Inadequate assessments, and symptoms not fully investigated First admission, 23 to 24 July 34. Miss B reported being in severe pain following a diagnostic endoscopy and was admitted to hospital for further assessment. The Trust said the medical team assessed her, provided pain relief and investigations into her symptoms were arranged. The Trust discharged her from hospital with a suspected migraine.
35. We considered this issue with help from our ED and stroke advisers.
36. GMC guidelines explain that if doctors assess, diagnose or treat patients, they must take account of their history, and where necessary examine the patient. They should also promptly provide or arrange suitable advice, investigations or treatment where necessary.
37. SIGN headache guidelines recommends that a patient with a first presentation of a thunderclap headache (headache that comes on suddenly and is extremely painful), should be referred to hospital for same day assessment and have a head computed tomography CT scan and a lumbar puncture (when a needle is inserted into the lower back and fluid is collected for testing).
38. It is noted in the medical records that towards the end of the endoscopy procedure, Miss B had a sudden and severe headache, and her symptoms did not settle. A decision was made to admit her for further assessment to the EDU, and later to an inpatient ward.
39. During this time her symptoms were reviewed and noted, her medical history was taken, and a number of investigations carried out, including a head CT scan.
40. In view of her severe headache, it appears the medical team also wanted to carry out a lumbar puncture to investigate if Miss B had a subarachnoid haemorrhage (a type of stroke that is caused by bleeding on the surface of the brain). It is noted in the medical records that the procedure and risks of it, were explained to Miss B.
41. We acknowledge Miss B told us that staff at the time, told her it was not worth doing a lumbar puncture. The medical records state she did not want to have a lumbar puncture as her headache had settled, and she felt back to normal. It also states that she accepted the risks of not having the procedure.
42. Miss B was noted to have full capacity at this time (ability to use and understand information to make a decision).
43. We recognise that Miss B’s view of what was discussed, differs to the Trust’s explanation. The medical records indicate that initially Miss B did not want to have a physical examination, due to the distress and pain she was in, and this included a lumbar puncture.
44. Later in the admission, it is recorded that when Miss B was asked if she was ready for a lumbar puncture, she explained to the consultant that she felt better and therefore did not want to go ahead with the procedure and would return to hospital if she became unwell again. We recognise how distressing this time was for Miss B.
45. Based on the evidence we have seen, we think the medical team assessed the symptoms Miss B was experiencing and arranged appropriate tests into them. The medical records also indicate the plan was for a lumbar puncture to be carried out.
46. Overall, we think that during the first admission, Miss B was assessed, and her symptoms investigated in line with the guidelines above. It appears the plan was for a lumbar puncture to go ahead, but unfortunately, we cannot reach a view on why this did not go ahead because we have two conflicting accounts that we cannot resolve.
Second admission, 25 July to 7 August 47. Miss B was admitted to the ED again on 25 July, after collapsing at her GP Practice, with several symptoms including a severe headache.
48. SIGN headache guidelines explain that a proper history and examination are crucial, and a head CT scan is recommended when a patient has a headache and abnormal signs.
49. NICE stroke guidelines recommends that all patients suspected as having an acute stroke should have urgent imaging.
50. An assessment into Miss B’s symptoms was carried out. This noted she had suffered a collapse with severe neck and head pain and was complaining of bilateral facial numbness and vomiting. It was also noted she had attended the previous day and had undergone a head CT scan that revealed no identified cause of the headache. The assessment carried out was in line with GMC guidelines.
51. We think a more detailed neurological examination should have been carried out given the neurological symptoms Miss B was displaying. However, the medical records state she was too distressed to comply with a further examination in the ED, and so the plan was for her to undergo a possible lumbar puncture as she did not have one the previous day. It appears the medical team were therefore considering a possible diagnosis of bleeding in her brain.
52. A presentation with a collapse and neurological symptoms (left sided numbness/speech problems and facial numbness) fits the criteria in SIGN headache guidelines for an urgent head CT scan to be carried out. This is to exclude serious causes of thunderclap headache, including different types of bleeding in and around the brain, or stroke.
53. We can see the medical team did not think an immediate head CT scan was necessary at the time due to Miss B having had one the previous evening which appeared to reassure them, as it was reported as being normal.
54. However, on the second admission, along with a severe headache, Miss B also had vomiting and neurological neck symptoms (left sided numbness, collapse, facial numbness, speech difficulties and a sudden worsening of neck and head pain), all of which would have warranted repeat imaging of her brain urgently, which is in line with the guidance above.
