Misdiagnoses and treatment of hand injuries
22. To consider if there was a failing here, we compared what should have happened with what did happen. We have done this, and we consider there was a failing with this part of the complaint.
23. We can see when Mr E attended the Trust it was noted he had pain in his right hand in the ‘AE (accident and emergency) initial assessment’ document.
24. In the ‘AE rapid assessment’ document it is recorded Mr E has a mild swelling along his lateral aspect (the thumb side) of his hand. Aswell as decreased range of movement on flexion (bending) fourth and fifth fingers.
25. As part of the assessment Mr E had an X-ray to rule out a fracture in his right hand. The X-ray revealed there was a fracture to his hamate with slight displacement at the base of the fourth and fifth metacarpals.
26. The radiology report for this X-ray also concludes ‘there [was a] fracture of the hamate with slight displacement of the bases of the fourth and fifth metacarpals.’
27. While in hospital, Mr E says the consultant (Consultant A) told him he had no broken bones in his hand and only aggravated an old injury. Mr E told the consultant his bones were not mispositioned before his accident and it was not an old hand injury.
28. Mr E says Consultant A was stubborn and did not accept this. He says they maintained he had not broken any bones in his hand, and it was an old injury - before advising him to start exercising his hand after 2 to 3 days.
29. Our adviser also reviewed the X-ray images of Mr E’s hand. They concluded although the Trust did the X-ray correctly, Mr E’s hand was rotated. This meant the fourth metacarpal displacement was visible, but it was subtle.
30. They advised Consultant A could have made a diagnosis from the X-ray alone. But, if they were uncertain, they should have either repeated it or requested a CT scan. CT scans show the area much better, as it is a 3D image.
31. Consultant A, the day after Mr E’s admission, diagnosed Mr E’s hand injury as a ‘fracture of right hamate – old injury’. They recorded his injury in the consultant summary of case as ‘old injury to right hand – hamate.’
32. The Trust discharged Mr E the following day, two days post admission. The diagnosis in the discharge notification was recorded as ‘…right hamate fracture? old’. It appears Mr E’s right wrist was either in a Futura splint (a brand of wrist brace to help with stability and provide support to the wrist) or there was a plan for a ‘future’ splint. This appears to be an incorrect diagnosis.
33. In these circumstances, given the clear evidence showing Mr E’s hand injuries we would have expected the consultant to diagnose this correctly. Our adviser considers this is fundamental and basic principles of fracture treatment, and therefore there is no specific guidance or standards that apply to this situation. As such, the GMC’s GMP is relevant here.
34. Domain one (Knowledge, Skills and Performance) of the GMP applies here, in particular section 15(a), which says:
‘[15] You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: (a) adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient’
35. Based on the evidence, we consider this was not followed. If it had, we consider on balance, the consultant would have correctly diagnosed Mr E’s hand injuries.
36. It is not clear where Mr E’s hand injury being old came from. The consultant said this information was given to them during the handover. The Trust confirmed it asked Mr E about this, and he confirmed this was not the case. The Trust expressed regret that this was recorded as a diagnosis.
37. As such, we consider there was a failure to correctly diagnose Mr E’s hand injuries.
38. This had a direct impact on the treatment of Mr E’s hand injuries. As said above, Mr E was discharged with no treatment to his hand other than a possible splint. Further, Mr E says he was encouraged to use his hand again after two to three days.
39. Our adviser considers it is again a fundamental principle of hand fracture treatment that dislocations should be reduced as quickly as possible. As such, this is not covered specifically in guidance or standards.
40. The GMP domain one is again relevant here, specifically section 15(b) which says promptly provide or arrange suitable treatment where necessary. As well as section 16(b) which says:
‘[16] In providing clinical care you must: (b) …provide effective treatments based on the best available evidence’
41. As explained above, we consider the evidence available to the consultant showed Mr E likely had dislocations in his hand.
42. As there is no specific guidance about this and only general, we considered our adviser’s experience about suitable or effective treatment of this injury as evidence to what should have happened.
43. Based on our adviser’s experience the Trust should have reduced the displacement and then stabilised it. Our adviser said there is some debate about how this should be done. They said most consultants would use K-wires (Kirschner wires – temporary pins used in orthopaedic surgery to hold bones in the correct position while they heal) to stabilise it. They said some may use plates (metal bar or splint surgically attached to a fractured or deformed bone using screws, to hold pieces together or maintain proper alignment for healing) which will be removed at a later date.
