
Parliamentary and Health Service Ombudsman Seeking continuous improvement wil be about learning. But it wil also be about attitude and 8 Remedy in the NHS June 2008 Complaint about Basildon and Thurrock University Hospitals NHS Foundation Trust (the Trust) and the Healthcare Commission (the Commission) Complaint about the care and treatment of a The Trust's response to the complaint critical y il child admitted with breathing encompassed three letters and two meetings problems, and complaint about the Commission's with Mr and Mrs A between February and subsequent review August 2004. The Trust acknowledged someshortcomings, apologised and highlighted actionsarising from the case including the introduction Background to the complaint
of individualised il ness management plans forchildren with complex conditions; a system of Miss A, aged 17, suffered from multiple and severe flagging children with special needs on the health problems from birth and her parents were patient administration system; and developing her ful -time carers. As she required frequent summary history sheets at the front of patients' hospital contact, she had direct access to the notes. The Trust also subsequently reported paediatric unit. In August 2003 she was admitted improved staffing levels. to the paediatric unit with shortness of breathand coughing, on the advice of the Paediatric In November 2004 Mr and Mrs A complained to Triage Team, which her parents had contacted.
the Commission, which reviewed the case having Some hours later, when her condition failed to taken clinical advice. In February 2006 it improve, she was transferred to the Intensive Care concluded that the Trust had taken steps toUnit; however, sadly, she died an hour later.
reduce the risk of similar problems occurring inthe future and that there was no scope to takethe complaint further.
The complaint to the Trust and the Commission
In January 2004 Mr and Mrs A complained to the What we investigated
Trust about Miss A's care and treatment and inparticular her delayed admittance to the Mr and Mrs A complained to the Ombudsman in Intensive Care Unit, the failure to cal the duty April 2006 and we investigated the complaint as consultant when Miss A was admitted and the put to the Trust as wel as the Commission's fact that the consultant was not on the hospital site. They believed that there had been a failurein care and that Miss A had not been adequately We had access to Miss A's medical records for the reviewed by a senior doctor. They also believed last five years of her life and copies of al that, had she been transferred to the Intensive complaints correspondence. We also took clinical Care Unit more quickly, she would have survived.
advice from a Senior Nurse with paediatricexperience and obtained a ful report from aConsultant Paediatrician.
Remedy in the NHS June 2008
What our investigation found
• Delay in transferring Miss A to a High Dependency or Intensive Care Unit despite Our investigation found the fol owing significant clear indications that she needed more failings during Miss A's admission: intensive care than was available on thepaediatric ward. • Inadequate monitoring.
We found that the standard of care provided to • Poor record keeping in terms of both nursing Miss A during her last il ness fel below a and medical notes.
reasonable standard. This amounted to servicefailure on the part of the Trust. We concluded • Failure to recognise the seriousness of that, while it would never have been possible to Miss A's condition. say for certain whether Miss A would havesurvived her il ness had she been transferred to • Delays in seeking and obtaining reviews by the Intensive Care Unit at an earlier stage, there seemed little doubt that her chances would havebeen improved. • Delay in contacting the on-cal consultant.
10 Remedy in the NHS June 2008 We also found that the Trust had not • the regular auditing of new joint medical and acknowledged or apologised in relation to several key issues from Mr and Mrs A's original complaint.
• the appointment of a paediatric clinical We also concluded that the Commission's review practice facilitator; and was seriously flawed because it was not clear thatsufficient clinical advice had been taken from a • the establishment of professional liaison with properly qualified adviser and the clinical advice the regional paediatric intensive care had not been recorded properly on file (the consortium as a resource for advice, training Commission's files contained only a brief note of and service strategy.
a discussion with an adviser which gave noindication of the adviser's qualification and did The Commission wrote to Mr and Mrs A to not make clear if the adviser had seen the apologise for the shortcomings in its review and relevant clinical records). for any distress or frustration that this hadcaused. The Commission also explained that its The investigation, which concluded in policy now required that clinical advice be September 2006, upheld the complaints against recorded in appropriate detail (either the adviser's the Trust and the Commission.
report or a signed record of a detaileddiscussion).
As a result of our recommendations the Trustwrote to Mr and Mrs A to apologise for theshortcomings identified in our report.
The Trust also drew up a comprehensive actionplan in response to our recommendations whichincluded: • the commissioning of a designated paediatric high dependency facility; • the implementation of a paediatric early warning system, which has been integratedwith an updated monitoring chart for critical yil children; • staff induction and training programmes, which include the recognition and resuscitation ofcritical y il children; Remedy in the NHS June 2008 Complaint about University Hospital Birmingham NHS Foundation Trust (the Trust) and the Healthcare Commission Complaint about the care and treatment of an discharge planning in general, with emphasis on elderly patient with Alzheimer's disease and older vulnerable adults who might have coeliac disease fol owing an admission for planned surgery, and complaint about the Commission's subsequent review Mrs L complained again, met with the Trust inApril 2006 and received a further writtenresponse in June 2006. The Trust acknowledged Background to the complaint
and apologised for several errors, including: thefailure to order gluten-free meals; Mr L being Mr L, aged 79, lived in a nursing home and had unable to take anti-sickness medication as it was Alzheimer's disease (he was not able to prescribed in the wrong form; and failure to communicate) and coeliac disease (he required a dispense medication due to wrong information gluten-free diet). In December 2005 Mr L was on a prescription.
admitted to Sel y Oak Hospital (the Hospital) forsurgery to remove a squamous cel carcinoma In July 2006 Mrs L complained to the Commission lesion (a common type of skin cancer). The which, in September 2006, asked the Trust to referral letter to the Hospital explained about provide Mrs L with a response to outstanding Mr L's medical conditions and that he needed issues, which they did in November 2006. Mrs L assistance with eating and drinking. The complained again to the Commission, but it operation, which was successful, took place on decided to take no further action. the day after Mr L's admission. Eight days afterthe operation Mr L was discharged and returnedto the nursing home by ambulance. What we investigated
Mrs L complained to the Ombudsman, in The complaint to the Trust and the Commission
February 2007, about the care and treatmentprovided to Mr L, in particular: Mrs L, Mr L's wife, complained to the Trust inJanuary 2006 about Mr L's discharge • that the Hospital did not pay sufficient arrangements, lack of adherence to his dietary attention to her husband's mental state, requirements, the decision to send him for al owing him to be taken into theatre for surgery when she was not present, and the surgery and later discharged back to the administration and prescription of drugs on nursing home without her being present; discharge (medication was prescribed in thewrong form and other medication could not be • that Mr L was not provided with gluten-free dispensed due to an error on the prescription).
meals during his time in the Hospital, despite She said that an inexcusable lack of consideration the fact that the staff knew about his by the Trust had caused Mr L great distress. In nutritional needs, and Mrs L was forced to February 2006 the Trust offered a number of bring food in for him herself; and explanations and apologised for theinconvenience and distress caused and said that • that Mr L's medication on discharge was wrong, in the light of the complaint they had looked at in that he was not given anti-nausea drugs to 12 Remedy in the NHS June 2008 prevent travel sickness and that his medication trying to rectify the failing or provide was not provided in a soluble form, despite his difficulties with swal owing.
• There was unacceptable confusion over Mr L's Our investigation considered Mrs L's complaints medication, which meant that he was given against the Trust as wel as the Commission's tablets despite his difficulties with swal owing, was prescribed the wrong medication ondischarge, and then did not receive the We had access to al relevant documentation medication because of an error. including Mr L's medical records and thecomplaint correspondence. We also took clinical • The Commission's investigation of Mrs L's advice from an adviser with expertise in the complaint was poor. There was little evidence nursing of the elderly.
that an objective investigation was carried outand no clinical advice was passed on to Mrs L We also took note of the relevant standards about the standard of care and treatment relating to clinical care and the treatment of older provided to her husband, or about the people. Of particular relevance were the National adequacy of the Trust's proposed initiatives to Service Framework for Older People (2001) and address the problems.
the NHS Modernisation Agency's benchmarkingtool ‘Essence of Care'.
The investigation concluded in September 2007and we upheld Mrs L's complaints against theTrust and the Commission.
