Miss A’s transfer to Royal Free
22. Miss A says Moorfields should not have discharged her to Royal Free, as it did not have the necessary experience or skill to care for her needs. She says the proof of this is that it transferred her back to Moorfields. She says Moorfields did not check with her that this transfer was actually more convenient for her. And it did not send her relevant records to Royal Free.
23. Moorfields said it referred her because it was unlikely her tumour would return, so it thought a local hospital would better suit her. It said Covid-19 had affected its capacity, so it needed to identify patients who could be safely treated elsewhere to free up capacity for those needing more urgent care. It said its letter of 27 November 2020 to Miss A was copied to Royal Free so the latter could ensure she was seen by an expert in the eye clinic there.
24. Royal Free says it did not receive Miss A’s referral letter from Moorfields and so was not aware she was being transferred to it. It says it has apologised for not obtaining her records and organising an appointment for her more quickly.
The chronology of events
25. We first looked at what the evidence tells us about how the events unfolded.
26. Moorfields had treated Miss A for a melanoma (a type of cancer) in her right eye in 2016. She needed regular follow-ups. In 2018 her vision deteriorated further in that eye. Moorfields again treated this successfully. Her sight was reduced but stable. After November 2019 her next follow-up was set for August 2020. NICE NG14 says the patient should have one follow-up a year in year four after the initial clinical issue. So this plan was in line with the guidance.
27. Due to the ongoing effects of the Covid-19 pandemic, Moorfields wrote to Miss A in mid July 2020 to cancel that appointment. That autumn the UK had a further wave of the pandemic which the NHS had to respond to.
28. In early November Moorfields wrote to Miss A to say it was transferring her to Royal Free. This letter was copied to a ‘consultant ophthalmologist’ (not a named person) at Royal Free. Moorfields has confirmed to us it considered it had transferred her at this point.
29. Miss A complained to Moorfields. It replied at the end of November. It said it had tried to call her back but had not been able to speak to her and had left voicemail messages. It said she was being referred to a named doctor at the eye clinic at Royal Free.
30. There appears to have been a telephone conversation between Moorfields and Royal Free. Neither trust documented this call, so we cannot say when it happened, which trust called the other or what exactly was discussed. Royal Free appears to have given Moorfields the name of an ophthalmology consultant. But we cannot say any further than that.
31. In early December Moorfields wrote to the ophthalmology consultant at Royal Free, referring to the above telephone conversation. Moorfields asked if the consultant would accept its referral of Miss A. It received a ‘read receipt’ for this message. We have not seen evidence Royal Free replied to or otherwise acknowledged this message. We have not seen evidence in the records of either organisation that Moorfields made any other contacts with Royal Free.
32. Miss A waited a couple of months, but heard nothing about an appointment at Royal Free. She contacted Royal Free to chase this up. It said it was not aware of her. In January 2021 her GP referred her to Royal Free. It reviewed her care in March, July and August. It referred her back to Moorfields. Moorfields saw her again in September 2021 and remains responsible for her care.
The standards
33. The relevant standards are NICE guidance 14 (NG14) and clinical guidance 138 (CG138), Moorfields’s ‘ADT policy’ and the GMC’s ‘Good Medical Practice’’. We have also considered our ‘Principles of Good Administration’. NG14 says organisations should give people support by discussing with them who will undertake their care, how to contact them and treatment options. CG138 says organisations should give people a service tailored to their needs and circumstances.
34. Moorfields’s ADT policy says its staff should make sure all appropriate information is handed on to an appropriate person, so it can transfer someone with the minimum of interruption in their care. Good Medical Practice says organisations should contribute to the safe transfer of care by checking a named clinician or team has taken over responsibility, especially where the patient is vulnerable.
35. Our Principles (‘Being customer focused’) say public bodies should communicate with people effectively in a way that is appropriate to them and their circumstances.
Our view on what Moorfields did 36. We understand the unique circumstances under which the NHS had to operate in autumn 2020. We appreciate Moorfields had to review its patient list and decide who could be treated elsewhere to help it manage its capacity during the pandemic.
37. It said it was transferring some patients to hospitals closer to their home because of the ongoing risk of Covid-19 infection and because travel was often difficult at that time. Miss A has told us Royal Free was actually less convenient for her. She says Moorfields did not discuss this with her.
38. ‘Good Medical Practice’, CG138 and Moorfields’s ‘ADT policy’ say practitioners should check another organisation can safely take over a person’s care, including providing the relevant expertise. They should ensure continuity of care and coordinate this so as to minimise the impact on patients.
39. Based on the evidence, Moorfields did not check with or get confirmation from Royal Free that it had agreed to take over Miss A’s care. Moorfields discharged her without being certain Royal Free would take her. We also have seen no indication Moorfields confirmed Royal Free had the relevant level of expertise to take over Miss A’s care.
40. Moorfields’s ADT policy says it should make sure it has handed over all appropriate information to an appropriate person when it refers someone. The evidence show Moorfields only sent her records to Royal Free in March 2021, after her GP referred her to Royal Free again. There is no indication it sent her records when it transferred her to the care of Royal Free.
