Written evidence from Colin Yeo (CAL 47)|
1. RENE THE
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.
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
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
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
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.
- 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.
- 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.
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
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
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
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
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
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
69. THE REASON
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
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
ICAS) AND REFERRAL
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
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
82. THE ROLE
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
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
93. Our experiences of systemic lying within
the NHS service, to quite high management levels, make this statement
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
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
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.
101. HOW TO
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.