What our investigation found
• Mr L was caused avoidable distress by the failure to ensure that his wife was presentwhen he was taken for surgery and when he As a result of the Ombudsman's was discharged. There was a lack of awareness recommendations, the Trust took a number of of his needs arising from his Alzheimer's actions, including: disease, because of the failure to adequatelyassess him upon arrival, the lack of a • the production of ‘Al about me' (a document personalised care plan, and the failure to begin aimed at improving communication with discharge planning at an early stage. patients and those caring for patients withdementia, head injuries and learning • The Hospital failed to provide a suitable diet for Mr L, despite being told in advance of hisneeds. It was unreasonable that Mrs L was • the development of a discharge care plan placed in a position where she felt she had to checklist to ensure safe and timely discharge bring food in from home for her husband, from hospital with provision of relevant incurring expense and inconvenience. Hospital information to patients and families; staff had then accepted this situation without Remedy in the NHS June 2008
• a range of dementia training and the • annual benchmarking of the suitability of nomination of an ‘older people's champion' in wards to care for older people with mental each ward or department to review the service • an offer to include Mrs L's experience in the • a review of the Trust's guidelines about Trust's training programme; and communicating with carers and relatives; • nutrition link nurses to highlight the nutritional • a successful bid to re-establish the post of needs of older people and special diets.
Trust Mental Health liaison nurse; As a result of the Ombudsman's recommendationthe Commission wrote to Mrs L to apologise forthe deficiencies identified in its review.
14 Remedy in the NHS June 2008 Complaint against Medway Primary Care Trust (Medway) and West Kent Primary Care Trust (West Kent) Remedy for a former general practitioner who After Mrs B wrote back to Medway confirming retired on health grounds as a result of the poorly her dissatisfaction with the Practice's response, handled investigation of a complaint against her they treated her letter as a request to proceed tothe second stage of the NHS ComplaintsProcedure. Responsibility for arranging a Review Background to the complaint
was delegated to Kent Primary Care Agency (theAgency) which operated under the management In August 2002 Mrs B took steps to register at the of the then Dartford, Gravesham and Swanley Practice at which Dr D worked. A ‘new patient' Primary Care Trust (now West Kent). The check was required before registration could be paperwork relating to the complaint got lost in a completed and was arranged for 3 September.
departmental move. During that appointment an altercation tookplace between Mrs B and the nurse, which Dr D On 2 October 2002 Dr D replied personal y to overheard. She advised the nurse to tel Mrs B Mrs B's complaint, apologising for the delay in that she would not be accepted for registration.
responding, caused by her absence on leave, and Mrs B left the surgery, verbal y abusing the nurse setting out her view of the events of as she left. Dr D fol owed Mrs B into the street, 3 September. On 11 November Medway realised and told her ‘You do not cal my nurse a bitch, that the Agency had not received the complaint lady'. The same day Mrs B sent Dr D a letter of documentation, and they forwarded the papers complaint, to which the Practice Manager replied again; Dr D's letter to Mrs B was not included. On setting out the Practice's view of events. 15 November Dr D wrote to ask the Agency ifthey had taken account of her letter to Mrs B On 6 September 2002 Mrs B wrote to the Chief when considering the Review request. She Executive of Medway to complain about Dr D, pointed out that she had never consulted with apparently not having received the Practice Mrs B. Two weeks later the Agency told Mrs B Manager's letter. Mrs B wrote to the Practice and Dr D that a Convener had decided that a Manager on 8 September, having by then received conciliator might help resolve the complaint.
her letter, explaining that she had complained to They did not answer Dr D's question about her Medway. On 16 September Medway asked Dr D to letter to Mrs B, nor address her point that sherespond to Mrs B's complaint letter and informed had not consulted with her. Mrs B that she could request an IndependentReview (Review) of her complaint if she was In January 2003 Mrs B and Dr D were told that the dissatisfied with the Practice's eventual response.
conciliation process had ended, and that Mrs B Mrs B replied that she had already received a could stil request a Review. She did so. The response from the Practice, which she felt was Practice Manager wrote to ask Medway and the unsatisfactory. Medway told Mrs B that she now Agency how a Review could be considered when had the right to request a Review, but did not say Mrs B was not a registered patient. The Agency they had already asked Dr D to respond directly responded that Mrs B had the same right to complain as any visitor to the Practice. Medwaywrote to Dr D in response to the PracticeManager's letter; they said they understood that aReview Panel had been convened, but did not Remedy in the NHS June 2008
answer the question about whether Mrs B wasentitled to pursue a complaint. In March Dr D'srepresentative wrote to Medway, repeating thatMrs B had never been a formal patient at thePractice. The Panel met in June 2003 and partly upheldMrs B's complaint. They said that Dr D had notbreached her Terms of Service for GeneralPractitioners, because Mrs B had not beenregistered with the Practice. The Panel's reportnoted that the complaint arose out of Mrs B'sattempts to register, but nonetheless said that ‘such a complaint fal s within the guidelines of the Health Service's Complaints Procedure'. Dr D's mental state was such that the day of the hearingwas her last day in general practice. She took sickleave and was admitted in September to apsychiatric hospital with bipolar disorder. Sheretired from general practice on health grounds inMarch 2004.
Dr D complained to the Ombudsman inAugust 2003, wanting an investigation into theprocess that had led to the Panel sitting at al . She felt she had been the victim of a ‘witch hunt' and said that the Trusts' mishandling of thecomplaint against her had cost her her career, and significantly disrupted her personal andfamily life. What we investigated
• The management of the complaint against Dr D, and whether the resulting stress had ledto the deterioration of her mental health andresignation from general practice.
• Dr D's al egations that both Trusts had been biased against her in favour of Mrs B, had 16 Remedy in the NHS June 2008 failed to treat her objectively, and had not • The Trusts' investigation lacked a sense of properly supported her.
perspective and proportionality. It was drivenpurely by process, with an absence of overal • The matter of the jurisdiction of Mrs B's leadership and guidance to determine whether original complaint, since this was a factor in the progress and direction of the investigation assessing the adequacy of the Trusts' were appropriate to the nature of the management of the investigations. • There was no evidence of bias against Dr D, or What our investigation found
that the Trusts had given her insufficientsupport throughout their investigation. • Key documents were not sent to Dr D in a We concluded our investigation in May 2007 andupheld Dr D's complaint. The maladministrative • Medway did not inform Dr D that they had handling of the complaint against her contributed told Mrs B that she could ask for a Review, to a significant change in the nature of a despite asking Dr D to provide a local pre-existing psychiatric il ness. There was resolution letter. extensive and persuasive medical evidence toindicate that that maladministration had led to • Dr D's letter to Mrs B was unreasonably Dr D's retirement on health grounds. dismissed throughout the investigationbecause it arrived very slightly late, despitevalid reasons for the delay. • The fact that a Review into the complaint had Both Trusts agreed to: been arranged was inappropriately disclosed toDr D as an aside in a letter.
• pay the sum of £25,000 to Dr D to remedy the significant injustice to her; • Both Trusts repeatedly failed to answer Dr D's reasonable questions about whether they had • write personal y to her to apologise for their considered her letter to Mrs B, and whether Mrs B was even entitled to pursue a complaintunder the NHS Complaints Procedure. • use our investigation to inform a thorough review of their existing complaint handling • We made no finding, however, on the issue of procedures, and use the findings of that Mrs B's status as a patient with the Practice at review to develop an action plan to be agreed the time of the incident, since the matter with the Healthcare Commission (in its role as turned on technical arguments that could only be settled in a court of law. Remedy in the NHS June 2008 Complaint about Good Hope Hospital NHS Trust (the Trust) (now Heart of England NHS Foundation Trust) and the Healthcare Commission (the Commission) Complaint about the care and treatment of a The complaint to the Trust and the Commission
woman who was later found to have pulmonary hypertension and who died fol owing surgery, and Ms C's mother, Mrs C, complained in a complaint that the Commission did not address November 2003 about the failure to diagnose the Trust's failure to fol ow the Commission's pulmonary hypertension at an earlier stage. She questioned whether the earlier commencementof specialist treatment for Ms C might haveprevented her death. The Trust could not find Background to the complaint
Ms C's medical records. Mrs C had a meeting with Trust staff in April 2004, but this failed to Ms C was 42 when she had a stroke in resolve matters. February 2002 and was admitted to hospital. She had a pulmonary embolus (a blood clot on In September 2004 Mrs C complained to the the lung) and was prescribed Warfarin (an Commission which took clinical advice from a anti-coagulating drug) which was stopped after Consultant Cardiologist, who found a number of six months. Tests were carried out to determine failings in the care provided to Ms C. In her blood clotting levels and to search for a December 2005, the Commission asked the Trust patent foramen ovale (a hole in the heart which to provide explanations of those aspects of would al ow blood clots to travel from the right Ms C's care and to change clinical procedures. The side of the heart to the left side and from there Trust responded in February 2006.