55. An immediate head CT scan should therefore have been carried out because of the emergence of further symptoms and to rule out several conditions that could have developed since the CT scan the previous day.
56. Our ED adviser explained that a severe headache with neurological symptoms has a range of differential diagnoses, and a CT scan is the most accurate in its diagnostic ability if it is carried out within 6 hours of the onset of symptoms.
57. We acknowledge Miss B’s view that she was dismissed in the ED and not taken seriously. We recognise how difficult and worrying this time was for her. The evidence we have seen, indicates the rationale for the medical team not carrying out a head CT scan was because it relied on the previous CT scan, but underappreciated the new presentation that included a collapse and unevaluated neurological symptoms.
58. As an immediate head CT scan was not carried out, a failing occurred in the investigation into Miss B’s symptoms. We have considered the impact from this below.
59. After Miss B was admitted to the stroke ward, a comprehensive range of tests was carried out into her symptoms. This included a lumbar puncture and a head magnetic resonance angiogram (MRA – imaging test that shows the blood vessels and blood flow). The medical team made a diagnosis of a brain bleed and suspected RCVS, and medications were commenced.
Third admission, including the diagnosis given – 13 to 14 August 2017 60. Miss B also complains that during the third admission, the doctor failed to diagnose her symptoms, and consider all possible diagnoses. The Trust did not provide a response to this part of the complaint.
61. GMC guidelines explain that if doctors assess, diagnose or treat patients, they must take account of their history, and where necessary examine the patient. They should also promptly provide or arrange suitable advice, investigations or treatment where necessary.
62. Miss B attended the ED on 13 August with a worsening headache, left sided weakness and facial droop.
63. The medical records document she was seen by the stroke team on arrival and her symptoms and history noted. She was immediately sent for a head CT scan to look for evidence of bleeding or a stroke. This is in line with NICE stroke guidelines which explain that immediate imaging should be carried out in this situation.
64. A review of the head CT scan showed resolving blood from the previous bleed Miss B had. No abnormalities were found during this admission, and she was discharged and advised to continue with pain relief.
65. The evidence indicates the medical team appropriately assessed Miss B’s symptoms during this admission, carried out investigations into them and this showed the brain bleed appeared to be resolving. The assessment and diagnosis given was in line with the NICE and GMC guidelines mentioned earlier.
Impact 66. As explained under issue one (paragraph 58), an immediate head CT scan was not carried out during Miss B’s second admission. This should have been carried out based on the symptoms Miss B displayed and in line with SIGN and NICE guidelines, that recommend a CT scan is carried out in a patient with a thunderclap headache and suspected stroke. Miss B fell into both of these categories.
67. We think the lack of head CT scan on Miss B’s second admission, led to a delay in the medical team diagnosing a brain bleed. This also meant that aspirin was given to Miss B when it should have been withheld. This is because aspirin thins the blood and may lead to more bleeding.
68. We looked at the effects of this. The brain bleed that Miss B had, did not need neurosurgical intervention. The bleed also did not appear to expand in size and Miss B did not clinically deteriorate any further during the admission.
69. We also considered if Miss B may have been able to access earlier physiotherapy had the delay not occurred. However, there is some evidence that very early physiotherapy within the first 24 hours following a brain bleed might worsen outcomes. We therefore do not think this would have changed the outcome (Rehab trial journal).
70. Overall, we do not think an earlier diagnosis of the brain bleed would have changed the outcome. We understand this was a difficult and worrying time for Miss B.
Delay in diagnosis of RCVS 71. As highlighted above, GMC guidelines explain that if doctors diagnose patients, they must take account of their history, and where necessary examine the patient. They should also promptly provide or arrange suitable advice, investigations or treatment where necessary.
72. As explained earlier, during the first admission we think that overall, Miss B’s symptoms were assessed and investigated appropriately. We have conflicting accounts about why the lumbar puncture did not go ahead that we cannot resolve. Based on the evidence we have seen and the results that were carried out, we think the diagnosis made during the first admission was appropriate.
73. On the second admission, the assessment noted Miss B’s symptoms and previous history, including what had happened the previous day. We have highlighted above that an immediate head CT scan was not carried out in ED, and this led to a delay in diagnosing the brain bleed.
