Mr Richard von Abendorff
2 March 2018
Dear Mr von Abendorff,
Our review of your complaint about our investigation decision and our service
1. I am writing to share the outcome of the review of our work on your complaint about Lewisham Healthcare NHS Trust1. You raised concerns about the way PHSO investigated your complaint, the findings and recommendations made, and the overall service provided to you. 2. Following a thorough and detailed review, we have upheld your complaint about PHSO’s service. The service you received fell significantly short of the standards we strive to achieve. For this I apologise sincerely. We have not upheld your complaint about our investigation decision. The service problems we identified did not have a significant impact on our decision and the overall outcome. The attached annexes explain our review findings and the reasons for our decision.
3. The history of your case is complicated and spans several years. In brief, you contacted PHSO in June 2012 with concerns surrounding the care and treatment the Trust provided to your late mother, Mrs Celia Abendorff. In particular, you were concerned about the Trust’s decision to give your mother naloxone2 and the subsequent management of her pain.
1 On 1 October 2013 Lewisham Healthcare NHS Trust merged with Queen Elizabeth Hospital (formerly part of South London Healthcare NHS Trust) to become Lewisham and Greenwich NHS Trust. 2 Naloxone is a drug which blocks or reverses the effects of opioid medication
4. PHSO assessed your complaint to see if we could and should investigate and provided a decision in October 2012. It was decided to take no further action at that time. We asked the Trust to send you information about improvements it was making to address the problems that had arisen in your mother’s care. PHSO told you that you could return to us if you remained dissatisfied once you had received the information from the Trust.
5. In November 2012 you complained about our decision. A review in early 2013 found no fault with the assessment decision and did not uphold your complaint.
6. In May 2013 PHSO began a second assessment of your complaint. By then, an inquest had been held into your mother’s death. You had received the further information from the Trust and remained dissatisfied.
7. The second assessment led to your complaint about the Trust being sent for investigation. Your case was allocated to an investigator (Ms Kingstone) in August 2013. Ms Kingstone left PHSO before the investigation was completed. Your case was allocated to another investigator, Ms Kedie. PHSO issued a draft investigation report in May 2014. PHSO provisionally found that the Trust had responded adequately to your concerns, acknowledged failings, and implemented appropriate remedial measures. We proposed to take no further action.
8. Your comments on the draft report led to a decision to restart the investigation. PHSO wrote to you in July 2014 to explain that we had not undertaken the investigation we said we would deliver. Your case was allocated to a third investigator, Mr Kuti. This time it was decided to treat your case as a complex investigation. As you had complained about the way your case had been handled, the new investigation ran concurrently with a review of our service.
9. Mr Comber from the Review Team carried out the review. Although it started promptly, the outcome of the review was not shared with you until July 2015. By this time, the investigation of your case had passed to a fourth investigator, Mr Corrigan.
10. PHSO shared the draft report of the investigation in stages. In February 2016 we shared a partial draft (covering the issue of naloxone). PHSO shared a complete draft in August 2016, followed by a revised draft in December 2016. PHSO issued the final report in February 2017.
11. You provided details about your concerns for the current review in August 2017. Ms Smith from our Customer Care Team worked on the review before she left PHSO in November 2017. Ms Green completed the review.
Your complaint about our investigation decision and service
12. The issues you have raised relate to both PHSO’s decision and its service. In terms of the decision, you complained that PHSO:
• omitted issues from the investigation;
• did not obtain or consider all the appropriate evidence;
• did not identify all the service failure in the matters we investigated;
• did not adequately describe and consider the injustice;
• did not properly consider whether the Trust’s action plan was adequate;
• did not make appropriate recommendations;
• did not explain our decision properly and share information with other organisations;
• did not take account of your comments on our draft reports, and
• did not establish whether the Trust had complied with our recommendations.
13. I understand that you are also dissatisfied with decisions made at other stages of the process including the two assessments and the provisional decision of the investigation discontinued in 2014. It would not be proportionate or practicable to re-examine every detail of the decision making over the years. We recognise that your case has taken a very complicated path through our processes, and that it has required a great deal of perseverance on your part to reach the point where PHSO upheld your complaint about the Trust.
14. Turning to your concerns about the service, you complained that:
• PHSO’s work on your case took too long;
• PHSO did not always keep you updated or do what we said we would do;
• PHSO was not impartial, and
• PHSO did not carry out adequate reviews of our decisions and service.
15. You said the way PHSO have dealt with your case has been traumatic for you and has prolonged the grief process. You said it had caused considerable stress to you, and also to your wife, who felt unable to continue assisting you with your complaint.
16. As outcomes to this review, you want PHSO to acknowledge errors and the impact they had on you. You also want PHSO to learn from your case and show evidence of change. You want to be compensated for your and your wife’s stress, time and printing costs.
17. The annexes to this letter set out the findings of the review of the investigation decision (pages 8 to 22) and PHSO’s service (pages 23 to 28).
18. In summary, the review saw that Mr Kuti and Mr Corrigan looked to meet your expectations and reach the right decision in the investigation of your complaint. They considered relevant information, took the right kind of professional advice, and involved you in the investigation. Many of our key findings were evidence based and defensible. There is evidence that PHSO considered your comments on the draft findings although we did not respond adequately to your concerns that issues had been omitted from the report.
19. In other areas, PHSO did not follow internal guidance and the service charter. We did not investigate all of the issues in the scope we shared with you. Some issues were considered very briefly, and some of our findings were not fully explained. We did not name a doctor who played a key role in your mother’s care in our investigation, or ensure our report was shared with the CQC.
20. Overall PHSO kept you updated; but there were times during the reviews when this was not the case. We did not always do what we said we would do, and our handling of your case took far too long. We consider that the need to restart the investigation in 2014 delayed the decision on your case by around 12 months. We consider that failure to progress the new investigation in a timely way delayed the decision by at least a further 12 months. In total, we consider that you experienced around two years of unnecessary delay.
21. Taking all of this into consideration, we have upheld your complaint about our service. The service provided fell far short of the expectations set out in PHSO’s service charter. We have not upheld your complaint about our investigation decision. The problems identified did not have a significant impact on our decision and recommendations.
22. You have explained that our handling of your complaint has been traumatic for you, affecting the grieving process and causing additional stress to you and your wife. We are sorry for the mistakes made and the impact our service had on you both. Given the extent of the delay and the other shortfalls in service, we would like to offer you a consolatory payment of £1000 in recognition of the emotional impact, the costs you have incurred, and the stress you and your wife have experienced as a consequence of our handling of your case.