to the brain thus causing a stroke). This test wasperformed initial y using a transthoracic and In April 2006 Mrs C complained to the subsequently a transoesophageal echocardiogram Commission, which said that the Trust had (an ultrasound test that can provide information complied with most of its recommendations, but about the structure and function of the various asked them to respond on the issue of the review areas of the heart). of guidelines for management of pulmonaryembolism. The Trust sent a further reply to After review as an out-patient, Ms C was Mrs C in June 2006 which made no discharged from care but was readmitted in acknowledgement or apology for the failings August 2002 and was found to have another identified by the Commission. pulmonary embolus. She was referred for an MRIscan which was due to take place in March 2003but, before this happened, she moved house. What we investigated
She was subsequently diagnosed elsewhere ashaving pulmonary hypertension and a large Mrs C complained to the Ombudsman in patent foramen ovale. She was transferred to September 2006. The complaints investigated by Papworth Hospital for treatment but died the Ombudsman were that: shortly afterwards.
• the Trust had failed to respond adequately to the Commission's recommendations fol owingits investigation; and 18 Remedy in the NHS June 2008 • the Commission had refused to take any further action despite that failing by the Trust.
As a result of the Ombudsman's We had access to al relevant documentation recommendations the Trust made a payment of including Ms C's medical records and the £500 to Mrs C in the light of the serious failings in complaints correspondence. We took clinical their complaint handling and to recognise the advice from a consultant cardiothoracic surgeon.
additional distress caused by their responses toMrs C fol owing the Commission's review. What our investigation found
We found that the Commission had carried out • apologised for the loss of records and an appropriate initial review of Mrs C's complaint explained that they had introduced a tracking that identified failings by the Trust and made system for physical documents, an electronic patient record for clinical data and weremoving towards al patient documentation We found that the Trust's response to the being accessible electronical y; Commission's recommendations was inadequate.
They had failed to acknowledge the failure in care • produced an amended template for recording and to explain the reasons for it. Neither had and reporting echocardiograms to help ensure they accepted the Commission's recommendation that clear diagnosis is obtained; that reporting procedures or guidelines neededto be reviewed. • reviewed their guidelines for the management of pulmonary embolism and We found that the Commission had failed to implemented those recommended by the properly consider Mrs C's subsequent complaint British Thoracic Society; about the Trust's response.
• offered an explanation of the criteria that We found that the Trust's actions (through would have led to onward referral for Ms C, mislaying papers and not responding an acknowledgment of the fact that a referral appropriately to the Commission's could have been made earlier and an apology recommendations) had caused Mrs C to suffer that the process was so protracted. They said distress and delay in receiving the explanation and that training was to be provided to staff to response to which she was entitled.
increase awareness of symptoms of pulmonaryhypertension and the need for onward referral; The investigation concluded in July 2007 and weupheld Mrs C's complaint that the Trust failed to • explained the procedure surrounding respond adequately to the Commission's transoesophageal echocardiogram tests and recommendations and that the Commission failed the reasons for delays in scheduling the MRI to properly consider her subsequent complaint scan for Ms C. They said that transoesophageal about the Trust's response.
echocardiograms that do not provide clearresults would be discussed at regular meetings Remedy in the NHS June 2008
and that transoesophageal echocardiogramresults would be audited for quality of dataand accuracy of interpretation. A leadconsultant for this work had been identifiedand staff training had led to British Society ofEchocardiography accreditation; and • acknowledged and apologised for the failure of care towards Ms C.
The Commission wrote to Mrs C to apologise forthe failings identified by our report.
20 Remedy in the NHS June 2008 Complaint about South Devon Healthcare NHS Foundation Trust (the Trust) and the Healthcare Commission (the Commission) Complaint about the care and treatment of The complaint to the Trust and the Commission
a patient in relation to a bilateral mastectomy, and complaint about the Commission's Two days after her discharge Mrs N complained to subsequent review the Trust in writing about the appropriateness ofthe surgery and the consent procedure in relationto the nature and extent of potential scarring. The Background to the complaint
Chief Executive responded to the complaint inSeptember 2005 and said that the bilateral In December 2004 Mrs N was referred by her GP mastectomy was the correct procedure and that for a mammogram which showed that she had the surgeon had acted appropriately.
smal tumours in both breasts. A bilateralmastectomy (surgery to completely remove both Mrs N remained dissatisfied and in October 2005 breasts) was recommended.
she complained to the Commission which foundthat the procedure was appropriate and the In February 2005 Mrs N attended Torbay Hospital scarring within normal range. It did, however, find where she was provided with information about shortcomings relating to consent and asked the her condition. Mrs N discussed the issue of Trust to look at those issues (both in terms of scarring with the Breast Care Nurse and reminders to staff about the importance of emphasised that the position and cosmetic ensuring that consent forms were completed ful y, appearance of the resulting scars were both very and giving patients the opportunity to ask important considerations for her. Later that questions when there is a time lag between month, the Consultant Surgeon who was to consent being given and an operation carried out) perform the operation gave Mrs N a consent form and to inform Mrs N of resulting changes into sign; however, she had yet to decide whether policy. The Commission, in two replies (February she would proceed with the proposed surgery and and March 2006) concluded that, despite thedid not sign the form immediately. shortcomings identified, consent had beenobtained on a properly informed basis.
In March 2005 Mrs N signed the consent form.
She was admitted to Torbay Hospital in early
April 2005, and underwent a bilateral mastectomy. What we investigated
When the bandages were removed Mrs N washorrified to discover that, rather than two scars In April 2006 Mrs N complained to the below the breast line, as she had been expecting, Ombudsman. Our subsequent investigation she had been left with what appeared to be a single horizontal scar across her chest wal , aboveher breast line. Mrs N was shocked and extremely • the Commission's handling of her case; and distressed by the extent, position and appearanceof her scarring and raised her concerns • the standard of care and treatment provided immediately with a member of the Trust's staff.
by the Trust in terms of informed consent, and Mrs N was discharged the next day.
the appropriateness of the procedure.
Mrs N made clear that she had pursued her decide whether or not to go ahead with the complaint in order to have it acknowledged that surgery with ful knowledge of the potential risk the operation she received was not the one for which she gave consent, not to obtain financialcompensation.
The investigation found that, having reviewedappropriate evidence and sourced appropriate We examined al the relevant documentation and advice, the Commission's resulting decision that obtained specialist clinical advice from a Mrs N's consent was ful y informed was Consultant Breast Surgeon who is also a Professor unreasonable, as it did not properly reflect the of Breast Cancer. We also took account of the evidence assessed or clinical advice received. relevant standards contained in the Department This caused Mrs N additional inconvenience of Health's ‘Reference Guide to Consent for and distress.
Examination or Treatment' (2001) and the GeneralMedical Council's ‘Seeking patients' consent: The The investigation concluded in February 2008 and ethical considerations' (1998).
we upheld Mrs N's complaints against both theTrust and the Commission.
What our investigation found
We found that the bilateral mastectomy was anappropriate procedure for Mrs N.
