London North West University Healthcare NHS Trust

3. Mr R complains about the standard of care and treatment his late sister-in-law, Ms O, received from the Trust between 9 June 2020 and 3 October 2020. Mr R raises the following concerns saying:

• it is unclear if Ms O received thyroid medication during her inpatient stay • the Trust failed to provide him with Ms O’s laparotomy notes • the Trust advised he would receive feedback from a clinical governance meeting held on 14 December 2021, but this did not happen, and • he was advised the Trust would liaise with the Registrar of Brent Council about a correction to Ms O’s medical certificate of cause of death (MCCD).

4. Mr R tells us the family’s experiences have been deeply upsetting and traumatic, and this has been made worse by the way the complaint was handled by the Trust.

5. As an outcome to his complaint, Mr R would like the Trust to accept its failings and further information.

6. On 9 June 2020, the Trust referred Ms O to an independent London hospital for a complex operation.

7. From 9 June 2020, Ms O received inpatient care. She sadly died in October 2020.

Thyroid medication and laparotomy notes

10. Mr R complains the Trust has been unable to advise him whether Ms O was receiving her thyroid medication during her inpatient stay at the hospital. We can see Mr R raised this concern with the Trust several times. We can also see Mr R has repeatedly asked for Ms O’s laparotomy notes, and the Trust has recognised this request.

11. We have reviewed the Trust’s responses and complaint file and can see the Trust explained why it is not always possible to administer routine medication, but it did not go on to explain whether Ms O was receiving specific medication and, if not, why not.

12. We refer to our Principles of Good Complaint Handling, which say public bodies should be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations and reasons for their decisions.

13. We do not think the Trust’s response was in line with our principles. We approached the Trust and asked it to give a response that did comply with those principles. The Trust agreed it would do so. The Trust has been unable to provide us with a completion date, as it has advised us it will need to request Ms O’s records from the hospital and then conduct an investigation.

14. Our principles also state public organisations should be transparent and information should be handled as openly as the law allows. Public bodies should give people information and, if appropriate, advice that is clear, accurate, complete, relevant and timely.

15. In light of our consideration, the Trust has advised it will ask for the laparotomy notes and share them with Mr R. Again, the Trust has been unable to provide us with a completion date, as it has advised us it will need to request Ms O’s records from the hospital.

16. We recognise the distress Mr R and his family have experienced as a result of the Trust’s actions and also while pursuing this complaint, and we are grateful for the information he has shared with us to help us consider the complaint. We hope we have explained the reasoning for our decision clearly and the resolution we have reached with the Trust helps resolve his concerns.

Clinical governance meeting

17. Mr R told us the Trust advised it would discuss Ms O’s case at a clinical governance meeting and then provide him with feedback. He explained this has not happened.

18. We can see the Trust apologised in its response from June 2022 for not providing Mr O with feedback, but said the case was discussed during a clinical governance meeting held on 14 December 2021. However, when we reviewed the complaint we saw no evidence the discussion had taken place.

19. In light of our consideration, we asked the Trust if it could provide further clarification on what had happened. The Trust explained Ms O’s case was not discussed at that meeting due to pressure of other business. These meetings are held every three to four months, and a presentation on the case was made at a meeting on 7 April 2022. The Trust enclosed a copy of the presentation.

20. We appreciate the Trust was unable to discuss Ms O’s case at the initial clinical governance meeting. However, we refer to our Principles of Good Complaint Handling, which state public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it or explain why they cannot do so. They should meet their published service standards or let customers know if they cannot.

21. We have seen no evidence to suggest the Trust acted in line with our principles, as it did not update Mr R on the delay in discussing Ms O’s case. We raised this with the Trust, and it has explained it will write to Mr R, apologise for the delay and provide a copy of the presentation. We hope Mr R is satisfied with what we have asked the Trust to do to resolve his concerns.

MCCD

22. Mr R complains the Trust advised its medical examiner would liaise with the Registrar of Brent Council about a correction to Ms O’s MCCD; however, this has not happened.

23. We raised this concern with the Trust. In light of our concern, the Trust confirmed the medical examiner’s office is liaising with Mr R. As this is the outcome Mr R wanted as a result of his complaint, there is nothing further for us to do.

24. We recognise the distress Mr R and his family have experienced as a result of the Trust’s actions and also while pursuing this complaint and we are grateful for the information he has shared with us to help us consider his complaint. We hope we have explained the reasoning for our decision clearly, and that the resolution we have reached with the Trust helps resolve his concerns.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mr R’s complaint about London Northwest University Healthcare NHS Trust (the Trust). We are sorry to hear how Mr R and his family have been affected by the events described. It is clear the family had a difficult and upsetting experience at what would already have been an upsetting time. We appreciate Mr R’s experience was not as it should have been and combined with his sister-in-law’s, Ms O’s, rapidly deteriorating condition and sad death, this has caused longstanding upset for the family.

2. We have spoken with the Trust and it has agreed to give Mr R the information he asked for. We will explain how we have reached this outcome in this statement. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Mr R for sharing his family’s experience with us.