The Ombudsman investigated three cases in which local statutory supervision of midwives failed, all of which occurred at Morecambe Bay NHS Foundation Trust. The cases clearly illuminate a potential muddling of the supervisory and regulatory role of supervisors of midwives. The current arrangements do not always allow information about poor care to be escalated effectively into hospital clinical governance or the regulatory system. This means the current system operates in a way that risks failure to learn from mistakes, which cannot be in the interests of the safety of mothers and babies and must change. Working with the Nursing and Midwifery Council (NMC), the Professional Standards Authority for Health and Social Care, NHS England and the Department of Health, the Ombusdman has identified two key principles that will form the basis of proposals to change the system of midwifery regulation: that midwifery supervision and regulation should be separated; that the NMC should be in direct control of regulatory activity. The Department of Health should convey these recommendations to its counterparts in Northern Ireland, Scotland and Wales and develop proposals to put these principles into effect.
This report concerns a case claiming for funding for care under s. 117 of the Mental Health Act 1983. The Ombudsmen found evidence of some failures of the part of the concerned Trust and Council, but in the absence of any consequent in justice that could be identified, did not uphold any of the complaints
This report is into a complaint by Mr & Mrs M concerning the treatment of the disabled daughter by their GP, the out of hours SEEDS services and the PCT Trust of the hospital their daughter was taken to. No service failure was found with regard to the GP; however the SEEDS doctors failings did constitute service failure. The PCT's handling of the complaint had lesser failures and did not constitute maladadministration
This report tells the story of Mr J, who was an active, outgoing and sociable man. He had Down's syndrome. He lived independently in rented accommodation with his wife. Newcastle City Council, latterly through the Coquet Trust, provided day-to-day support to Mr J and his wife to help maintain their independence. In 2005, owing to concerns about a significant deterioration in his skills and health, Mr J was admitted to hospital for a five to six week assessment. Mr J remained in hospital for seven months, some five of those after he had been declared ready for discharge. Mr J was discharged into inappropriate locked accommodation, which he only left following his death 10 months later. Mr J was 53. Mr J's brother, Mr K, complained about the care provided to Mr J. This joint investigation with the Local Government Ombudsman found significant failings on the part of both Northumberland, Tyne and Wear NHS Foundation Trust and the Council. They are to compensate, and apologise to, the family. The NHS Trust and the Council will also prepare, share and update progress on an action plan showing what they have done (or will do) to prevent recurrence of their failings.
This is an investigation, carried out jointly by the Health Service Ombudsman and the Local Government Ombudsman, into serious complaints about the support provided to a vulnerable person with long history involvement with mental health services, living independently in the community, by 5 Boroughs Partnership Trust and St Helen's Metropolitan Borough Council. The complaints, made by the vulnerable person's cousin, were: that the consultant psychiatrist failed to respond appropriately; that there was no support in claiming for welfare benefits; that care plans were not implemented; and that no one had responded appropriately to developing signs of risk. The first two of the complaints were not upheld but it was found that the Trust and Council had failed in their joint responsibility
This report sets out the findings of the investigation of a patient's complaint about dentist Rajesh Narendranath (known as Mr Nath), of Stone Family Dental Practice in Stone, Staffordshire. The patient, Mrs D, complained that Mr Nath had been rough and had hurt her while trying to take x-rays, and also that he had been rude to her when she had objected. Dissatisfied with the response she received from Mr Nath to her complaint, Mrs D escalated it to the Healthcare Commission. The Healthcare Commission upheld Mrs D's complaint and told Mr Nath that he should apologise to her. When Mrs D did not receive this apology, she took the matter further - first to the General Dental Council, who told her they had warned Mr Nath that he should follow the recommendations of professional bodies, and finally to Health Service Ombudsman. The Ombudsman investigated and upheld the complaint, recommending that Mr Nath that he should acknowledge his failings in full and apologise. She also recommended that Mr Nath pay Mrs D £500 compensation for the feelings of shock and offence she had suffered. To date, Mr Nath has not complied with these recommendations. The Ombudsman has also taken the step of sharing the findings of her investigation with the General Dental Council who are currently considering what action they may need to take in relation to Mr Nath's fitness to practise as a dentist. South Staffordshire Primary Care Trust are also considering what further action to take.