As a result of our recommendations the Trust andthe Commission agreed to apologise to Mrs N for We found that some parts of the consent process the shortcomings identified in our report and the were reasonable, insofar as different treatment injustice she had suffered. options were described, nursing staff wereinvolved in the consent-making process, and In addition to the action they had taken as a Mrs N was given the opportunity to reflect before result of the Commission's recommendations, theand after making a decision. However, we noted Trust also agreed to give Mrs N an assurance that that there was no review of the consent at the lessons had been learnt from her complaint and time of the admission immediately before the an explanation of the changes made to prevent operation. We also concluded that, based on the such failures being repeated.
information given to Mrs N pre-operatively, itwould have been reasonable for her to expecttwo separate scars running horizontal y across thelower to middle part of her chest. The fact thatMrs N was not given more specific informationabout the risks of the procedure impacted on herability to give ful y informed consent. We foundthat, overal , there were sufficiently seriousshortcomings in the consent process toundermine the validity of the consent, with theresult that Mrs N was denied the opportunity to 22 Remedy in the NHS June 2008 Complaint about Southend Hospital NHS Trust (the Trust) and the Healthcare Commission (the Commission) Complaint about the care provided to an elderly January 2003, he appeared to be better and was dying man, the attitude of staff towards him and sitting out of bed, although he was stil very his wife, and about the way a complaint was depressed. Over the next week, his condition handled by both the Trust and the Commission fluctuated as he became drowsy anduncommunicative, and unwil ing to eat or drink.
He refused further intervention and said that he Background to the complaint
wanted to be left alone. As time went on, he wasin more pain; his opiate painkil er dose was Mr V was 86 years old when he was admitted to increased and given on a regular basis. He became Southend Hospital in December 2002, unresponsive, and his condition deteriorated complaining of abdominal pain, intermittent further. He died in mid-February 2003.
vomiting and diarrhoea. He had a history ofdiverticulitis (a digestive disease caused byinflammation of pouches which have formed on The complaint to the Trust and the Commission
the outside of the colon) and irritable bowelsyndrome with chronic abdominal pain. On this Mrs V, Mr V's wife, complained to the Trust in occasion, the doctors diagnosed a smal bowel December 2003. She attended a meeting with obstruction: he was given intravenous fluids as them in February 2004 at which statements by the diarrhoea and vomiting had made him nurses (which detailed their communications with Mrs V about her husband's care) were read out.
Mrs V was extremely upset by those statements; Mr V was cared for in the Intensive Care Unit for the Trust then wrote to her expressing regret that two days and, having made an initial recovery, was the meeting had not resolved matters, but gave transferred to a surgical ward and then, 13 days no explanations about her husband's care. An later, to a medical ward. Within a few days of this exchange of letters fol owed and, in August 2004, latter transfer, Mr V became less wel . He Mrs V requested a further meeting; the Trust complained of abdominal and back pain, became refused and said that she could approach constipated and had a poor appetite. His left arm the Commission.
became swol en and pressure sores developed onhis elbows; MRSA was detected in the left elbow.
In May 2005 the Commission referred Mrs V's He appeared depressed and was given an complaint back to the Trust, asking that a antidepressant. It seemed that a long-standing conciliation meeting be held. Neither Mrs V nor thyroid function problem was not being the Trust agreed to this. In September 2005 Mrs V adequately addressed, so his thyroxine daily dose complained to the Ombudsman. As the was increased.
complaint had not been investigated by theCommission, it was referred back for review. In Mr V then developed a fever and blood tests January 2006 the Commission wrote to Mrs V, indicated an infection, so he was given with their final decision, suggesting that she intravenous antibiotics. Nine days later, Mr V contact the Information Commissioner if she complained of back pain and was prescribed an wished to have medical records corrected. Mrs V opiate painkil er. Over the fol owing fortnight, contacted the Ombudsman again in Mr V's chest condition improved. By the end of February 2006.
Remedy in the NHS June 2008
What we investigated
• staff were unhelpful and unsympathetic to both Mr and Mrs V; and Mrs V remained concerned about the care herhusband received on the ward and subsequent • neither the Trust nor the Commission had complaint handling. Her complaints responded adequately to her complaints.
correspondence made clear that she believedthat Mr V had been caused undue suffering and We had access to Mr V's medical and nursing stress and that she had been caused unnecessary records and al of the complaints distress by the way in which her complaints had correspondence. We also took clinical advice been handled. The main elements of her from a Hospital Consultant with experience in the Care of the Elderly and a Senior Hospital nurse.
• the nursing care provided to Mr V on the In framing the recommendations on this case we medical ward was inadequate; made particular reference to the NHSModernisation Agency's benchmarking tool‘Essence of Care' (2003).
24 Remedy in the NHS June 2008 What our investigation found
We found that while there was evidence of As a result of the Ombudsman's reasonable medical and nursing care in most recommendations the Trust: areas, there had not been adequate planning forcommunication with Mr and Mrs V. Mrs V had • wrote to Mrs V in October 2006 to apologise; also been very concerned to see her husband inpain, and we found that pain relief interventions • said that the Deputy Ward Manager would could have been made at an earlier stage. attend a specialist external training course onrecord keeping and then facilitate training There was also evidence in the nursing records sessions for staff on record keeping. These and statements made by nursing staff that they elements would also be emphasised in staff had found it difficult to deal with Mrs V. It induction and in ongoing training; appeared that they had held negative perceptionsof Mrs V and had provided little support when • put in place a programme to implement the her husband died. We found that junior staff had ‘Essence of Care' communication standard and not been wel supported by their seniors in al other ‘Essence of Care' standards, with the dealing with a difficult situation. assessment of the medical ward to take placeas part of that programme; and We found that the Trust had failed to addressMrs V's complaint adequately by not responding • reviewed and republished their complaints to her original concerns about Mr V's care and policy and procedure (along with other that this served to increase her distress.
supporting documentations) with particularemphasis on the support available to staff We found that the Commission failed to members in handling ‘Difficult situations or adequately address Mrs V's concerns about the complainants', the need to avoid judgmental Trust as it misunderstood her complaint, believing statements and a designated framework for it to be about inaccuracies in medical records and conducting local resolution meetings.
therefore advising her to approach theInformation Commissioner. The investigation concluded in October 2006 andwe upheld Mrs V's complaints against the Trustand the Commission.
Remedy in the NHS June 2008 Complaint about Cambridge University Hospitals NHS Foundation Trust (Cambridge) and Hinchingbrooke Health Care NHS Trust (Hinchingbrooke) Complaints about the assessment and (ICU) lead – the difficulty of placing a breathing management of an adolescent's scoliosis; the tube in Q's throat because of his rigid neck. It was post-operative care and treatment which led to decided to pass a flexible fibre optic scope his death; and the handling of complaints about through Q's nose to visualise the opening of the windpipe and to pass a breathing tube over thescope and into his windpipe. That wasaccomplished and the operation went according Background to the complaint
to plan. Dr Y and Dr P decided to keep Q on abreathing machine for 24 to 48 hours after the In January 2000 Q, then aged 13, attended a surgery, by continuing to ventilate him through combined Spinal Deformity Clinic at Cambridge the nasal tube. After surgery Q was transferred to (the Clinic), at which Mr M (Paediatric the ICU, where he was placed on volume Orthopaedic Surgeon) and Mr H (Visiting control ed ventilation and received fluids. There Consultant Orthopaedic Surgeon from were unexpected problems with Q's care: he Hinchingbrooke) assessed children and developed Adult Respiratory Distress Syndrome adolescents with scoliosis (a spinal deformity).
