Complaints and Litigation - Health Committee Contents


Written evidence from Colin Yeo (CAL 47)

1.  RENE THE PERSON

2.  Rene was 93 years old and lived with her family who were her registered carers with registered Lasting Power of Attorney for Health and Welfare.

3.  She had spent her life doing voluntary work of one form or another even in her 90s.

4.  Rene went out four and half days a week prior to a fall and fracturing her knee.

5.  Rene enjoyed entertaining family and visiting them especially on family anniversaries etc.

6.  RENE'S TREATMENT

7.  Despite many admissions over recent years Rene was not diagnosed with Bowel, Liver and Lung Cancer until a few weeks before her death.

8.  Rene was admitted and was in hospital for four weeks with a fractured knee before it was diagnosed

9.  Occupational Therapists tried daily, for four weeks, to get mum to stand on her fractured knee.

10.  Occupational Therapists were not aware that mum's toe nails were exceptionally long and cut into her adjacent toes.

11.  Nobody in the RD&E Hospital was qualified to cut mum's toe nails.

12.  A further eight weeks of hospitalisation and, despite the symptoms of bowel cancer, no diagnoses of her cancers were discovered.

13.  Rene's cancer was only discovered on an emergency admission about three weeks after discharge from a twelve week hospital stay.

14.  At the fifth attempted discharge a home assessment was done with the hospital matron and occupational therapist doing the assessment. The matron accused a family member that they had abused the staff by having a camera.

15.  After the fifth aborted discharge mum was discharged to a residential home where 24 hour care could be provided.

16.  The residential home discovered mum had severe painful problems with her bowel which resulted in her going to the toilet with diarrhoea every 40-60 minutes day and night.

17.  Rene was re-admitted into hospital with severe abdominal pain from the residential home about three weeks after hospital discharge.

18.  Rene was diagnosed with cancer and given only a few weeks to a month to live.

19.  Rene was discharged back to the residential home only to be re-admitted a few weeks later when she went in for an X-ray. She was so poorly they had no choice. However the next day a Ward Nurse phoned, unaware of mum's condition, telling us she was being discharged to us. We explained the situation and mum was kept in hospital for a further nine days before being discharged to a nursing home.

20.  Mum received the best care in the privately run nursing home which cost only £570 per week. We were told the council residential home cost over £600 and the hospital £700 per day.

21.  Rene Schneider passed away a few weeks later.

22.  FAMILY OBSERVATIONS

23.  During mum's stay she was under the responsibility of about ten different Doctors or Consultants.

24.  No one professional member of NHS Staff was responsible for her total stay.

25.  Responsibility for her care was passed from one professional to another -like pass the parcel.

26.  At one point during her stay no Doctor or Consultant admitted responsibility for her care.

27.  The family often found mum dehydrated and being given inappropriate foods for her illnesses.

28.  Low or zero fat foods are not available on menus despite this issue being raised eight months previously in which the Director of Nursing promised this would be corrected.

29.  Many of the Nursing staff are not aware of the importance of hydration.

30.  Many of the Nursing staff are not aware of the fat content of food.

31.  Many of the Nursing staff are not aware of the symptoms of dehydration.

32.  Many of the Nursing staff are not aware how disease can spread.

  1. 32.1  When the nurses have soiled sterilised gloves on, they would pass keys from their pocket to another nurse with clean hands. The result was the first nurse's pocket, keys and the second nurse's hands are all contaminated without either nurse being aware.
  2. 32.2  When a nurse sneezes into her hands she continues working without washing her hands. She could be passing meals or just doing normal nursing work.

33.  NHS Staff and Social Services Management/ Staff spent vast amounts of time trying to save money by playing pass the responsibility between each other. The NHS discharge when patients are ill and social services delay accepting responsibility. The result is increased cost to tax payers and severe suffering to patients and their families.

34.  Nursing staff were observed using expensive bed protection sheets to wipe up a spilt drink. When asked we were told it was quicker than getting out the mop.

35.  Nursing staff pull electronic equipment around by its mains lead. As an electrical engineer this can cause intermittent operation of the equipment leading to medical misdiagnosis and making the equipment difficult to repair.

36.   NHS Staff will not write down what they tell the patient verbally. They will not allow you to record what they say concerning your condition or treatment. They will not let you take photographs or videos. They will not let you access to the patient's medical condition or records. This applies to both the patient and the patient's representatives. This makes it impossible to bring the bad staff to account.

