What a difference an investigation makes.

Dame Julie Mellor, in her role as the Ombudsman, can be seen to be wagging her finger at NHS service providers for delivering poor care in both of the cases recently reported on below. In the first at Morecambe Bay she concludes that there has been a ‘lack of openness and honesty’ and states that poor complaint handling, “caused the complainant and his family further unnecessary distress at a very difficult time.”

Very serious allegations showing up dire shortfalls in service delivery and complaint handling. Yet three years earlier the Ombudsman refused to investigate this incident at Morecambe Bay saying she was, ‘pleased with the way the Trust responded’.  Only with the threat of an impending judicial review did the Ombudsman change her mind and decide to look into the matter and look at what they found.

Same case, same issues, different outcome.

Ombudsman: ‘Lack of openness and honesty’ at Morecambe Bay

27 February, 2014 | By Sophie Barnes

A “lack of openness and honesty” at University Hospitals of Morecambe Bay Trust caused further distress for a family which had lost a child, a watchdog has concluded.

Dame Julie Mellor, the parliamentary and health service ombudsman, investigated five complaints relating to the way in which the trust handled the Titcombe family’s complaints about the death of their 9-day-old baby Joshua in 2008.

The complaints investigated focused on the quality of the investigations the trust carried out into the death, inappropriate email exchanges between hospital staff, and alleged collusion amongst midwives in preparation for an inquest into the baby’s death.

The complaint about the quality of the investigations by the trust and the two complaints about inappropriate email exchanges were upheld. However, the allegation of collusion amongst midwives before the inquest was not upheld.

A fifth complaint against the North West Strategic Health Authority has already been resulted in the ombudsman ruling that regulation of midwifery in the area was flawed.

Dame Julie said the reports “highlight the need for more openness and transparency in the way hospitals and the wider health and social care system deal with complaints”.

“In these cases the trust failed to be open and honest about what went wrong and this caused the complainant and his family further unnecessary distress at a very difficult time,” she added.

In the introduction to today’s report Dame Julie wrote: “Change is needed in hospitals, in the way investigations are conducted and in the wider health and social care complaints system.”

Without the investigation all of this would still be left uncovered. 

In the second case Dame Julie Mellor states that, “the NHS trust ‘failed’ Mr Prentice. She added,  ‘This tragic case highlights the importance of joined-up care. It is crucial that the NHS and local authorities communicate with each other to ensure patients’ needs are met. One missed opportunity by staff can lead to tragic consequences. Staff need to feel empowered to intervene and alert others when they have concerns about a patient.”

One missed opportunity indeed, for the Ombudsman refused to investigate this case when it was brought to her attention three years earlier and this refusal caused ‘unnecessary distress at a very difficult time’ for the Prentice family.  It was only through repeated requests that Mrs Prentice managed to obtain a Local Government Ombudsman investigation into the social care aspects of the case.  The LGO then pulled in the Ombudsman to carry out a joint review and look at what they found.

Same case, same issues, different outcome.

NHS trust and council failed man who overdosed on cocktail of drugs for his debilitating pancreatitis after disease cost him his job, marriage and home

Andrew Prentice was diagnosed with pancreatitis at the age of 15
He suffered from severe pain and fits, leading to the break-up of his marriage and losing his job
38-year-old died in 2009 after being left to administer his own medication
Somerset council and NHS trust criticised for not looking after him
By HUGO GYE

PUBLISHED: 17:51, 10 March 2014 | UPDATED: 17:51, 10 March 2014

A seriously ill man died from an overdose of medication after he was left to administer his own treatment by his local council and NHS trust.

Andrew Prentice suffered from pancreatitis for more than two decades before his death at the age of 38, during which time he lost his home and job and his marriage fell apart.

Now Somerset County Council and Somerset Partnership NHS Trust have been criticised for failing the patient by not helping him administer the powerful medication he needed.

Two ombudsmen, one for local government and another with responsibility for health, ordered officials to apologise to Mr Prentice’s mother Brenda, who has campaigned since her son’s death five years ago.

‘If the problems had been recognised and sincere apologies given in the beginning and lessons learned this would not have been necessary,’ said Mrs Prentice, 71.

‘Deny, defend, delay is often the case with authorities. We need openness, fairness and transparency. I was pleased that the ombudsmen took my complaints seriously.’

Mr Prentice, once a promising sportsman, developed pancreatitis overnight at the age of 15 and had to have his pancreas removed.

He found a job in a shop and got married, but he suffered from chronic abdominal pain, frequently vomited, became diabetic and suffered fits and collapses.

After losing his job, home and marriage, he started suffering from depression, and in July 2009 died from an overdose of prescription drugs.

At an inquest into his death, a coroner heard that the drugs left him so confused he could not remember whether or not he had taken his medication.

However, he recorded an open verdict because he said it was impossible to determine if he had intended to kill himself.

In the report into Mr Prentice’s death released last week, Parliamentary and Health Service Ombudsman Julie Mellor said the NHS trust ‘failed’ Mr Prentice.

She added: ‘This tragic case highlights the importance of joined-up care. It is crucial that the NHS and local authorities communicate with each other to ensure patients’ needs are met.

‘One missed opportunity by staff can lead to tragic consequences. Staff need to feel empowered to intervene and alert others when they have concerns about a patient.

‘The trust failed this young man and it needs to ensure that its staff are appropriately trained in caring for vulnerable people, so that other patients receive the high quality care they deserve.’

Read more: http://www.dailymail.co.uk/news/article-2577603/NHS-trust-council-failed-man-overdosed-cocktail-drugs-debilitating-pancreatitis-disease-cost-job-marriage-home.html#ixzz2vm9Cn5av
Follow us: @MailOnline on Twitter | DailyMail on Facebook

Or see LGO site for full report:  http://www.lgo.org.uk/news/2014/feb/somerset-authorities-urged-review-training-following-man-s-death/

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