74. Following ED, the medical teams assessed Miss B again and numerous investigations into her symptoms were carried out, including an MRA and a CT cerebral angiogram (looks at the arteries that supply the blood to the heart). A multidisciplinary meeting (group of different health professionals that work together to make decisions regarding treatment of a patient) was also held to discuss the test results.
75. It was felt that Miss B had suspected RCVS, and she was started on nimodipine that can reduce the intensity and frequency of headaches. A lumbar puncture and brain magnetic resonance imagining (MRI – produces detailed images of the brain) were carried out. Following this, a further MDT was held and a review of her results, indicated Miss B had RCVS.
76. Miss B explained that her white blood cell count during the second admission was high, which indicates she had cerebral vasculitis (inflammation of blood vessel walls in the brain or spine), and if her lumbar puncture had been evaluated properly, the medical team would have noticed that this contradicted the potential diagnosis of RCVS.
77. We acknowledge that during the admission, the medical team wanted to rule out other conditions, including cerebral vasculitis due to the symptoms Miss B was displaying. It is reasonable for the medical team to be thinking of differential diagnoses while undertaking tests, this is to rule out other conditions to help reach a diagnosis.
78. We think the medical team carried out the relevant investigations at that time and based on this overall, this pointed to a suspected diagnosis of RCVS, and nothing else.
79. We acknowledge the diagnosis of RCVS was not made immediately on admission and it was a suspected diagnosis. The diagnosis was difficult to reach as Miss B had a history of migraine and potential signs of a functional syndrome, both of which can cause the presenting symptoms she had.
80. There are no clear diagnostic criteria for RCVS, and this is reached through an assessment of symptoms, and evaluation of tests results. Symptoms from RCVS can also resolve after a period of time, and patients who clinically improve are usually monitored with repeat scans. We think the Trust undertook the relevant investigations into it during the admission, along with planning a follow up to carry out further tests and review Miss B’s symptoms at a later date.
81. We think the medical team assessed the symptoms she had and carried out appropriate investigations into them in line with GMC guidelines highlighted above. This did take some time and the medical team made the suspected diagnosis part way through the admission due to the complexity of Miss B’s condition, but we do not consider this to be a failing in care.
Discharge notes on second admission, 25 July to 7 August 82. Miss B says her discharge notes were wrong following the second admission, as her scans were reported as being normal when they were not, and no diagnosis was recorded.
83. GMC guidelines explain that doctors should record their work clearly, accurately and legibly.
84. During Miss B’s second admission, the CT angiogram was initially reported as being normal. However, on discussion at the stroke MDT on 7 August, the images were re-reviewed, and the medical team thought there were multiple areas of vessel narrowing. This was not recorded on the discharge summary, which says the CT angiogram was normal.
85. The discharge summary following this admission, also fails to mention the cause of the symptoms, which was thought to be RCVS. We have identified a failing occurred as the discharge summary was not accurate and this is not in line with the GMC guidelines above. We have considered the impact from this below.
Impact 86. We have thought about if the failing had an impact on Miss B. Miss B says due to incomplete discharge papers, the next doctor who treated her was not aware of what she had been suffering from.
87. We understand Miss B’s concern that the inaccurate discharge summary affected the care she had after.
88. We have looked at what happened during Miss B’s third admission on 13 August, as detailed above. We think the assessment and investigation of Miss B’s symptoms during this admission was appropriate, the medical team took on board her medical history and the symptoms she presented with. We therefore do not think the inaccurate discharge summary affected her future care.
89. In its complaint response, the Trust explained that Miss B’s case would be reviewed for governance and educational purposes and once complete, an addendum would be added to the original discharge summary. We think this is appropriate action to take and puts right the inaccurate record.
Pain management 90. Miss B complains she was left in pain during the first three admissions and discharged without adequate pain relief. We have considered what happened in each admission below, with help from our nursing and general advisers and by referring to the relevant guidance in this area.
First admission, 23 to 24 July 91. NEWS guidance explains that symptoms of pain should be recorded and responded to by the medical team.
92. NMC code says nurses should accurately assess signs of normal or worsening physical and mental health in the person receiving care. They should also make a timely referral to another practitioner when any action, care or treatment is required.
93. GMC guidance explains that in providing clinical care, doctors must provide effective treatments based on the best available evidence and take all possible steps to alleviate pain and distress, whether or not a cure may be possible.
94. At 11.40am on 23 July, a nurse documented in the medical records that following the endoscopy procedure, Miss B was in a lot of pain in her head, this was escalated to a doctor, and it was documented she should be given pain relief.