44. We cannot see either of these treatments, or any treatment of his dislocations, was done during Mr E’s admission at the Trust, contrary to the GMC’s guidance.
45. We therefore consider there was also a failing when the Trust did not appropriately treat Mr E’s hand injuries.
46. Our adviser explains there is a short window in which to do this, around three weeks. This means the follow-up appointment and treatment in May 2021 Mr E received to his hand in this case is immaterial to his hand injury and this complaint. This is because the window in which to treat his hand injuries, had already been missed at this point. Therefore, we will not consider Mr E’s hand treatment after the initial admission.
47. The Trust said it could not treat Mr E’s hand injury because of his spinal injury and the increased risk associated with surgical intervention or using general anaesthetic (GA). It also said Mr E ate when at the Trust, so could not have had GA for any treatment.
48. We are not certain about the nature of Mr E’s spinal injury, however, it was likely stable as Mr E was in hospital for two nights and was given a neck brace. Our adviser’s view is that this would not have prevented the necessary treatment of Mr E’s hand injury.
49. Our adviser’s view is that this treatment could be done using local anaesthetic rather than GA. Therefore, the Trust not being able to use GA does not mean it could not provide Mr E with the treatment he needed.
50. In any event, we consider the Trust failed to recognise Mr E’s injuries, which meant he did not receive the treatment he needed.
51. In conclusion, we consider the consultant should have correctly diagnosed Mr E’s hand injuries and planned prompt and appropriate treatment as described above. We consider these are failings.
52. We considered Mr E’s alleged impact and what impact, if any, is linked to the failing. We use our adviser’s experience to help us consider what impact the failing may have caused.
53. We have set out Mr E’s alleged impact above in the scope of this complaint. To avoid repetition, we will only summarise this here.
54. Mr E alleges there was a physiological impact of a permanent hand injury which causes him pain and discomfort, and limited movement. He says this impacts his enjoyment of life and everyday tasks. Mr E says this in turn has an emotional impact, causing him stress and negatively affecting his mental health.
55. Mr E says to this day the dislocated bones protrude up from the back of his hand. He says this is a further constant reminder of this failing.
56. Our adviser considers, if Mr E had the appropriate treatment, as outlined above, his outlook was excellent. They consider there was a high probability and certainly on balance Mr E’s hand would have returned to full function.
57. Our adviser’s view is that Mr E’s hand condition will stay as it is indefinitely. They noted it is not progressive – meaning it will likely not get worse.
58. Mr E has a deformity in his hand and our adviser’s opinion is that he will have pain from the displacement, as well as limitation of his grip and loss of flexibility. They said this will negatively impact, by around 15%, his ability to run a small holding which requires manual work.
59. Our adviser noted Mr E does have the option to fuse the in his hand joints, but this will mean he will lose flexibility and dexterity in his grip.
60. We therefore consider Mr E’s alleged permanent physiological impact is linked to the failing. On balance, if the Trust had done the appropriate treatment, Mr E would not have had the permanent hand injury and the symptoms and emotional impact that comes with that.
61. We also consider the evidence shows the symptoms Mr E has described is consistent with what we expect to see from a person with this injury.
62. We consider, a permanent hand injury that comes with pain and loss of function would impact a person’s enjoyment of life, and everyday tasks. We also consider it is reasonable this could then in turn impact a person’s mental health.
63. We therefore consider Mr E’s alleged impact is linked to the failing.
64. We considered what the Trust has already done to remedy this failing. Mr E would like the Trust to accept and acknowledge what went wrong and for it to improve its service.
65. The Trust initially made some admission to some failings with Mr E’s care, but later maintained its care was appropriate.
66. The Trust instructed an independent medical expert to consider Mr E’s care. Prior to this, the Trust maintained nothing went wrong with Mr E’s care and treatment. The Trust’s independent medical expert found the Trust could have done more. The Trust sent a copy of this report to Mr E.
67. Despite the report findings, the Trust did not apologise for or acknowledge its failings. It also did not say what it would do to avoid this happening again. Given what the Trust found in its instructed medical experts report, we would have expected the Trust to have at least acknowledged this and apologised. We will discuss this in more detail below.
68. We consider the Trust never appropriately acknowledged and remedied what went wrong with Mr E’s care at the Trust. We therefore consider the Trust has not remedied the failing we have found.
