Revealed: The most devastating failures by public services


A woman whose husband died hours after one of England’s biggest NHS hospitals missed several chances to diagnose his fatal condition was given just £2,000 in compensation, according to files published today, that highlight “devastating” failures by public services.

University Hospitals Birmingham NHS Foundation Trust mistakenly said the man was suffering from a blood clot when he actually had a tear in the blood vessel from his heart to his body, which resulted in his death. The case is one of 81 anonymised summaries of complaints - 58 healthcare and 23 Parliamentary cases – revealed by the Parliamentary and Health Service Ombudsman so “valuable lessons” can be learned.

It is the first time the public can search the watchdog’s website to see the range of complaints it deals with. The Ombudsman investigated 2,199 cases in 2013/14 compared to 384 the previous year.

A geographical breakdown of healthcare cases showed that the East of England had the highest number of complaints dealt with between February and March this year with a total of 15. West Midlands’ hospitals received 13 complaints, East Midlands had seven and London six. The North East and South West had the fewest complaints with just one each.

The report said that regarding Mr F’s case in Birmingham, his symptoms were not typical for his condition, which made it more difficult to diagnose. It concluded: “However, the Trust missed several chances to correctly diagnose Mr F, including taking account of his previous medical history and unusual symptoms, carrying out a chest X-ray and misreporting a scan. While we cannot say that Mr F’s death was avoidable (because his condition was very serious), it is clear that the Trust lost the chance to give him treatment that might have prevented or delayed his death.”

In another case two Trusts failed to communicate effectively when a woman suffering from bladder cancer had her wishes for surgery ignored leading the watchdog to describe the last six months of her life as “wasted just waiting”. It concluded an “unacceptable delay” had taken place as Bedford Hospital NHS Trust and Cambridge University Hospitals NHS Foundation Trust could not agree on the best course of treatment, although the Ombudsman concluded that due to Mrs C’s condition the delays did not affect her prognosis.

The Trusts paid £1,750 compensation to Mrs C’s family “for the upset and frustration they experienced as a result of the poor care given to their mother”.

The Home Office was among the Government departments criticised in the files after a teenage asylum seeker spent 10 years in the UK without legal status waiting for his case to be decided. The 17-year-old applied for permission to stay with his mother, who had fled from her home country, but was told he would need to reapply after he turned 18 and was left in administrative limbo.

Repeated requests from his MP were also ignored by the Home Office until a decade had passed. He eventually received an apology from the Home Office and £7,500 compensation for the “serious mistakes” that occurred.

Ombudsman Dame Julie Mellor said: “Our investigations highlight the devastating impact that failures in public services can have on the lives of individuals and their families. We are modernising the way we do things so we can help more people with their complaints and to help bodies in jurisdiction learn from mistakes other organisations have made to help them decide what action to improve their services.

“We will continue to work with others including consumer groups, public service regulators and Parliament, using the insight from our casework to help others make a real difference in public sector complaint handling and improve services.”

A Department of Health spokeswoman said: “Listening to patients is one of the best ways to improve standards and we welcome this increased transparency around complaints. Hospitals should make sure patients, their families and carers know how to complain - including displaying information on the complaints system in every ward.”

Other cases

A woman in her late 90s died on the toilet at home in her granddaughter’s arms after doctor discharged her without examining her abdomen. She had perforated diverticulitis. Miss T complained to East Kent Hospitals University NHS Foundation Trust and said that the Trust had failed to provide an adequate response regarding her grandmother’s death and had tried to ‘cover up’ its failings, but no evidence was found to support the claim. The Ombudsman recommended the Trust pay £500 in compensation for Miss T's distress.

Harrogate and District NHS Foundation Trust failed to spot signs of sepsis when Mr L arrived at hospital in the early hours of the morning from his care home. After being seen in A&E he was assessed as being safe for discharge back to his care home with some antibiotics, but died the following day. His wife complained to the Trust and said that if her husband had been admitted for treatment, he might have survived. The Ombudsman said because Mr L’s full diagnosis was not known, it could not say for certain whether his death was preventable. The Trust apologised and paid Mrs L compensation of £2,000.

A patient’s death from deep-vein thrombosis could have been avoided after a London GP practice failed to properly investigate her symptoms or refer her for further tests over two appointments.  At both appointments the GPs who saw Mrs G failed to follow the relevant medical guidelines on investigating a possible DVT. They also failed to investigate her symptoms properly. The practice provided Mrs G’s relatives with evidence of what they had learnt from the complaint and apologised to them.

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