14. We have set out the reasons for our decision under headings below, for clarity.
Sectioning
15. Mrs Y complains the Trust failed to section Miss X multiple times under the ‘Mental Health Act 1983’ (the MHA) between April 2020 and April 2021. Mrs Y says the Trust did not conduct a formal assessment of Miss X under the MHA and instead, decided one was not required. Mrs Y says Miss X had also requested to be sectioned herself.
16. If a person is sectioned under the MHA (or the ‘Mental Capacity Act 2005’ – the MCA), it means they are detained in hospital, under the relevant section of the legislation (which depends on the circumstances of their case). The MHA and the MCA give health care professionals (and others) the right to detain, restrain, and treat patients where they would otherwise decline for those actions to be taken. They also set out the rights of the patient, and their family. The decision to section a person under the MHA and the MCA are not taken lightly. People detained need urgent treatment for a mental health disorder and are at risk of harm to themselves and others.
17. Miss X had multiple admissions to hospital between April 2020 and 2021. These admissions were usually because she had attempted to take her own life or had drunk too much alcohol and was at risk of harm. There are also instances where Miss X had phone conversations with the Northumberland Recovery Partnership (NRP) and the Initial Response Services (IRS). We recognise this was a difficult time in Miss X’s life, and it was also very difficult for Mrs Y and her family.
18. We have considered all instances where Miss X engaged with the Trust, and its services, between April 2020 and April 2021.
19. We understand a formal assessment of Miss X was not completed during any of her admissions to hospital, or during any telephone conversations between April 2020 and April 2021. This is because the staff who assessed or treated Miss X did not consider she needed a formal mental health assessment after considering her circumstances.
20. The applicable standard here is NICE’s CG136: ‘Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services’. This says:
21. ‘Assessment in crisis should be undertaken by experienced health and social care professionals competent in crisis working, and should include an assessment of the service user’s relationships, social and living circumstances and level of functioning, as well as their symptoms, behaviour, diagnosis, and current treatment’.
22. Our adviser told us Miss X was assessed each time she interacted with the service and that each assessment included a risk assessment.
23. We have seen evidence in the records, the clinicians who assessed Miss X considered her current and historical risk factors and, in doing so, reviewed whether a formal mental health assessment under the MHA and the MCA was required. However, they did not consider their assessment raised any cause for concern. They also updated Miss X’s risk profile. A risk profile is a toolkit that provides a framework to record a risk assessment, and to formulate a risk management plan, which then assists future assessments.
24. The staff who assessed Miss X also put in place a management plan as part of each assessment. This included confirmation about how Miss X would get home (if it was an in-person assessment) and with whom, details of any upcoming appointments she had with mental health services, such as the drug and alcohol service, community consultant psychiatrist and community treatment team. It also included whether any input from Miss X’s GP was required.
25. We consider this to be in line with NICE’s CG136: ‘Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services’. We recognise how distressing this experience was for Mrs Y and her family and in reaching this decision, we do not underestimate or ignore the fact there were risks to Miss X’s safety and well-being. There is no evidence the Trust failed to act in line with the NICE guidance when it carried out its assessments of Miss X.
26. As such, we will take no further action with regards to this aspect of the complaint.
Communication
27. Mrs Y complains the Trust failed to implement and follow its own policies, and NICE’s guidelines regarding communication. She says she and her family were not heard, involved, or seen to be a vital part of the assessment and treatment planning in Miss X’s care. Therefore, Mrs Y is concerned the lack of communication and involvement with her and her family, in relation to Miss X’s treatment, meant the Trust was not always aware of the facts of Miss X’s condition. She says this, in turn, meant the treatment the Trust provided was not correct.
28. In considering her concerns about the communication aspect of Miss X’s care, we have considered the Trust’s ‘Triangle of Care’ and ‘Working Together to Support the Person You Care For’ guidance.
