A medical practice in the Milton Keynes area

3. Ms R complains the Practice inadequately handled her complaint about the care and treatment provided for her father, Mr A, by district nurses during a home visit in February 2019. She specifically complains that:

a. the Lead Nurse did not identify that Nurse A and Nurse U had incorrectly used female catheters, or that this could cause an injury, until Ms R raised this.

b. the Lead Nurse did not identify that Nurse A breached confidentiality (by discussing Mr A’s health with his cleaner) until Ms R raised this.

c. the Lead Nurse did not identify that Nurse A and Nurse U did not act in line with duty of candour, until Ms R raised this.

d. the Lead Nurse did not identify that the concerns were about a serious patient safety incident.

e. there should have been oversight of the investigation of her complaint by another staff member at the Practice.

4. Ms R says that the failure of the Practice to identify errors in care and professional practice led to her spending weeks researching and finding out what happened to her father. She said this caused her, and her family, a lot of stress.

5. Ms R said the Practice’s investigation took six months and left her drained and unwell. She said it had an emotional and mental impact on her as she was tired, lacking in concentration, and constantly thinking about the concerns. This impacted her ability to carry out other day-to-day tasks, such as caring for Mr A.

6. Ms R said she wants the Practice to acknowledge, and apologise for, the way it handled her complaint and the impact that this had on her. She said she wanted the Practice to make improvements to the way it investigated complaints so that similar failings do not happen in future. Ms R also said she would like the Practice to provide her with a financial remedy.

7. District nurses changed Mr A’s catheter monthly. On 18 February 2019, Nurse A incorrectly fitted a female catheter, that had been prescribed by a pharmacy in error. While female patients can use standard length catheters, men cannot use female length ones as the 'balloon' part of the catheter, which is inflated with sterile water to stop the device falling out, will still be in the urethra rather than the bladder. This can cause severe trauma to the urethra and retention. Nurse A then advised Mr A and his cleaner to contact the Practice if urine was not draining into the bag.

8. The District Nurse team (part of the Practice) was contacted later that day because Mr A’s penis was bleeding. Nurse A and her supervisor, Nurse U, returned to reassess him. Nurse U was concerned he was retaining urine and she inserted another female catheter. There were large blood clots coming from Mr A’s penis, so she stopped and called 999. The nurses left Mr A with Ms R to wait for an ambulance. Mr A’s son arrived and took him to hospital.

9. Mr A was admitted to hospital with urine retention and blood in his urine. He had a high temperature, fluctuating blood pressure, and abdominal pain. He had a swollen bladder and was bleeding from the urethra. Doctors made multiple attempts to reinsert a catheter before this was successful. On 20 February, Mr A developed urinary sepsis, caused by a blocked catheter. He was treated with intravenous antibiotics and his condition improved. Mr A was discharged on 25 February on oral antibiotics.

10. Ms R telephoned the manager of Nurse A and Nurse U (the Lead Nurse) on 25 February because she was concerned something had gone wrong. She had further conversations with the Lead Nurse and other Practice staff before submitting a formal complaint about her father’s care on 6 March. The Practice responded to Ms R in April, and there was further correspondence and meetings between the Practice and Ms R until February 2020, when the Practice informed Ms R that its investigation had been completed.

Complaint a

13. We first consider Ms R’s complaint that the Lead Nurse did not identify Nurse A and Nurse U had incorrectly used female catheters, or that this could cause an injury, until Ms R raised this. In looking at this aspect of the Practice’s complaint handling, we assess whether it acted in line with Our Principles of Good Complaint Handling (Our Principles). These say that Being customer Focused includes: ‘dealing with complainants promptly and sensitively, bearing in mind their individual circumstances’.

14. Ms R told us she telephoned the Lead Nurse on 25 February 2019 because she was concerned something had gone wrong with her father’s care. She said the Lead Nurse reassured her that nothing had gone wrong, and that this often happens to elderly patients. Records show the Lead Nurse advised Ms R that she would ‘discuss with nurses involved in care’.

