The Royal Wolverhampton NHS Trust

9. Mrs O complains, from 13 March to 25 April 2017, a locum consultant mismanaged the treatment of her mother, Mrs E, by not following National Institute of Clinical Excellence (NICE) and British Society for Gastroenterology (BSG) guidelines around IDA.

10. Mrs O says the Trust failed to put in place the recommendations from its RCA report. She says the Trust has failed to have adequate procedures in place to recruit and monitor the performance of its staff and, in particular, locum consultants.

11. Mrs O complains this has caused her distress and frustration and caused her to lose faith in the Trust.

12. As an outcome of her complaint, Mrs O would like the Trust to apologise and review its policies and procedures regarding recruitment and supervision of patients’ care. She also wants the Trust to provide evidence it has implemented changes from the failings and recommendations from the RCA report.

13. In March 2017 Mrs O’s mother, Mrs E, was referred to the Trust on the colorectal fast-track pathway for asymptomatic IDA. She was seen by an agency locum consultant. The locum consultant requested a CT scan (computerised tomography scan – a form of X-ray examination) of Mrs E’s abdomen and pelvis to investigate IDA, which was completed on 23 March. It found no diagnostic features to explain Mrs E’s anaemia.

14. In April, the locum consultant discharged Mrs E back to her GP. The GP organised blood tests in May, which found her anaemia had resolved.

15. In August Mrs E was referred to the Trust for suspected cholecystitis (inflammation of the gallbladder). The Trust found biliary obstruction (the blockage of any duct between the liver and gallbladder). The Trust provided antibiotic therapy and management of biliary sepsis.

16. The Trust undertook an endoscopic retrograde cholangiopancreatography (ERCP), which combines an endoscopy (examination of the upper gastrointestinal [GI] tract using a flexible tube with a camera inside it) and X-rays to examine and treat conditions of the bile and pancreatic duct. The Trust performed an abdomen and pelvis CT scan on 4 September, which found liver metastases. Ampullary cancer was later confirmed. Ampullary cancer affects an area of the digestive system where the bile duct and pancreatic duct join. The cancer was found to be advanced and inoperable.

17. In December the Trust had finished a RCA and found two root causes. The first was a non-adherence to the NICE/BSG guidelines for the investigation of IDA. The second was the agency locum consultant’s actions, in relation to the investigation of IDA, were unchallenged.

18. The Trust created an action plan setting out the recommendations and the actions it would take to help reduce the risk of these errors occurring again. The recommendations are detailed in a later section of this statement.

19. In January 2018 Mrs O received a letter and investigation report from the Trust. This report raised concerns about the treatment the agency locum consultant gave to Mrs E. It said the agency locum consultant who had seen Mrs E did not follow the NICE or BSG guidelines. Specifically, the Trust said endoscopic investigations should have been the first-line investigations rather than a CT scan.

20. In February Mrs O made her complaint to the Trust. In April Mrs O attended a meeting with the Trust. The meeting notes show the Trust explained the errors made by the locum consultant. It said it had referred the locum consultant to the General Medical Council (GMC).

21. The Trust said when the locum had first started working for the Trust and was under supervision, he had dealt appropriately with patients and followed IDA treatment pathway guidelines. The Trust said over time the locum consultant had started to request inappropriate tests and had failed to follow the relevant guidelines.

22. Mrs O complained to the Trust in October 2019, as she felt the Trust had not taken sufficient action to follow its action plan recommendations. The Trust replied to her on 5 December. It said it had implemented changes, including to the process for induction and monitoring of locum staff.

25. Mrs O has told us the Trust failed to enact the recommendations from its RCA report completed in December 2017. The RCA raised concerns about the locum consultant failing to follow IDA guidelines and his work going unchallenged by the Trust. The Trust produced an action plan to reduce the risk of these issues occurring again.

26. The Trust’s RCA identified two root causes, as explained in an earlier section. The Trust set out six recommendations to address the root causes and the planned actions to achieve this. We considered these and whether the Trust had taken appropriate steps to follow the recommendations in its action plan.

Guidelines on the investigation and management of IDA should be made easily available to all relevant staff

27. The action plan recommended the Trust take actions to reduce the risk of non-adherence to the NICE and BSG guidelines for the investigation of IDA. The action plan recommended making relevant guidelines easily available to all staff.