29. We understand that this guidance is the Trust’s approach to how it communicates with the carers and family of patients. It sets out its commitment to the principles the Trust aims to follow, and deliver, when providing care to patients and when communicating with carers and family about that care. For example, this guidance says carers (or the family of the patient who act as carers) may often be the only form of consistent support the patient has. It recognises these may be there when a crisis occurs, and are likely to understand the patient’s needs and condition extremely well. As such, the guidance says the Trust sees carers and family as a ‘vital partner’.
30. We have also considered NICE’s ‘Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services’. This guidance includes a section on involving families and carers. This section says:
‘Discuss with the person using mental health services if and how they want their family or carers to be involved in their care. Such discussions should take place at intervals to take account of any changes in circumstances, and should not happen only once. As the involvement of families and carers can be quite complex, staff should receive training in the skills needed to negotiate and work with families and carers, and also in managing issues relating to information sharing and confidentiality.
If the person using mental health services wants their family or carers to be involved, encourage this involvement and:
• negotiate between the service user and their family or carers about confidentiality and sharing of information on an ongoing basis • explain how families or carers can help support the service user and help with treatment plans • ensure that no services are withdrawn because of the family's or carers' involvement, unless this has been clearly agreed with the service user and their family or carers
If the person using mental health services wants their family or carers to be involved, give the family or carers verbal and written information about:
• the mental health problem(s) experienced by the service user and its treatment, including relevant text from NICE's information for the public • statutory and third sector, including voluntary, local support groups and services specifically for families and carers, and how to access these • their right to a formal carer's assessment of their own physical and mental health needs, and how to access this (see NICE's guideline on supporting Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services (CG136).
If the service user does not want their family or carers to be involved in their care:
• seek consent from the service user, and if they agree give the family or carers verbal and written information on the mental health problem(s) experienced by the service user and its treatments, including relevant text from NICE's information for the public • give the family or carers information about statutory and third sector, including voluntary, local support groups and services specifically for families or carers, and how to access these • tell the family or carers about their right to a formal carer's assessment of their own physical and mental health needs, and how to access this (see NICE's guideline on supporting adult carers) • bear in mind that service users may be ambivalent or negative towards their family for many different reasons, including as a result of the mental health problem or as a result of prior experience of violence or abuse.’
31. There is also a specific section of this guidance in relation to the involvement of the patient’s family and/or carers as part of an ‘assessment and referral in a crisis’. This says:
‘Consider the support and care needs of families or carers of service users in crisis. Where needs are identified, ensure they are met when it is safe and practicable to do so.’
32. With this in mind, it is clear the Trust’s own approach, is to involve family and carers where it can, and this is in-keeping with NICE’s national guidance. Therefore, we have considered whether we can see evidence of this in Miss X’s clinical records, and what the Trust said to Mrs Y during the complaints process.
33. We can see from the clinical records there were times when Mrs Y and her family were involved in discussions about Miss X’s care. For example, it is documented in Miss X’s clinical records that Mrs Y was contacted by the IRS on 12 February 2021, prior to them speaking with Miss X. Also, Miss X’s father was involved in discussions during an assessment on 8 April 2021 by the psychiatric liaison team.
34. That said, there are also instances where there is no evidence Mrs Y or her family were involved. Mrs Y specifically tells us about an appointment with a psychiatrist on 6 April 2021 where she tried to have an input and, the psychiatrist put their hand in her face and told her it was for Miss X to talk, and not her. The psychiatrist has since apologised for this, but Mrs Y is concerned it demonstrated well her general experience with regards to communication with the Trust.
35. For the instances when Miss X’s family were not involved, or contacted, there are no notes to indicate this was because Miss X had withdrawn her consent for information to be shared.
36. Our adviser told us the sharing of information is dependent on whether the patient has mental capacity and, if so, whether they provide their consent. However, they also said it is a judgement call by the clinician as to whether to involve the family, even with consent, and this will depend on the situation at the time. They told us for instances where there is nothing documented to say consent has been withdrawn, and there are no notes to indicate the family have been involved in discussions, they would assume consent had not been withdrawn and the clinician had decided not to involve the family.
37. With this in mind, we consider there to be indications of failings here.
38. This is because while there are instances where the family were clearly involved in discussions, there are also instances where there is no evidence they were involved, and there are no documented reasons as to why they were not involved. This is not in line with NICE’s ‘Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services’.