23. PHSO did not share the investigation report with the CQC at the appropriate time. We will do this now and draw attention to the matter referred to in paragraph 45 of annex one, so the CQC is aware of our findings and can decide whether it needs to take any action.
Learning from your complaint
24. Since you first contacted us in 2012, PHSO has made significant improvements to our service. We no longer carry out lengthy, in-depth assessments of complaints to decide whether we should investigate. We recognised that this process resulted in significant double handling and meant we could only investigate a small proportion of the complaints we received. Now, complaints go through a much shorter assessment process before we decide whether we should either investigate or make a decision at assessment stage. This has simplified our process and enabled us to investigate and remedy many more complaints than previously.
25. In July 2015 PHSO introduced a service model and service charter to help to ensure the quality and consistency of our casework. The service model and associated guidance sets out the investigation process which casework staff must follow. The service charter sets out the commitments to the people who use our service.
26. In 2017 PHSO made further improvements to the way we assess and triage cases. Now, complaints are assessed and investigated by the same caseworker. This is more customer focused for people using our service, and helps to reduce double handling and delay due to handovers.
27. We have recently completed core training for all managers and caseworkers on the foundations of our work. This will be followed by further training to improve the professional skills and behaviours of our staff. An external training provider will deliver this training, which will focus on professional skills in casework. I have seen your reaction on social media to this initiative but I respectfully disagree with your view of its relevance.
28. We have identified the following learning points from your case:
• Your case was complex – PHSO should have treated it as such and passed it to complex investigations in 2013. We need to ensure that in future complex cases are allocated to the correct team. The improvements we have made to our triage process should help to ensure this happens at the earliest opportunity.
• While PHSO shared the scope of its investigation in writing with you and the Trust, it did not go on to investigate all of the issues. We need to ensure that we agree workable scopes and stick to these. If it becomes necessary to change the scope, we need to inform all the parties and explain the reason for our decision. This requirement is set out in our service model guidance. Our investigation process, including scoping, was part of the training programme that all our staff have recently undertaken.
• Before we make undertakings (about timescales, ways of working), we need to be consider how we intend to deliver them, particularly if we plan to depart from our usual process. PHSO did not do this in your case, and so did not demonstrate the commitment in our service charter to explain how we will work, and what we can and cannot do.
• We need to think carefully about the recommendations we make and whether they are capable of demonstrating positive change. We also need to consider how to respond when the information provided by an NHS organisation does not provide the assurance sought.
• Our handing of your case became complicated and lengthy. We recognise that our processes contributed to this, and that you had to persevere with our service for five years before we reached a definitive decision on your case. At various stages, PHSO took different views about some of the issues. We are confident that the changes we have made to streamline our processes and the training we have implemented will help to prevent this situation from happening again.
29. I acknowledge your view that there should be some external function to review our decisions but I do not share this view. By law, we make the final decisions on complaints about the NHS and some government organisations and it would not therefore be appropriate to pass that role to another organisation or individual.
30. That said I do believe there is more we can do to improve the quality of our decision making and the way we communicate with people who contact our service. We are also taking too long to look into and respond to complaints. We will provide feedback on the individual learning points we have taken from your case to the relevant staff and their line managers. Our Change Delivery team will also consider the learning points from your case to identify any further actions needed to secure improvements across the wider organisation.
31. I acknowledge there is more we need to do to improve the experience of people using our service. Absolutely essential to this is the ambitious and comprehensive training programme we have introduced for all of our staff. The changes we are implementing and the staff training we have commenced will of course take time to embed and take effect. However, I am confident this will lead to significant improvements in our service.
32. I am very sorry you have experienced such poor service from PHSO. Whilst I appreciate none of the changes we are making can change your experience I hope I have reassured you that we have taken your concerns seriously. I very much hope you will accept the offer of a consolatory payment of £1000 as a tangible recognition of the impact of the failings in our service on you and your family, at what is already a very difficult time.
33. As we agreed previously I am prepared to meet with you to discuss the outcome of the review and the actions we intend to take to address the learning points identified. If you think that such a meeting would be useful, please contact my Assistant Private Secretary (email@example.com) who will be happy to assist in making arrangements.
Rob Behrens CBE
Ombudsman and Chair
Parliamentary and Health Service Ombudsman
Annex 1: The review of our investigation decision
Issue omitted from our investigation
1. Before we started our investigation, we should have written to you and the Trust to confirm the scope, in order to ensure that all parties understood which issues we intended to look into. Mr Kuti wrote to you in January 2015 confirming that the scope of our investigation was as set out on the investigation plan which he shared with you. The scope included seven heads of complaint: the administration of naloxone, the syringe driver, the assessment of your mother’s heart, pain management and end of life care, the Liverpool Care Pathway (LCP), complaint handling, and staff attitude/communication. A number of sub-issues were listed under each head of complaint.
2. After Mr Corrigan took over your case, he set out a slightly different list of issues in an email sent June 2015. It included the assessment of your mother on admission to hospital, naloxone, pain relief after naloxone, referral to palliative care, administration of palliative care, LCP, cause of death (information included on death certificate), communication and complaint handling.
3. The narrative summary of your complaint, set out in our investigation report, is not an exact reflection of either the scope we confirmed in January 2015 or the list of issues emailed to you in June 2015. The summary covers the administration of naloxone, subsequent pain management and monitoring, delay in obtaining palliative care input, problems with the syringe driver, whether your mother suffered cardiac problems as a result of pain and opiate withdrawal, the Trust’s failure to act in line with your mother’s advance directive, lack of consent to treat, the Trust’s complaint handling, and the adequacy of the Trust’s end of life care policy.
4. The findings of our investigation covered most of the issues set out in the summary. But, we did not make any specific findings about your mother’s advance directive or the adequacy of the Trust’s end of life care policies. Our findings about complaint handling were brief, and did not fully reflect the points set out in the summary of the complaint.
5. Other issues which were included in the scope confirmed in January 2015 and/or noted in Mr Corrigan’s email of June 2015 did not feature in the findings of our report including your concern about being treated as a vexatious complainant, the LCP, and your mother’s incontinence.