95. Miss B was transferred to a ward and there is evidence she was given paracetamol and dihydrocodeine at 2.35pm later that day, these are used to treat mild to moderate pain.
96. This means Miss B was left without any pain relief for approximately three hours and a failing in her care occurred.
97. On the same day, prior to 10.30pm, the nursing team did not record any of Miss B’s pain scores as part of their assessment. Miss B has explained that she was left in pain during this time and dismissed. In its complaint response, the Trust has acknowledged that Miss B was left feeling that staff were not taking her pain seriously.
98. We think the evidence shows the nursing team were dismissive of her pain during the day on 23 July, as it did not take steps to fully assess or record it in the medical records. This is not in line with the NEWS or NMC code and means a failing in care occurred. We are sorry to hear of how distressing this was for Miss B.
99. Once on the ward, the nursing evaluations show Miss B had some moderate to severe pain in her head. This was responded to by medical reviews and the administration of intravenous (IV – medicine given through a vein) morphine (a strong painkiller used to treat severe pain), paracetamol and dihydrocodeine. She was also given diazepam (to help her muscle spasm which was thought to be significantly contributing to the pain).
100. On the morning of 24 July, Miss B was noted to be very distressed, and she was given paracetamol again. She had been vomiting intermittently since the onset of her headache, and therefore is unlikely to have absorbed the paracetamol. This indicates the medical team did not control her pain effectively at this point.
101. The plan at the ward round at 9.40am, was to give Miss B IV morphine again and this was administered to her.
102. The Trust discharged Miss B later that day. The discharge summary indicates no new or strong pain relief was provided for her to take home. Given the severe pain she had been in, the medical team should have provided her with additional strong pain relief to take if/when the pain returned at home. This is not in line with the GMC guidance above and a failing occurred.
103. In summary, we think that overall, staff did not fully manage Miss B’s pain during the first admission, nursing staff were dismissive of her pain on 23 July, and the medical team discharged her without appropriate pain relief. We go on to consider the impact of this below.
Second admission, 25 July to 7 August 104. On 25 July, Miss B was readmitted to the Trust with a severe headache and vomiting.
105. The medical records document she was triaged in ED at 9.59am and ondansetron (an anti-vomiting drug) and paracetamol were given through IV at 10.45am. A doctor assessed her at 11.08am and noted she had a severe headache and vomiting. At 11.50am it is noted that Miss B was distressed and retching. The doctor prescribed oramorph (liquid form of morphine) which was given at 1.45pm.
106. At 2.40pm another doctor assessed Miss B and documented they were unable to examine her as she was yelling in pain. No pain scores were documented at this time.
107. Between 25 to 31 July, the medical records document that Miss B was frequently in pain. While this appears to have been assessed and recorded, overall, her pain was not controlled well, and this is not in line with GMC guidelines, which explains that doctors must take all possible steps to alleviate pain and distress.
108. The evidence shows that on 28 July, Miss B was crying with an occipital headache (headache that involves shooting, shocking, throbbing, burning or aching pain). She was given oral morphine at 12pm. At 2.18pm Miss B was crying in pain again as she was not given oramorph at the time she required, despite asking for it. This indicates the medical and nursing teams were not controlling the pain she was in.
109. On 30 July, Miss B was prescribed a fentanyl patch (medication to treat serious pain) and the dosage increased on 31 July. From this date, Miss B’s pain scores indicate she was either in no pain or mild pain.
110. The acute pain team reviewed Miss B during the admission and recommended switching oramorph to oxycodone. On 7 August it is documented that her pain was under control, and she had no pain for 48 hours that was a real issue.
111. On 7 August, Miss B was discharged and supplied with oxycodone (medication to treat moderate to severe pain) to take at home. Prior to discharge, her pain was well controlled with this medication, so it was appropriate for her to be given this to control any further pain. She was also advised to contact her GP or the pain team if her pain got worse. This is in line with GMC guidelines.
112. The evidence indicates that during the second admission, overall, the medical team did not control Miss B’s pain effectively and there were delays in medication being given to her. This is not in line with NMC and GMC guidelines and we think a failing in her care occurred. The impact of this is considered below.
Third admission, 13 to 14 August 113. On 14 August, at around 10.30am, the Trust admitted Miss B with severe pain that was uncontrolled, and she was very distressed. At the time of triage this had settled to mild. The medical team prescribed IV morphine at around midday. The medical records note that her pain had resolved at 12.35pm.