28. To do this, the action plan recommended the guidelines should be included in the adult surgical guidelines and medical guidelines pages on the Trust’s intranet.

29. The Trust has provided us with documentation showing links to information on the ‘Management of Iron Deficiency Anaemia’ on the adult surgical guidelines page on the Trust’s intranet. The Trust has also shown us evidence to suggest a link for IDA guidelines has also been added to the adult medical guidelines intranet page.

30. The Trust has produced a new ‘Temporary Workers Information Pack’. This information pack provides a link to all policies and procedures used at the Trust. The information pack says new clinicians should seek advice from their supervisors if they have queries.

31. The Trust has told us it has updated its PowerPoint used in training fourth-year medical students. The update references how the Trust carries out IDA treatment.

32. The GMC guidelines require doctors to keep their professional knowledge and skills up to date. There is an expectation clinicians will take steps to be aware of clinical guidelines relevant to their area of practice.

33. Considering the GMC guidelines, doctors have a personal responsibility to make sure their knowledge is up to date. However, we appreciate the Trust has a role in training its staff. As we have seen, the Trust has already accepted the errors in its approach to making clinical guidelines readily available to staff.

34. Our Principles for Remedy say where maladministration (mismanagement or fault) or poor service has led to injustice, public bodies should try to offer an action to put things right (a remedy) that returns the complainant to the position they would have been in otherwise. If that is not possible, alternative actions should be offered.

35. This can include remedial action, which may include revising published material, revising procedures to prevent the same thing happening again, training or supervising staff, or any combination of these.

36. Our Principles of Good Administration say organisations should do what they say they are going to do. If they make a commitment to do something, they should keep to it.

37. We have found the Trust has taken sufficient action to help improve the accessibility of guidelines to clinical staff. The evidence shows the Trust has taken action to make the guidelines easily accessible to all staff and it particularly draws attention to this availability to new staff. This aspect of the complaint will not be upheld.

Teaching sessions

38. To implement this recommendation, the Trust also said it would raise awareness of these guidelines via directorate teaching sessions and grand rounds. The action plan says the documentation required to evidence the action has been completed is an attendance sheet and the agenda of directorate teaching.

39. The Trust has supplied us with an email from the Trust’s Clinical Director for gastroenterology. The email suggested the action ‘raise awareness of these guidelines via directorate teaching sessions/grand rounds’ had been completed.

40. The Trust has not provided us with evidence of these actions, either through our original request or after follow-up requests. Given the opportunities and time the Trust has had to provide this evidence, we consider it is more likely than not this evidence does not exist.

41. Without this evidence, we are unable to conclude the teaching sessions have been completed as recommended by the action plan. We have found the Trust has failed to act in line with our Principles for Remedy and Principles of Good Administration. It has not taken the remedial action it said it would.

42. We will consider the impact of this on Mrs E in the impact section.

Move all referrals for IDA to gastroenterology clinics to facilitate consistency in the investigation for IDA

43. The Trust’s RCA says in 2017 IDA referrals could be directed to both colorectal and gastroenterology services. This is because the fast-track referral forms for both services contain IDA as the reason for referral.

44. The Trust’s action plan recommended moving all IDA referrals to gastroenterology, which treats upper GI tract conditions (oesophagus, stomach and the first part of the small intestine, the duodenum). The Trust thought this would help facilitate consistency in the investigation of IDA and help avoid the risk of non-adherence to NICE/BSG guidelines.

45. To complete this, the Trust developed new fast-track referral proformas for upper GI and lower GI patients with IDA who were being referred.

46. The Trust has provided us with copies of the new fast-track referral forms. The lower GI referral form now advises doctors to refer patients presenting with IDA to use the upper GI referral form, which will lead to a referral to gastroenterology.

47. The upper GI referral form contains reference to IDA and a section for the referrer to detail the results of related blood tests.

48. Considering the evidence, we have found the Trust has taken the action set out by the action plan. We have found the Trust has taken relevant action to revise its procedures. By ensuring referrals are only sent to gastroenterology, it will improve the consistency of IDA investigations. This is in line with our Principles for Remedy and Principles of Good Administration detailed in a previous section. We will not uphold this part of the complaint.