(ARDS – a severe form of acute lung injury) from Q was assessed as having scoliosis and put on the which he did not recover. He lost fluids and his waiting list for surgery. In January 2001 Q's father, blood pressure dropped. A central venous Mr R, asked if the operation could be carried out pressure line was inserted and a tracheostomy in early summer. Mr H explained that many was performed, al owing the nasal tube to be parents wanted their children treated at a time removed. Secretions on the tube from sinusitis that did not interfere with schooling, but he cultured positive for MRSA. Steroids were started would do what he could. as treatment for the acute lung injury but Q'scondition continued to deteriorate. He died on In September 2001, shortly before the planned 27 July, aged 17. operation, Mr H belatedly reviewed an MRI scantaken in April, which had been filed away. Thescan indicated a Syrinx (abnormal dilation of the The complaint to the Trusts
central canal of the spinal cord). The surgery tocorrect that took priority over the scoliosis In August 2003 Mr R asked both Trusts to review surgery, and was carried out at Cambridge in Q's treatment to find out what had contributed April 2002. The procedure markedly decreased to his son's death. He also raised concerns, Q's neck mobility. It was noted that Q's parents including the management of Q's scoliosis and his preferred the scoliosis care to be continued at care in the ICU. Hinchingbrooke's report to Mr R Cambridge, but Mr M had no access to contained explanations from the clinicians appropriate beds there. concerned. It concluded that Q's ‘untimely death was not the result of a single or even several Mr H and Mr M carried out the scoliosis surgery specific incidences of carelessness, neglect or at Hinchingbrooke on 17 June 2003. Before the inadequate care'. Cambridge apologised for the operation, the Consultant Anaesthetist at failure to either forward Q's MRI scan results to Hinchingbrooke (Dr Y) discussed with Dr P – the Hinchingbrooke or for them to have been read Consultant Anaesthetist and Intensive Care Unit and acted upon at Cambridge. Mr R's subsequent 26 Remedy in the NHS June 2008 request for an Independent Review was refused by In considering Mr R's complaints, we soughtthe Convener, despite a Consultant Anaesthetist's advice from a Consultant Orthopaedic Surgeon, a report identifying shortcomings in Q's care and Consultant Orthopaedic and Spinal Surgeon, a treatment in the ICU. Mr R complained to the Consultant in Paediatric Intensive Care, a Ombudsman in December 2004. Consultant Anaesthetist and a Nurse Consultantin Critical Care. We also considered evidenceprovided by Mr and Mrs R at interview and in What we investigated
writing, the documents relating to the Trusts'response to Mr R's original complaint, relevant In terms of the assessment and management of clinical records, and the testimony of Mr M and Q's scoliosis we investigated the fol owing Mr H. We also discussed the management of Q's anaesthesia and post-operative care with Dr Yand Dr P. We gathered information from the • the nature of the scoliosis was not adequately Trusts about planned changes to the Clinic and took account of the ‘British Scoliosis SocietyGuide to Practice' (2001). • investigations were not undertaken with sufficient promptness and regularity; What our investigation found
• there was a delay in reviewing the MRI scan; Assessment and management of the scoliosis
• Q was not prioritised appropriately; There should have been a paediatric assessmentfor Q because of the length of time since • there was no reassessment about where the his previous assessment (in 1995). Mr H now scoliosis surgery should take place; and ensures that al younger patients go for paediatric assessment. • whether the organisation of the Clinic had any detrimental effect on Q's assessment and It was not common practice in 2000 to request an surgical treatment.
MRI scan of a scoliosis patient until surgery wasclearly indicated, unless there were additional On Q's post-operative care and treatment we factors. In Q's case there were no abnormal signs and surgery was not indicated untilDecember 2000. Although it would have been • the management of ventilation and best practice to order regular X-rays every six months, the length of time between X-rays(December 2000 and September 2001) was • the MRSA infection; and not unreasonable. • the standard of nursing care.
Clinicians must take responsibility for ensuringthat test results are reviewed; in this case there We also investigated the Trusts' was a failure to review an MRI scan promptly.
Remedy in the NHS June 2008 Mr H was limited to six sessions a year to undertake scoliosis surgery requiring two The Trusts' responses to Mr R's original surgeons and was faced with conflicting demands complaints were inadequate and did not answer from his patients. Problems with waiting times his questions. Neither Chief Executive explained and prioritisation for scoliosis patients were not about the arrangements at the Clinic which led to uncommon in 2000-01; therefore it was some patients entering a different care pathway unreasonable to hold Mr H individual y from other patients with similar clinical needs.
responsible for the pressures on the service. Hinchingbrooke's response to Mr R's complaintwas effectively provided by the clinicians Because of his rigid neck and the degree of spinal concerned, and their failure to thoroughly review curvature, Q would have benefited had a the factors which contributed to Q's unexpected multi-disciplinary pre-operative discussion taken death was unacceptable. We were highly critical place in order to assess the risks of the of the decision to refuse Mr R's request for an anaesthesia and the most appropriate site for Independent Review. While the ICU team scoliosis surgery. undertook a clinical review of Q's death,Hinchingbrooke did not take the opportunity to The combined Clinic arrangements did not analyse the failings which contributed to the provide the necessary infrastructure to support problems with Q's care and treatment and to al scoliosis patients referred to it. Adolescent learn lessons.
scoliosis patients entering the Hinchingbrooke‘stream', such as Q, were disadvantaged because We upheld most aspects of Mr R's complaints.
they did not access the advice and support of Individual and organisational failings resulted in paediatric anaesthetists and paediatric intensive the assessment and management of Q's scoliosis care staff that was available to Mr M's patients. fal ing below a reasonable standard. Althoughthese shortcomings were unlikely to have Post-operative care and treatment
impacted on the correction of the scoliosis, they The management of Q's post-operative led to unnecessary delays and increased ventilation was poor and, in al likelihood, had discomfort and distress for Q. The organisation of contributed to the damage to his lungs. The the combined Clinic had a detrimental effect on ventilatory parameters used immediately after Q's assessment and surgical treatment, as Mr H's surgery were too high for a patient of Q's age and patients did not have the benefit of the build, and the ventilation strategy used was not multi-disciplinary support and assessment consistent with accepted practice in 2003. The available to Mr M's patients. There were avoidable management of Q's fluid balance was deficient factors which led to the development of ARDS and the excessive fluid transfusion contributed to and Q's subsequent death. Mr and Mrs R had a the rapid onset of ARDS. We were satisfied that right to expect a thorough, joint investigation of MRSA did not contribute to Q's deterioration the arrangements at the Clinic fol owing the and we found no deficiencies in the nursing devastating loss of their child, but the Trusts' responses to their complaints and concerns were inadequate. 28 Remedy in the NHS June 2008 Our recommendations to Cambridge includedthat they: We made 14 recommendations aimed at bringingabout systemic improvements to services for • provide evidence that the arrangements for adolescents with scoliosis, and assisting both the transfer of the results of investigations, Trusts in addressing the very serious issues raised correspondence and other records for Mr H's by our investigation. Al our recommendations patients from the Clinic to Hinchingbrooke Both Trusts agreed that: In addition, both Trusts agreed to address thearrangements for pre-operative cardiopulmonary • each Chief Executive would send a letter of apology to Mr and Mrs R for the shortcomingsidentified and the failure to investigate theirson's death adequately; and provide them withdetails of the action taken in response to ourrecommendations and of the changes to theSpinal Deformity Service. Among the recommendations we made toHinchingbrooke were that they: • revise their management of ventilation and fluids in intensive care and their managementof intra-operative fluid balance during anymajor operation with risk of significant bloodloss or prolonged surgery. In doing so, werecommended that they revisit the publishedresearch and rewrite their guidelines in linewith current knowledge and expert opinionfrom the local Network and the Royal Col egeof Anaesthetists; and • ensure that the Chief Executive and the Medical Director receive assurance thatcurrent anaesthetic and ICU practice is safeand that they consider the further stepsneeded to understand the factors thatcontributed to Q's death.
Remedy in the NHS June 2008 Complaint about Cambridgeshire and Peterborough Mental Health Partnership NHS Trust (the Trust) and the Healthcare Commission (the Commission) Complaint about a decision to withdraw an a private arrangement, largely by neighbours. anti-dementia drug, Aricept, from an elderly Mr S had been recently widowed, but he had two patient, about the care and treatment adult sons who monitored his situation closely. In provided to him subsequently, and about March 2004 Mr S's condition had deteriorated the Commission's review and he was admitted to hospital. Mr S remainedan in-patient until September 2004 when he wasdischarged to a nursing home.
Background to the complaint
Mr S was referred to the Trust by his GP in The complaint to the Trust and the Commission
May 2002 because of poor memory and was seenby a Consultant Psychiatrist for Older People in In July and August 2004 Mr S's son, Mr T, June 2002. It was thought that Mr S had mild complained to the Trust about a number of issues cognitive impairment but that dementia might be relating to Mr S's care including: the failure to developing and an anti-dementia drug, Exelon, inform Mr S's family and those caring for him was prescribed. In July 2002 Exelon (which had about the stopping of Aricept; the lack of a care made Mr S unwel ) was replaced with a plan fol owing that; and the fact that Mr S's prescription for Aricept. Mr S attended further condition had been al owed to deteriorate. The appointments in September and November 2002.
Trust replied in September 2004 and provided a At that stage it was intended that he would number of explanations as wel as several continue taking Aricept and that his mental apologies relating to communication with Mr T state would be assessed by a Community and the provision of information to him.