6. Mr Corrigan’s email of June 2015 also referred to the adequacy of staffing levels at the Trust. Paragraph 59 of our report said we were prevented from looking at staffing issues because personnel management was outside of our jurisdiction. There is no evidence we took jurisdictional advice to check this was the case. We can see how the reference to staffing in Mr Corrigan’s email would have created an
expectation that we could, and would, investigate your concerns about staffing levels.
7. While we did not get things rights here, the failure to investigate and/or make findings about these issues did not have a significant impact on our decision and recommendations. Although our investigation report did not include any findings about your mother’s advance directive, it was referred to in the advice from our consultant palliative care adviser which was annexed to the report. The adviser indicated that potentially reversible causes of your mother’s symptoms would fall outside of her advance directive. Later, the adviser referred to opioid toxicity as a reversible condition. As such, it is likely that our investigation would have found that treatment given for suspected opioid toxicity fell outside of your mother’s advance directive.
8. The paperwork in your mother’s clinical records show that the LCP was started on 23 August 2011. Your family believe it was started before this. We would expect staff to be very clear in their discussions with you and your family about such an important matter. We accept that this was not your experience. However, it would have been difficult for us to establish exactly what was said, and in turn to say whether the way staff communicated fell so far short of the applicable standards that it amounted to service failure.
9. Your mother’s incontinence may have been caused by the administration of naloxone. Alternatively, it may have been due to her reduced level of consciousness. Irrespective of the cause, the Trust had already accepted there was a delay before her hygiene needs were met. It had apologised for this and confirmed that the ward matron had raised the matter with nursing staff. It is unlikely that our investigation would have achieved anything further here.
10. The review noted that your concern about being treated as a vexatious complainant related to the Trust’s decision not to engage further with you once you had raised your initial complaint with us. Had we investigated this issue, it is unlikely that we would have been critical of the Trust. It is reasonable for NHS organisations to consider that our involvement signifies the end of the local complaints procedure. We would not expect NHS organisation to keep engaging on the same or closely related issues other than to undertake any specific actions we had recommended.
11. To investigate staffing, we would have needed to compare information from staffing rotas against the required staffing numbers and skill mix for the ward where your mother was nursed. While we did not investigate staffing, we knew that the CQC was aware of potential problems in this area. As part of our recommendations, we asked the Trust to update you about the action it had taken and the progress made in this area. Even if we had investigated staffing and found service failure, it is unlikely that we would have achieved anything further here. The on-going monitoring of the Trust’s performance in this area is the responsibility of the CQC.
12. We often refer to the policies of NHS organisations in our investigation of complaints as they help us to establish what should have happened. But, it is not our role to evaluate the adequacy of local policies. It is unclear why we referred to the adequacy of the Trust’s End of Life Care policy in the complaint summary in our report.
13. There were other issues that you felt we had omitted from our report. The review found that these had been covered briefly in paragraph 61 (response to the safety alert), paragraph 62 (investigation of the syringe driver problems), and paragraph 54 (fentanyl withdrawal). You also mentioned the effect that the interaction between fentanyl and naloxone had on your mother. Although it was not specifically mentioned in the scope, our investigation plan said we would take clinical advice on this issue. Advice from our consultant palliative care adviser said ‘…the combination of fentanyl and bolus naloxone had the effect of suddenly reversing Mrs Abendorff’s pain control’. Our report reflected this advice.
14. In summary, the review found that while our investigation covered the key issues, we did not investigate the detailed scope confirmed with you in January 2015. This is likely to have been due in part to the handover between investigators. However, not all of the points set out in Mr Corrigan’s email of June 2015 were investigated either. There may have been valid reason for this, in which case we should have been open and explained why we were changing the scope. In not investigating the scope we shared with you, we did not do what we said we would in line with our Principles of Good Administration3. We also failed to demonstrate the commitment in our service charter, to follow an open and fair process.
The evidence considered
15. You complained that our investigation did not take account of all the relevant evidence including the George and Vandenberg reports, the safety alerts on syringe drivers and naloxone, the Trust’s complaints policy, and the findings of CQC inspections. You also complained that we did not take appropriate professional advice or conduct interviews.
16. Paragraph 8 of the investigation report sets out the evidence we considered. We looked at information you provided, the complaints correspondence, your mother’s medical records, and evidence considered by the inquest including the George report and the Vandenberg report. We also looked at clinical standards and guidance including the British National Formulary, Toxbase4, GMC standards on prescribing drugs and treatment5, and regional palliative care guidance6 .
4 A specific database for clinicians treating poisoning called Toxbase.
5 Good Medical Practice, GMC, 2009
6 The South East Cancer Network ‘Adult palliative care guidance’ published in 2011
17. The review found that the reports, standards and guidance we considered were relevant to the issues raised in your complaint. The evidence was described in the body of the report and/or included as an annex. Where relevant, the investigators flagged the George and Vandenburg reports in their requests for clinical advice to ensure that our clinical advisers considered the implications of these reports on your mother’s care. The review found that on the whole, our key findings were compatible with both reports.
18. The safety alert on naloxone post-dates the events we investigated. As such, the investigators did not use it to establish what should have happened. However, it was relevant to our consideration of the action taken by the Trust since your complaint and also to our recommendations.
19. The investigation report referred to the Trust’s response to the safety alert on syringe drivers. It stated that the Trust had met the timescale for introducing new syringe drivers with additional safety features, although we saw no evidence it had taken the required interim actions.
20. The investigators also took account of CQC inspection reports. Our report appropriately noted that the CQC’s inspection findings reflected some of the issues highlighted by your complaint. We incorporated this information into our recommendations to try to provide additional assurance to you about systemic improvements at the Trust.
21. The review found no evidence that the investigators considered the Trust’s complaints policy or any other standard, such as the NHS complaints regulations. We should have referred to the regulations to explain our view on your complaint about delay in the Trust’s complaints handling. As noted in paragraph 30 below, even if we had done, it is unlikely that we would have made a finding of service failure.
22. Turning to the professional advice, the investigators took clinical advice from two physicians, a palliative care consultant, a palliative care nurse, and a consultant cardiologist. They also took advice from an acute hospital nurse although our findings did not rely on this evidence. The disciplines of the advisers were relevant to the issues raised. The advice they provided was sufficient to inform the investigators’ view of what happened, what should have happened, and the impact of any failings. The advisers were suitably qualified and experienced. The review found no reason to doubt their knowledge and ability to advise on your case.
