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 happen (by using relevant standards, guidance, protocols or the law) and then looking at what did happen to see if this falls so far short to be considered a failing. We often refer to this as ‘maladministration’.
16. When we identify maladministration, we next go onto see if the injustice claimed and the impact caused can be linked to be ‘flowing’ from this injustice, i.e., the claimed failing case all, some or none of the injustice. If we can link the injustice and impact, we next go onto consider what an organisation has done to acknowledge this and put matters right. We often refer to this as the ‘remedy’. It is for the Ombudsman to decide whether the organisation’s remedy is fair and proportionate to the claimed injustice.
The Trust’s official palliative care mobile phone was either switched off or left unanswered rendering Mrs H unable to get help and seek emergency end-of-life support for Mr H
17. Mrs H says the Trust’s official palliative care mobile phone was either switched off or left unanswered rendering Mrs H unable to get help and seek emergency end-of-life support for Mr H.
18. Mrs H said the morning of 24 July she and Mr H’s carer tried calling the Trust’s designated palliative care mobile number several times, but the phone was turned off.
19. Mrs H says this experience caused the Mr H and the whole family distress. She says she feels she let Mr H down and allowed him to suffer unnecessary. She says Mr H suffered for hours from 3am until 9:30 am, approximately six to seven hours and occurring only once during his car eon tis day. She says he was in pain and very unwell and restless during this time and this caused uncertainty and worry in not being able to get through to or reach a nursing assistant.
20. In its complaint response the Trust said the night nursing phone is diverted daily at 8:00am to a named nurse working during the day shift. This is done to ensure that any urgent calls coming to the night staff mobile are dealt with in a timely manner. The Trust reviewed the call logs for 24 July 2024 and explained they could not identify any calls received during this specific period but had identified and received calls at 7.58am, 8.39am and 08.44am.
21. The Trust further reviewed the appointment records for other visits that occurred on the evening of 24 July 2024 and can see that the community nurses on shift that night reported that they had arranged some of the visits they undertook following a telephone call. The Trust said this would suggest that the phone was not diverted.
22. The Trust further requested the telephone records from the Trust IT department though the Trust IT team was unable to retrieve this information. To explore this further, the Trust asked the IT department to contact the provider of the Trust's network mobile phones, but they reported they are also unable to access records of incoming calls. As a result, the Trust explained it does not have direct evidence confirming the time of Mrs H’s calls other than what was identified in its response.
23. The Trust noted that the number used by Mrs H was only active during standard working hours (8.00am-6.00pm), which explained why her calls did not connect to this number on the evening of 23/24 July 2024. The Trust further said the night nursing team responded to a call from another patient/family and conducted a home visit demonstrating that the phone was not switched off for the entirety of the night shift.
24. Additionally, the Trust further examined the nurse’s phone, to which the calls were diverted at the end of the night nursing shift, as is usual practice. The Trust said, while no record was found of Mrs H’s number being redirected to nurses’ phone during the night, the log showed that once the nurse’s phone was switched on at the start of their shift, they began receiving calls. The Trust explained that calls made to a switched-off phone will appear in the log once the device is powered back on, and no records relating to any calls from Mrs H were found.
25. We recognise this technical detail of the phone being unpowered and not accepting calls would be distressing and upsetting to Mrs H.
26. The Trust acknowledged that the process of diverting the telephones is reliant on staff ensuring that this is done in the morning and at night and therefore, there is the potential of human error. The Trust, in recognition of this and the potential impact this could have, said it will review this process.
27. The Trust apologised for Mrs H experience and recognised during complain handling that it is unable to change her experience. The Trust, in order to learn from Mrs H’s feedback, undertaken number of actions to impose its service. This includes review of its internal process of diverting telephones, and changes made to improve the communication between the Community Nursing and Palliative care team to strengthen the care being provided for palliative care patients and to minimise this occurrence in the future.
28. The Trust also said the night team will specifically undergoing palliative care refresher training to ensure they are fully up to date with their knowledge and competent in the delivery of compassionate and responsive palliative care and the Trust will bringing a summary of Mrs H’s complaint to the Trust End of Life Care Steering group to share the learning from her experience wider.
29. With an indication of failing we then consider our complaint standards and what should happen NHS Complaint Standards | Parliamentary and Health Service Ombudsman (PHSO). The standards set out that organisations should take a fair and balanced approach to complaint handling to take ownership and responsibility when something has gone wrong. They should be open and honest and recognise where things have gone wrong, that improvements may be needed. In summary, we consider those improvements should be fair, reasonable and proportionate and responsive to recognising the individual circumstances of the complaint.