15. Ms R told us she checked her father’s medical records and found a sticker showing a female catheter had been used on 18 February, and that she had found female catheters in her father’s home. Ms R said she telephoned the Lead Nurse (on 27 February) and asked what the relevance of the female catheter sticker might be. She said she also asked if it meant a female catheter had been used. Ms R said the Lead Nurse told her she was unsure and would speak again with the nurses but did not think this was relevant to something going wrong.

16. Ms R said the Lead Nurse told her she had spoken with the nurses and offered further reassurances following her discussion with them. The Lead Nurse also said she would ask for a urology nurse to speak to Ms R. Records document this telephone call as being ‘about multiple concerns’, and that the Lead Nurse would ‘speak to district nurse team and GP about options about re-catheterisation’.

17. A urology nurse spoke to Ms R on 28 February. Ms R said the urology nurse reassured her nothing had gone wrong. However, she told the urology nurse she intended to make a complaint because she had found an ‘audit trail’ that showed the district nurses had made an error when they used female catheters.

18. The notes of this conversation record that the urology nurse spoke to Ms R about concerns relating to ‘the catheter, catheter bags, care of the catheter and the recent hospitalisation’. After this phone call, Ms R found advice saying a female catheter should never be used on a man. She telephoned the pharmacy and it confirmed it had mistakenly prescribed these.

19. Ms R told us she tried to contact the Lead Nurse at the beginning of March to make a complaint. On 5 March, a Practice GP telephoned Ms R. Ms R said the GP did not raise any concerns about the issue of a female catheter being used. The notes show the discussion was about ‘follow up of improvement post hospital admission he is doing okay but still not back to baseline’.

20. The Lead Nurse telephoned Ms R on 6 March. Ms R said she told the Lead Nurse that she had discovered her father had been prescribed female catheters in error and these should not have been used on 18 February. She wrote to the Practice the same day asking it to investigate her father’s catherisation and his avoidable hospitalisation.

21. It is clear from the records we have seen, and from Ms R’s account of events, that none of the Practice staff she spoke to identified that a serious clinical failing may have occurred when female catheters were used on her father. However, we would not have necessarily expected them to identify a failing, as a formal investigation into his care had not started at that point. This is why it is concerning that the Lead Nurse, the urology nurse, and the GP all appear to have given Ms R misplaced reassurance that nothing serious had gone wrong, without a thorough consideration of the facts.

22. We do not agree with Ms R that the Lead Nurse should have identified failings in Mr A’s catheter care prior to it being fully investigated. What the Lead Nurse and other staff should have done, but did not appear to do, was to treat Ms R’s concerns as a complaint that needed to be investigated at the earliest opportunity. Certainly, by the 27 February or 28 February at the latest, the Practice should have been treating Ms R’s concerns as a formal complaint and we can find no evidence that this happened. This is not in line with Our Principle of Being customer Focused. However, we note that Ms R did subsequently submit a complaint on 6 March, so the delay in starting an investigation was minimal.

Complaint b

23. We now turn to Ms R’s complaint that the Lead Nurse did not identify that Nurse A breached confidentiality by discussing Mr A’s health with his cleaner, until Ms R raised this. Again, we assess this aspect of the Practice’s complaint handling in line with our Principle of Being customer focused and ‘dealing with complainants promptly and sensitively, bearing in mind their individual circumstances’. Also, we will consider whether the Practice acted in line with Our Principle Being open and accountable, which includes: ‘providing honest evidence-based explanations and giving reasons for decisions’.

24. We can see from the records that the first reference to Nurse A discussing Mr A’s health with his cleaner was in the Practice response to Ms R’s complaint dated 5 April. The Practice said that when Mr A’s catheter was changed on 18 February, Nurse A advised him and his cleaner ‘to contact the District Nurse team if urine wasn’t draining into the bag’. Ms R wrote to the Practice in May expressing dissatisfaction with the Practice’s response, and said it was inappropriate for the cleaner to have been asked to do this.