23. According to the investigation plan, Mr Kuti initially planned to take clinical advice from a pharmacist and an anaesthetist. On advice from one of our lead clinicians, he decided this was not necessary because our consultant palliative care adviser would be able to provide information about the effects of the various drugs your mother received. The review found this decision was reasonable. Our general approach is to take peer advice, and we were not investigating the actions of a
pharmacist or anaesthetist. Nor did we need advice from a pharmacist or an anaesthetist to investigate the impact of any failings. During your mother’s admission, there were missed opportunities to refer her for specialist palliative care. We took specialist advice from a consultant palliative care adviser to establish what should have happened in respect of specialist palliative care.
24. The review found that on the whole, the questions the investigators asked the advisers were relevant to the scope of the investigation. The investigators sought further advice from some of the advisers to clarify their thinking. While the clinical advisers held different views about the decision to administer naloxone, the review found this was likely to reflect their area of practice and clinical perspective rather than indicating that we had not sought the right kind of advice.
25. The investigators did not take legal advice on your complaint about capacity/consent despite an initial plan to do so. To investigate this matter, we needed to establish what doctors should have done before treating a patient who was unable to consent to treatment but had an advance directive in place. In the first instance, it was appropriate to ask our clinical advisers what should happen in this situation.
26. Similarly, the investigators did not conduct any interviews despite noting the intention to do so on the investigation plan. In line with our internal guidance, the method of obtaining evidence should have been proportionate to the importance of the information sought and the potential outcome of the investigation. The review found that in your case, the decision about interviewing depended largely on the aim of the investigation. If we had intended to explore why failings happened (as we initially said we would), it would have been essential to conduct interviews. In the event, we did not examine the underlying causes of the failings found. Therefore, the lack of interviews did not compromise our findings or decision. The investigators were able to establish an adequate understanding of what happened from other sources of evidence including the clinical records and your family’s account. It is unlikely that they would have obtained significant additional information through interviews with staff.
Findings of service failure
27. While you are satisfied with our overall decision, you feel that our findings should have gone further. You complained that we did not identify service failure in respect of delays in the Trust’s complaint handling; the Trust’s critical incident investigation into the syringe driver; and the failure to treat your mother’s pain management as a medical emergency, escalate her case to a consultant on 23 August 2011, and regard what happened to her as a serious incident. You also complained that our report did not state whether or not your mother was opiate toxic or refer to her human rights.
28. Our investigation report grouped the findings under four headings: opiate toxicity and naloxone, subsequent care and pain management, cardiac assessment and care, and complaint handling. Paragraphs 69 and 70 of the report summarised the failings and specified whether or not the Trust had already acknowledged them.
29. In respect of the Trust’s complaint handling, our report said that while the Trust had to extend its timescale for sending the complaint response, we were satisfied that ‘this length of time was appropriate’. This finding was not evidence based. Our report did not state how long the Trust took to respond or refer to the applicable time limit (six months) in the NHS complaints regulations.
30. In actual fact, it took around four and a half months for the Trust to complete its investigation and share its response with you. Given the complexity of your complaint, this length of time is not excessive and it is within the timescale allowed by the NHS complaint regulations. Our decision was reasonable; but we should have explained it better.
31. Paragraph 62 of the report briefly addressed the Trust’s incident investigation into the syringe driver. It stated: ‘We have seen that the Trust registered this [problem with the syringe driver] as an adverse incident, but the report completed after the incident does not explore the underlying reasons behind the failure. In terms of learning, the incident report does not identify any areas for work’. The report did not state whether the quality of the Trust’s investigation fell so far short that it amounted to maladministration.
32. The review noted that the Trust’s complaint response had acknowledged that the investigation of the syringe driver incident was not adequate and apologised for this. The Trust had indicated that the matter was ‘a learning point’ for the staff member, which she would apply in future investigations. As the complaint response indicated that the Trust has addressed the poor quality of the incident investigation with the staff member concerned, it is unlikely that a finding of maladministration here would have made a significant difference to our recommendations.
33. The advice from our consultant palliative care adviser refers to the failure to escalate your mother’s care to a consultant on 23 August 2011. The adviser states that if the junior doctor was unsure what action to take, they ‘should have escalated the clinical situation to a more senior doctor or contacted specialist palliative care as a matter of urgency. We do not find service failure in respect of each individual action or omission. Not mentioning this point in the report did not affect our overall finding that the Trust failed to manage your mother’s pain effectively after the administration of naloxone.
34. Similarly, while the report did not describe the difficulties in controlling your mother’s pain as a medical emergency, it is clear from the findings that staff should have acted with much greater urgency.
35. The reporting and management of serious incidents is separate to the complaints process. We did not make a finding about whether the Trust should have treated what happened to your mother as a serious incident because this was not within the scope of our investigation.
36. Turning to the question of opiate toxicity, the clinical advice indicates that the Trust’s doctor never fully established whether your mother was opiate toxic because of the way he administered the naloxone.
37. Finally, in respect of your mother’s human rights, it is not our role to make findings about whether a person’s human rights have been breached. However, where a complaint raises a human rights consideration, we may refer to the FREDA principles (fairness, respect, equality, dignity and autonomy) which underpin the Human Rights Act. NHS organisations should have regard for the FREDA principles in the provision of care.
38. Your complaint to us referred to your mother’s human rights. Mr Kuti recognised this and noted a human rights consideration on the investigation plan. The review found that our report should therefore have commented on the FREDA principles (in particular how inadequate pain management impacted on your mother’s dignity). This omission did not affect our overall decision or recommendations.
Our consideration of the injustice
39. You expressed concern that we did not understand the seriousness of the injustice or refer to ‘iatrogenic suffering’ in our report. You said your mother’s pain contributed to her death, and that the lack of monitoring of her vital signs meant we could not say what impact the failings had on her heart or circulatory system. You also said we did not consider your injustice.
40. Paragraph 4 of the investigation report described the claimed injustice to you and your mother. The injustice was described differently in the scope we shared with you in January 2015. There, it referred specifically to ‘iatrogenic suffering’ and your view that prolonged extreme pain and opiate withdrawal may have contributed to your mother’s death. It would have been sensible to use the same wording in our report.
41. Our analysis of the injustice is set out in paragraph 72 of the report. There is a brief but adequate description of the impact of the failings in terms of the avoidable pain suffered by your mother and the distress this caused your family. There is no reference to the impact of pain or opiate withdrawal on your mother’s heart in the section of the report which talks about the impact of the failings. However, the ‘findings’ section briefly explains that while naloxone could have caused a cardiac event (via the mechanism described in the Vandenberg report), there was no evidence to support or discount this happening in your mother’s case. There is no explicit reference anywhere in the report to whether failings in care contributed to your
mother’s death. This is despite the fact that two of our clinical advisers commented on this point.
