Attendance at ED
12. Mr F says when he arrived at the ED he presented his protocol to reception and asked they escalate his care. He says reception ignored this and told him he had to wait in the queue outside. He waited outside and when he was reviewed by the triage nurse at the door of the ED he presented his protocol again but both his protocol and his views were ignored.
13. He says the Trust should have acted in line with his protocol, prioritised his care and admitted him to a ward urgently. He says he waited both outside and inside the ED for a very long time and was only admitted to a ward on the morning of 16 November 2022.
14. Mr F also says the Trust should have acted in line with his protocol and provided pain relief medication within 30 minutes of his attendance at the ED. He says the Trust has its own guidance displayed in the ED for the management of adult sickle cell acute painful crisis which also states it should ‘provide analgesia within 30 minutes’ of attendance at the ED. He says the Trust did not provide him with any pain relief medication until 12.30am, over 5 hours after he attended.
15. We reviewed the Trust complaint responses and found it has upheld each of these points of complaint. In its letter of 4 July 2023 the Trust has said:
‘I am saddened to learn that our staff did not listen to you when you arrived at ED. Your records document that you were suffering from abdominal pain and your medical history was noted.
The doctor personally submitted your concerns to the ED Clinical Governance Lead to investigate. A meeting was held with the ED Matron, Clinical Governance Lead in ED and the doctor to discuss what happened during your admission and put actions in place to improve the care our patients receive for the future.
I am sincerely sorry that you had to wait outside in the cold and that our staff did not respond positively to your suggestions.
We have implemented a reminder to the Navigation Team and Triage Nurse at ED Reception to expedite the triage process for patients who present with a sickle cell disease crisis.
The ED clinical leadership team has already sent a formal letter to the Matron, Receptionists, and Triage Nurses to implement your protocol with immediate effect. We have also made some changes to the computer system to remind junior doctors of the importance of early initiation of pain relief.
We recognise that your experience was not acceptable, and we are sincerely sorry. The UEC Division has taken on board your comments and responded to your poor experience.
I fully recognise that this was a very distressing situation for you and accept that ED staff were not fully aware of your symptoms at the time. I would like to assure you that we have learned and reflected on your poor experience, to ensure staff are aware of the warning signs and how to respond to them.’
16. The Trust has also upheld this aspect of Mr F’s complaint in its second letter dated 26 March 2024. In this letter the Trust has said:
‘We sincerely apologise and acknowledge that this was not the ideal. This was the protocol at the time for patients attending ED.
We have sought guidance from our Haematology team and understand that your protocol presented is not one that we have agreed, however this does not mean that staff should not have been guided by it.
Since your complaint the ED Governance Lead met with the Haematology team as a direct response of your admission. They agreed a set of recommendations as follows:
• Feedback has been given to all the staff concerned in the incident.
• As further review of the process, we have taken some action in the ED to try to avoid this unfortunate event to re occur.
• We have put in place a reminder to the Navigation Team, Triage Nurse at the Reception Team in the ED to expedite the triage process for any sickle patients presenting with crisis. Our ED has already sent formal letter to the Matron, ED Receptionist and the Triage Nurse to implement this with immediate effect.
• We have also made some changes in the Cerner1 software as a reminder for the junior doctors of the importance for early initiation of pain relief.
• We are also undergoing a rolling yearly audit in the ED to improve our service going forward.
• We would like to invite you to our Trust wide Learning Event which is where you can describe your experience from your perspective. This event is widely attended by Trust staff. Please contact Claire Atkinson, Interim Head of Patient Experience, via email at Claire.Atkinson10@nhs.net for further details.’
17. We agree with both Mr F and the Trust that the level of care and support he received when he attended the ED was unacceptable and below the required standard. We acknowledge how distressing this incident was for Mr F. It is clear he was extremely concerned about the lack of action at the ED despite giving the Trust prior warning of his attendance. It is also clear Mr F was fearful at this time that his condition would deteriorate further if he did not receive urgent care and treatment set out in his protocol.
