15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.
16. If we see some evidence there is a difference, we next consider whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. If there are we may proceed to a detailed investigation.
Consultation
17. Ms F complains between 7 and 21 December 2023, Dr A discussed E’s needs with a neighbouring service without due consideration for E’s history with that service, or without seeking consent to do so first. Ms F says this demonstrates a lack of consideration for E’s complex past with the neighbouring service and does not demonstrate putting E’s well-being first. She also says it has eroded their trust in the service. We were very sorry to hear about how Ms F and E were feeling.
18. NHS guidance says the service should talk to you about what is happening to allow you to prepare and ask questions. NICE guidance says clinicians should start transition planning early for young people in out-of-authority placements. There is no guidance that specifies what order events should happen in.
19. We asked our adviser if this contact was in keeping with the guidance and what we would normally expect to see in this situation. They confirmed it was.
20. We recognise Ms F’s concerns about their history with the service and we can appreciate why she was so concerned the contact was not discussed with her first. Given the complex history, this would have been preferrable. However, taking the guidance and clinical views into consideration, we cannot say the actions of the Trust fell so far short of expectations set out in guidance that there was a failing.
21. Overall, it is our view the Trust has acted in line with guidance and we do not intend to consider this part of the complaint any further.
Dr A’s explanation
22. Ms F says on 5 January 2024, Dr A lied about her level of contact with other services and the information she disclosed in contact with the neighbouring service in December. Ms F says the Trust’s investigation has not demonstrated it has explored why there were discrepancies in the information Dr A shared about the information she disclosed, nor has it taken steps to prevent a repeat of this.
23. Our complaint standards say in investigating complaints organisations should carry out proportionate investigations that explore what happened and what should have happened. If they find something went wrong, they should assess the impact and think about its effect.
24. The Trust’s complaint response recognised what went wrong and it identified it was a result of human error. It considered the impact of the human error and in its complaint response Dr A apologised for the mistake and the distress it caused Ms F.
25. We understand Ms F’s concerns the Trust has not identified why there was human error or reassured her further instances have not and will not occur.
26. It is possible further human errors exist or will occur, however, there is no indication Dr A’s account is false or that there are further instances of error at this time. On this basis we consider the Trust’s response is proportionate given the evidence available.
27. Based on the information we have seen there is no indication Dr A’s human error affected anyone other than Ms F and E. In documenting the complaint formally, discussing the matter with Dr A and in her personally apologising, we are satisfied the Trust’s actions are in line with what we would normally expect to see in cases of this nature to prevent reoccurrence.
28. We understand Ms F’s concerns and thank her for bringing it to our attention. Overall, we are satisfied the Trust’s consideration of this point was in line with our guidance and we do not propose to consider it any further.
Disclosure of discussion
29. Ms F complains an email chain between the two organisations dated 14 December has not been disclosed to her or included in E’s records.
30. In the Trust’s complaint response, it refers to an email chain dated 14 December. Ms F has asked the Trust for this record in a subject access request (SAR, a formal request for data an organisation holds) and in her complaint, but it has not provided it.
31. We asked the Trust for E’s medical records and a copy of this email, or its rationale for withholding it. The Trust provided medical records and a complaint file. It told us on repeated occasions it has provided everything to us.
32. The medical records do not contain the email. This corresponds with Ms F’s account.
33. The complaint file includes an email from the complaint investigator to Dr A in April 2024, asking for a copy of the email from 14 December. There is a response from Dr A dated 30 April stating the email was attached, but with no attachment we could view. We have asked the Trust to provide this to us on several occasions, but it has not provided any further information and repeated that we have all the information it has.
34. Ms F says her daughter’s records are incomplete, and without the email she is left with concerns about the level of discussion and impact the missing information will have on her daughter’s future care. She also has wider concerns about the reliability of the information in E’s records overall.
35. Based on the response from the Trust and the outcome Ms F is seeking we are not the most appropriate organisation to address this issue for Ms F.
36. The ICO directs individuals unhappy with their response to a SAR to complain to it. If it thinks an organisation has not responded to a request as it should have done, it can give them advice and ask them to solve the problem.
37. Depending on the specific nature of Ms F’s SAR, she should either complain to the ICO about the Trust’s compliance with her SAR, or she should make a new SAR request that covers the email that appears not to have ever been added to E’s records.
38. We appreciate Ms F has told us she has not had a positive experience with the ICO in the past and we understand this is not the outcome she was hoping for. We hope she is reassured that we have carefully considered this matter before directing her to its services.
Complaint handling
39. Ms F says the Trust reframed her complaint as being about a confidentiality breach, ignoring her concerns about the level of information discussed and record of the discussion.
40. Our complaint standards say organisations should normally clarify the complaint before beginning an investigation to avoid issues later.
41. In her complaint Ms F says she wants an investigation into: • the provision of false information in Dr A’s email of 5 January • all communication between Dr A and the neighbouring service, as clinical notes are incomplete • E’s clinical notes updating.
42. Ms F requested all correspondence in writing. The Trust acknowledged Ms F’s complaint on the same day and allocated it to an investigating officer. There was an email to Ms F from the investigating officer acknowledging the complaint.
43. There are further internal emails from the investigating officer throughout the investigation process that summarise the complaint. They say it is relating to identifiable information being shared on 7 December, when Dr A said this had not happened, and the missing record from E’s notes from14 December. At this stage it seems the complaint was in keeping with Ms F’s expectations and fully understood by the Trust.
44. The final complaint response to Dr A’s communication was framed as a consideration of a data breach. Whilst this was not Ms F’s main concern the response on this point did provide an explanation about Dr A’s comments, in doing so it addressed the first concern Ms F had raised.
45. The Trust’s final complaint response also demonstrated it considered the level and content of communication between Dr A and the neighbouring service. It has not addressed the issue around E’s incomplete records, despite identifying this as part of its investigation. There is an indication of a failing in this element of its consideration.
46. We have set out our view regarding the incomplete record/ missing email above and directed Ms F to raise a further SAR or contact the ICO regarding this matter.
47. We rarely investigate issues about complaint handling, unless we consider them to be very serious. Given there are other avenues to explore to gain access to the information, the remaining impact Ms F told us about is frustration and a significant factor in a loss of trust in the service. We do not diminish the impact of this on Ms F and her daughter, particularly given the sensitive time it was in E’s transition and their history with the neighbouring service.
48. The emotional impact described although meaningful, is not at a level that would justify us looking at the complaint handling as a standalone issue. For this reason, we will not consider this part of the complaint any further.
Accuracy of wording
49. Ms F says the Trust changed the tense of events when responding to her concerns, referring to Dr A’s communication on 21 December as stating she ‘would be liaising’ with the neighbouring service when she already had.
50. Our complaint standards say organisations should investigate thoroughly and provide accurate accounts of events.
51. The email from Dr A on 21 December says she has been consulting with several people and departments about E’s transition. It also refers to plans for ongoing contact and discussions.
52. The Trust’s response could have included reference to both historical and ongoing contact Dr A referred to in her email. In referencing only ongoing contact it was not wrong, but it was an incomplete picture.
53. We do not consider the Trust to have deliberately changed the tense or misrepresented the contact. Nor do we consider its omission to be so serious that we would considering it a failing in complaint handling. We recognise it had an impact on Ms F and we hope our consideration of the issue offers some reassurance.
54. We understand how important Ms F’s complaint is to her and her daughter. We hope our explanation helps assure her of the careful consideration and scrutiny we have given her concerns and brings much of these matters to a close for them.