69. Considering all the above we uphold this part of the complaint. We recommend the Trust writes to Mr E acknowledging and accepting the failings. We also recommend the Trust improve its service. We will discuss this below at the recommendations section.
Complaint handling
70. To consider if there was a failing here, we again compared what should have happened with what did happen. We have done this, and we consider there was a failing with the Trust’s complaint handling.
71. Mr E set out various specific reasons why he considered the Trust failed with its complaint handling of this case. We consider it is more appropriate and proportionate to consider the complaint handling generally and overall. We consider this covers Mr E’s main concerns about the Trust.
72. Mr E first complained about the above issue to the Trust in July 2021. This was in the form of a 16-page letter setting out what he felt went wrong with his treatment.
73. The Trust responded on 4 August 2021. The Trust acknowledged, in relation to the hamate fracture there was a misdiagnosis of it saying, ‘regrettably sometimes diagnoses are missed initially on X-rays. Unfortunately, it happens to all specialists.’ It said hamate fractures are rare and not easily diagnosed. It did not mention the dislocations when saying this. It went on to say, ‘a standard X-ray possesses a high rate of false negative interpretations. It was however diagnosed subsequently and [Consultant B] does not think the delay to the diagnosis has had any negative consequence to you or your hand.’ The Trust apologised for this.
74. The Trust discussed Mr E’s dislocations when discussing the May 2021 treatment. It said during a clinic appointment on 11 May 2021 Consultant A felt the fracture position had changed and arranged for a hand specialist (Consultant B) to see Mr E. The Trust said Consultant A regrets the delay reaching this decision.
75. The Trust said this type of fracture dislocation is rare. It said Consultant B, who was treating Mr E’s hand in May 2021, decided surgery was not clinically appropriate at that stage and considered Mr E’s hand would recover over time.
76. The Trust said these types of injuries are best dealt with in the first couple of weeks, when a closed reduction can be undertaken. This is consistent with our above findings. The Trust therefore said, by the time of May 2021 appointment, a conservative approach was appropriate.
77. We consider this response overall is okay, as the Trust sets out what happened, what may have gone wrong, and apologised for this and made service improvements. That said it is vague, and it is not clear if the Trust considers it misdiagnosed Mr E or missed the opportunity to appropriately treat him.
78. The Trust in its letter refers to ‘mistakes’ when discussing its service improvements. Although it is not clear what mistakes the Trust is referring to. It seems the Trust are saying there was a communication failing rather than anything else.
79. Mr E went back to the Trust following its response with further questions in November 2021. This was another long document of 12 pages.
80. Consultant A wrote a retrospective statement about these events. This statement is undated. The statement refers to an email dated 5 October 2021. This means it cannot have been written before this date. The Trust dated the statement in the file name it sent to us, as 18 October 2021.
81. Consultant A said in this statement the initial X-rays of Mr E’s hand ‘…showed a dorsal lip fracture of [the] hamate with mild displacement of the ring finger metatarsal.’ Consultant A said there was a mention of an old injury which Mr E denied. This is different to what Consultant A wrote in Mr E’s records.
82. Consultant A said as Mr E was still in pain they arranged for further X-rays. Consultant A says this further X-ray shows satisfactory alignment of the bones.
83. We asked the Trust for all the images from Mr E’s time at the Trust during this admission. We can only see the initial X-ray done on 16 April 2021 was reported on. In the second X-ray, Mr E’s hand is rotated. As said above, our adviser’s view was the fourth metacarpal displacement was visible, but it was subtle.
84. Consultant A says Mr E’s ‘significant cervical spine injury’ meant there was a high risk of complications from general and/or regional anaesthetic and manipulation of his neck. They said this ‘factor weighed strongly’ on their mind when advising Mr E his fracture was minimally displaced and could be managed conservatively.
85. Unfortunately, on the face of it, this is not consistent with the records, which does not show Consultant A considered this. This also appears, albeit from a lay perspective, to contradict what Consultant A said about the second X-ray showing there was satisfactory alignment. This would presumably be the strongest factor when deciding against surgical intervention.
86. This may make sense from a clinical perspective, but as Mr E is a lay person, and this is a complaint response to him, the Trust should explain this to him, as per our Principles of Good Complaint Handling. Otherwise, there appears to be a contradiction. Our principles say public bodies should:
‘Use language that is easy to understand, and communicate with the complainant in a way that is appropriate to them and their circumstances.’