114. Miss B was discharged with no change to her pain management regime and advised to continue on the medication from the previous discharge.
115. This was a short admission. The evidence indicates her pain was assessed, recorded and responded to. Her pain had resolved on discharge, and she already had pain relief from the previous admission. Her pain management during this admission was in line with the NMC code and GMC guidelines already highlighted under this issue.
116. We recognise that pain levels can change, and we are sorry that this happened following this admission, and Miss B had to seek further help. At the time of the admission, and on her discharge, we think her pain was managed appropriately.
Impact 117. We have identified that overall, the nursing and medical teams did not manage Miss B’s pain effectively on the first or second admission. Staff were also dismissive of her pain levels on the first admission and discharged her from this admission with no pain relief.
118. As a result of this, we think Miss B was left in moderate to severe pain during both admissions and on her discharge following the first admission. We think this is also likely to have caused Miss B distress and being fearful of having to be admitted to hospital again. We are sorry to hear of how she was affected at this time.
119. Our complaint standards say public organisations should look for continuous improvement and use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service and apologise when things go wrong.
120. In its complaint response, the Trust has acknowledged Miss B’s pain was poorly controlled and she was left feeling that staff were not taking her pain seriously. It apologised for this and said it has had one-to-one meetings with staff directly involved in her care and sent a reminder to all staff to ensure pain assessments are completed appropriately.
121. The complaint has also been shared with the wider team for learning. We think these actions are in line with our complaint standards and should improve the service provided to future patients.
122. Miss B is also seeking a financial remedy, and we have made a recommendation at the end of this report to address this.
Unable to pass urine on the second admission, 25 July to 7 August 123. Miss B complains that during the second admission she was unable to pass urine.
124. Catheter care guidance explains that a temporary urinary catheter is an appropriate rationale for urinary retention.
125. It is documented in the medical records that Miss B was passing urine independently on the toilet throughout the whole of 3 August, until midday on 4 August. Nursing staff then identified Miss B was in retention (of urine). Nursing staff scanned her bladder and inserted a urinary catheter.
126. Nursing staff would have been reliant on Miss B to tell them when she was having problems passing urine because she was independent on the toilet. Once the nursing team identified she was in retention on 4 August, the appropriate action was taken, and a catheter was inserted. This is in line with catheter care guidance.
Nursing issues from the first admission, 23 to 24 July 2017 Miss B was left for 24 hours without medication for her heart 127. NMC medicines guidance explains nurses are expected to administer medications in line with the prescriber’s direction. It also says that if there is any reason why the prescription cannot be followed, this should be clearly documented.
128. The heart medications ivabradine and flecainide were given at, or just after midnight on 23 and 24 July. Ivabradine was omitted at the prescribed time of 5 to 6pm and flecainide should have been given between 9 to 10pm. It is not clear why the doses were delayed, and this means a failing occurred.
Impact 129. Ivabradine was delayed by approximately six hours and flecainide by two hours. Miss B told us that due to having PoTS, missing this medication would have increased her heart rate.
130. There does not appear to have been a lasting clinical impact on Miss B from the delayed medication. This is because an electrocardiogram (ECG – test to check a person’s heart rhythm and electrical activity) was normal on 24 July and her National Early Warning Score (NEWS – determines a person’s clinical deterioration by looking at measures including respiration rate, blood pressure and pulse rate) was also within normal ranges.
131. We do understand the worry the delayed medication caused Miss B and we looked at what the Trust has already done about this.
132. In its complaint response, the Trust apologised to Miss B for the delayed medication and said the matron has reminded nursing staff to ensure regular medications are given as prescribed.
133. We think this is in line with our complaint standards highlighted under the previous issue and should ensure the NMC medicines guidance is met in future care given to patients.
Blood sugar levels 134. The Trust explained on 23 July, Miss B’s blood sugar level was routinely checked, and it was normal. It said it is not normal practice for the Trust to continue to check blood sugar levels in patients who are not diabetic.
135. NMC code says that nurses must make sure the fundamentals of care are delivered effectively. Our nursing adviser explained there is no national guidance or standard that states that a patient’s blood sugar should be checked in this situation. We acknowledge that Miss B has PoTS and this can affect blood sugar levels, however there is no indication this was the case during the first admission.
136. We therefore do not think there was a requirement for the Trust to check Miss B’s blood sugar levels again. Although we do understand the worry this caused Miss B.