25. The Practice responded in June saying: ‘it is routine procedure to ask the patient or anyone in the home to report to the team if urine isn’t draining into the bag’. The Practice told Ms R that this was acceptable, and it had identified no learning. Ms R raised the issue about a breach of confidentiality again at a meeting with the Practice in July. The notes of the meeting (sent to Ms R in August) show that the Lead Nurse agreed that confidential patient information about Mr A should not have been shared with his cleaner and set out the actions that would be taken, to remind the nursing team about the importance of confidentiality.

26. We understand why Ms R thinks that the Practice’s investigation should have identified a breach of patient confidentiality by Nurse A. However, it is clear to us that Ms R’s initial conversations with the Practice were about her concerns about her father’s care, and her subsequent complaint was focused on clinical errors made during his catheterisation. The Practice’s investigation rightly considered this. Undoubtedly, it would have been good complaint handling for the issue of a breach of patient confidentiality to have been considered further when it first came to the attention of the Practice. However, it appears it was not something Ms R formally complained about until May.

27. We are critical that the Practice initially dismissed Ms R’s concerns about a breach of confidentiality in its letter sent in June. This was not in line with Our principle of Being open and accountable and providing honest evidence-based explanations and giving reasons for decisions. Despite this undoubted failing, there is evidence that the Lead Nurse subsequently accepted there had been a breach of confidentiality at the meeting in July, and informed Ms R of the actions to be taken to remedy the breach.

Complaint c

28. We now consider the complaint that the Lead Nurse did not identify that Nurse A and Nurse U failed to act in line with duty of candour, by not reporting their clinical errors in Mr A’s catheterisation, until Ms R raised this. To consider this aspect of the Practice’s complaints handling, we assess whether it acted in line with Our Principle of Acting fairly and proportionately, which includes: ‘complaints are investigated thoroughly and fairly to establish the facts of the case’.

29. In April, the Practice responded to Ms R’s complaint about her father’s catheterisation. The Practice said it had spoken to Nurse A and she said she had checked the date of the catheter on 18 February but had ‘omitted to recognise that it was a female catheter’. It said it had also spoken to Nurse U who said she: ‘recognised that the catheter was a female catheter but proceeded to attempt to insert the catheter as she felt she had no option as she was concerned [Mr A] was in retention and there were no other catheters in the house’.

30. The Practice said that Nurse A recognised that she should have checked the information on the catheter in greater detail and not used a female catheter. It said Nurse U recognised that she should have telephoned 999 as soon as she noted there were only female catheters available and should not have attempted to re-catheterise.

31. Ms R responded to this in her letter in May. She said Nurse A and Nurse U had not reported their errors to Practice management. Ms R also said that Nurse U had recognised that a female catheter had been used, but did not tell the family this, while they were waiting for an ambulance. The Practice apologised in its letter, in June, that the nurses had not told the family that the incorrect catheter had been used. It recognised that this information would have aided Mr A’s care once he arrived at hospital. The Practice said it planned to discuss information sharing at a team meeting later in July.

32. The issue was further discussed at the meeting early in July. The notes of this meeting said that the Lead Nurse had spoken to Nurse A and Nurse U about the failure in duty of candour, and they had completed a reflective account which ‘captures learning from the event’. This was discussed again in a meeting with Ms R in August, where the Lead Nurse said: ‘an error was made, they [Nurses A and U] should have recorded it and reported it to me. We can only apologise that this has happened, but there was no intention to conceal on our part’.

33. It is clear from the Practice’s response in April that errors had been identified in the catheterisation of Mr A. However, it was also apparent at that point that these had not been reported by Nurse A or Nurse U. The Lead Nurse should have recognised this given her previous conversations with them, prior to Ms R’s formal written complaint. If she had reviewed Mr A’s records, she would also have seen that there was no mention of the clinical errors that occurred, and which had been subsequently admitted to by Nurse A and Nurse U.

34. In those circumstances, we would have expected the Practice to have identified this lack of a duty of candour in its response to Ms R, along with a consideration of any actions that needed to be taken as a result of the breach. It did not do so until prompted by Ms R. We find that the Practice did not act in line with Our Principle of Acting fairly and proportionately by ensuring Ms R’s complaint was investigated thoroughly and fairly to establish the facts of the case.