42. The review found that our report should have explored the impact of the failings in more depth. Even if this had happened, it is unlikely that our findings and decision would have been different. Our cardiologist adviser said that there was no evidence in the clinical records to suggest that naloxone either precipitated a cardiac event or speeded your mother’s death. Our physician adviser found no evidence that naloxone played any causal part in your mother’s death. He noted that according to the safety alert and the Vandenberg report, harm would be caused by a surge of endogenous catecholamine release7, which was liable to cause rapid heart rate and high blood pressure. Our physician adviser said there was no compelling evidence that this happened as neither your mother’s pulse or blood pressure were substantially different after naloxone was given. He added that the George report did not indicate that your mother had tachycardia, and that the coroner had not found that naloxone had caused your mother’s death.
Adequacy of the Trust’s action plan
43. You complained that we did not take ‘expert’ advice on the adequacy of the Trust’s action plan. You said the action plan was not SMART and did not address all of the failings. You said the CQC had found similar failings indicating that the action plan was not adequate.
44. Our consideration of the action plan aimed to identify whether the Trust had taken steps to try to prevent a recurrence of the service failure we had found. The review found that the investigators took a lay view on the adequacy of the Trust’s action plan. This approach was not necessarily unreasonable. For the majority of the failings we found, it is possible to identify a corresponding remedial action in the Trust’s action plan. However, the reviewer noted that our findings about the action plan may have been more comprehensive and robust if we had asked our clinical advisers whether they were satisfied that the steps outlined on the plan were sufficient to remedy the failings we had identified in your mother’s case.
45. Although we had not asked this question, the reviewer saw that one of our nursing advisers had expressed concern that the Trust’s action plan did not include any specific actions to ensure that nursing staff had the knowledge, skills and competencies to undertake pain assessments and plan and deliver care accordingly. We did not refer to this advice despite finding ‘a complete absence’ of pain assessments in your mother’s records. Had we incorporated this advice into our investigation report, we may have gone on to make an additional recommendation to help to ensure that staff carried out and recorded pain assessments in future.
7 Naloxone indirectly causes adrenaline to be released from the adrenal glands.
46. It is disappointing that you have observed that the CQC has since found similar failings to those that occurred in your mother’s case. For positive change to occur, actions plans need to be adequate and robust; but they also need to be embedded in practice. The latter is not something we can enforce or monitor. Ongoing monitoring and regulation of the activities of NHS organisations is a matter for the CQC. Unlike the CQC, we do not have a regulatory function. We do not carry out audits and inspections of NHS organisations nor do we have enforcement powers. Consequently, we are not best placed to provide the assurance you seek about sustained improvements being made at the Trust. In sharing our investigation report with the CQC, we will draw attention to the issues raised by your mother’s case so that it can take them forward as part of its ongoing monitoring of the Trust. In particular, we will draw attention to our nursing adviser’s concern about pain assessments as this did not form part of our recommendations.
47. You complained that our recommendations did not remedy the failings. You said we should have obtained audit results from the Trust for the purpose of our investigation, and made specific recommendations.
48. We make recommendations for systemic remedy to try to prevent the failings we find through our investigations from happening again. We do not usually make specific recommendations unless we can see that a particular action is required.
49. In your case, we considered that the action plan the Trust had implemented was capable of addressing the key failings we found through our investigation. To provide further assurance to you, we asked the Trust to update the plan with actions taken in response to subsequent CQC inspections. We also asked the Trust to provide audit results to show the progress it had made. The review found that this approach was reasonable in the circumstances. However, as noted above, we could potentially have made a further recommendation relating to pain assessments.
50. We do not generally obtain audit results from NHS organisations to use as evidence in our investigation of individual complaints. In doing so, we could be seen to be monitoring the Trust’s compliance and ongoing performance in relation to the issues complained about. This is not our role. It is important that our activities do not overlap with the function of other bodies such as the CQC.
51. You also complained that our investigation had not considered your request for compensation to cover your legal fees. You said the Trust’s approach had forced you to seek legal advice and that the coroner had also advised you to do this.
52. The investigation plan we shared with you in January 2015 noted that we would not usually make a recommendation to cover legal costs or loss of earnings for pursuing a complaint. Taking legal advice is matter of personal choice. It would not
be possible for us to robustly demonstrate that the Trust’s approach compelled you to pay for legal advice.
How we explained our decision
53. You complained that our investigation report did not refer to appropriate standards and contained serious omissions, errors and misunderstandings. You said the report was contradictory because it stated that the Trust’s action plan was adequate, even though the Trust had not accepted some of the failings. You also said our report should have referred to risks to other patients and families, and to our systemic report on end of life care.
54. The standards and guidance on which our findings were based were either referred to in the body of the report or summarised as an annex. Our report described what happened during your mother’s admission and identified where the Trust did not get things right. It drew on all the available evidence including your family’s account, clinical standards and guidance, and our clinical advisers’ comments. The review found that on the whole, our investigation report provided a reasonable explanation of our findings and decision. However, there were some areas where we should have explained our findings more fully, particularly in relation to your complaints about delays in the Trust’s complaint handling and how staff obtained consent for treatment. Although we found failings in relation to consent for treatment, the reviewer was not satisfied that we had properly investigated this issue with reference to applicable GMC guidance.
55. It is not uncommon for there to be discrepancies between different sources of evidence. Weighing up what is most likely to have happened in the face of conflicting or incomplete information is part of our usual process of analysing the evidence. The review saw no evidence that a significant dispute in the facts prevented the investigators from reaching appropriate findings.
56. Our report stated that the Trust had either not accepted or had only partially accepted some of the failings we found. On the face of it, this is at odds with our view that the Trust had already taken adequate action to address the failings. I can see why you are questioning how the Trust could have taken adequate remedial action if it had not first accepted that something had gone wrong. However, not all the steps taken were contingent on the Trust’s acceptance of failings. For example, the Trust had not acknowledged that it should not have given your mother naloxone. Nevertheless, the new guidance it had produced in response to the NHSE safety alert would help to prevent a recurrence of such an event.
57. Finally, our report was concerned with the care and treatment provided to your mother. We would not necessarily comment on wider patient safety risks or our systemic work in an individual investigation report. The fact we did not do this does not detract from our findings or decision.