37.  COMPLAINTS HANDLING

38.  The family had Rene's verbal/ written consent and Registered Lasting Power of Attorney (LPA) for Health and Welfare but all details of her current medical condition and treatments were withheld.

39.  The family were told that the medical records could only be viewed using the Freedom of Information Act which could cost up to £50 and take up to 40 days.

40.  The family tried to collect evidence to prove Rene was medically unfit for discharge. This involved taking photos of Rene in her single room with no staff present.

41.  The senior staff said the use of a camera in hospital was illegal.

42.  The senior staff refused to confirm this in writing.

43.  The NHS Devon Information Governance Officer said this was not true, photos could be taken, provided no third party was involved.

44.  The Matron said the LPA could not be used unless the patient had been declared mentally incapacitated. Research proved we could decide mum was mentally incapacitated.

45.  To avoid argument mum gave us her written consent.

46.  A meeting with the Matron and Complaints Manager was organised to raise our concerns.

47.  At the meeting we presented mum's written consent and the Matron then said mum didn't have mental capacity to sign the form.

48.  The Matron and Complaints Manager took a copy of our registered LPA and promised this would be put on record so that we would not need to present it again.

49.  The Matron and Complaints Manager re-iterated that the LPA could only be used through the Freedom of Information Act.

50.  They both decided that problems with mum's medical care at the RD&E hospital were not their responsibility. NHS Devon buy the services from the RD&E unit.

51.  Many actions were verbally promised at the meeting but were not done. No minutes were taken by the Matron or Complaints Manager.

52.  We wrote a letter to the Information Governance Officer asking her to confirm the situation regarding access to mum's medical records. This letter was both posted and sent by email (the address we had used successfully before). This letter has never been replied to.

53.  Rene was diagnosed with cancer at the same time as the family received a letter accusing them of abusing staff. This was done by falsely accusing the family of taking photos of NHS staff.

54.  A letter of complaint to the Chair of NHS Devon asking for a proper investigation into the staff abuse and mum's medical care was answered by the same Complaints Manager who previously failed to do her job.

55.  The Complaints Manager refused to investigate because she denied the family had Lasting Power of Attorney which she had previously taken a copy of.

56.  Subsequent attempts to contact the Chief Executive via her personal assistant were redirected to the Complaints Manager.

57.  The ICAS advocate wrote a letter to the Chair of NHS Devon expressing concerns about the independence of the investigation by the Complaints manager. They were contacted by the Complaints Manager who said there was no conflict.

58.  A Parliamentary and Health Ombudsman Advisor, who agreed with our concerns, tried to contact the Chief Executive of NHS Devon but was redirected to the Complaints Manager who again said there was no conflict of interest.

59.  Our MP, Ann- Marie Morris, contacted the Chief Executive and asked for an investigation.

60.  The investigation for our MP said no investigation was possible because they only had a copy of our application for Lasting Power of Attorney.

61.  The ICAS advocate's communications could prove that this was not true so we requested a copy of all communication between the ICAS advocate and NHS Devon.

62.  ICAS initially told us it would take a few days. It took about six weeks to arrive.

63.  The Patients Association who were working with the Daily Mail to investigate NHS care for the elderly asked the NHS Devon for a copy of the application.

64.  The Chief Executive of NHS Devon apologised for previously stating we had not supplied the correct Lasting Power of Attorney. She admitted that a mistake had been made.

65.  The Chief Executive promised an independent review into mum's health care and the complaints handling procedure.

66.  The Chief Executive has sent the family a terms of reference for the independent investigation.

67.  The NHS Devon terms of reference want to check if NHS procedures have been followed. The family want to know what went wrong. This could include whether the staff had failed to do their job and/or whether their procedures are wrong.

68.  We think it has the potential for another cover up.

69.  THE REASON FOR RECENT SHARP RISE IN NHS COMPLAINTS

70.  We believe the reason for NHS complaints increasing is the complaints procedure does not lead to a correction of faults occurring in the system.

71.  The staff (or the NHS system) involved in mistakes are not corrected by improved procedures, retraining or dismissal.

72.  Since nothing is learnt from mistakes these mistakes become acceptable practice and result in further complaints occurring. No systems are changed, no one is retrained and no staff, who are incompetent, are dismissed.

73.  THE EFFECTIVENESS OF THE CONSTITUENT PARTS OF THE COMPLAINTS SYSTEM: LOCAL RESOLUTION (SUPPORTED BY ICAS) AND REFERRAL TO THE OMBUDSMAN

74.  The PALs unit are not effective because their main brief appears to advise, liaise and prevent litigation.

75.  Our experience of the PALs unit showed that these people do not tell the truth. Local resolution was never reached because they refused to allow us to record the local resolution meeting. This was probably to prevent litigation.