Complaint d

35. We now consider Ms R’s complaint that the Lead Nurse did not identify that her concerns were about a serious patient safety incident. We again assess if the Practice’s handling of this aspect of Ms R’s complaint was in line with Our Principle of Acting fairly and proportionately, which includes ‘complaints are investigated thoroughly and fairly to establish the facts of the case’.

36. The records show the Lead Nurse told Ms R at the meeting in early July that she only became aware of potential clinical errors in Mr A’s catheterisation during her telephone call with Ms R on 6 March. She said she then ‘commenced an internal significant event investigation’.

37. At the second complaint meeting in August, Ms R’s personal notes show that she asked how the incident had been categorised as an 'internal significant event' investigation, and what the Practice’s policy was about this. She also asked why Mr A’s catheterisation had not been treated as a serious safety incident. The Practice’s notes of the meeting said that the Lead Nurse explained the significant event process and ‘the CCG… were happy for us to raise our own investigation as part of our significant event procedure’.

38. The Practice has only provided us with minimal information about the reporting of this incident. We can see that the Lead Nurse completed a ‘Root Cause Analysis 72 Hour Investigation Report’ on 27 August. This was emailed to the CCG in September, in what appears to be in preparation of a Serious Untoward Incident Investigation. On 25 February 2020, the Lead Nurse telephoned Ms R and told her the CCG had finished looking at her complaints, and she asked her if she wanted a copy of the action plan. Ms R told us she was unaware of the CCG’s involvement up until that point.

39. We have not seen any evidence to verify the Lead Nurse’s statement that she started an internal significant event investigation on 6 March, or that the CCG were happy with this approach. What we can say is that it is clear from the records we have seen that the Lead Nurse should have identified that this was a potential Serious Untoward Incident and followed the relevant guidance.

40. In 2005, NHS England published Serious Incident Framework – Supporting learning to prevent recurrence. This guidance outlines good practice in identifying, investigating, and learning from serious incidents in order to prevent avoidable harm in future. It says that serious incidents in the NHS include: · ‘Acts and/or omissions occurring as part of NHS-funded healthcare (including in the community) that result in … unexpected or avoidable injury to one or more people that has resulted in serious harm…’

41. It also says that serious incidents must be declared internally as soon as possible, and immediate action must be taken to establish the facts by conducting a Root Cause Analysis Investigation.

42. It should have been clear to the Lead Nurse, much earlier than August, that Mr A’s catheterisation on 18 February should have been treated as a potential Serious Untoward Incident, and a Root Cause Analysis completed in line with the NHS guidance. This also should have been addressed in the Practice’s responses to Ms R very early on, and we can see that it was not. Because of this, we find that the Practice did not act in line with our Principle of Acting fairly and proportionately by ensuring Ms R’s complaint was investigated thoroughly and fairly to establish the facts of the case.

Complaint e

43. We finally turn to Ms R’s complaint that there should have been oversight of the Lead Nurse’s investigation by another staff member at the Practice. In assessing this aspect of Ms R’s complaint, we consider whether the Practice acted in line with Our Principle of Acting fairly and proportionately, which includes: ‘ensuring that complaints are reviewed by someone not involved in the events leading up to the complaint’.

44. Ms R told us she had concerns that the Lead Nurse had a conflict of interest as the investigator of her complaint because she was a friend of the family, and she also managed Nurses A and U. It appears she discussed this after the meeting in early July, according to her letter to the Practice, from later in July, which requested a further meeting.

45. In the letter, Ms R asked for the Practice manager to be present due to the unresolved potential conflict of interest issue. At the meeting in August, a Human Resources manager attended instead. The Lead Nurse addressed the conflict of interest issue. She said:

· ‘there is not a conflict of interest’ as she was ‘responding to the points raised in her position as manager of the team, so speaking on their behalf’…. The way [she] has handled the situation would not be any different if she knew [Ms R] or not. All issues are investigated fully in all circumstances.’