This publication contains an article by Dr Richard Kirkham, Lecturer in the School of Law at Sheffield University, on the history of the post of Parliamentary Ombudsman to mark the 40th anniversary of its establishment, together with a foreword written by the current postholder, Ann Abraham. The paper discusses the origins of the Office and its creation through the Parliamentary Commissioner Act 1967, as well as its existing and future role, the changing landscape of the administrative justice system and possible amendments to Office's powers. The paper concludes that "a few required amendments aside, the Parliamentary Commissioner Act remains a good piece of legislation and the constitution is much stronger for the Parliamentary Ombudsman. As well as improving the power of the citizen to gain redress, as was originally intended, Parliament itself has gained a valuable tool in the ongoing process of calling the government to account.
These are the reports of two cases which were jointly investigated by the Health Services and Local Government Ombudsmen,, both of which involve the provision of services by local council and by NHS trusts and both, to some extent, concern the actions of staff working in mental health services. The first involved Enfield Council and Barnet, Enfield and Haringey Mental Health Trust & Barnet and Chase Farm Hospitals NHS Trust. The other case involved Havering and the North East London Mental Health Trust. Neither case was upheld in respect of the Councils though partly upheld in respect of North East London Mental Health Trust
In this supplement to the main report 'Listening and learning: the Ombudsman's review of complaint handling by the NHS in England in 2010-11' (HC 1522, session 2010-12, ISBN 9780102975086) the Ombudsman publishes more detailed data on complaints about primary care trusts and relevant care trusts. For each trust the data shows how many complaints: were received; resolved through intervention; accepted for investigation; and reported on (with the percentage upheld, partly upheld and not upheld). The data is presented in four categories, according to whether the complaint was about: the trust itself (PCT or care trust); a GP or GP practice; a dentist of dental practice; or opticians, pharmacies or healthcare funded by the trust but provided by a private company.
In 2007-08 the Parliamentary Ombudsman received 7,341 complaints about government departments and a range of other public bodies. Of these, 2,574 were about the Department for Work and Pensions (DWP). This is not surprising given the size and nature of DWP's business, serving as they do over 20 million customers at any one time. It is understandable, even inevitable, that mistakes will happen. What is important is how DWP dealt with the complaints arising from mistakes. Many, but by no means all, of the complaints received could have been resolved much sooner and by DWP themselves, if the complaint handling had been more customer focused. This report contains an anonymised digest of selected cases, highlighting poor information, delays, poor record-keeping, poor communication. Local resolution of complains should be the most efficient way to secure an appropriate outcome. It is hoped the report will encourage DWP to seek ways to improve the service they provide to citizens.
the Ombudsman's review of complaint handling by government departments and public bodies 2010-11 , ninth report of the Parliamentary Commissioner for Administration session 2010-12
the Ombudsman's review of complaint handling by government departments and public bodies 2010-11 , ninth report of the Parliamentary Commissioner for Administration session 2010-12
This report reveals complaint handling across government to be inconsistent, haphazard and unaccountable, operating without any overarching design, overall standards or common performance framework. This is unhelpful for people who want to change their experience of interacting with a public service by making a complaint. It also means opportunities to improve public services through complaint handling are being missed. There is no shared view across government of the standard of complaint handling that a member of the public can reasonably expect. Complainants may be required to navigate anything between one and four stages of a complaint procedure before 'local resolution' is completed and the complainant can bring their complaint to the Ombudsman. The absence of any clear methodology or machinery to share best practice, or ensure lessons from complaints are learnt across government departments, increases the likelihood of the same mistakes being repeated again and again. The Ombudsman's Principles of Good Complaint Handling are a good starting point for government in the task of ensuring that all departments share an understanding of the importance of fairness, transparency, and accountability. But there is a need for strong leadership from the top, committed to developing a culture across the civil service that values complaints. The report covers the survey of departments, case studies, and gives statistics on complaint handling and the financial costs of poor complaint handling.
the Ombudsman's review of complaint handling by the NHS in England 2010-11 , tenth report of the Health Service Commissioner for England session 2010-12
the Ombudsman's review of complaint handling by the NHS in England 2010-11 , tenth report of the Health Service Commissioner for England session 2010-12
The Health Ombudsman resolved a total of 15,186 complaints about the NHS in England in 2010-11. This report shows how, at a local level, the NHS is still not dealing adequately with the most straightforward matters. As the case studies illustrate, minor disputes over unanswered telephones or mix-ups over appointments can end up with the Ombudsman because of knee-jerk responses by NHS staff and poor complaint handling. While these matters may seem insignificant alongside complex clinical judgments and treatment, they contribute to a patient's overall experience of NHS care. The escalation of such small, everyday incidents represents a hidden cost, adding to the burden on clinical practitioners and taking up time for health service managers, while causing added difficulty for people struggling with illness or caring responsibilities. Two particular themes stand out this year. Poor communication - one of the most common reasons for complaints in the last year - can have a serious, direct impact on patients' care and can unnecessarily exclude their families from a full awareness of the patient's condition or prognosis. Secondly, in a small but increasing number of cases, a failure to resolve disagreements between patients and their GP has led to their removal from the GP's patient list - often without the required warning or the opportunity for both sides to talk about what happened. As GPs prepare to take on greater responsibility for commissioning patient services, this report provides an early warning that some are failing to handle even the most basic complaints appropriately.