Sharing our report with others
58. You complained that we did not share our report with the CQC. You also complained that we did not name the doctor who administered naloxone or share information about him with the GMC. 59. Our records show that you asked us to liaise with the CQC and send it our investigation report several times during late 2016 and early 2017. In line with our internal guidance, when we uphold or partly uphold a complaint and make systemic recommendations, we should ask NHS organisations to share our report and their action plan with the CQC. 60. As we upheld your complaint and made recommendations to check progress on systemic actions, we should have asked the Trust to share our report and its response to you, with the CQC. It was particularly important because the CQC had an interest in your case; they had asked us for information early in the investigation and we had shared the scope with them. The review saw no evidence that we asked the Trust to send the report to the CQC, or that we shared the report directly. When you queried this is April 2017, Mr Corrigan told you that we sent the CQC summaries of our investigations on a quarterly basis. This was no longer happening at this point. I am sorry you were misinformed about this. We will send a copy of our investigation report to the CQC now so it is aware of the issues raised and can decide whether any action is needed.
61. We name people in our investigations to allow individuals who have taken or authorised the actions complained of, an opportunity to comment on any allegations contained in the complaint. This is a legal obligation under the Health Service Commissioners (HSC) Act 1993 which governs the work of our office. Naming an individual in an investigation does not mean that we refer to them by name in our report.
62. We did not name anyone in our investigation of your complaint. The review found that as a minimum, we should have named the doctor who prescribed naloxone. When Mr Corrigan responded to your comments on our draft report, he told you that we would normally only name individuals if we were likely to make a referral to a registering body, such as the GMC. This is also incorrect. I am sorry that you were again misadvised.
63. Section 15(1) (e) of the HSC Act 1993 allows us to share information with relevant parties such as the GMC if this is in the interests of patients’ health and safety. This is not something we do lightly, nor do we share information simply because we have found service failure. Before we share information, we have to carefully consider whether we have sufficient evidence of a threat to patient safety, and whether it is appropriate to raise our concerns about a health professional in an alternative way, for example, through their employing NHS organisation.
64. We did not share information about the doctor who administered naloxone to your mother with the GMC. The review did not consider this was warranted. The events pre-dated the NHSE safety alert on naloxone, and our investigation pointed to a lack of clarity in the guidance in place at the time. It is also evident that clinicians, including our own clinical advisers, held differing views on the matter. We were able to raise our concerns about the decision to given naloxone to your mother through our usual casework process.
Consideration of your comments
65. You complained that we ignored your comments on our draft reports. According to our records, you discussed your comments on a partial draft report (shared in February 2016) with Mr Corrigan in March 2016. You provided extensive comments on the complete draft report (shared in August 2016) by email the same month. It is not entirely clear but your comments on the revised draft appear to be an email you sent on 23 January 2017 with the subject line ‘HSIB and a promised PHSO external case review-a request and question’.
66. The review found evidence that we took account of the comments on the draft report that you provided in August 2016. Some of your comments were about the findings and decisions of our investigation. Others were concerned with our method and process. Mr Corrigan provided an early response to your comments, followed by a more comprehensive response when he shared the revised draft report in December 2016. Mr Corrigan felt that the report already covered some of the points you had raised and he explained this to you. However, he also added more detail to the report in places and made changes to reflect your account of what happened. Mr Corrigan also responded to your comments about our process, explaining why we did not conduct interviews or name the doctor who prescribed naloxone in our investigation. Not all of the information he gave you was accurate and I am sorry for this.
67. The review saw that you expressed concern that some issues had been omitted from the report. Mr Corrigan’s early response noted that you had had raised the issue of your mother’s diarrhoea as a possible withdrawal symptom. He told you he would include this in the report. The review saw no evidence that this happened. There was also no evidence that he took this opportunity to investigate the other issues which had been omitted from our report. Nor did he provide a detailed explanation of why we were not going to investigate these issues. In failing to robustly address the omissions you highlighted, I agree that we did not adequately consider your comments. As noted in paragraphs 7-12 above, investigating these issues is unlikely to have made a significant difference to our overall decision and recommendations.
68. Mr Corrigan’s cover letter for the final report noted that your comments on the revised draft report were about matters that had already been raised and addressed. On the whole, the reviewer agreed with this; but she noted that this was a further opportunity to act on your observation that issues had been omitted from the investigation.
69. You also complained that we ignored your comments on the draft report prepared by Ms Kedie as part of the earlier investigation that we discontinued. This is not so. Your comments directly led us to start the investigation over. While we did not respond in detail to your comments, the review found that this was reasonable in light of our decision to begin a fresh investigation. The report produced as part of the new investigation supersedes the draft report written by Ms Kedie.
The Trust’s compliance with our recommendations
70. You complained that the Trust did not comply with our recommendations. You said the Trust’s response did not acknowledge it was wrong to administer naloxone, and showed that there had been further incidents with syringe drivers. You also said the Trust had retracted acknowledgments of failings over time.
71. The recommendations set out in our final report asked the Trust to write to you to apologise and acknowledge the failings we had found, and to pay £750 in recognition of the injustice you had experienced. We also asked the Trust to send you an updated action plan, evidence of progress it had made in response to problems identified by the CQC (around end of life care, older persons’ care and staffing), various audit findings, and data on the occurrence of adverse incidents involving naloxone in cardiac patients and those on long term opiate medication.
72. The review found that the Trust had gone some way to complying with our recommendations. The Trust apologised to you and provided the financial remedy. The Trust acknowledged that it had not managed your mother’s pain properly. In respect of naloxone, the Trust stated that ‘decisions were made that resulted in her experiencing pain’. The reviewer agreed that this fell a little short of what we asked the Trust to do. While the Trust accepted that naloxone caused your mother’s pain, it did not explicitly state that she should not have been given naloxone.
73. The Trust complied with our recommendation to provide an updated action plan. One of the actions on the plan related to the ongoing monitoring of syringe driver incidents. The Trust said there had been nine incidents involving T34 pumps in the last 12 months. I can understand why you were disappointed to learn that further syringe driver incidents had occurred. Without details of the nature of the incidents and figures for previous years, it is difficult to draw any conclusion from this information or identify trends.