39. Mrs Y says Miss X’s death was avoidable and the last two years of her life were traumatic. This left her and her family significantly distressed, and they felt increasingly helpless. She says if the Trust had done more to involve her and her family, Miss X may have received the treatment she needed to break the cyclic nature of her alcohol use, and the negative emotional impact this had on her. She has also told us she and her family have been diagnosed with PTSD following Miss X’s death.
40. The Trust said in its complaint response, dated 6 September 2022, that it recognises involving patient, carers, and their families in making decisions about their care can lead to better outcomes and a better overall experience. It explained the information it can share does depend on whether the patient gives permission for this to happen. That is, if permission is not given, the Trust cannot share the information. That said, the Trust accepted it was not always the case that Miss X had told it not to share information with Mrs Y, or her family.
41. The Trust apologised that it did not always involve the family, or communicate what action was to be taken in Miss X’s care and treatment. It said as a consequence of the complaint it would make recommendations internally to the relevant services regarding the importance and value of ‘patient, carer and family involvement’ and how this can have an impact on care and treatment.
42. In its later letter dated 13 July 2023, the Trust said, ‘It is clear we did not work with you, as a family, as we should’ and that there was ‘no indication in the clinical records of any direct involvement with you’. It also said while it has done a lot of work on involving carers and families as standard practice, it was ‘clear’ it still had a long way to go.
43. It said its crisis team now has a staff member whose role is to work specifically with carers and was in the process of recruiting a carer involvement lead, whose role would be to ensure the crisis team are up to date and worked effectively with carers.
44. We do not doubt this experience was, and continues to be, distressing for Mrs Y and her family. They had supported Miss X over many years and did all they could to try and help her get treatment that would help her. We do not consider we could say, on the balance of probabilities, that Miss X’s death would have been avoidable had the Trust always involved Mrs Y and her family in discussions during 2020 and 2021. This is because we cannot say how much, if at all, Mrs Y’s and her family’s involvement would have had in terms of affecting the assessments, or the proposed plan of action.
45. We are unable to say Mrs Y and her family would not have been diagnosed with PTSD had the Trust communicated with them in line with the guidance outlined above.
46. This is not meant to diminish their experience in any way. However, we are unable to say Miss X would not have died when she did if her family had been involved, or that the emotional impact on Mrs Y and her family was solely because of inadequacies in the Trust’s communication. That said, we appreciate these inadequacies compound the distress they feel in what is a very distressing situation.
47. That said, we recognise the fact the conversations were not always had, means some of the Trust’s assessments may have been skewed because they did not always have a rounded picture of the situation. The involvement of family and carers means information can be provided that the patient may not provide themselves (either deliberately or due to an unreliable recollection).
48. Our ‘NHS Complaint Standards’ say organisations should recognise when it gets things wrong, acknowledge and apologise for this and, where necessary, compensate its service users appropriately. Organisations can compensate service users in a number of ways, ranging from apologies and explanations to service improvements and financial remedies. Organisations should be open to providing the correct remedy to put right the impact of its mistakes, and should take learning from the complaints it receives.
49. We also refer to our ‘Severity of Injustice Scale’ when considering whether an organisation has done enough to put things right, in recognition of the impact of any mistakes it makes.
50. After considering the above, we consider the Trust has already done enough to put things right. It has recognised its communication was not always adequate and fell short of what was expected. It has also explained to Mrs Y what learning it has taken from its mistakes and what improvements it would make. However, recognise the length of time that has passed since the Trust said it intended to make changes, and the date of our decision, we have asked the Trust to provide an update on what improvements have now been made.
51. The Trust has agreed to do this by 29 November 2024. Overall, we think this is enough to put things right for Mrs Y. As such, we have decided to take no further action with regard to this aspect of the complaint.
Treatment and care planning
52. Mrs Y complains the Trust did not act in line with the national NICE guidelines in the treatment and care planning it provided to Miss X. Specifically, she says the Trust did not act in line with NICE’s ‘Borderline personality disorder: recognition and management’ and ‘Coexisting severe mental illness and substance misuse: community health and social care services’.
