13. Miss I’s main priority is to make sure others do not experience the same issues. She wants confirmation that changes have been made, that errors have been recognised and a further apology.
14. Miss I contacted the Trust with her concerns three times. The Trust sent a response to Miss I on 1 October 2022. The Trust accepted the care fell below the expected standards when Mr I was left alone in the X-ray department without any oxygen. The Trust said oxygen should always be available with a second cylinder for back up. The Trust said it is disappointed this did not happen and it apologised for the care falling below the care delivery expected.
15. Towards the end of Mr I’s life, his sister visited the hospital at night-time. She says a staff member stopped her from entering the ward due to visiting times being over. She says the communication skills and handling of this situation was awful.
16. At this point, Mr I had significantly deteriorated and was coming to the end of his life. The Trust said it has reminded staff of the hospital’s values and that all communication with patient’s relatives should be delivered with compassion and kindness.
17. We can see the Trust has acknowledged its mistakes and it has put steps in place for staff to communicate better. It shared the family’s experience with staff to highlight the failings in Mr I’s care. It says it has spoken to the staff member concerned about their communication. The Trust apologised to Miss I and her family for the distress it caused.
18. We have carefully considered Miss I’s complaint and how she says she and the family were affected.
19. We talked to Miss I about how we would speak to the Trust to see if we could achieve the outcomes she was looking for. Miss I said she would be happy if the Trust would do what she wanted.
20. We asked the Trust for confirmation of the service improvements it has made and to acknowledge its failings. We asked the Trust to send a further apology to Miss I for the errors made when Mr I was under its care.
21. The Trust agreed to do this and provided a formal response.
22. This explains the improvements it has already made and the improvements and measures it plans to work on because of the significant failings that this complaint has highlighted.
23. The Trust’s response focuses on these areas: • lack of nursing attention and supervision • nurses not making sure enough oxygen was available between transfers • nurses were not aware of care requirements • poor communication and a lack of compassion with family members in general.
24. The Trust confirmed an intentional comfort rounding process has been rolled out on all wards after a successful pilot (trial). This encourages a proactive approach to direct patient care and allows regular communication, attention of nurses and health care support workers and close supervision of patients.
25. The Trust confirmed it will closely monitor, audit and review this, with any gaps being highlighted immediately.
26. The Trust confirms the patient transfer policy has been reviewed and updated so patients are transferred safely between wards and departments. The policy has been circulated and shared with all teams to make sure the level of patient care and transfer is safe.
27. The Trust confirms that staff have been reminded that oxygen is available in the X-ray department and should be used when required. The Trust says patients should never be left alone and instead concerns should be escalated.
28. The Trust confirms daily handovers take place as well as nurse and doctors ward rounds to make sure patients care requirements are understood.
29. The Trust apologised for the poor communication experienced and confirmed training has been identified as a key requirement for all staff. The Trust says most nurses have now completed the training.
30. The Trust confirmed daily huddles (meetings) allow reflection and learning points from patient and user feedback. We think it is clear the Trust has given a big focus to the importance of effective communication.
31. The Trust recently started a Homerton assessment, accreditation and recognition programme. This looks at the quality and standard of care delivered to patients. Patient safety partners are in place to speak to patients and families on the ward and feedback is actioned immediately.
32. The Trust explained the service improvements it has made and apologised for its failings. Our Principles say to put things right, organisations should:
‘provide an apology, explanation, and an acknowledgement of responsibility, as well as remedial action, which may include reviewing or changing a decision on the service given to an individual complaint; revising published material; revising procedures, policies or guidance to prevent the same thing happening again; training and supervising staff; or any combination of these.’
We think the Trust’s actions are in line with our Principles.
33. We think the Trust has provided a response that addresses all the issues Miss I raised. It has done what she wanted.
34. Miss I said she would never be fully satisfied with the situation, which is understandable, but she was grateful for the efforts we made in contacting the Trust and getting more detail. Miss I is happy her complaint has managed to get improvements and better ways of thinking and acting.
35. We hope this provides some reassurance that her complaint has made a difference and she may have changed the experience of lots of people who go to the Trust in the future. We wish Miss I and her family well for the future.