Individual reflection for locum consultant regarding understanding of clinical pathway

49. The Trust’s action plan said it would send a copy of the final RCA to the locum consultant for reflection.

50. The HSC Act section 7(1) says we should not conduct an investigation of actions taken in respect of appointments or removals, pay, personal matters or discipline to service under the National Health Service Act 2006.

51. Considering the HSC Act, we are unable to investigate the Trust’s actions around the locum consultant’s performance. This aspect of the complaint is outside our remit, and we have no powers to investigate. As such we cannot consider whether the Trust has taken action to fulfil this aspect of the action plan.

Review of directorate’s staffing resource and reduce the dependence on agency locum staff

52. The Trust’s action plan said the Trust should review the Directorate’s staffing resource and reduce the dependence on agency locum staff. It said the Trust would appoint an NHS locum to cover long-term absence.

53. This aspect also falls under the HSC Act, which says we should not conduct investigations into the appointment or removal of staff.

54. This aspect of the complaint is outside our remit, and we have no powers to investigate. As such we have not considered whether the Trust has taken appropriate action to fulfil this aspect of the action plan.

Examine supervision process for locums working at consultant level

55. The Trust’s action plan says the Trust should review the supervision process for those locums working at consultant level. The action plan notes locum consultants are already supervised for clinics, theatre lists, endoscopy examinations and while on-call.

56. The Trust’s meeting minutes say the consultant locum had worked under a period of supervision with no cause for concern. It is clear the locum’s errors began to occur once this supervision period ended.

57. The action plan says the Trust will introduce a process to review correspondence from outpatient clinics at regular intervals, on an ongoing basis, to provide assurance of practice.

58. The Trust has provided us with evidence to suggest this process has been put in place. The Trust says a former senior consultant in the colorectal team undertook the review. The Trust said checks were made on a newly appointed consultant, but no audit trail was completed as there were no causes for concern.

59. The Trust told us it had not implemented a formal written process to make sure correspondence checks of locum consultants’ outpatient clinics happened. It said it would ask a new Clinical Director of General Surgery to raise this issue with the Chief Medical Officer.

60. Given the opportunities and time the Trust has had to provide evidence, we consider it more likely than not this evidence does not exist. Without this evidence, we have concluded a robust review process of outpatient clinic correspondence has not been put in place.

61. We have found the Trust has failed to act in line with our Principles for Remedy and Principles of Good Administration. It has not taken the remedial action it said it would. We will consider the impact of this on Mrs O in the impact section.

Review of Trust-wide approach to formalising supervision and competency assessments for locum appointments

62. The Trust’s action plan said it would undertake a review of the trust-wide approach to supervision and completing competency assessments for locum appointments.

63. The Trust has shown us its newly introduced ‘Temporary Workers Information Pack’. The document is provided to all new temporary staff. It explains the requirements of new temporary staff to complete an induction and mandatory training before starting work.

64. The information pack also details important information on how the Trust functions. For example, the pack includes details on how to make out-of-hours referrals or how to report incidents. The information pack makes it clear when new staff are unclear about Trust policies, they should seek advice from their supervisors.

65. Temporary staff must also sign documentation detailing their ‘Understanding of the Limits of Competence’. This document states it is a staff member’s responsibility to identify limitations in their abilities or training. It tells new staff not to carry out a particular task or procedure without sufficient training. The document says a discussion should be held between new staff and a manager or supervisor about limitations of competence before signing.

66. The review and introduction of a new information pack for temporary workers indicate the Trust has reviewed the Trust-wide approach to supervision and assessments for locum appointments.

67. We have seen evidence the Trust has reviewed its processes and produced new published materials. We have found the Trust has taken the remedial action it said it would. The Trust’s actions are in line with our Principles for Remedy and Principles of Good Administration detailed in an earlier section. We will not uphold this part of the complaint.

Shared learning

68. As part of the lessons learned, the Trust recommended sharing learning from the RCA. The Trust said it would share the RCA summary across all clinician directorates.

69. We have seen evidence the RCA summary was circulated to all directorates. The summary explained the RCA findings and stated IDA guidelines would be linked in the intranet.

70. In its RCA, the Trust has said the failures of the locum may have been caused by a lack of knowledge of the IDA pathways guidelines. The Trust said it would expect a clinician at consultant level to have knowledge of the pathway.

