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County Durham and Darlington NHS Foundation Trust

P-002843 · Statement · Decision date: 20 August 2024 · View County Durham and Darlington NHS Foundation Trust scorecard
Administration Communication Access Complaint handling Complaint record keeping failures
Complaint (AI summary)
Mrs U complained about unprofessional emergency department staff, including incorrect symptom transcription, not being listened to, discussing private matters, repeated tests, and long waits without adequate pain relief.
Outcome (AI summary)
The ombudsman closed the complaint as it fell outside the time limit for the emergency department issues and found no failing in the complaint investigation process.

Full decision details

The Complaint

3. Mrs U complains about aspects of the care and treatment by County Durham and Darlington NHS Foundation Trust (the Trust) during an emergency department (ED) admission on 1 August 2022 by ambulance. She was experiencing neck pain, neck spasms and a thunderclap headache. She complains the following about the Trust’s ED:

• Staff incorrectly transcribed and misunderstood her symptoms.

• Staff did not listen to her and take her symptoms seriously.

• Staff were unprofessional and lacked empathy.

• Staff discussed her private matters in front of people in a small waiting room.

• Staff repeated her blood tests as they incorrectly completed a form.

• Staff made her wait five hours without any stronger pain relief or observational checks.

4. Mrs U complains the Trust’s matron in charge of ED carried out the complaint investigation. Mrs U says she felt and still feels frightened and her and her husband are still distressed. She felt and still feels angry when the staff had to repeat her blood tests. She said her consultant commented her experience was life changing.

5. She still fears attending hospitals and ED re-admitting her in the future for any medical condition. She has been treated by a counsellor. She felt more distressed when she received the complaint response and realised the matron in charge of ED investigated the complaint. Since then, she started having anxiety attacks again.

6. Due to the above experience, she suffered and still suffers anxiety attacks. She still physically shakes thinking about the incident. She would like service improvements and a financial remedy.

Background

7. Mrs U was admitted to the Trust’s ED on 1 August 2022 by ambulance. She was experiencing neck pain, neck spasms and a thunderclap headache. A thunderclap headache is a severe headache that can suddenly appear.

8. She saw a doctor five hours later when he referred her to have a computed tomography (CT) scan. The Trust then transferred Mrs U to the neurological centre at another hospital where she had further treatment.

9. Mrs U formally complained to the Trust on 2 September 2022 and received a response on 1 February 2023. She got some advice from solicitors about her complaint in February 2023 and August 2023. She complained again and received the final response on 18 August 2023.

10. Mrs U submitted her complaint to us on 14 December 2023. We opened a case on 15 December 2023. We decided Mrs U could seek alternative legal advice and closed the case on 19 February 2024.

11. Mrs U returned to us in March 2024 to April 2024. She sent us evidence showing she contacted further solicitors during that time. We opened a new case on 1 May 2024.

Findings

ED experience 1 August 2022

14. The Health Service Commissioners Act 1993 says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.

15. In reaching our decision, we consider all delays incurred in the complaint process. This includes consideration of how long the complainant and the Trust took, and where delays may be present, if the reasons for delay are justified.

16. Where we see justification that prevented a complainant from progressing their complaint, we may then consider waiving the time limit if the reasons are fair and exceptional. Our starting expectation is a complainant is responsible to ensure a complaint is brought in time.

17. We discussed this with Mrs U to understand the reasons why she could not bring her complaint to us earlier. We also considered relevant information to assist in our decision. Mrs U said the issue happened and she became aware of it on 1 August 2022, when the ED admitted her. This was when she had a reason to complain.

18. Mrs U formally complained to the Trust on 2 September 2022, and it responded on 1 February 2023. Mrs U complained again, and the Trust provided its final response on 18 August 2023. It said it concluded its investigation and if the complainant would like to take the matter further, she could contact us.

19. We can see Mrs U did not delay in complaining to the Trust as she complained within a month of the issues. Mrs U told us she is the type of person who likes to act proactively as she wanted closure, so she quickly complained to the Trust and responded to it promptly when it provided its first response. The Trust responded in a reasonable timeframe, within six months, each time she complained.