76.  The ICAS unit is run by staff working part time, who have no authority, are poorly trained and were reluctant to push the NHS Trust to fulfil their legal and moral responsibilities.

77.  We found it very difficult to contact our advocate because she worked part time (she never told us), was often away on training courses, was on holiday or sick. She helped to compose a letter to the NHS Trust Chair saying he had a statutory obligation to reply to our letter. This was done but he never replied to this or any letters we sent. Our complaint was passed to the person we were complaining about to handle it. The Advocate thought this unfair but said she said she was powerless to change it.

78.  It was felt that care must be taken when dealing with ICAS. They appear very reluctant to challenge NHS Devon. They will ignore letters and emails. Everything takes a long time to be done.

79.  The Ombudsman has no authority.

80.  An Ombudsman advisor agreed with us that the person we were complaining about should not be handling the complaint. Although officially she was not involved she did phone the NHS Trust to change this but failed.

81.  Our complaint must have cost hundreds, if not thousands of pounds, in money wasted on NHS personnel who handle complaints. Nothing was achieved. It should have involved just one person with the result of large savings in future NHS costs.

82.  THE ROLE OF PATIENT ADVICE AND LIAISON SERVICES AS A GATEWAY TO THE COMPLAINTS SYSTEM

83.  The complaints system is part of the PALs unit and is a gateway to the complaints system brick wall.

84.  The whole system which includes the PAL service, ICAS and the Health Ombudsman is designed to take a long time, to frustrate, extend the suffering and wear you down. They are very effective at achieving this.

85.  PAL service, ICAS and the Health Ombudsman are obsessed with procedures even when things are clearly wrong.

86.  The complaints procedures are not available to anyone who does not have the patient's authority (ie a hospital visitor who observes a patient being badly treated has no right to complain).

87.  The Patient Advice and Liaison Services assume that the patient or loved one who reports a fault needs advice or a liaison service. They assume that there has been a misunderstanding. This can be useful but when there is a complaint the issue is referred to the complaints department within the PALs unit.

88.  To minimise the number of complaints received they make it impossible for most people to complain by saying that only the patient or the Executor of their Will can complain. A person with Lasting Power of Attorney can complain but in practice every obstacle possible is used to prevent this occurring.

89.  The Complaints department work very closely with the legal department to minimise litigation but this has the effect of allowing mistakes to be continually repeated.

90.  There appears to be no department with the task to improve quality of healthcare in the hospital.

91.  Our complaint should have led to a couple of extra X-rays being taken to save three months of hospitalisation.

92.  THE FAILURE OF SOME FOUNDATION TRUST TO REPORT COMPLAINTS

93.  Our experiences of systemic lying within the NHS service, to quite high management levels, make this statement very likely.

94.  There is no procedure to handle complaints against the PALs unit which includes the Complaints department. We could not get these people to be made accountable for lying even though we had the proof and involved Ann-Marie Morris our Member of Parliament.

95.  THE COST OF LITIGATION AGAINST THE NHS

96.  Generally the cost of litigation is inversely proportional to how much effort the NHS has put into preventing the problem from occurring (ie problems are continually being repeated which the complaints system should have stopped a lot earlier).

97.   The cost of litigation will be proportional to the number of complaints made in a fair system (ie reducing the number of complaints through reducing NHS mistakes will reduce litigation costs). Currently the complaints system reduces the number of complaints by making it very difficult to complain.

98.  Damages are large when the NHS continues to make mistakes when they know the mistakes have a long history.

99.  The cost of litigation is a lot lower than it probably should be because the suffering and loss of life for the elderly is of a lower value than the young (ie a mistake on a 25 year old mother would have higher litigation costs than a 65 year old grandmother).

100.  The cost of litigation is a small proportion of the problem. Our mother was misdiagnosed with a fractured knee with the result of a three month hospital stay which should have been only a week. At £700 per day this adds up to approx. £60,000.

101.  HOW TO IMPROVE THE NHS COMPLAINTS PROCEDURE

102.  To improve the complaints procedure you need to reduce the number of complaints.

103.  NHS staff and the systems they work with must be made accountable. This means accepting that either: operating systems may need changing; staff may need retraining; staff may need to be dismissed.

104.  To make it easier to validate complaints, patients and their representatives should be allowed to request to record interviews on their healthcare. This can then be used as evidence should a complaint arise.

December 2010



 
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Prepared 6 July 2011