Dehydration 137. NICE fluid therapy guidance explains that indications a patient is dehydrated includes dry mouth, reduced urine output, low blood pressure, high but weak pulse and an increased respiratory rate. It also explains blood tests that indicate dehydration, are high sodium and low potassium levels.
138. Miss B has explained to us that due to having PoTS, she suffers from increased symptoms before she would be classed as clinically dehydrated.
139. During the admission, nurses monitored Miss B’s physiological observations using NEWS (routine monitoring of reactions including heart rate, respiratory rate and blood pressure) and from this, there is no indication that Miss B was dehydrated or displayed symptoms that indicated this. Her blood test results were also normal.
140. There were no signs of dehydration, so no further action was required by the nursing team.
Not being treated for a urine infection on the fourth admission, 21 to 29 August 2017 141. NICE urinary tract guidance states that healthcare professionals do not prescribe antibiotics to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women because it is not effective. Unnecessary treatment with antibiotics can also increase the resistance of bacteria that cause urinary tract infections, making antibiotics less effective for future use.
142. Miss B was admitted to the Trust directly from the private neurology clinic on 21 August. The nursing records note that on 22 August at 2.15am, her urine was tested with a dipstick and was positives for nitrates which is an indicator of a possible urinary tract infection (UTI – infection of the bladder, kidneys or the tubes connected to them). There is no mention in the medical records at this time that Miss B was complaining of any symptoms such as pain on urination or increased frequency.
143. The urine sample was cultured and grew a coliform bacterium which often causes UTIs. A further urine sample was tested on 24 August but was unsuitable for analysis in the laboratory. There is no documentation that Miss B had any symptoms suggestive of a UTI at that time.
144. On 28 August it is noted that Miss B queried if she had a UTI but also stated that she was on her menstrual cycle at that time. No further details of her symptoms are documented.
145. When Miss B returned to the ward on 26 September, the Trust picked up that she had not received any treatment in August and provided antibiotics to her.
146. NICE urinary tract guidance does not recommend treatment of asymptomatic cases of bacteria in the urine in Miss B’s age group. It is also known that UTIs can be cleared from the body without treatment in some cases.
147. We recognise that Miss B queried if she had a UTI towards the end of the admission, but according to the medical records she did not highlight that she had any specific symptoms at that time.
148. We acknowledge the Trust did not treat Miss B for a UTI during the fourth admission. There is no evidence that she was suffering from any symptoms suggestive of a UTI at that time, and therefore treatment is not recommended. When she returned to the Trust in September and explained how she was feeling, she received treatment. We therefore do not consider a failing in her care occurred.
Complaint handling 149. Miss B further complains about the Trust’s handling of her complaint and specifically that it did not respond to her issues about the third admission (13 to 14 August) or tell her it could not do so.
150. Our complaint standards explain that people making complaints, receive a consistent and positive experience and are confident that organisations take issues raised seriously and take action to address them.
151. In December 2019, we identified the Trust had not responded to issues that Miss B had raised relating to the third admission (13 to 14 August 2017). We asked the Trust if it would be willing to consider the further issues that Miss B had and provide a response. We made Miss B aware of this.
152. In February 2020, the Trust confirmed the doctor involved in Miss B’s care and treatment during the admission, had agreed to review the further issues and provide comments.
153. Miss B did not hear anything from the Trust and so contacted us again. In early October 2020, we wrote to the Trust to explain that Miss B had not had an update or response. We asked the Trust to contact Miss B and update us. We also explained that if we did not hear from the Trust by the end of October, we would consider if we needed to carry out a detailed investigation without a further response.
154. The Trust’s complaints team contacted us shortly after this and explained it had not received any comments from the doctor involved in the third admission and would chase this.
155. We did not hear anything so contacted the Trust again in November 2020. We asked the Trust if it could commit to a date for a further response, either through getting the original doctor to respond or by getting someone else to consider the complaint. We did not receive a response to this and decided to consider the complaint further.
156. We acknowledge the Trust had difficulties in contacting the original doctor who treated Miss B and it appears it could not find another suitable person to provide a further response.
157. In line with our complaint standards, we would expect the Trust to provide a response to Miss B’s further issues or write to her to explain why it could not do this. As the Trust did not provide any response to her about this, we think a failing in the complaints handling occurred.
Impact 158. We have identified the Trust did not provide a further response to Miss B relating to her concerns about the third admission or tell her it could not do so. We think this led to Miss B feeling the Trust did not take her complaint seriously, which caused upset. We have made some recommendations to address this below.