74. The Trust also complied with our recommendation to provide updates on action it had taken in response to CQC inspections. It said it had developed a ‘Principles of End of Life Care’ framework to replace the LCP, and a frailty pathway aimed at preventing unnecessary hospital admissions in older people. The Trust also said it had ‘focused on’ the recruitment and retention of staff, particularly nursing staff, to reduce its use of agency staff. It did not provide any figures, or details about the steps it had taken to improve substantive staffing levels.
75. The Trust was unable to provide all the audit findings we asked it to send you. The Trust said it did not currently have any audits registered with its Clinical Audit Department for ‘palliative care take up’, ‘pain scores’ and ‘cardiac testing in at risk patients admitted through the ED’. However, the Trust did provide the findings of the National Care of the Dying Audit for 2015, showing how it had performed in this area against national results. It also provided audit findings for medicines reconciliation on admission for 2016. The figures showed an improvement compared to the previous year; but they also showed that the Trust was still not meetings its own standards.
76. Finally, the Trust complied with our recommendation to provide information about adverse incidents. The Trust said there had been eighteen incidents involving palliative care and one incident involving naloxone in patients taking opioids during the previous twelve months. The review recognised that without any information to benchmark these figures, it is difficult to draw any conclusions about positive change.
77. In summary, we found that the Trust had complied with the majority of our recommendations. However, it could not provide all of the information we had asked for, and some of the information it did provide was of limited value. Your complaint highlights the importance of ensuring that we carefully consider the recommendations we make in cases like your mother’s to ensure that meaningful information is provided.
78. The matter of the Trust retracting acknowledgements of failings is mentioned in an email that Mr Corrigan sent to the Trust in January 2017. The email indicated that the Trust’s comments on our draft report ‘challenged our findings about seeking palliative care [input]’, despite previously acknowledging it should have done this. The review noted that the Trust said it did not believe it was necessary to contact the on call Palliative Care team for advice specifically about the administration of naloxone. The Trust’s complaint response said ‘It would have been appropriate for your mother to have been referred earlier to the Palliative care team… ideally on admission or on the post take round’. The review did not agree that this amounted to the Trust retracting acknowledgements of failings.
Annex 2: The review of our service
1. The review found that we took too long overall to handle your case. While we completed our earlier work reasonably promptly, from the point we accepted your case for investigation, there has been significant delay. The investigation we started in August 2013 took around nine months to reach draft report stage. This timescale may have been acceptable if we had produced a robust draft report. However, we realised that we had not properly investigated your complaint. Instead of looking at the primary evidence and comparing what happened to what should have happened, we based our consideration on the Trust’s complaint response and the George report. This led us to discontinue our investigation.
2. The new investigation took around two and a half years to complete. Although the case was allocated to an investigator in July 2014, we did not hold an investigation planning meeting until January 2015. According to the investigation plan agreed at that meeting, we anticipated closing your case by the end of April 2015. This timescale was unrealistic given the complexity of the issues, the initial plan to conduct interviews and the amount of information we needed to consider. In the event, we did not complete the investigation until February 2017, having extended our target date numerous times.
3. Various factors contributed to the delay. Your case is complex; the review found that it should have been passed to complex investigations in 2013. Treating the case as a standard investigation (and then having to restart it from scratch) led to a delay of around 12 months.
4. While handovers between staff cannot always be avoided, this inevitably also led to delay as each new investigator familiarised themselves with a complex case. The review found that the handover between Mr Kuti and Mr Corrigan in particular resulted in considerable double handling. It is very unfortunate that so many handovers were necessary in your case.
5. The review found that competing demands on the investigator’s time was also a factor. Mr Corrigan’s workload meant he was unable to dedicate the time needed to progress your case in a timely way. Emails he sent to you towards the end of the investigation indicate that he was juggling the demands of a new job role in PHSO with the outstanding work on your case, and was not benefiting from protected time to progress the investigation. We should not have allowed this to happen; your case should have been our priority at this point.
6. In short, there has been significant and avoidable delay on your case. This does not reflect our Principles of Good Complaint Handling8, or the commitment in our service charter, to provide a good service.
Doing what we said we would
7. You complained that we did not honour various commitments we made including providing expert palliative care oversight of your case, interviewing the Trust’s staff, undertaking Root Cause Analysis (RCA), producing a tabulated list of all your complaints and the Trust’s failings, arranging a meeting with Mick Martin (former Deputy Ombudsman) and carrying out an external review of your complaint about us.
8. Our records show that we gave you many assurances about our work. During a meeting in October 2014, we told you we were going to interview staff from the Trust. Referring to the coroner’s expert (Professor George), we told you we would try to ‘…secure a palliative care expert of that kind of standing…’, and that we would look at having ‘…an expert for every step of the way’, including a ‘medical person to work alongside’ the investigator and accompany him to interviews. We also told you we would look at why failings occurred. We made a similar undertaking about looking at the cause of failings in an email sent soon after the meeting.
9. In the event, we did not examine why failings occurred or interview anyone. The investigation was not overseen by a palliative expert; but our intentions were unclear here. The transcript of the meeting in October 2014 suggests we planned to take ‘expert’ palliative care advice and arrange for an experienced internal clinician to provide some degree of oversight. An email from Gavin McBurnie, Director of Complex Health Investigations, sent 28 November said ‘We shall be using palliative care expertise to guide us in the investigation particularly on all clinical issues… I am aware of my commitment to have an experienced clinician provide some oversight/guidance’. Dr McBurnie wrote to you again the next month, telling you we would ask for advice from an ‘expert’ in palliative care; but emphasising that our investigations were lay-led. Our approach should have been clear from the outset. It was not, and I can see how this created an expectation that our investigation would be overseen by an expert in palliative care.
10. With regard to a ‘tabulated list’, our records indicate that you wanted us to provide a definitive timeline of the events you complained about which cross-referenced the Trust’s failings and the source of the evidence. In May 2015 Mr Corrigan sent you a timeline. You asked him to include more information. Mr Corrigan sent two documents in June 2015: a timeline of the events and a timeline of your complaint to the Trust.
11. There does not appear to have been a common understanding of what information would be included on the timeline/‘tabulated list’, so it is difficult to say whether we did what we said we would. The reviewer noted that the timeline was to assist us with our investigation; it was not an end in itself. The documents Mr Corrigan prepared were very detailed and would have achieved this aim. While I accept we not meet your expectations, I am satisfied that we took reasonable steps to produce a timeline for the purpose of the investigation.