41. This is not in line with its ADT policy. We have found Moorfields got something wrong when it did not send Miss A’s records to Royal Free.
42. Miss A is also unhappy that Moorfields did not speak to her about the transfer. Our ‘Principles of Good Administration’ say organisations should communicate with people in a way that suits their circumstances (‘Being customer focused’). NICE guidance NG14 and CG138 says organisations should take an individualised approach to patients’ needs.
43. Moorfields said it initially tried to call its patients when it decided to transfer some of them, but very few were answering. It decided to write to them instead. We appreciate this was difficult time for the NHS; it was at the height of the Covid-19 pandemic. We could see writing to patients meant the Trust could be more certain they would get the information. But this also meant it could not have a discussion with them about their preferences.
44. Based on the evidence it appears the first Miss A knew about the transfer was Moorfields’ 2 November letter. She made a complaint by email. Moorfields says it called her and left voicemail messages in response. Miss A confirms she received these, but was unable to take the calls. Moorfields’s records say it gave her a number to call on which she could discuss her concerns about the transfer. She says she had a number, but she did not know if it was a direct line or a general number. She says it just rang out when she called and she could not leave a message.
45. We can see this was really frustrating for Miss A. When we weigh up the evidence, we cannot say Moorfields did something wrong here. She did not have the chance to discuss the decision to transfer her before Moorfields made it. But we cannot conclude that was because it did something wrong. When she complained, we can see it tried to call her to discuss this. Both she and Moorfields agreed it tried to call her, and that it gave her a number to call back. For us to say Miss A was not able to discuss her concerns about the transfer with Moorfields because it did something wrong, we would need to see strong evidence of that. We have not seen this. Moorfields was trying to communicate with Miss A as our Principles say it should have. The evidence is that regrettable timing meant Moorfields and Miss A were not able to speak when they tried to call each other.
46. It is also not possible for us to conclude that the outcome would have been any different if Miss A had been able to speak to Moorfields, either before or after it decided to transfer her. We know her preference was to continue to go to Moorfields and she may have felt more reassured if she had had the chance to speak to someone about this. But the circumstances during the pandemic meant Moorfields had to consider alternative places of care for many of its patients.
Our view on what Royal Free did
47. We have carefully considered whether Royal Free got something wrong regarding this transfer. We know someone at Royal Free opened the email Moorfields sent to the named ophthalmology consultant in early December because Moorfields has a read receipt. We cannot know if it was actually the consultant. We know Royal Free did not confirm to Moorfields that it had accepted the referral for Miss A. We also know it had limited information about her, only the brief details Moorfields had included in and with the letters.
48. Based on the evidence we have seen, we cannot say Royal Free got something wrong here. It would have been better if Royal Free had responded to the email Moorfields sent in early December, as the evidence shows someone opened it. But it did not accept the referral or make any promises to pick up Miss A’s care. We have not identified a failing in what Royal Free did. We appreciate Miss A is frustrated it did not do more here.
The impact of Moorfields’ mistakes
49. We have thought about what would have been different if Moorfields had waited until Royal Free had confirmed if it could accept the referral for Miss A and sent her records.
50. It is clear this would have prevented her frustration at learning Royal Free did not know she needed an appointment, and the extra effort she had to make to get her GP to refer her. It would likely have reduced her worry that this led to a delay in her having a review and the impact on her eyesight.
51. When Miss A’s GP referred her to Royal Free in January 2021, they explained her history and that Moorfields told her it had transferred her care, but this appeared to have got lost. Royal Free did accept the GP’s referral and arranged to see her in March. At that first appointment, Royal Free reviewed her and arranged to see her again in May to confirm her condition, which it did. It then arranged to see her again in three months, so it could set a new baseline for her so it could see how she was progressing. However, it saw her again in July after she complained of new issues with her eyesight. It did an eye scan and organised a further appointment to review her.
52. Royal Free saw Miss A again in August and prescribed her eye drops. It decided it would refer her to Moorfields as it said she seemed to be demonstrating new symptoms which it felt Moorfields was best placed to diagnose and treat. It saw her for the last time in September 2021, when it noted she was not responding to the eye drops. It discharged her formally back to Moorfields, which then took over her care.
53. When we weigh up the evidence, on the balance of probabilities we think Royal Free would have accepted her transfer in November 2020. There is no indication Royal Free felt unable to manage her reviews until she started having new symptoms.
54. Moorfields had originally planned to do Miss A’s annual review August 2020. It had last seen her in November 2019, so she should have had a review by November 2020. When Moorfields wrote to Royal Free, this was about to be overdue. This was at the height of the Covid-19 pandemic and we recognise NHS organisations had to limit access to non-urgent services in line with national guidance. We cannot say on the balance of probabilities that Royal Free would have been able to give Miss A an appointment before March 2021 if Moorfields had done the right thing. Moorfields’ letters to Royal Free in November 2020 did not say the transfer was urgent. The GP did make an urgent referral to Royal Free in January 2021, but Miss A had been waiting almost three months by this point. Based on the evidence, we cannot say Miss A was waiting longer than she should have for an appointment at Royal Free because of what Moorfields got wrong.