53. She says the Trust should have considered providing medication, such as Naltrexone (a depot injection used to treat opioid and alcohol dependents), to Miss X but it refused to do so because it thought she would use it inappropriately. She also says the Trust’s approach to treating Miss X was to expect her to get herself off alcohol before it would treat her mental health. Mrs Y says the two were interlinked and one could not be treated effectively without the other.
54. We have considered the following NICE guidelines when considering this aspect of Mrs Y’s complaint:
• ‘Borderline personality disorder: recognition and management’ • ‘Coexisting severe mental illness and substance misuse: community health and social care services’ • ‘Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence’.
55. In the previous section, we have already given our view on the communication involved in the treatment and care planning. As such, we have not revisited it in this section, despite the above guidance referring to the inclusion of family and carers in conversations about care and treatment. We have instead focussed on whether other aspects of Miss X’s care and treatment were in-keeping with the above guidance.
56. Our adviser told us Miss X was diagnosed with EUPD in August 2019. In relation to treatment for individuals with a diagnosis of EUPD, NICE’s ‘Borderline personality disorder: recognition and management’ recommends psychological treatment and, in relation to drug treatment, says:
‘Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (for example, repeated self-harm, marked emotional instability, risk-taking behaviour and transient psychotic symptoms).
Antipsychotic drugs should not be used for the medium- and long-term treatment of borderline personality disorder.’
57. The clinical records and the Trust’s complaint responses show the Trust felt Miss X would benefit from a psychological treatment, rather than medication. Our adviser told us a plan was made to review the medication she was taking, and had been for some years, and to adjust them accordingly when clinically appropriate. This is in line with the guidance outlined above.
58. NICE’s ‘Coexisting severe mental illness and substance misuse: community health and social care services’ says there should be a multi-agency approach to address physical health, social care, housing or support needs. Specifically, it says:
‘The person's care coordinator should adopt a collaborative approach with other organisations (involving shared responsibilities and regular communication) when developing or reviewing the person's care plan. This includes substance misuse services, primary and secondary care health, social care, local authorities and organisations such as housing and employment services.
Ensure the care plan includes an assessment of the person's physical health, social care and other support needs, and make provision to meet those needs.’
59. It also says:
‘Ensure agencies and staff communicate with each other so the person is not automatically discharged from the care plan because they missed an appointment. All practitioners involved in the person's care should discuss a non-attendance.’
60. The clinical records we have seen show care planning between the multiple agencies involved in Miss X’s care. Assessments carried out were regularly shared with Miss X’s GP, the community treatment team, NRP, and the psychologist she was working with. This is in line with the guidance above.
61. With regard to Mrs Y’s concerns that the Trust should not have expected Miss X to get off alcohol herself, our adviser told us alcohol dependency does not mean a patient is excluded from care such as medication, CBT, or other treatments.
62. However, if you are on medication and drinking alcohol, the medication will not work. Similarly, those who are drinking are not likely to take on board the information being provided via CBT, or other psychological treatments. Our adviser said this is likely why the family were told Miss X needed to address her alcohol dependency before substantive treatment could be given.
63. Further, we can see NICE’s ‘Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence’ says:
‘After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering acamprosate or oral naltrexone in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol misuse.’
64. However, oral Naltrexone was only licensed for use in alcohol dependence, and added to this 2014 guidance, in October 2022. This means that at the time of the events we have considered, oral Naltrexone was not licensed for use in patients with alcohol dependence. There is no reference to the use of Naltrexone being licensed for use as a depot injection for use in alcohol dependence, as mentioned to us by Mrs Y.
65. Our adviser told us the guidelines are clear about what drugs could be used and, while the Naltrexone Mrs Y has asked about was not licensed for use at the time, other drugs (such as acamprosate) could only be used when a patient was abstinent from alcohol.
66. With all the above in mind, we consider the Trust has acted in line with the guidance set out. As such, we have decided to take no further action on this aspect of the complaint.
