The Parliamentary and Health Service Ombudsman (PHSO) has from this week begun to routinely publish its investigations including those cases where serious mistakes have been made and not readily admitted nor addressed.
Incidents of avoidable death, delayed cancer diagnosis, and an ambulance being five hours late are among the upheld complaints published on the PHSO website.
The Ombudsman said these cases provided valuable learning for the NHS in England and Government bodies by showing what needs to change to help prevent the same mistakes happening again.
The PHSO has published 15 cases closed between June 2020 to January 2021. These are a mix of upheld, partly upheld and not upheld complaints intended to showcase the breadth of its investigative work.
The cases include:
- North Cumbria University Hospital NHS Trust failed to act on abnormal chest X-rays in July 2014 and May 2015 showing a shadow on the lung. “This delayed the diagnosis of the patient’s lung cancer by around three years, leading to it spreading to his brain and, tragically, his death,” the PHSO said. The Trust was defensive and insensitive when the patient’s daughter made a complaint.
- East of England Ambulance Service NHS Trust failed to promptly send an ambulance to help a retired grandfather in excruciating pain. The ambulance was delayed by five hours “despite the man having a stomach aneurysm and nearing the end of his life”.
- Sandwell and West Birmingham Hospitals NHS Trust failed to regularly observe a grandmother and provide her with one-to-one care. If they had done so then they would have noticed her deterioration and heart attack, and prevented her from dying. They also didn’t give her daughter answers when she complained to them so she did not know exactly what had happened to her mother until PHSO investigated, the Ombudsman said.
- NHS East Leicestershire and Rutland CCG wrongly denied fast track Continuing Healthcare to an elderly man in end of life care. “This failing meant his son had to appeal and prepare for an unnecessary review at an already difficult time, causing him significant distress.”
Rob Behrens, Parliamentary and Health Service Ombudsman, said: “Most public sector organisations deliver an excellent service day in and day out, but it’s essential that lessons are learnt when mistakes are made.
“It’s not about blame or pointing the finger but listening to feedback and acknowledging what went wrong.
“Today we begin the routine publication of our casework which will make our findings much more accessible to the NHS in England and Government bodies and help drive improvements in their services.”