30. When considering indications of failing it is also important for the Ombudsman of understand the impact and injustice experienced. We refer to our own Severity of Injustice scale to assist with a consistent and fair decision approach across the work that we do.
31. The scale has six bands ranging from levels one and two of a lower-level injustice lasting under a year and diminishing with time and up to a level six, where the injustice claimed is often fatal, systemic organisation wide failing, lifelong detrimental, or has had a devastating impact. The scale represents the Ombudsman’s judgement about the sort of injustices and financial sums that are both appropriate and proportionate for us to recommend.
32. The level of worry, inconvenience and distress experienced would be maximum level two on our scale. These are cases which will generally be similar to, but more serious than cases involving level one injustice, but where we consider that an apology on its own is not an adequate remedy. Typically, the injustice will arise from a short or low impact failing, often resulting in a degree of distress, inconvenience or pain, but the duration of the injustice will tend to be longer than in cases with level one injustice. Alternatively, level two may involve single instances of more serious injustices where the impact was of short duration. We would expect the situation to return to normal once the poor service had ceased.
33. Level two cases also cover emotional impact of distress, worry, annoyance and similar injustice of the sort for a period from one to two weeks to about six months. We would reasonably expect any impact to diminish completely in the fullness of time.
34. From discussing the injustice and the impact with Mrs H, we understand this experience caused the Mr H Mrs H distress. Mrs H felt she let Mr H down and allowed him to suffer unnecessary. She says Mr H suffered for hours from 3.00am until 9:30am, a total of five and a half hours. She says Mrs H was in pain and very unwell and restless during this time. We understand this was on a backdrop of Mr H being on palliative care. We also note the community nurse visited Mr H later in the day (24 July)
35. Here, we recognise Mr H was on palliative care and a vulnerable patient. We recognise the impact he experienced would have been exacerbated due to his condition.
36. Whilst we recognise Mr H was on palliative care, we note the impact claimed lasted less than six hours, this was a one-off occurrence which did not occur again.
37. Mrs H is seeking service improvement and acknowledgement. From precedent checks into the Trust (checks that we do on all organisations we look into to explain if there are unresolved concerns or emerging themes or issues) we cannot see there to be an organisation wide or systemic issue regarding similar matters. Thus, informed by the PHSO NHS Complaint Standard we must consider what actions to remedy the complaint part are fair, proportionate and reasonable.
38. The PHSO NHS Complaint Standard says when an organisation has got something wrong it should be fair, proportionate and reasonable in its approach to remedy, that an organisation should take ownership for this and offer an apology.
39. Against this standard, we can see the Trust apologised and acknowledged Mrs H’s experiences. We can see they have investigated her complaint and have tried to establish the matter with the Mrs H’s call.
40. Further to this, the Trust, in order to learn from Mrs H’s feedback, have undertaken number of actions to impose its service. This includes:
• review of its internal process of diverting telephones • changes made to improve the communication between the Community Nursing and Palliative care team to strengthen the care being provided for palliative care patients • palliative care refresher training for the night team to ensure they are fully up to date with their knowledge and competent in the delivery of compassionate and responsive palliative care • bringing a summary of Mrs H’s complaint to the Trust End of Life Care Steering group to share the learning from her experience.
41. Therefore, we have seen the Trust apologise, recognise Mrs H’s experience, and implement service improvements.
42. We consider this is enough to remedy Mrs H’s injustice. As such we have seen no unremedied injustice and will take no further action on this complaint point. If we were to progress further to a detailed investigation stage, based on this type of injustice we do not consider we will recommend any further action for the Trust to complete.
43. Therefore, we will take no further action on this complaint point.
The Trust did not answer the text messages Mrs H sent despite these being read by staff
44. Mrs H says she sent text messaged to the community nurse phone number, after being unable to call them. She says the Trust did not answer the text messages she sent despite these being read by staff.
45. Mrs H says this experience caused the Mr H and the whole family distress. She says she feels she let Mr H down and allowed him to suffer unnecessary. She says Mr H suffered for hours from 03.00 until 9.30. She says he was in pain and very unwell and restless during this time.