18. We are satisfied the Trust has accepted that the delays and lack of cooperation with his protocol Mr F experienced in the ED was unacceptable. The Trust has apologised to Mr F and taken action to put in place significant service improvements. The Trust also committed to implement Mr F’s protocol with immediate effect.
19. We do not investigate complaints that have already been upheld by the organisation involved and where we can see appropriate action has been taken to address the failings and the impact they had. We use the Principles for Remedy to determine whether a remedy is appropriate to address the failings. The Principles for Remedy state:
‘Good practice with regard to remedies means:
• Getting it right • Being customer focused • Being open and accountable • Acting fairly and proportionately • Putting things right • Seeking continuous improvement’
20. We think the action taken by the Trust after upholding this aspect of Mr F’s complaint is appropriate to address the failings and the impact they had. We think the action taken by the Trust is consistent with the action we would recommend if we upheld such a complaint and in line with the Principles for Remedy. For this reason we do not think there is anything further we can achieve in relation to this aspect of Mr F’s complaint.
21. The Trust complaint responses only address the points of complaint relating to Mr F’s attendance at the ED. However we can see he also raised several points of complaint about the inpatient care that followed.
Inpatient care
22. Mr F says after he was admitted to the ward the Trust doctors refused to discuss his condition, care and treatment. He says the surgical team also refused to discuss his condition or the ERCP procedure he underwent with him. He says as his requests for discussions were refused by the doctors he discharged himself from their care.
23. Mr F also complains about the care and treatment he received during this period. He says the ERCP procedure was planned for 18 November 2022 but had to be cancelled at the last minute. He says on the morning of the procedure he was taken to theatre only to find the consultant surgeon was not there. He was told by the surgeon present that the procedure could be cancelled if he insisted the consultant surgeon perform it. Mr F says he had no choice but to cancel the procedure as he did not think it was appropriate for a different surgeon, unfamiliar with his care protocol, perform the surgery.
24. In his initial complaint to the Trust Mr F also complains the clinicians were not acting in line with his care protocol whilst he was an inpatient with respect to his hydration, warmth, oxygen levels and pain relief medication. He says he was deteriorating and getting weaker at this time and the care he received from the Trust contributed to this.
25. These are serious complaints and the Trust has not investigated or addressed any aspects of the inpatient care Mr F complains about. In its response of 26 March 2024 the Trust said:
‘I further understand your complaint letter does not just cover your time in the Emergency Department (ED) but your experience during your admission on the ward. Although we are sorry for the lack of delayed care you experienced on the ward, this response is only related to your ED attendance on 15 and 16 November 2022.
This does not in any way mean that lessons learnt from the ED and on the wards are not inter-sharable. They most certainly are especially under the new Patient Safety Incident Response Framework (PSIRF) which sets out the NHS’s approach to develop and maintain effective systems for responding to patient safety incidents with the focus of learning from these to improve patient safety.’
26. We consider this to be poor complaint handling from the Trust. It is clear its decision not to fully investigate Mr F’s complaint contributed to the breakdown in the relationship between the Trust and Mr F and reaffirmed his view that the Trust did not wish to engage with him with respect to his condition or his care.
27. We have discussed Mr F's complaint with representatives at the Trust. The Trust has acknowledged it should have investigated and responded to these additional points of complaint and it was inappropriate to focus its response solely on Mr F’s attendance at the ED. The Trust has now committed to investigate and respond to these points of complaint.
28. The Healthcare Commissioners Act 1993 prevents us from investigating a complaint that has not exhausted the NHS complaints process. For this reason we do not investigate complaints that have not been thoroughly investigated and responded to by the organisation involved.
29. As the complaint about the inpatient care has not been through local resolution with the Trust these points of complaint are not ready for us to consider at this time. However if Mr F remains dissatisfied with the response from the Trust once it has completed its investigation he can bring his complaint about the inpatient care back to us.