Referral for support
67. Mrs Y complains the Trust failed to make a referral for, or allocate a full-time CPN, drug and alcohol worker, or adult mental health social worker to support Miss X.
68. We can see from the clinical records that Miss X was allocated a CPN in November 2019. This CPN remained allocated to Miss X until her discharge from the community treatment team in September 2020. At the time of Miss X’s discharge, her CPN noted in the clinical records that if Miss X was able to maintain a period of sobriety for six months and felt able to engage with treatment, she could ask her GP or the NRP to refer her back to the community treatment team. Miss X was referred, and accepted, back to the community treatment team in March 2021 and was allocated a new CPN. Miss X was in regular contact with the CPN until her death.
69. We can also see Miss X was allocated a senior recovery co-ordinator with the NRP in January 2020 after Miss X self-referred for support with her alcohol use. Their role was to support Miss X plan a route towards recovery and well-being. Again, Miss X was in regular contact with this co-ordinator.
70. Finally, with regards to the allocation of a mental health social worker, our adviser told us there are no specific guidelines about who should or should not be allocated one. They told us mental health social workers are typically allocated depending on resource at that particular trust and whether or not the patient has a support network themselves. They said generally speaking, a patient with a CPN would not have a social worker as well.
71. They also told us social workers tend to be allocated to people with a severe and enduring mental illness such as chronic schizophrenia, rather than bipolar disorder, or other personality disorders.
72. With this in mind, we do not consider there to be any indications of service failure by the Trust. As such, we will take no further action on this aspect of the complaint.
LAAR
73. Mrs Y complains the LAAR group is not fit for purpose because they take an uncritical view of actions taken leading up to a serious incident or death, and it appears to have been used as a way to praise itself rather than improve. She also says neither the LAAR, or the Trust, attempted to answer any of her concerns when she responded to the LAAR report. She says the LAAR was not carried out appropriately, and it should have included them as Miss X’s family. At the heart of their concerns, Mrs Y believes the LAAR process is not fit for purpose, because the Trust chooses what it reviews and therefore, can cherry pick to affect the outcome of that review.
74. In this section we have focussed on the composition of the LAAR, and whether Mrs Y and her family should have been included. We have considered her concerns that the Trust, and LAAR, did not respond to her specific response to the LAAR report, under the ‘Complaint Handling’ section, later in our statement.
75. A LAAR is a type of After Action Review (AAR). It is a method of evaluation that is used when outcomes of an activity or event is unexpected. The focus of an AAR is on learning.
76. The Trust’s ‘How an After Action review is Carried Out’ lists different types of AARs. One type of AAR is a LAAR. It says a LAAR is for ‘potentially complex incidents may on further investigation be escalated i.e. reported via Serious Incident to the Strategic Executive Information System’. It gives an example of an incident where an LAAR will be required as being ‘deaths that occur within the additions service’.
77. This policy explains that the lead clinician and, where applicable, investigating officer may invite other professionals to review the case ‘to help explore specific aspects of care’. It says the main purpose is to help the teams involved draw out answers, insights and previous unspoken issues. The overall aim is to identify good practice, discuss key learning points and what, if any, actions need to be taken to prevent further incidents of a similar nature re-occurring. The policy does not stipulate that family or carers are to be involved in an LAAR.
78. Our adviser told us the Trust’s LAAR did not include all the relevant clinical teams. We can see from the evidence available to us that the LAAR team the Trust created consisted only of members of staff from the addictions team. No other wider service input was sought despite, for example, the community treatment team and NRP being services that were actively and regularly involved in Miss X’s care. Our adviser told us there should have been input from all the wider services involved in Miss X’s care, so all views and information could be taken into account.
79. They told us including other services would have ensured a more rounded and well-informed overview of Miss X’s care and treatment, and her level of engagement with her treatment plan could have been assessed more robustly. It is possible the outcome of the LAAR could have been different had all services been involved, but it is not possible to know if this would have been the case.
80. In its response to Mrs Y’s complaint, the Trust apologised that all teams were not involved in the LAAR. It said Miss X was not using some of the services historically involved in her care so, it was not against its policy to not include them but, upon reflection, it would have been an opportunity to focus on a longer period of her care.