Mr T complained to the Commission in By May 2003 Mr S's GP considered that his mental October 2004. In November 2005 the state had deteriorated and asked for him to be Commission told Mr T of its decision to refer reassessed. When Mr S was reassessed in July and matters back to the Trust to provide details November 2003 it was noted that his memory about the guidelines used to discontinue Aricept.
was continuing to deteriorate, that he wouldcontinue to be monitored and that the In December 2005 Mr T complained to the Community Psychiatric Nurse would keep in Ombudsman. However, as the Commission had touch with his carers to discuss any concerns.
not sought independent clinical advice, werecommended that it look at the complaint again.
In January 2004 Mr S was seen by a Staff Grade The Commission sent its revised decision to Mr T Psychiatrist for Older People, with the result that in February 2006 advising that the clinical care the Aricept was stopped and Mr S was discharged given to Mr S was appropriate, that guidelines had to the care of the Community Mental Health been fol owed but that the Trust could have Team. At this time Mr S was living in his own provided more information to Mr T.
home and his day-to-day care was provided under 30 Remedy in the NHS June 2008 What we investigated
What our investigation found
In March 2006 Mr T complained to the Our investigation found that the Trust failed to Ombudsman. Our investigation covered the communicate significant changes in Mr S's fol owing concerns: treatment plan (that is, the withdrawal of Aricept)to those most closely involved in his care. • the Trust withdrew Aricept from Mr S in January 2004 without informing Mr T, his We found that the Trust did not identify and plan carers, or the local social services department; for the risk of Mr S's deterioration fol owing thedecision to discontinue Aricept and also failed to • fol owing the decision to withdraw Aricept no ensure that Mr S was adequately monitored after care plan was devised and implemented, and the Trust failed to monitor Mr S to avoiddeterioration; We found that there would have been no benefitin re-prescribing Aricept to Mr S, even though • Aricept was not re-prescribed to Mr S despite this was recommended by a member of the the opinion of a member of Trust staff that it should be, and despite Mr T's repeatedrequests; We found no documented evidence of anyconsideration of Mr S's individual circumstances in • the Trust applied the National Institute of the application of the NICE guidelines. Clinical Excel ence (NICE) guidelines strictlyand without thought or consideration for We found that Mr S was given the opportunity of Mr S's individual circumstances; review by an alternative Consultant Psychiatristfor Older People. • the Trust denied Mr T's request for a change of consultant for his father; We found that the Commission did not takesteps to understand Mr T's complaint ful y; • the Commission's handling of Mr T's complaint failed on two occasions to take independent was inadequate.
medical advice from an appropriately qualifiedperson with the necessary expertise; did not We examined al relevant documentation provide Mr T with an adequate explanation concerning the case, including complaint for its decision; and failed to respond in a correspondence, Mr S's medical records, and the Commission's papers. We also obtained clinicaladvice from an experienced Consultant Our investigation concluded in March 2007 Psychiatrist. We also took into account the and partly upheld the complaint against the relevant NICE guidelines in place at the time, Trust and ful y upheld the complaint against ‘Technology Appraisal Guidance No 19: Guidance the Commission.
on the Use of Donepezil [Aricept], Rivastigmineand Galantamine for the Treatment ofAlzheimer's Disease'. Remedy in the NHS June 2008
As a result of the recommendations made in ourfinal report the Trust also agreed to: The Trust had, before our investigation concludedin March 2007, already taken some action in • apologise to Mr T and provide him with response to Mr T's complaints including: evidence that senior medical staff have been apologising for the lack of communication over reminded of the importance of careful the withdrawal of Aricept; revising their care plan monitoring and fol ow-up of patients where approach which includes the identification and medication is discontinued; and management of risk; undertaking to remind seniorstaff of the need for monitoring and fol ow-up • conduct an audit of consensus meeting where medication is discontinued; and a documentation (to ensure that this format is structured format for consensus meetings (which used and that the requisite level of should result in proper recording of the information is recorded).
decision-making process and factors taken intoaccount when medication is discontinued).
The Commission agreed to apologise for thefailings identified in our report.
32 Remedy in the NHS June 2008 Complaint about Berkshire Healthcare NHS Trust (the Trust) Remedy for poor treatment of an adolescent girl her GP to refer Miss G to the private clinic. suffering from anorexia nervosa Mrs G took out a loan of £45,000 to pay for thetreatment. Al the other patients at the clinicwere said to be NHS-funded. Miss G put on Background to the complaint
weight and was discharged in December.
Miss G was 15 years old when she was referred tothe Berkshire Adolescent Unit (the Unit), because Complaint to the Trust
of weight loss and self-induced vomiting, inNovember 2002. She was assessed at the Unit in Mrs G complained to the Trust in August 2003 January 2003, and admitted to a re-feeding and received the Chief Executive's response in programme in February. Miss G used laxatives and November. Amongst other things, the letter said diuretics and made herself sick in order to lose that the matter of Miss G having absconded any weight gained. She left the programme in would be fol owed up in the Unit. Mrs G was March, and a week later took an overdose, having dissatisfied with the response and approached felt guilty about eating something at a barbeque. the Independent Complaints Advocacy Servicefor help. They referred her complaint to the In May 2003 Miss G was readmitted to the Ombudsman in May 2004. programme, but continued to lose weight. On14 May the Consultant Psychiatrist, Dr Z, metMiss G for the first time. Because of Miss G's What we investigated
poor progress at the Unit, her mother askedabout a transfer to a specialist unit within the We investigated Mrs G's al egations that the Unit NHS or to the private sector. Fol owing this had not provided adequate care for Miss G; that meeting Miss G attended the Unit as an in- there were failings in the care provided by the patient on weekdays, but she stil felt distressed if Unit, in that she was able to abscond from there;she put on weight. and that Miss G was not seen personal y by theConsultant Psychiatrist until May 2003. Mrs G told Miss G absconded from the Unit four times in us that she did not want any other family to have June 2003. On the first occasion she telephoned the same experience. She had sought help from her mother to let her know that she had left the the private sector, when she thought her Unit; Unit staff were unaware that she had gone.
daughter's life was in danger, and wanted to be Miss G took another overdose in July, fol owing reimbursed for the loan. which Mrs G asked Dr Z if her daughter could betransferred to a named private clinic (which A Consultant and Professor of Adolescent specialised in treating anorexia nervosa in children Psychiatry and two Psychiatric Nursing Assessors and adolescents) as an NHS patient because she provided us with advice on clinical issues and felt that her daughter had deteriorated. In nursing matters. mid-July, at a time when Miss G was in a poorstate, Dr Z and others who might have advised As the National Institute for Clinical Excel ence Mrs G about her daughter's ongoing care were al (NICE) did not issue its guidelines about eating on leave. Feeling she had no alternative, she asked disorders in adolescents until 2004, we relied on Remedy in the NHS June 2008 our clinical advisers to indicate the care standards not offered other choices, nor given a clear sense that Miss G and her family could reasonably have of direction when al local options seemed to be expected in 2003. We were advised that the ineffective, inappropriate or unavailable. response to treatment of young people withanorexia nervosa is very variable and tends to be Although the Chief Executive told Mrs G in poor when laxative and diuretic misuse and November 2003 that the issue of Miss G having self-harm are involved. Some aspects of progress absconded would be fol owed up in the Unit, the would be expected within six months, however, letter was dated some five months fol owing the and it would be of concern if none of these were event. It was not apparent that an urgent apparent. These include some engagement with investigation had been carried out immediately treatment aims and development of good fol owing Miss G's undetected absence. relationships with one or two key staff; and somecontainment of the young person's maladaptive The gap between Miss G's admittance to the Unit eating and associated non-eating behaviours. and being seen by Dr Z was unacceptable, givenher clear lack of progress, a moderate to high We expected the Unit to have policies on level of risk and high parental concern. observation and assessment, and an approach tothe planning of care consistent with the Care We concluded our investigation in Programme Approach (CPA). Further guidance was November 2007, and upheld Mrs G's complaint.
set out in ‘Modernising the Care Programme The service failures described above, together Approach', issued by the Department of Health in with the fact that she was left without any clear 1999, which noted that risk assessment and guidance about when a decision might be made management are integral components of CPA, about referring Miss G elsewhere left Mrs G and that contingency planning should be an fearing for her daughter's life. element of risk management as a means ofpreventing and responding to crises.