46. From her complaint Mrs H is seeking service improvement and acknowledgement.
47. In its response the Trust explained they have interviewed one of the two-night shift nurses, and they were unable to recall receiving the text messages that evening. The Trust was unable to interview the second night shift nurse as they were on long term sickness absence but will talk to them on their return. As a result, the Trust explained that there is no way of determining exactly who it was that opened the text messages Mrs H sent to the night shift’s mobile phone number on the evening of 23/24 July 2024. The Trust recognised this is not the answer Mrs H was hoping for and apologised. The Trust further explained the two-night shift nurses would be met by the senior management team to undertake a meeting of concern regarding their conduct.
48. As part of our consideration, we held up our complaints handling standards our severity of injustice scale to determine the impact and if the remedy is suitable.
49. The level of worry, inconvenience and distress experienced would be maximum level one on our scale. These are cases which will generally be similar to, but more serious than cases involving level one injustice, but where we consider that an apology on its own is not an adequate remedy. Typically, the injustice will arise from a relatively low impact failing, often resulting in a degree of distress, inconvenience or minor pain, but the duration of the injustice will tend to be longer than in cases with level one injustice. Alternatively, level 2 may involve single instances of more serious injustices where the impact was of short duration. We would expect the person affected to recover quickly once the poor service had ceased. Level two injustice will not usually have a significant lasting impact, or any effect on the complainant’s ability to live a relatively normal life.
50. Level two cases cover emotional impact of distress, worry, annoyance and similar injustice of the sort which a healthy adult would be expected to deal with on a regular basis, without external support, and which does not impact on the affected person’s day to day functioning, or their ability to live a normal life for a period from one to two weeks to about six months. We would reasonably expect any impact to diminish completely in the fullness of time.
51. From the impact Mrs H claims we understand this experience caused the Mr H and Mrs H distress. Mrs H felt she let Mr H down and allowed him to suffer unnecessary. She says Mr H suffered for hours from 3.00am until 9:30am, a total of five and a half hours. She says Mrs H was in pain and very unwell and restless during this time. We understand this was on a backdrop of Mr H being on palliative care. We also note the community nurse visited Mr H later in the day (24 July)
52. Here, we recognise Mr H was on palliative care and a vulnerable patient. We recognise the impact he experienced would have been exacerbated due to his condition.
53. Whilst we recognise Mr H was on palliative care, we note the impact and uncertainty experienced lasted less than six hours, this was a one-off occurrence which did not occur again.
54. Mrs H is seeking service improvement and acknowledgement. When we consider remedy, we also consider other similar complaints and the actions we have taken, and we look to see if the complaint is identifying a theme that may show there are organisation wide issues that we need to be considerate of.
55. Form doing ‘precedent check’ searches we have not seen anything that suggests there are systemic organisational failings similar to this. We have also seen similar types of injustice across NHS organisations, and they type of remedy which have occurred.
56. The aforementioned Complaint Standard says when an organisation has got something wrong it should be fair, proportionate and reasonable in its approach to remedy, that an organisation should take ownership for this and offer an apology.
57. Against this standard, we can see the Trust apologised and acknowledged Mrs H’s experiences and the distress caused. We can see they have investigated her complaint and have tried to establish who read the text messaged sent, however was unable to determine who it was.
58. Further to this, the Trust has taken active learning form the complaint and organised a meeting between the night shift nurses and the senior management team to undertake a meeting of concern regarding the matter to minimise future occurrences.
59. From the overall complaint response we also note, the Trust have made changes to improve the communication between the Community Nursing and Palliative care team to strengthen the care being provided for palliative care patients, have arranged palliative care refresher training for the night team to ensure they are fully up to date with their knowledge and competent in the delivery of compassionate and responsive palliative care and discussed a summary of Mrs H’s complaint at the Trust End of Life Care Steering group to share the learning from her experience.
60. Therefore, we have seen the Trust apologise, recognise Mrs H’s experience, and implement service improvements.
61. In consideration of all the actions taken the Ombudsman’s view is these are fair, reasonable and proportionate to the injustice claimed. We are pleased to note Mrs H’s complaint has shaped future care and been acted upon to prevent similar occurrences. In sight of these actions, we must then consider what more we can do and if there is any further value moving to a detailed investigation. Based on the individual circumstances of the complaint and the Trust’s actions we propose no further action and seek to reassure Mrs H that the outcomes already achieved would be consistent with what the Ombudsman would recommend. Therefore, we will take no further action on this matter.
62. We thank Mrs H for bringing her complaint to our attention. This marks the end of our consideration of the complaint.