87. Consultant A goes on to say there was a plan to review Mr E in the fracture clinic in two weeks, although this was not recorded. They said Mr E presented weekly for collar care. They acknowledged Mr E mentioned his hand pain and deformity to the team delivering his collar care. Consultant A said this hand pain and deformity was not escalated by the collar team to them.
88. Consultant A said in isolation, Mr E’s hand would ‘…ideally be treated with closed reduction and K wire fixation…’ they said due to the combination of the spinal fracture and risks of complications, and the minimal displacement, Mr E’s hand injury could be managed conservatively.
89. Consultant A said when he saw Mr E in clinic on 11 May 2021 the repeat X-rays showed ‘the fracture and the carpometacarpal joints (the joint at the base of the metacarpal bone with the carpal bone of the wrist) of his ring and little finger had displaced further.’
90. Consultant A’s statement maintained there were no failings with their care of Mr E’s hand injuries.
91. We can see the Trust had a ‘clinical governance meeting’ on 15 October 2021, which was around the same time Consultant A’s undated statement was drafted. It is recorded in this meeting Mr E’s case was discussed. We know this was Mr E’s complaint because it matches his ‘hospital number.’ This is a reference number the Trust uses for administrative purposes which is unique to each patient.
92. It is recorded in the meeting notes ‘[Consultant A] shared with us a complaint about a patient who had a missed diagnosis regarding a hand injury. Learning points noted.’ This seems to contradict Consultant’s A statement where they maintained nothing went wrong with Mr E’s care. This likely happened three days before Consultant A wrote their statement. Mr E considers this is evidence Consultant A was being dishonest and attempting to cover up the above failing.
93. The Trust provided a second response on 11 March 2022. This response was different to the first response and seemed to contradict it and some of Consultant A’s statement. The Trust provided this response with the help of Consultant C. Mr E considers Consultant C was also dishonest.
94. This response says Consultant C’s view was that the X-ray shows a fracture in the hand, but there was no dislocation. Consultant C agreed with Consultant A regarding the conservative approach and the higher risks of complications due to the spinal injury. Generally, in this letter, it is Consultant C supporting what Consultant A said in their statement.
95. Mr E went back to the Trust again in March and April 2022. The Trust provided a third response on 25 July 2022. This complaint was more focused on the Trust’s complaint handling rather than Mr E’s care.
96. The Trust, in this response, maintains no failing with its complaint handling and Consultant A’s care. It said, about the apparent contradictions, what Consultant C said could have been clearer and it apologised for this. It said Consultant C did not consider there was a displacement in the X-ray image, but acknowledged the radiographer reported there was slight displacement.
97. The Trust also did not agree the two responses contradict each other or that there are any contradictions within what it said. It said the first response was not focused on Consultant A’s ‘factual account’. It said Consultant A felt their interaction with Mr E could have been better and they wanted to focus on apologising for this and reassuring Mr E.
98. The Trust also said Mr E’s case was discussed on 18 August 2021 in the departmental audit meeting. It said it was felt Mr E’s injury was ‘rare’, and the consensus was that the injury was treated ‘appropriately’.
99. Mr E again returned to the Trust in November 2022. The Trust responded saying it would instruct an independent medical expert (consultant orthopaedic & hand surgeon). The independent medical expert produced a report dated 23 January 2023.
100. The report found the Trust missed the opportunity to perform ‘standard practice’ investigations on 17 and 18 April, and 11 and 13 May. It said this would have revealed the extent of Mr E’s injuries and how to properly treat them. They went on to say, ‘…the 4th metacarpal fracture base was dislocated at least in 75% of its width, and reduction of this displacement could have been relatively easy achieved in skilled hands within [the] first couple [of] weeks from injury’.
101. Following this the Trust did not acknowledge the report findings or try to remedy them. It wrote to Mr E enclosing a copy of the report and advised him to get legal advice.
102. The Trust did provide a fourth response. But this was mainly focused on the complaint handling and the allegations of dishonesty and covering up. It again mentioned the Trauma and Orthopaedics Governance meeting on 18 August 2021 meeting which concluded Mr E’s hand injury was treated appropriately, and that it could not locate the minutes of this meeting.