12. The meeting with Mr Martin is noted in an email Sarah Fox-Bose (Head of the Ombudsman’s Casework Team) sent you on 15 December 2015. Ms Fox-Bose said: ‘With regard to a meeting as we discussed we agreed it would be helpful/necessary for Dr Gavin McBurnie to be present at any meeting – unfortunately he is out of the office from Friday of this week until 26 January (and there is no availability in Mick’s diary this week). As such, I do not expect a meeting will be possible until the end of January’. In February 2016 Ms Fox Bose referred to ‘a possible meeting’ with Mr Martin. She told you she did not agree she had ‘made a promise’ that such a meeting would take place. The review found that the content of the earlier email gave the impression that a meeting with Mr Martin was more than a mere possibility. I can see why you believe we retracted the offer of a meeting.
13. In July 2015 we offered you a comprehensive external review of your concerns about our services, to be completed after we had issued our final investigation report. In the event, we did not issue our report until February 2017. By this time, we no longer commissioned external reviews. Amanda Smith, who began the current review, explained the situation to you in April 2017. While the offer of an external review was made in good faith, we did not foresee that changes to our services meant this resource was no longer available. Although you have not had the external review you were promised, we have sought to provide an objective and comprehensive internal review.
14. In summary, the review found that we did not do many of the things we said we would do. This is contrary to our Principles of Good Administration and our service charter. Bias
15. You complained that the tone of Ms Kedie’s emails to the Trust was different to those she sent to you. You said this shows a lack of impartiality. You also complained that Ms Kedie made a critical comment about you after a ‘smear’ by the Trust.
16. The review found that Ms Kedie’s correspondence with both you and the Trust was courteous and professional. Ms Kedie addressed the Trust’s complaints manager less formally, in that she used her first name. I do not consider this amounts to evidence of bias.
17. When the Trust sent us the papers on your case, it included a complaint letter from another patient. Referring to this letter in an internal document, Ms Kedie stated: ‘Interestingly, the complaint made by another patient tells a very different story and highlights how demanding of staff Mr VA and his family were and that this was to the detriment of other patients’. The review did not find evidence that the letter influenced or biased our investigation; but it was inappropriate for us to comment on it in the way we did.
18. In an internal email to an assistant director sent 25 June 2014 Mr Kedie said ‘…Mr VA is a demanding complainant…’. It is not appropriate for staff to express subjective opinion about people who use our service. Doing so does not demonstrate the commitment in our service charter, to treat people with courtesy and respect. I am very sorry for the offence this caused you.
Our reviews of your case
19. You complained that our reviews took too long, were not scoped broadly enough, did not acknowledge the injustice our service caused you and your wife, and did not provide a remedy. You said Ms Kedie reviewed herself.
20. There was no delay in completing our first review of your case in 2013. You clarified your concerns in January 2013. We passed your case to a reviewer the following month. The review was completed and the response shared with you by mid April 2013.
21. The second review began in 2014. The Review Team accepted your complaint about our service on 13 July. The review was completed by Mr Comber and referred to our Casework Team. It remained there until July 2015 when we sent you our review response.
22. It is very difficult to see why the review response was not sent to you shortly after it was referred to our Casework Team. The delay was entirely unacceptable. There is no audit trail as to the work that was ongoing, although there are signs that issues surrounding the investigation and review became blurred, causing confusion and misunderstanding as to what the two distinct processes (review and investigation) were covering.
23. You are also unhappy with the time the current review has taken. We acknowledge that it has taken longer than it should have done due to the handover between Ms Smith and Ms Green, which inevitably lengthened the timescale.
24. Next we turn to the issue of scope. Our first review looked at the outcome of our assessment in 2012, when we decided to take no further action on your complaint pending further work by the Trust. The reviewer, Nicola Bubb, restricted her consideration to our overall decision. She did not consider the detail of your concerns which were set out in a 17 page letter and several emails. Ms Bubb took the view that
your detailed concerns could be addressed through a second assessment of your complaint. The review found that this decision was reasonable given that further substantive work was imminent.
25. However, when we started the second assessment, we told you we would only look at whether the Trust’s action plan was robust. Narrowing the focus of the second assessment was unfair given that we had previously indicated it would consider your detailed concerns, which were wider than the adequacy of the Trust’s action plan. Our decision making did not affect the eventual outcome, in that your complaint was still sent for investigation. But the way we applied our processes here was confusing and contradictory.
26. The report of the second review explained that some of your concerns fell outside its scope because they related to the provisional findings of the investigation undertaken by Ms Kedie and the judgments underpinning them. Mr Comber explained that it was more appropriate that these matters were dealt with as part of the new investigation. Given that the provisional findings in Ms Kedie’s report were to be set aside and superseded by a new investigation, we consider that this decision was reasonable.
27. The cover letter for the second review acknowledged the ‘further distress and inconvenience’ you experienced due to problems with our service. The letter explained that the matter of remedy would be decided once the ongoing investigation had concluded. The review found that the decision – to provide a complete remedy once the full impact of any errors was known – was reasonable.
28. The current review found no evidence that Ms Kedie ‘reviewed herself’. Our records show that in June 2014 Ms Kedie prepared a detailed analysis of your comments on the draft report she had written. Ms Kedie also prepared an apology for our handling of your case, which was to be signed off by a director. As the investigator, Ms Kedie was most familiar with your case and it was appropriate that she completed these tasks. The work Ms Kedie did was not a review. The review was undertaken by Mr Comber in August 2014.
29. You complained that we did not always keep you updated. You said Ms Smith, who began the current review, did not tell you she was leaving PHSO. You said Mr Corrigan was the only investigator who shared ‘what we were seeing’.
30. The review found that on the whole staff kept you updated about our assessments and investigations. This was particularly true of the investigation we concluded in 2017. The investigators involved you at every stage and were in frequent contact with you. We did not always keep you updated about the progress of our reviews. The reviewer noted at least two occasions when you sought Mr Corrigan’s assistance to find out what was happening with the reviews.
31. Ms Smith last contacted you on 6 November 2017. She said her review was ongoing and that she would be able to send a more detailed update the following week. There is no evidence that she contacted you again before she left PHSO. Amanda Campbell, Chief Executive Officer, apologised for this on 23 November and explained that your case would be passed to Ms Green.
32. The requirement to explain ‘what we are seeing’ is part of our service model, which came into effect while Mr Corrigan was handling your case. Previous investigators may not have shared information to the same extent. This is likely to have been a reflection of the way we were working at the time.