81. It also said it does not include family members in LAAR’s but, if the matter investigated proceeded to a serious incident review, then family input would be sought. The Trust also said it had identified learning from Mrs Y’s complaint and, in relation to this aspect of the complaint, it would ‘ensure all AAR involve and include all necessary services and personnel to allow for meaningful discussion and actions’.
82. It said it was currently reviewing its own responses to incidents (and how they are investigated) more generally, and it had plans to implement the nationally introduced Patient Safety Incident Response Framework (PSIRF). The Trust said Mrs Y’s concerns would be considered as part of the Trust’s review of its AAR processes.
83. After considering the evidence available to us, we recognise the Trust’s policy does not say it will include family or carers in a LAAR. While we recognise Mrs Y thinks the Trust should do this, the fact is that there is no policy or guidance that says the Trust should take this action.
84. That said, we recognise the Trust did not involve all the services it could have when considering the care Miss X received. This means Mrs Y will not know if the outcome of this would have been different, had other services been included. We have not seen any evidence that would cause us to say the involvement of these services would have led to a different outcome. That is, that the Trust would have decided to escalate matters to a serious incident review in which Mrs Y and her family would have been asked for input, or that Miss X would not have taken her life.
85. Nevertheless, we recognise this is distressing for Mrs Y and her family.
86. We set out earlier what our ‘NHS Complaint Standards’ say and how we use these to consider whether an organisation has taken enough action to put thing things right when it makes mistakes. We consider these alongside our ‘Severity of Injustice Scale’. As such, we will not repeat this information here.
87. With this guidance in mind, and taking account of the Trust’s actions, we consider it has done enough to put right the emotional impact its mistakes had on Mrs Y.
88. As we outlined earlier in this statement, we have asked the Trust to write to Mrs Y to provide evidence of its learning, and the improvements made. This is because at the time the Trust corresponded with Mrs Y, it was yet to implement its improvements, and as such could not provide evidence that it had made improvements. The Trust has agreed to write to Mrs Y by 29 November 2024.
89. With the above in mind, we have decided to take no further action in regard to this aspect of the complaint.
Complaint handling
90. Mrs Y complains the Trust’s complaint responses were inadequate because they did not answer all the questions raised, and did not explain why failings occurred or what remedial actions it would take to prevent repeating failings. We have also considered Mrs Y’s concerns that the Trust did not respond to hers and her family’s response to the LAAR report.
91. In considering the Trust’s complaint handling, we have also considered our ‘NHS Complaint Standards’ and ‘Principles of Good Administration’. Amongst other things, these say organisations:
• should do what they say they are going to do and, if they make a commitment to do something, they should keep to it, or explain why they cannot • should behave helpfully, dealing with people promptly within reasonable timescales • should bear in mind a person’s individual needs, and respond flexibly to the circumstances of the case • should communicate effectively, using clear language that people can understand and that is appropriate to them and their circumstances • should acknowledge when mistakes happen, apologise, explain what went wrong and put things right quickly and effectively • should take action where necessary to make sure learning is identified and use it to improve services.
92. In January 2022, Mrs Y contacted Miss X’s senior recovery co-ordinator (who worked for the NRP which falls under the Trust). She asked whether the AAR, which they had been told in the days after Miss X’s death would be carried out, had been started.
93. Mrs Y asked this because she says the senior recovery co-ordinator had told them shortly after Miss X’s death they would be involved. In a phone call with the senior recovery co-ordinator in February 2022 and they told Mrs Y the review had been carried out ‘some time ago’ and that the Trust had concluded it had handled Miss X’s case well. Mrs Y says she was told the person responsible for co-ordinating the review would contact them but this did not happen.
94. On 6 April 2022, Mrs Y raised a formal complaint with the Trust. The complaint was detailed and 19 pages long. She met with the Trust on 27 April 2022 to discuss her concerns and again on 19 August 2022 to discuss the Trust’s findings (ahead of issuing a written response). The Trust’s written response to the complaint was issued on 6 September 2022.
