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Great Western Hospitals NHS Foundation Trust

P-002032 · Statement · Decision date: 28 June 2023 · View Great Western Hospitals NHS Foundation Trust scorecard
Complaint (AI summary)
Miss A complained about an incorrect diagnosis, rude staff, medication errors, issues with surgery decisions, security intervention, and other significant care and communication problems during her hospital stay.
Outcome (AI summary)
The ombudsman closed the complaint because it was submitted outside the 12-month time limit, and no justification for the delay was accepted.

Full decision details

The Complaint

3. Miss A complains about the Trust’s care and treatment from 5 to 16 December 2020. She says:

• an A&E doctor made a wrong diagnosis • there was difficulty inserting a cannula (a tube that is inserted into a vein to give medication) • a nurse had a rude attitude • her usual antidepressant (venlafaxine) was not prescribed • venlafaxine was wrongly written as an antipsychotic (a type of psychiatric medicine) in her clinical records • a consultant surgeon raised his voice angrily when talking about something that had happened before • the medication she was admitted with went missing • there was confusion over the decision to operate • staff failed to tell her brother the operation was not happening • she was held down by security guards • a complaint she made before was mentioned in her clinical records • her transport home was delayed.

Background

4. Miss A was admitted to the Trust on 5 December 2020 for gallbladder surgery. Miss A first complained to the Trust on 4 October 2021 and she brought her complaint to us on 24 May 2022. We asked Miss A to continue the complaints process with the Trust as she had not complained about everything she was unhappy about.

5. Miss A returned to the Trust on 10 June 2022 and it sent her a final response on 13 September. Miss A brought her complaint to us on 7 October.

Findings

8. The law says we can only investigate complaints which have been brought to us within one year of the person becoming aware of a problem. We can put this time limit to one side if we see a good reason to.

9. Miss A knew there was a problem on16 December 2020. This means the complaint should have been brought to us by 16 December 2021. Miss A brought her complaint to us on 11 October 2022, making the complaint ten months out of time. We looked at the reasons for the delay.

10. To help her make her complaint to the Trust, on 11 May 2021 Miss A asked it for her clinical records. We asked Miss A about the five-month gap between her becoming aware of the need to complain and asking for her records.

11. Miss A said she had just been in hospital for 11 days with a serious gallbladder issue. She says she was discharged on 16 December 2020 and was then on antibiotics for four months.

12. Miss A says because she had complained before, she knew she would need her records so she had all the information. She says the Trust did not deal with her first complaint fairly and she did not want to have the same experience again. She says she was very unsure about complaining again because of her last experience. She says she decided to complain again to protect others so they would not be put through what she was.

13. We understand Miss A’s concerns and we can see she was supported by an advocate from January 2021. With the advocate’s help, we think Miss A could have asked for her records before 11 May 2021.

14. Miss A did not tell us about any other reasons why she delayed getting her medical records.

15. If Miss A’s health issues stopped her from making her complaint between 16 December 2020 and 16 April 2021, there is still a gap of 25 days from 16 April to 11 May when she could have requested her records.

16. Miss A could have made her complaint without having seen her records. The questions Mrs A asked about her admission in December 2020 were mainly based on her own experience. Only two out of the 25 questions Miss A asked the Trust were about information she got from her records.

17. The Trust sent Miss A the records on 14 July 2021, six weeks after she asked for them.

18. Miss A complained to the Trust on 4 October 2021, almost three months after getting her records. Miss A says on 10 August 2021 she had an emergency admission to another hospital, where she stayed for two weeks and nearly died.

19. We understand Miss A was experiencing serious health issues at this time and we have taken this into account when looking at the reasons for delay.

20. The Trust replied to Miss A’s complaint on 27 December 2021, almost three months after she made it. We have also taken this time into account when looking at the reasons for delay.

21. Miss A complained to us on 24 May 2022, five months after getting the Trust’s reply to her complaint. Miss A said she did not complain to us straightaway because she had a major breakdown towards the end of January 2022, caused by reliving what had happened to her. She said she was afraid to go to bed because of nightmares. She says her flashbacks were out of control and other past horrors were overtaking her. She says the breakdown caused her to feel powerless and it was made worse by having to deal with the Trust who had caused the breakdown. She says she was also unwell physically because of the problems with her gallbladder.

22. Miss A had another complaint in progress with us at this time. Our records show Miss A was able to discuss this complaint with us in April 2022 despite her health issues. Because of this, we consider Miss A could have brought her second complaint to us at any time from April 2022.

23. On 30 May 2022, we asked Miss A to complain to the Trust about everything she was unhappy about. Miss A returned to the Trust on 10 June, 11 days later.

24. On 13 September the Trust replied to Miss A’s complaint. We have taken into account the three months it took for the Trust to handle the complaint. Miss A brought her concerns to us on 7 October 2022, about three weeks after getting the Trust’s response.

25. After looking at all the reasons for delay, we have not seen good reason to put the time limit to one side and to investigate the complaint further.

Our Decision

1. The Parliamentary and Health Service Ombudsman has carefully considered Miss A’s complaint about Great Western Hospitals NHS Foundation Trust (the Trust). We are sorry to hear about the events which led Miss A to complain.

2. Miss A made her complaint to us outside of our 12-month time limit. We have looked at the reasons why Miss A was not able to bring her complaint to us sooner and have not seen good reason to put our time limit to one side. For this reason, we will not be taking any further action. We will explain our decision in more detail below.

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