71. We have found the sharing of the RCA summary will help reduce the risk of this error happening again. The Trust has taken remedial action to prevent the same thing happening again. This is in line with our Principles for Remedy and fulfils the recommendations of the action plan. We will not uphold this part of the complaint.

Impact

72. Our Principles of Good Administration say organisations should do what they say they are going to do. If they make a commitment to do something, they should keep to it. As we have set out above, the Trust has not done this.

73. Mrs O told us the Trust’s failure to take the actions it said it would has caused her distress, frustration and a loss of faith in the Trust.

74. Mrs O has told us she would like the Trust to apologise, and she has requested the Trust implement the recommendations of its action plan. She also wants the Trust to provide evidence it has implemented recommended changes.

75. As set out above, we have found the Trust has failed to undertake the actions it said it would in the action plan. These are the failure to raise awareness of IDA guidelines in teaching sessions and the failure to embed a process to check outpatient clinic correspondence of locum consultants. The Trust has, therefore, not complied with its own recommendations.

76. The Trust’s action plan set target dates to complete the actions. The latest target completion date was January 2018. The failure of the Trust to put recommendations in place after almost five years is concerning.

77. This extended time frame has denied Mrs O a resolution to her complaint and caused her additional distress and frustration. We can understand how the Trust not taking the required actions has caused Mrs O distress, especially given the events that happened with Mrs E.

78. We have set out our recommendations to address the injustice Mrs O has experienced below.

1. The Parliamentary and Health Service Ombudsman would like to thank Mrs O for bringing this complaint to us. We want to offer our condolences for the loss of her mother, Mrs E. We understand how hard it must have been for Mrs O to revisit these issues over this prolonged period.

2. Based on the evidence, we partly uphold this complaint. This is because we have identified the Royal Wolverhampton NHS Trust (the Trust) has not implemented aspects of the recommendations of a Root Cause Analysis (RCA) and the related action plan.

3. We have found the Trust has failed to put in place two recommendations made in its action plan. This has caused Mrs O distress and frustration and caused her to lose faith in the Trust.

4. The first recommendation was the need to raise awareness of the treatment pathway guidelines of iron deficiency anaemia (IDA). IDA is a reduction in red blood cell production due to low iron stores in the body.

5. The action plan recommended the Trust complete this through teaching sessions or grand rounds. Grand rounds are a method of medical education in which a particular problem is presented to a clinical audience. We have seen no evidence this has taken place.

6. We also found the Trust has failed to introduce part of the action plan recommendations to reduce the risk of poor practice going unchallenged.

7. The action plan recommends the Trust introduce a process for review of correspondence from outpatient clinics run by locum consultants (who work for the Trust on a temporary basis). We have not seen enough evidence to confirm this has taken place.

8. Considering these failings, we recommend the Trust apologise to Mrs O and explain the reason for the delay in taking these actions. We also recommend the Trust make swift process changes to make sure the recommendations of the action plan are followed.

79. In considering our recommendations, we have referred to our Principles for Remedy. These state where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

80. Our Principles for Remedy say organisations should quickly identify and acknowledge maladministration and poor service and apologise for this. An apology means acknowledging the failure and accepting responsibility for it. The organisation should explain why this happened were possible, and it should express sincere regret for any resulting injustice.

81. In line with this, we recommend the Trust write to Mrs O within four weeks of our final report. The Trust should acknowledge the failure to complete all of the recommendations of its action plan. It should also apologise for the impact this has had on Mrs O. The Trust should explain the delay and confirm it intends to complete the remaining recommendations of its action plan. A copy of this letter should be sent to us.

82. Our Principles for Remedy say public organisations should look for continuous improvement and use the lessons learned from complaints to make sure they do not repeat maladministration or poor service.

83. We recommend the Trust take the action it has said it would in its action plan. It should provide evidence of the action it has taken (or is taking if this is an ongoing action). The Trust should also explain who is responsible for each of these actions and when the actions will be completed. They should also explain how and when the actions will be reviewed to make sure they have been completed and have had the desired effect.

84. The Trust should undertake this within 12 weeks of our final report. A copy of this information should be sent to:

• Mrs O • us • the Care Quality Commission (CQC) and • NHS Improvement.