103. Regarding the 18 August 2021 meeting. Mr E questioned if this happened, and this has contributed to his feelings that the Trust have acted dishonestly. A manager at the Trust emailed Mr E, confirming they cannot find any evidence of the meeting on the 18 August 2021. The Trust said in its fourth response the meeting notes were taken and relied on for its responses, but it produced no formal minutes. It said it now ratifies and files minutes for all meetings.
104. We have to accept the Trust’s reason why it cannot produce minutes of this meeting. That said, we do question its reliance on this meeting as part of its complaint investigation when it does not have a copy of the notes. It is unclear how the Trust can be sure what was discussed in this meeting. We can appreciate how this would at best create a feeling of distrust in the Trust, and at worst lead a complainant to think the Trust is covering up.
105. Mr E also questioned the Trust about the two-week follow-up appointment after his admission it said it booked for him. Mr E contacted the same manager as above. The manager said they could not find any evidence of an appointment been booked or cancelled. Mr E feels again this is evidence of dishonesty. This could also be explained as a mistake that has then become part of the narrative.
106. In summary, the Trust initially accepted there was a misdiagnosis of the hamate and regretted not treating the dislocation sooner. But said this did not amount to a failing.
107. It is recorded Consultant A said in a meeting Mr E ‘had a missed diagnosis’.
108. Consultant A then said, in their statement, the initial X-ray showed minimal displacement, but the second X-ray showed there was a satisfactory alignment of bones, before saying one of the main factors for not undertaking surgery sooner was because of Mr E’s spinal injury and the minimal displacement.
109. The Trust and Consultant C then said Mr E did not have a dislocation.
110. The Trust then instructed an independent medical expert who found there was a missed opportunity to diagnose and treat Mr E’s dislocations sooner. The Trust did not provide any redress or acknowledgement of this.
111. The Trust does seem to say different and conflicting points. It says sometimes these injuries can be missed, but Consultant A acted appropriately, and it was a sound clinical decision to treat conservatively. But then it says the Trust and Consultant A regret not referring Mr E to a hand specialist sooner. It says Mr E had a displacement, but it was only minor, but then also says his bones were appropriately aligned and there was no dislocation. It then explains this saying Consultant A was not providing a ‘factual account’.
112. It is understandable this complaints process would be at best confusing for Mr E, and at worse lead him to assume there is dishonesty or a cover-up. It is reasonable it could give a complainant the impression the Trust is trying to justify what happened rather than being accountable to any failing it may have found or should have found. We agree this gives the impression the Trust was dishonest or disingenuous which was an attempt to deliberately evade responsibility. We will discuss this more below.
113. The Trust then exacerbated this feeling when it did not acknowledge what its independent medical expert found and instead advised Mr E to seek legal advice. It also further compounded this feeling with the specific issues such as, when Consultant A contradicting himself days apart in his statement and the October 2021 meeting, when the Trust relied on discussions in a meeting but had no record of it, and when the Trust relied on Consultant A booking Mr E into a two week appointment it could find no record of.
114. We would not expect an organisation’s version of events to change throughout the complaints process, and if it does, for example if it previously got something wrong or misunderstood the circumstances, we would expect it to robustly explain this.
115. Our principles of good complaint handling say, at section three, public bodies should:
‘Be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations, and reasons for their decisions. When things have gone wrong, public bodies should explain fully and say what they will do to put matters right as quickly as possible’
116. We cannot see the Trust did this throughout its complaint process. We consider the above evidence suggests the Trust did not provide clear or evidence-based explanations for its decision.
117. We also consider the Trust missed opportunities to find the failings we found and what the independent medical expert it instructed found. We therefore cannot consider the Trust explained fully what went wrong and say what it would do to put matters right as quickly as possible.
118. From December 2022 the NHS Complaint Standards also apply to the Trust’s complaint handling. This says, ‘staff [should] give a clear, balanced account of what happened based on established facts’ and ‘wherever possible, staff explain why things went wrong and identify suitable ways to put things right for people. Staff give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.’
119. As above, we again cannot see this was done when the Trust seemed to contradict itself without explanation and missed the opportunity to find and respond to its failings. We cannot see the Trust gave a balanced account based on established facts. It was based on Consultant A’s recollection which seemed to change, and evidence such as a meeting it has no record of.