Arrangements for handling crises are expected to be included in care plans. The Trust agreed to apologise to Mrs G for theirfailures and for the distress caused to her, and to What our investigation found
pay her compensation of £500; to reimburse Mr and Mrs G the ful cost of the private We found that the Unit had no adequate systems treatment and to pay the interest on the loan; in place for care planning, communication, risk to ensure that they have a clear policy on assessment and risk management to provide out-of-area treatment that can be shared with Miss G and her parents with a sense of parents and patients; and to implement the NICE engagement and containment, nor did it give Clinical Guideline 9 (‘Eating disorders – Core them a clear sense of direction about Miss G's interventions in the treatment and management care. She lost weight and her health and safety of anorexia nervosa, bulimia nervosa and related were compromised by a lack of effective eating disorders'). arrangements to manage the risk that herbehaviour presented. Miss G and her parents were 34 Remedy in the NHS June 2008 Complaint about Peterborough and Stamford Hospitals NHS Foundation Trust (the Trust) and the Healthcare Commission Complaint about a decision to discharge from acknowledged by the Trust in their discharge hospital an elderly vulnerable patient, who died letter and said that the Trust were being asked to shortly after readmission, and complaint about explain what action they had taken on that point.
the Commission's review.
In December 2005 the Trust sent a furtherresponse to Mr F. They apologised for any distress Background to the complaint
caused and explained that they were trialing anelectronic discharge letter. They said also that a Mr E, aged 88 years, went to live in a nursing letter used for inter-hospital transfers was being home in September 2004. He suffered with extended to transfers to nursing homes in severe dementia. In January 2005 he was admitted complex cases and that the importance of to Peterborough District Hospital with signs of providing complete and legible information in internal bleeding and a chest infection, and, discharge letters was being emphasised in training 17 days later he was discharged back to the and in staff meetings.
nursing home. Three days later he was readmittedto the hospital where he died at the beginning In December 2005 Mr F complained to the of February.
Ombudsman but as the Commission had notsought independent clinical advice during itsreview it was asked to look at the complaint The complaint to the Trust and the Commission
again. In February 2006 the Commission sent itsrevised decision to Mr F and said that, having Mr E's son, Mr F, complained to the Trust in taken clinical advice, it took the view that February 2005. He raised concerns about the the Trust's documented actions, including the discharge decision and its planning, and their recommended fol ow-up actions, appeared communication with the nursing home and The Trust replied in March 2005 that Mr E had What we investigated
been properly assessed and discharged safely.
They apologised for the fact that the Ward In March 2006 Mr F complained to the Manager had failed to inform the nursing home Ombudsman. The investigation covered the that Mr E was no longer diabetic and for a lack of fol owing concerns: information in the discharge letter to Mr E's GP.
• the Trust should not have discharged Mr E Mr F remained dissatisfied and in June 2005 the from hospital in January 2005; Commission confirmed that it would look at hiscomplaint. The Commission then looked at Mr F's • the Trust did not discharge Mr E with a care complaint and replied in November 2005. It plan. Instead, the hospital left it to the staff at referred to a breakdown in communication the nursing home to devise a care plan but did between the hospital and the nursing home but not provide them with sufficient information said it was not apparent that this was the fault of with which to write one; the Trust's nursing staff. It referred to the gaps Remedy in the NHS June 2008 • neither the nursing home nor Mr E's GP was they apologised for the fact that Mr E was properly informed about his condition and discharged without more investigation into his treatment on discharge from hospital. Proper procedures for the discharge of vulnerablepatients were not fol owed; We found that the Trust were under noobligation to discharge Mr E with a care plan. • the Trust refused to provide the nursing home with information about Mr E's condition; We found that the Trust's discharge letter wasinadequate, that the use of a telephone cal from • the Commission's handling of Mr F's complaint the Trust to the nursing home to provide was inadequate.
additional information was not an appropriateway to handle this complex discharge and that We examined al relevant documentation good practice would have involved a higher level including complaint correspondence, copies of of pre-discharge liaison with the nursing home. Mr E's medical records and the Commission'spapers. We also obtained advice from a We did not find any evidence to support the geriatrician and from a nurse with significant complaint that the Trust refused to provide the experience of older people's care.
nursing home with information about Mr E. We took account of the prevailing standard We found that the Commission's handling of which in this case was the Department of Mr F's complaint was inadequate as it failed to Health's ‘Discharge from hospital: pathway, obtain independent clinical advice from an process and practice' (2003).
appropriately qualified person with the necessaryexpertise and did not give an adequateexplanation for its decision.
What our investigation found
Our investigation concluded in March 2007 and We did not find evidence to support the Trust's we partly upheld Mr F's complaint against the decision that Mr E was ready to be discharged Trust and ful y upheld his complaint against from hospital. This is not to say that, had he the Commission.
remained in hospital, the outcome for Mr E wouldhave been any different. Rather, the Trust shouldhave carried out a more thorough assessment of his needs at that time and of the ability of thenursing home to care for him. Because the acute The Trust agreed to review their documentation il nesses that Mr E was suffering from had on pre-discharge planning and their procedures to improved and his vital signs were within normal ensure compliance with Department of Health limits, it was assumed that Mr E was fit for guidance on the proper discharge of complex discharge. Instead, the totality of relevant factors elderly patients.
should have been considered. The Trust agreedthat Mr E should have remained in hospital until a The Commission agreed to apologise to Mr F for ful assessment was made before discharge and the shortcomings identified in our report.
36 Remedy in the NHS June 2008 Complaint about Dr Mrozinski, a locum GP Complaint that a GP unreasonably prescribed The complaint to Trafford North/South Primary
amoxicil in to a patient recorded as being al ergic Care Trust (the Trust) and the Healthcare
to penicil in, and mishandled the patient's Commission (the Commission)
subsequent complaint On 28 June 2004 Mrs K complained to the Trust,asking for an apology and compensation for her Background to the complaint
ruined honeymoon and the distress Dr Mrozinskihad caused her. After Dr Mrozinski failed to Mrs K's history of penicil in al ergy, based on her attend a local resolution meeting arranged by account of a previous reaction, was marked on Mrs K's GP, she told the Trust that she wanted a her medical summary card, on her Lloyd George ful written response to her complaint from (paper) folder and on her computer records. Dr Mrozinski. His eventual reply did not provide On 3 June 2004, shortly before her honeymoon an account of his actions nor explain why he had in Mexico, Mrs K had an appointment for prescribed antibiotics. He said that if Mrs K was vaccinations at the surgery. The Nurse was questioning his clinical competence or claiming concerned about vaccinating Mrs K, who was gross professional misconduct she should contact congested, and arranged for her to see the General Medical Council (GMC). If she was Dr Mrozinski. By Mrs K's account Dr Mrozinski claiming medical negligence she should expect a asked her if she was al ergic to antibiotics, to possible counterclaim. The Trust made several which she replied: not that she was aware of.
attempts to engage Dr Mrozinski in the (Mrs K was aware of her penicil in al ergy but did complaints process, and reminded him of his not associate antibiotics with penicil in.) responsibilities under the GMC guidance and Dr Mrozinski prescribed a five-day course of NHS Complaints Procedure. When no substantive amoxicil in, an antibiotic of the penicil in family. response was forthcoming, Mrs K took hercomplaint to the Commission, which began Mrs K flew to Mexico on 9 June 2004. The next an investigation. day a rash appeared on her back and arms. Herbody became red, swol en and hard to the touch, The Case Manager visited the surgery, where covered in lumps and blisters. She assumed she Mrs K's GP demonstrated the warning notice had been prescribed penicil in. Mrs K spent the displayed on the computer when an attempt was last days of her holiday in her hotel room, and made to prescribe a drug to a patient with a she described the flight home as ‘painful and recorded sensitivity or al ergy. It was noted that frightening'. She immediately saw her regular GP, the warning could be manual y overridden. The who told her that Dr Mrozinski had written on GP pointed out Dr Mrozinski's computer entry, her notes that he had asked her if she was al ergic prescribing amoxicil in for Mrs K. The Commission to penicil in, to which she had answered that wrote to Dr Mrozinski three times asking for a she was not. Mrs K disputed that account of response to Mrs K's complaint, but received no the consultation. reply. With Mrs K's agreement the Commissionreferred her complaint direct to the Ombudsmanin April 2005, as we have powers to obtainevidence from witnesses.