The Parliamentary and Health Service Ombudsman responsible for investigating complaints regarding whether governmental departments, agencies and some other public bodies in the United Kingdom, and the National Health Service (NHS) in England, have acted properly or fairly, or have provided poor service. This is the first report from the Parliamentary and Health Service Ombudsman of the new 2008-09 session, and sets out 20 cases that the Ombudsman believes illustrate good and poor practice in dealing with complaints from the public, and further demonstrate how things might have been handled differently if the public body concerned had in the mind the Ombudsman's three sets of principles on: good administration; remedy; and complaint handling.
Last year over 449 individual complaints from prisoners and former prisoners were received by the Ombudsman about the loss by a Home Office contractor of sensitive personal data about them on an unencrypted data stick. This report explains why the complaints were not investigated. Whilst there are clear indications of maladministration surrounding the circumstances leading to the loss of the data stick, there is not in the way the Home Office responded to the data loss. Furthermore, much of the information that was on the data stick is already in the public domain, Therefore the complainants could not reasonably be worried about its contents being made public. The Contractor has publicly apologised and the Home Office has also asked for its apologies to be transmitted. Therefore there does not appear be unremedied injustice. What is highlighted, though, is the need for public bodies to consider proactive and timely communication with individuals if their data has been lost. In the case considered here, the Home Office decided not to contact the majority of those affected but to let them learn about the loss through press reporting and those concerned did not feel sufficiently informed or reassured.
A woman, Mrs D, and her son complained that the Environment Agency, Lancashire County Council and Rossendale Borough Council had failed to take appropriate action against a neighbour who was tipping, burying and burning large quantities of waste illegally, blocking public footpaths and intimidating anyone trying to use them. The activities, carried out over a period of seven years, made the landscape, which had been a local beauty spot, unrecognisable, made it impossible for her and her son to live peacefully in their family home; and may well have caused long-term damage by polluting the land and local water supplies. The Parliamentary Ombudsman and Local Government Ombudsman jointly investigated and fully uphold the complaint, finding maladministration, by all three bodies, that caused considerable injustice over a lengthy period. The Ombudsmen make five recommendations in relation to the complaint, including making good the financial loss on the value of the property, estimated at £35,000 by the District Valuer, and paying £60,000 compensation for the distress caused. In addition, the Environment Agency and Lancashire County Council should put in place an agreement on how to work together on illegal waste matters.
Report of the Health Service Ombudsman on Ten Investigations Into Nhs Care of Older People; Fourth Report of the Health Service Commissioner for England, Session 2010-11
Report of the Health Service Ombudsman on Ten Investigations Into Nhs Care of Older People; Fourth Report of the Health Service Commissioner for England, Session 2010-11
In this report, "Care and compassion?" the Health Service Ombudsman says the NHS is failing to treat older people with care, compassion, dignity and respect. The report is based on the findings of ten independent investigations into complaints about NHS care for people over the age of 65 across England. It serves to illuminate the gulf between the principles and values of the NHS Constitution and the felt reality of being an older person in the care of the NHS in England. The Ombudsman's findings show how ten older patients suffered unnecessary pain, indignity and distress while in the care of the NHS. Her investigations highlight common failures in pain control, discharge arrangements, communication with patients and their relatives and ensuring adequate nutrition. These are not isolated cases. Of the nearly 9,000 properly made complaints to the Ombudsman about the NHS last year, 18 per cent were about the care of older people. The Ombudsman accepted twice as many cases for investigation about older people as for all other age groups put together. The findings reveal an attitude - both personal and institutional - which fails to recognise the humanity and individuality of the people concerned and to respond to them with sensitivity, compassion and professionalism. These accounts present a picture of NHS provision that is failing to meet even the most basic standards of care. The NHS must close the gap between the promise of care and compassion outlined in its Constitution and the injustice that many older people experience.
This report relates to a stroke patient who died of a pulmonary embolism. The patient's niece complained that poor care and lack of nutrition led to the patient's early death. The Ombudsmen decided that the Council and PCT in question did not act in line with recognised quality standards or established good practice and that the care the patient received amounted to service failure. However, they did not find that the poor nutrition and hydration could be linked to the patient's death
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