95. Mrs Y responded to the Trust, outlining her concerns with its initial response, on 21 September 2022. Again, this was a detailed complaint, and over 20 pages long. Amongst the further issues raised, and comments the family made on certain points the Trust had made in its own response, Mrs Y asked for a copy of the LAAR report. The Trust provided a copy of the LAAR report in November 2022.
96. Mrs Y and her family subsequently wrote to the Trust again on 6 December 2022 to complain about the content of the LAAR report, and they provided an annotated version of it that contained their views.
97. In the months that followed Mrs Y and her family asked the Trust for updates on when its response to their complaint would be forthcoming. They spoke to the Trust on several occasions and were told the response was ‘just about finished’ and it was awaiting a quality control before it could be issued.
98. However, the Trust’s response was not forthcoming until 13 July 2023. From the evidence available, we can also see the Trust did not provide a separate response to Mrs Y’s letter in December 2022 that focussed solely on the LAAR process, and the content of that report.
99. After considering the above, there are times when we think the Trust acted in line with our ‘NHS Complaint Standards’ and ‘Principles of Good Administration’. We recognise Mrs Y’s view that the Trust did not answer her questions or, respond at all to her annotated version of the LAAR report. However, we consider the Trust has addressed the concerns Mrs Y raised. Mrs Y’s complaints were set out in a very specific way, and, in its responses, the Trust sought to replicate the structure of Mrs Y’s complaint, and respond to her points in turn, to try to ensure its response was understood.
100. There are times when the Trust conflates some points and asks Mrs Y (and the reader) to refer to its answers to earlier points where it thought it had already addressed the question. We are sympathetic to the fact this can, at times, cause a person to feel that they are not always receiving answers to each and every question.
101. Further, there are times where Mrs Y appears to have made a statement in response to something the Trust has said, and it is not clear whether she expected a response, or whether she wanted that statement to be noted on record. Again, if an organisation interprets something as a statement, rather than a direct question, it would not be fair to criticise it on this point.
102. With regards to the lack of response to Mrs Y’s correspondence about the LAAR report itself, we note Mrs Y asked the Trust to consider this correspondence alongside their letter dated 21 September which contained their further responses. As such, we consider it was appropriate for the Trust to provide one response to both sets of correspondence, and this was in-keeping with our guidance.
103. That said, we do not consider the Trust always acted in line with our ‘NHS Complaint Standards’ and ‘Principles of Good Administration’. This is because there is evidence the Trust did not always keep to its promises and commitments. The Trust did not always keep Mrs Y and her family up to date on the progress of its investigation or manage their expectations about how long it would be before a response was issued.
104. We recognise the investigation into Mrs Y’s concerns was likely to take time, given the length of the complaint and the complexity and nature of the issues at the heart of it. That said, we consider the Trust should have been proactive in its management of the investigation.
105. Instead, Mrs Y and her family had to frequently contact the Trust to get an update on progress and, even in these instances, it gave commitments it did not keep to. Further the Trust did not acknowledge in either of its responses to Mrs Y’s complaint the length of time it took to respond, nor did it apologise in its final response for the failure to keep to its commitments.
106. During the course of our work, the Trust recognises its complaint handling did not always meet the standards it, and we, expect. It recognises this would have compounded the distress Mrs Y and her family were already feeling because of the traumatic experience they were dealing with. In recognition of this, it has agreed to write to Mrs Y by 29 November 2024 to acknowledge this, and apologise for the impact of this.
107. We consider this is enough to put right the impact of the mistakes the Trust made with its complaint handling. With this in mind, we have decided to take no further action.
Conclusion
108. We recognise how traumatic and distressing the circumstances that led to Mrs Y bringing her concerns to us have been. We do not take lightly how upsetting it will have been for her and her family to have brought these concerns to us, and to have spoken to us about them on numerous occasions. We hope our statement sets out clearly the reasons why we have decided to take no further action and, that the further work the Trust has agreed to carry out will go some way to helping reassure them their complaint has been heard, learning taken, and improvements have been made.