A damning report has criticised the way hospitals deal with complaints when they have made mistakes. A report from the Public Services Ombudsman for Wales said Wales' health board's had an inability to accept wrongdoing when handling patient complaints, instead responding to any issues raised "defensively."
The report includes shocking examples of care delivered at hospitals in Wales. In one case, the Ombudsman concluded that a patient's death was avoidable after medics failed to spot the signs of infection but the same health board, in their own investigation, found no wrongdoing with the patient's care.
The following cases have been highlighted in the report:
- One patient was given £750 in compensation after the Ombudsman intervened in a complaint that found they were not told they had tested positive for coronavirus while in hospital.
- One patient waited over 16 months before it received a response to a complaint. When the Ombudsman intervened, the health board agreed to pay the patient £350 in compensation
- One patient's cancer surgery was delayed by five weeks after the health board failed to schedule in a surgery after giving the patient a date. The response from the health board did not admit the surgery had not been booked until the Ombudsman intervened
- One patient died after medics failed to spot the signs and symptoms of appendicitis. The Ombudsman's investigation found her death was avoidable and that the health board failed to acknowledge it did anything wrong when investigating her case
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Public Services Ombudsman for Wales, Michelle Morris, said she is "struck by the similar pattern of complaint handling failings" that her office has identified in cases involving health boards across Wales. She added that the failings identified in the report have real impact on patients and their families, often compounding the trauma caused by mistakes in care and treatment.
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Ms Morris said: “During my first year as Ombudsman, I have been struck by the similar pattern of complaint handling failings which my office has identified in cases involving Health Boards across Wales. Although most health care across Wales is delivered in an excellent and professional manner, inevitably, sometimes organisations make mistakes. In 2022/23, we found that Health Boards made mistakes and should put things right in between 22% and 41% of our complaints about these bodies - depending on the Health Board area.”
“When mistakes happen, we expect health bodies to respond openly and honestly to patients and their families. This does not always happen. In fact, we have seen an increase in complaints about poor complaint handling by Health Boards.”
“For example, we often see that, when Health Boards respond to complaints, they have not objectively assessed the care and treatment provided. In another example, even when, following investigation, the facts of a case clearly show that the Health Board made a mistake, we see that organisations do not acknowledge this in their complaint responses. These failings have real impact on patients and their families, often compounding the trauma caused by mistakes in care and treatment.”
“We trust that the duty of candour will have a positive and transformational impact on the way in which complaints are handled within health boards. However, if we see in our complaints that the health boards are not taking the duty into account as they should, we will continue to call it out.”
The report identified the following areas where learning and improvement was urgently needed to improve the patient complaint experience:
- A lack of openness and candour
- A lack of objective review of clinical care and treatment
- Timeliness and quality of communications
- Robustness and fairness of investigations undertaken by Health Boards.
Commenting on the report, Welsh Conservative Shadow Health Minister, Russell George, said he was disappointed that the complaints and lessons brought forward in 2017 by the Ombudsman’s office have yet to be fully addressed six years on. He called on the Welsh Labour Government to ensure there are robust procedures in place to address the issues highlighted in the report.
The complaints
Cwm Taf University Health Board
Mrs V complained about the care her cousin, Mrs F, received at the health board when she presented with symptoms of severe abdominal pain and low blood pressure at Princess of Wales Hospital on July 17, 2020.
Blood tests results indicated the presence of a significant infection but medics did not identify and treat the appendicitis that caused a ruptured appendix. Mrs F was sent home without being prescribed antibiotics and health board arranging appropriate and timely investigations, including scans.
The report said that when Ms F returned for a review and further investigations on July 20, the scan ruled out gallstones as the cause of her symptoms, but again she was not admitted to hospital, and told to return two days later. Sadly, Ms F did not return for further review, and she died at home on August 1, 2020.
The Ombudsman found that Ms F death was avoidable. The report also said that the hospital's investigation into this case did not find that it had done anything wrong. The Ombudsman report said: "In our view, the health board missed clear opportunities during the complaints response process to identify failings at an earlier stage and avoid the need for Ms F’s family to escalate their complaint to us. However, when we shared the draft version of our report and our clinical advice with the Health Board, it accepted our recommendations."
Hywel Dda University Health Board
The report includes cases of complaints made to every health board in Wales. One complainant waited 13 months after making a complaint to Hywel Dda University Health Board in December 2021 regarding the death of his mother. In February 2023, he contacted the Ombudsman to inform then he had not received a response to the complaint from the health board.
The health board were instructed to respond by 20 March, 2023, they were unable to do so and requested to extensions before the Ombudsman set a final deadline of a response by April 28. The health board agreed to pay £350 in compensation for the delay.
Betsi Cadwaladr University Health Board
At Betsi Cadwaladr University Health Board, a complaint was made by a patient's sister (Mrs A) regarding the care her sister (Mrs B) received at Ysbyty Glan Clwyd between May 2019 and May 2020. She sadly died after being discharged on May 5.
Mrs A was concerned her sister did not receive appropriate bowl care when she was in hospital in April 2020. She needed specific help in this area and no skilled staff were available to provide it. According to the report, nurses did not update doctors that it had not been done. She then developed a bowel blockage, but this was not considered and she was discharged on May 5.
The Ombudsman could not be sure that the inadequate care she received contributed to her death as she was very unwell with other problems, but the failings meant Mrs B had a loss of dignity. The Ombudsman report said they were concerned the health board did not respond to Mrs A's complaint well and robustly enough, nor did they review her care in a detailed, rigorous and transparent way.
Swansea Bay University Health Board
Mr D complained to the health board that he was not informed of his positive Covid-19 test when he was a patient at a hospital in the area, he also claimed he was not given the right discharge advice about self-isolation. The health board could not provide the Ombudsman with evidence that Mr D had been told about the positive Covid test or give him advice about self isolation, which should have been done as it was ward policy at the time.
The Ombudsman told the health board they should apologise to Mr D and pay him £750 for these failings. But it took further detailed discussions before the full settlement was finally accepted by the health board.
Aneurin Bevan University Health Board
The Ombudsman' investigated a complaint relating to a cancer patient (Mr J), who was told on February 1, 2022, he would have surgery on March 21. However the hospital did not schedule the surgery but Mr J did not find out about this until he contacted the ward the day before the surgery was due to take place.
This resulted in an avoidable five week delay until the surgery took place. Although records clearly indicated that the health board had made a mistake, its complaint response to Mr J was not candid and was contrary to the health board's duty to be open. The health board agreed to apologise and complete an audit of its colorectal scheduling processes and controls.
Cardiff and Vale University Health Board
Miss X complained about the care and treatment her late father, Mr Y, received at University Hospital of Wales in March 2020. He went to the emergency department but was sent home and died two days later after emergency surgery. The Ombudsman found that he should not have been discharged from the ED. The Ombudsman found his symptoms were not identified, and there was a delay in them being recognised when he was readmitted two days later. This led to a delay in surgery.
He was very ill after surgery but was not taken to the intensive care unit. The Ombudsman found that the decision not to do this reduced his chances of survival. The report found his death may have been preventable. The report concluded: "The health board’s response to the original complaint accepted that communication with Mr Y’s family was poor. However, we were concerned that its investigation did not identify that there were several missed opportunities to treat Mr Y and that there were therefore failings in the care provided to him.
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