55. We understand that Miss A is very concerned about the impact on her condition of having to wait longer than usual for a review. Our adviser has provided some comments, which we are sharing as we hope these reassure Miss A. They said the records show the vision in her right eye had deteriorated since 2020. But she sadly she has an aggressive disease. Survival rates of over five years are around 67% but further eyesight degeneration is expected, which is why she has annual reviews. The reviews themselves cannot prevent the deterioration.
Complaints to Moorfields
56. Miss A says Moorfields did not investigate her complaint as it should have done. She says it did not log it properly in its complaints system, did not investigate in a timely fashion and did not address her concerns adequately.
57. The relevant standard is Moorfields’ complaints policy. This says a formal complaint is something which requires an investigation and a written response, if the patient has requested it be listed as a formal complaint and if there is a suggestion of clinical error or risk. It says the aim is to send completed responses to a complaint within 25 days, unless that is not possible.
58. We can see she raised concerns with Moorfields three times between late November and early December. We can also see it told her in an email in early December it had managed her complaints in a non-formal manner. This was undoubtedly concerning for Miss A. But we can see from the records it had logged these as complaints and had already given her a formal response before it sent that email. The first two times it responded were within a few days of her contacting it. The third time was within a few weeks, but it had asked the oncology team for some information and it spanned the Christmas period. Each response was within the timeframe set out in its complaints policy. On the basis of the evidence, we cannot say Moorfields did not log Miss A’s complaint or failed to respond in a timely manner.
59. Its investigation did not accept Moorfields got anything wrong in her transfer to Royal Free. So we understand why Miss A was and remains frustrated. We cannot say this was because it did not follow its complaints policy. But we are making recommendations to Moorfields in relation to what we have found it got wrong in her transfer. We set out our recommendations later.
Complaints to Royal Free
60. Miss A says Royal Free took too long to answer her complaints and did not always respond to all her queries. She says it refused to look at issues it thought were out of time, even though we had said it needed to do so.
61. Royal Free says Miss A made several complaints with new information each time. It says this made it harder for it to investigate and respond to her complaints. But it also acknowledged it did take too long to resolve her concerns.
62. Miss A first complained to Royal Free in October 2021. This was about her treatment at her three appointments that year. It responded in February 2022. She brought the complaint to us, but she had not yet asked Royal Free about its part in her transfer from Moorfields. She went back to Royal Free to raise her concerns about that. Initially it said that complaint was out of time. But in June 2022 it agreed to provide a response and did so in August 2022. She raised further concerns in November and Royal Free reopened her complaint. Miss A raised additional concerns about its complaints team in April and May 2023. It provided a further response to her concerns, including those from April and May, in June 2023.
63. The relevant standard is the Royal Free’s ‘Complaint Policy and Procedure’. Complaints should be made within 12 months of an incident or someone’s date of knowledge that they had cause to complain to the organisation. The Trust’s policy says it should show flexibility and sensitivity about this where necessary. It also says, if it has not completed its investigation, it should update complainants within 35 days and then keep them informed about progress.
64. Royal Free responded to Miss A’s initial complaint in around four months. That was outside the Trust’s own policy timeframe, but within the six months set out in the NHS complaint regulations. So we do not think there was a failing. But we can see there were delays in Royal Free giving her responses to some of her questions between February 2022 and June 2023.
65. When Miss A asked Royal Free to look at her concerns about her transfer to Royal Free, it misunderstood the complaint. It interpreted this as about events in November 2020. Complaints should be raised with an NHS organisation within a year of when the complainant became aware of their concerns. This would have made Miss A’s complaint about the transfer seven months out of time. We cannot say Royal Free was wrong to consider whether her complaint was out of time. But we contacted Royal Free to explain the situation and it agreed to look into the matter. The misunderstanding was unfortunate, but we do not think it amounts to a failing. We are pleased to see Royal Free then put this right and investigated Miss A’s concerns.
66. But it did not answer her all of the questions she raised in November 2022, or proactively update her during the seven months she was waiting for a response. This was not a new complaint, and we have not seen a good reason for this delay. We think this was a failing in Royal Free’s complaint handling. We can see this caused more frustration for Miss A after a very difficult time for her.
67. The NHS Complaint Standards say organisations should apologise, provide a remedy and demonstrate they have learned from what they got wrong. Royal Free accepted it had taken too long to answer some of Miss A’s questions, not kept her updated as it should and had made assumptions about what sort of responses she would prefer. It apologised and paid her £250 to reflect the impact on her of what it got wrong. It provided evidence of service improvements in its complaints process. This is in line with the NHS Complaint Standards. We cannot see there is anything more we need to ask Royal Free to do to put things right.