20. It took approximately four months for Mrs U to bring her complaint to us in mid-December 2023. The complaint is four months out of time when she brought her complaint to us initially. We spoke to Mrs U to better understand and explain the gap in the timeline from August 2023 to December 2023. Mrs U said her father had been in hospital from April 2023 to May 2023.

21. Mrs U said she had numerous bereavements from February 2023 to August 2023. The major bereavement was in June 2023 when her father sadly died. She said she was overwhelmed with being the executor of her father’s estate. We recognise this must have been a very upsetting and distressing time for her and her family.

22. Mrs U said when she received the Trust’s final response, she could not deal with it straight away as she was at a low point in her mental health. She went on holiday, thought about and discussed with her husband whether they should take the case further. She wanted to calm down and think logically without being overly emotional and thinks this may have contributed to the delay in her bringing the complaint to us.

23. She returned from holiday and got in contact with a firm of solicitors. She knew about us when she got the Trust’s final response. She said she did not think she could bring the complaint to us due to the delay and our time limits. She said no one told her that we could use our discretion to set aside our time limit until a solicitor told her in December 2023. She then brought her complaint to us.

24. Mrs U said had she known we could use our discretion she would have brought the complaint to us sooner. She does not think any factors or issues would have been a barrier to her bringing the complaint to us. She thinks she could have brought her complaint straight away to us in August 2023 if she had known we could use our discretion.

25. We acknowledge Mrs U was dealing with a lot at the time especially as her father sadly died whilst she was going through local resolution with the Trust. We have seen she was still actively seeking legal advice during local resolution. We recognise this was very admirable of her at such a challenging and upsetting time. She has also said she sought legal advice after her holiday.

26. As she was actively still pursuing her complaint we would reasonably expect after the Trust’s final response she could have brought her complaint to us within a couple of months. This was because she was aware of us from the Trust’s final response in August 2023. There is clear information on our website about our time limits and our use of discretion.

27. She was already very proactive and able to actively get legal advice throughout local resolution. She was able to bring her complaint to us quickly after she spoke to solicitors again in December 2023. We recognise how important the complaint is to Mrs U and the challenges she has faced. We consider she did not need to speak to solicitors to know about our time limit and discretion.

28. From review of the available information, we do not think the above reasons indicates a significant barrier which prevented her from bringing the complaint to us sooner.

We do not consider the reasons provided are sufficient for us to set aside our time limit. Therefore, we will not consider the complaint further.

Complaint handling

29. Mrs U complains the Trust’s matron in charge of ED carried out the complaint investigation. The Trust’s responses confirm this. Mrs U was concerned the matron would be biased in their response. NHS Complaint Standards says NHS organisations should ensure when a complaint does not suit early resolution and needs more detailed consideration and investigation, this is done fairly.

30. It says, where possible, staff who have not been involved in the issues complained about should look at the complaint. If it is not possible, the person looking into the complaint should openly demonstrate they are acting fairly when they consider all the issues. Mrs U confirmed she did not see the matron of ED throughout the time of events.

31. We consider although the matron of the ED investigated Mrs U’s concerns, they were not actively involved in the complaint issues. The matron would have had an overseeing role to the staff in ED, and they were not directly involved in the care and treatment of Mrs U during the time of events. From the available information, we are satisfied the Trust acted in line with NHS Complaint Standards.

32. Therefore, we have not found any indications of failing in the Trust appointing the matron of ED to investigate the complaint and shall not consider the issue further. We recognise Mrs U was going through an upsetting and emotionally difficult time dealing with the loss of her father as well as her own struggles with the Trust and her health. We wish her all the best in her health going forwards.

Our Decision

1. We have carefully considered Mrs U’s complaint about County Durham and Darlington NHS Foundation Trust (the Trust). The complaint falls outside of our time limit, and we have decided there is no good reason for us to put our time limit aside to consider it further for the ED issues. We found no indications of failing in the Trust appointing the matron of ED to investigate the complaint.

2. We recognise Mrs U experienced a traumatic event due to the sudden onset of her medical condition and the time waiting to be treated for her symptoms. We understand how challenging and upsetting she found the events and how difficult she finds the ongoing anxiety she experiences.

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