Remedy in the NHS June 2008 What we investigated
Dr Mrozinski's initial response to Mrs K'scomplaint was unhelpful, negative and bel igerent We investigated whether Dr Mrozinski had in tone, and his threat of a counterclaim did not unreasonably prescribed amoxicil in to Mrs K and comply with NHS complaints regulations and whether he had appropriately handled her GMC guidance. It was only after we contacted complaint about that. We took account of the Dr Mrozinski about Mrs K's complaint, that he GMC's 2001 publication, ‘Good Medical Practice', provided a response to the substance of it, but which stated that clinicians must explain ful y and there was no explanation of why he had not promptly what has happened if harm has been provided an earlier explanation and no apology.
suffered. It also stated they should appropriately Dr Mrozinski's refusal before then to explain his apologise and that patients who complain about actions showed a blatant disregard of GMC care or treatment they have received have a right guidance and the NHS Complaints Procedure.
to a prompt, open, constructive and honestresponse. We also bore in mind the NHS We concluded our investigation in Executive's Guidance on the NHS Complaints September 2006 and upheld Mrs K's complaints.
Procedure for General Practices which reminds Although it was not clear that she had suffered as GPs of the need to ‘listen careful y and a result of Dr Mrozinski's prescription, he should understand the person's perspective not have prescribed antibiotics without further discussion, and should have told her that it wasrecorded that she was al ergic to penicil in.
Dr Mrozinski's handling of Mrs K's complaint was What our investigation found
total y unacceptable; his repeated refusal torespond to the substance of her complaint put We concluded, on the basis of clinical advice her to unnecessary time and trouble, and added from the Ombudsman's GP Adviser, that it was to her distress. not certain that amoxicil in was the cause ofMrs K becoming unwel : although Mrs K was notaware of it, she had twice been prescribed penicil in (in 1994) with no il effect.
We recommended that Dr Mrozinski send Mrs K a Mrs K's penicil in al ergy was clearly recorded; written apology and pay her £250 compensation although Dr Mrozinski did not total y disregard for the unnecessary distress he had caused her.
the need to check if she was al ergic before He refused to do so and wrongly questioned the writing a prescription, he should not have Ombudsman's authority to investigate clinical disregarded the al ergy warnings, or overridden a matters. At our suggestion, the Trust made the computer alert, without discussion with her. He payment to Mrs K themselves, on the basis that should also have recorded that Mrs K's ‘the patient is more important than the principle'.
understanding that she was not al ergic toantibiotics was inconsistent with her medicalrecords. There was conflicting evidence aboutwhat Dr Mrozinski had asked Mrs K during theconsultation, which could not be resolved. 38 Remedy in the NHS June 2008 Complaint about Gloucestershire Hospitals NHS Foundation Trust (the Trust) and the Healthcare Commission Complaint about the care and treatment of an accuracy of the death certificate. Mrs J believed elderly patient who died during an in-patient that Mr W had been caused undue suffering and admission, and complaint about the Commission's stress during his admission and that their family subsequent review had been caused unnecessary distress.
Mrs J complained to the Trust in March 2003; they Background to the complaint
responded in July 2003. A local resolution meetingwas held in August 2004. Mrs J was unhappy with Mr W, aged 74, was admitted to Gloucester Royal the action taken by the Trust and complained to Infirmary as an emergency in August 2002 for the Commission in October 2004.
treatment of an infective exacerbation(pneumonia) of chronic obstructive pulmonary In November 2005 the Commission referred disease. He was treated in the Intensive some aspects of the complaint back to the Trust Treatment Unit until the end of August when he for action (requesting an update on was transferred to a respiratory ward. Mr W then improvements to record keeping and had episodes of confusion, difficulty with oxygen communications between staff and families) and intake and some bleeding from a catheter site.
asked them to look at the timing of Mr W's He later contracted MRSA, developed diarrhoea transfer from the Intensive Treatment Unit. Mrs J and was found to be infected with C.difficile.
complained, again, to the Commission in Mr W was transferred to Standish Hospital at the December 2005, which said, in May 2006, that it start of October, where he suffered with would take no further action as it was satisfied recurrent C.difficile infection. Mr W died in with the Trust's actions and responses. November 2002, with the cause of death notedas respiratory failure.
What we investigated
The complaint to the Trust and the Commission
Mrs J asked us to investigate al aspects of hercomplaint against both the Trust and the Mrs J, Mr W's daughter, questioned whether the Trust's actions had contributed towards hisdeterioration and death. She had specific We considered al the available evidence and took concerns about the care and treatment that he clinical advice from an experienced General had received, including: his transfer from the Physician (who is also a Consultant in Elderly Care Intensive Treatment Unit; the timing of medical Medicine) and an experienced Nurse. We also reviews fol owing that transfer; the general took account of the relevant standards and standard of hygiene and nursing care (Mr W had guidelines including the Department of Health's been found by his family with bloodstained National Service Framework for Older People pyjamas and bedclothes and there was a delay in (2001), the British Society of Geriatrics' ‘Standards providing continence pads when he suffered from of Medical Care for Older People' (revised 2003), diarrhoea); effectiveness of communication (both the Nursing & Midwifery Council's ‘Standards for between staff members and with the family); the Records and Record Keeping', the NHS management of MRSA and C.difficile and the Modernisation Agency's benchmarking tool Remedy in the NHS June 2008
‘Essence of Care' and the March 2001 guidance • a lack of monitoring while Mr W waited to be about resuscitation decisions published jointly by transferred from the Intensive Treatment Unit; the British Medical Association, Royal Col ege ofNursing and the Resuscitation Council.
• a delay in carrying out a medical review; • extremely poor nursing care in relation to care What our investigation found
planning, communication, pain management,infection management, patient privacy and We found that the timing of Mr W's discharge dignity, and monitoring fluid intake/output; from the Intensive Treatment Unit wasappropriate; that the medical care in late • a lack of multi-professional working and senior August/early September 2002 was general y reasonable; that there was no objective evidenceof MRSA being implicated in Mr W's death; that • poor record keeping; and the medical management of C.difficile wasappropriate; and that the Trust's response on the • poor end-of-life care (including lack of a accuracy of the death certificate was reasonable.
care plan and no discussion with the family However, when taken in the round, the evidence about resuscitation and the seriousness of we saw pointed to serious failings in the Trust's Mr W's prognosis).
service to Mr W and his family which were: 40 Remedy in the NHS June 2008 We concluded that, irrespective of the poor practice identified, the final outcome for Mr Wwould not have been different, but that the In this case we decided to involve Monitor, the failings identified would have significantly body which authorises and regulates NHS affected Mr W's quality of life and the level of Foundation Trusts, because we were highly critical distress he suffered. We also found that Mr W's of the nursing care at the Trust and were keen to family were caused undue distress due to the ensure that there was an appropriate review of condition in which they sometimes found Mr W the Trust's progress in learning lessons from the and because they had no opportunity to come to terms with the fact that his life was ending and tomake suitable arrangements.
The Trust agreed to: We acknowledged the time and effort the Trust • write to Mrs J and her family to acknowledge took in attempting to resolve Mrs J's concerns and apologise for the failings identified; and that they readily acknowledged severalfailings and took action to address them.
• review the areas where we had identified However, we concluded that Mrs J's complaint serious failings in order to ensure that their should have prompted a wider review of nursing practices were in accordance with current care which may have led to a more co-ordinated guidance and standards; approach to implementing improvements and, inturn, provided reassurance for Mrs J that her • provide Monitor with information to complaint was being taken seriously. demonstrate that their practices (in the areaswhere we had identified serious failings) are in We found maladministration in the Commission's line with current standards; and handling of Mrs J's complaint (including failure to seek clinical advice, not providing her with • report back to Mrs J on the action taken in regular updates and failure to assess the priority response to our recommendations.
of the case) which had exacerbated her worry and distress.
The Commission agreed to write to Mrs J and herfamily with an apology and pay £250 The investigation concluded in March 2008 and compensation in recognition of the worry and we upheld Mrs J's complaints against both the distress caused by its poor complaint handling.
Trust and the Commission.
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