Clinical care and treatment
15. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances.
16. We have discussed this with Mrs M to understand their circumstances and the outcomes they want. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.
17. Mr L and Mrs M could pursue a clinical negligence claim because they believe the Trust’s clinical care and treatment led to their daughter sadly dying. In discussion with Mrs M, she has confirmed they would like to take this option, and they have started to pursue legal action.
18. Mrs M told us they want to gain accountability in the form of a finding of clinical negligence, and a financial remedy as an outcome to their complaint and this is something they could achieve through legal action. In conversation with Mrs M, she also explained they want an apology and service improvements. These actions may not be directly achievable through the courts, but they could still happen because of a successful legal claim.
19. Based on what we have considered, we think it would be reasonable for Mr L and Mrs M to pursue legal action in relation to the clinical care and treatment provided to B in April 2023.
20. If they remain unhappy following legal action, they can return to us if they have outstanding issues, or outcomes they have been unable to achieve through the courts. However, we cannot consider issues a court has examined.
21. If Mr L and Mrs M are unable to proceed with the legal route and want us to consider this part of their complaint again, they can also contact us. It is important they approach us as soon as possible. This is because we can usually only look at complaints that are raised within 12 months of the person becoming aware of the issue, although we can sometimes put our time limit to one side if we feel it is reasonable to do so.
Behaviour and attitude of security guard
22. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so, we have found the Trust has already done enough to put right the impact of these events.
23. Mr L and Mrs M complain about the behaviour and attitude of the Trust’s security guard when Mr L went to visit his daughter on 8 April. They say the security guard was stood chatting while Mr L waited to be taken to see Mrs M and B, and then Mr L was taken to the wrong place, which caused a delay. They also complain about the way the Trust investigated this concern.
24. In its complaint response, the Trust said it was not the security guard’s intention to come across in a negative way and it took them around 10 minutes to take Mr L to the correct location. The Trust explained the team treating B, were not present in ED so could not provide clear instructions to the security guard as to where Mrs M and B were. The security guard said they tried to do all they could to take Mr L to the correct location.
25. The Trust apologised that the behaviour of the security guard added to their distress. It also tried to obtain the CCTV footage from the incident as Mr L and Mrs M said the delay was longer than 10 minutes. The Trust explained this is deleted after 30 days so unfortunately it was not available to view. It said it therefore could not verify the amount of time it took to bring Mr M to B’s bedside. It apologised for this and the impact the incident had on them, including that it could not bring Mr M to B sooner.
26. We are sorry to hear of what happened and recognise the upset caused when Mrs M and B were left alone.
27. Our complaint standards say organisations should give fair and accountable responses that set out what happened and whether mistakes were made. It also says staff should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.
28. We recognise there are conflicting recollections of what happened during the incident, and these are hard for us to resolve. In its complaint response, the Trust set out what happened and provided an apology. The security guard also appears to have reflected on the incident as in the Trust response, it explains they recognised the emotion and stress of the situation. We think this is an appropriate response and offers an apology for what happened.
29. Mr L and Mrs M also complain that the Trust did not investigate the incident, and CCTV was not looked at despite them requesting this in their meeting with the Trust on 23 April 2023. They told us by the time the Trust requested this, the footage was deleted.
30. As explained above, the evidence indicates the Trust investigated the incident and provided a response about what happened. It said it requested the CCTV after Mr L and Mrs M shared feedback on the investigation in June, when the timings of events were disputed. It apologised for any misunderstanding during the meeting in April and that the CCTV was not available for review when they requested it in June.
31. We think the Trust took the correct approach to investigate the incident by speaking with the security guard to try and establish what happened. We would not expect organisations to request CCTV footage for all complaint incidents, as this is not proportionate. It was right for the Trust to request this when Mr L and Mrs M disputed the timings of the incident, but unfortunately it was not available then.
32. We think that overall, the Trust took the right steps to explain what happened, apologised for the incident and investigated the concern appropriately. This is in line with our complaint standards.
Memory box
33. Mr L and Mrs M also complain that after their daughter’s death, the Trust gave them a memory box that was empty.
34. Within its complaint response, the Trust explained that due to a breakdown in communication, it thought the child death review team were collecting a memory box for an old case. Unfortunately, it therefore gave the team an empty memory box that was for another child. It said as soon as the error was discovered, the Trust made sure that B’s memory box was handed over. It also said that B’s memory box had been stored safely.
35. The Trust said it let down Mr L and Mrs M, and clearer communication should have happened, and the contents of the memory box checked before being given to the family. It apologised that this occurred and said that it had been raised with staff involved.
36. We recognise this was a distressing event for Mr L and Mrs M and added to their upset when they were already going through a difficult time.
37. 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 poor service and apologise when things go wrong.
38. The Trust explained what happened, acknowledged what went wrong, apologised for this and raised this with staff involved for learning to take place. This should hopefully prevent the same thing from happening again to another family.
39. We think these actions put right what went wrong, and we hope provides some reassurance to Mr L and Mrs M, that their concerns have been taken seriously. We do not underestimate the distress this incident caused to them after losing their daughter.
40. We thank Mr L and Mrs M for bringing their complaint to us and for speaking to us about it, we recognise this will have been difficult. We have decided to take no further action on the complaint as they can pursue legal action for part of it, and the Trust has already put right the impact from the other issues we considered. We hope we have clearly explained the reasons for our decision.