120. In light of the Trust’s instructed medical expert’s report, we would have expected the Trust to have provided Mr E with a response highlighting the failing it found. We would have expected it to provide a remedy for the failing, like an apology, and then take learning from it. Instead, the Trust seemed to be worried about litigation and advised Mr E to get legal advice.
121. This is again contrary with the above guidance, NHS Complaint Standards says:
‘Organisations [should] empower staff to identify suitable and appropriate ways to put things right for people who raise a complaint. They [should] provide guidance and resources to make sure any proposed action to put things right is consistent.’
122. Finally, as detailed above, the Trust complaint process was long and drawn out. Our principles say organisations should,
‘Ensure their complaints procedure is simple and clear, involving as few steps as possible. Having too many complaint handling stages may unnecessarily complicate the process…’
123. We do not consider this was done. Because the Trust missed the opportunity to find the failings with Mr E’s care the process went on for longer than it should have. We consider this did unnecessarily complicate the process. This may also explain some of the discrepancies with the Trust’s responses and the evidence it relied on.
124. Therefore, we consider there was failing with the Trust’s complaint handling when it did not provide Mr E with consistent responses and missed the opportunity to identify and remedy the failings.
125. Mr E considers the Trust was dishonest in its responses. It is difficult to establish dishonesty. Dishonesty looks the same as a sincere mistake without knowing what a person or an organisation’s intent was. In this case, we do not know the Trust’s or the clinicians’ intent other than what they say it was. That said, we can understand why Mr E would consider this was dishonesty, and some of the evidence may suggest this was the case.
126. There may be other explanations for the contradictions. As said above, we consider the Trust overcomplicated the process and it is possible it confused the complaint for itself. Therefore, concluding dishonesty is speculative because there may be another explanation. The Trust has maintained it acted in good faith. Without any definitive evidence to the contrary, we can only accept that the Trust acted in good faith.
127. Nevertheless, we can say, regardless of the Trust's intent, there was a lack of accountability at the Trust and evidence-based investigation. We consider this would leave a complainant with no faith or trust in its investigation and lead a person to conclude this was an attempted cover-up. We are not trying to dismiss or diminish Mr E’s feelings about this and it is a reasonable conclusion to draw.
128. Mr E said the complaint handling caused him depression, including a suicidal episode. We were sorry to learn of the impact Mr E said this had on him. We recognise he went through a difficult time.
129. We consider it is reasonable a person may experience distress and frustration, which could cause depression, if they consider their complaint is being ignored or covered up. While we consider the Trust was not doing this intentionally, we consider Mr E did sincerely believe this to be the case which is reasonable. We therefore consider this could reasonably cause someone depression.
130. We cannot say if this would have caused a suicidal episode. We understand this may have contributed to it, but there are many factors that can contribute to a person’s emotional wellbeing and we cannot say this is linked to the failing.
131. We therefore consider we can link some of the alleged impact to the failing here, namely depression and an emotional impact including but not limited to distress, upset, and frustration.
132. The Trust have not acknowledged there may have been a complaint handling failing. Therefore, it has not remedied this impact.
133. Considering all the above, we uphold this part of the complaint. We recommend the Trust writes to Mr E acknowledging and accepting the failing. We also recommend the Trust improve its service. We will discuss this below at the recommendations section.
Our recommendations
134. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services.
135. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.
136. Mr E said he would like the Trust to accept what went wrong with how it treated him, and to establish where it failed, along with service improvements. He would also like the Trust to explain what it said about his care was wrong, explain why it said this, and acknowledge its failings.
137. In line with this we recommend the Trust should write to Mr E, acknowledging the above failings, and provide an explanation of what happened and where possible, why. We will expect this will draw a line in the sand and be an end to this matter for Mr E.
138. Our principles say that public organisations should look for continuous improvement and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service. In line with this, we also recommend the Trust provides an action plan with actionable goals that should avoid the same failings happening again.
139. In particular we want to see the Trust puts actions in place to ensure appropriate hand treatment is not missed such as in Mr E’s case. We also want to see the Trust’s puts actions in place to ensure it follows the NHS complaint standards and is accountable and open when things go wrong.
140. We also recommend the Trust sends a copy of the action plan to Mr E along with the above-mentioned letter.
141. We acknowledge the impact these events had on Mr E, and it is understandable why he has brought his complaint to us. We are sorry to learn of Mr E’s permanent hand injury on his dominant side and the emotional impact this will bring along with going through the complaints process. We understand Mr E has been going through this for a long time.