46. We fully understand why Ms R concluded there was a potential conflict of interest with a family friend investigating her complaint. In those circumstances, it might have been prudent (although certainly not required) to have another member of staff overseeing the complaint, if only to offer reassurance to Ms R that the investigation was being conducted in a fair and impartial way.

47. However, we have seen no evidence to suggest that the Lead Nurse was an inappropriate person to investigate the complaint. She managed Nurses A and U (which we do not consider was a conflict of interest as Ms R believes) and was not involved in any of the events leading up to Ms R’s complaint. This was entirely in line with our principle of Acting fairly and proportionately.

Summary

48. We do not find that the Lead Nurse should have identified failings in Mr A’s catheter care prior to it being fully investigated. However, Practice staff did miss an opportunity to treat Ms R’s concerns as a formal complaint at the earliest opportunity, but the delay was minimal. We also do not find that the Lead Nurse should have identified a breach of confidentiality prior to Ms R raising this, although we are critical that she initially dismissed Ms R’s concerns about this. Moreover, we do not find that the Lead Nurse was an inappropriate person to investigate Ms R’s complaint, or that there should have been oversight by another staff member at the Practice.

49. However, we have found two significant failings in the Practice’s complaint handling. The first was the failure of the Lead Nurse to identify that Nurse A and Nurse U had not acted in line with the duty of candour until Ms R raised this as an issue. The second was the significantly belated recognition of both Mr A’s catheterisation as a Serious Untoward Incident, and in addressing this in the complaint responses. We have considered whether these failings fall so far below the relevant standards to be maladministration and we have concluded that they do.

Injustice

50. Ms R says that the failure of the Practice to identify errors in care and professional practice led to her spending weeks researching and finding out what happened to her father. She said this caused her, and her family, a lot of stress.

51. Ms R also said the Practice’s investigation took six months and left her drained and unwell. She said it had an emotional and mental impact on her as she was tired, lacking in concentration, and constantly thinking about the concerns. This impacted her ability to carry out other day-to-day tasks, such as caring for Mr A.

52. We can see that in the two significant failings we have identified in the Practice’s complaint handling, Ms R had to direct the investigation to a certain extent to reach correct conclusions and learning. It is clear to us that the Practice should have identified much earlier that there were important issues around Duty of Candour and Serious Untoward Incident reporting that needed addressing in its response to the complaint. Ms R should not have had to unnecessarily spend a lot of her own time pushing the Practice to provide robust answers to these issues. That she had to do this was an injustice to Ms R, and we can see how this could have an emotional impact on her of the type she describes.

1. We have found failings in some aspects of the Practice’s handling of Ms R’s complaint, and this was maladministration. This maladministration led to an injustice to Ms R, which has not yet been remedied. We therefore uphold Ms R’s complaint.

2. We have recommended that the Practice write to Ms R to acknowledge and apologise for its errors in its complaint handling and the impact this had on Ms R. We have also recommended that the Practice should explain how similar failings will be prevented in future. We have that recommended the Practice pay Ms R £250 as a financial remedy

53. In considering recommendations, we have referred to our Principles of remedy. These say that where maladministration or poor service has led to injustice or hardship, the public organisation(s) should take steps to provide an appropriate and proportionate remedy.

54. They also say that public organisations should seek continuous improvement and should use the lessons learnt from complaints to ensure that maladministration or poor service is not repeated.

55. The Practice should therefore write to Ms R, within four weeks of the date of the final report, with an open and honest acknowledgement of the failings we have identified in the way it handled Ms R’s complaint. It should also apologise for the impact the poor complaint handling had on Ms R and explain how similar failings will be prevented in future. A copy of this letter should be sent to us.

56. Our Principles also say that public organisations should ‘put things right’ and, if possible, return the person affected to the position they would have been in if the maladministration had not occurred. If that it is not possible, they should compensate them appropriately.

57. To decide a level of financial remedy we review other cases where a similar injustice has arisen. We also refer to our Severity of Injustice Scale. Following this review, we have assessed that the Practice should pay Ms R £250 in recognition of the injustice she suffered within eight weeks of the date of final report. Proof of payment should be sent to us.