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Nhs Complaints Procedure

Volume 404: debated on Tuesday 6 May 2003

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1 pm

I am delighted to have secured this short debate. There is a widespread consensus across the House and in the Government that the NHS complaints procedure is in need of reform and, almost without exception, hon. Members will have had experiences of cases that demonstrate that need. Although the issues are largely generic, it was the death of Mrs. Peggy Scott, the mother of my constituent, Mrs. Christine Hawkins, in Eastbourne general hospital that brought these issues forcefully to my attention and underlies my request for today's debate. I shall refer to the specific complaint in respect of Mrs. Scott's unexpected death but, of course, I do not expect the Minister to be able to respond on a case-specific basis. Instead, I would like to try to draw some general points from Mrs. Hawkins' experience of the complaints process.

Mrs. Hawkins' concern to find out what really happened to her mother was treated as a complaint from the outset. Although it was initially a search for information and the truth, the system insisted on treating it as a complaint. Mrs. Hawkins first came to see me in 2001, some two years after her mother's death, and it was not until last June that the process reached its culmination with the publication of the report by the health service ombudsman on Mrs. Scott's death. For almost all the period that I have been involved with the case, the Government's commitment to reform of the NHS complaints procedure has acted a backdrop to the specifics of this case.

I began applying for this Adjournment debate some time ago, certainly before the publication of the Government's document on NHS reform. It is purely fortuitous that the Health and Social Care (Community Health and Standards) Bill, which will deal with these issues to some extent, will receive its Second Reading tomorrow.

Because things have moved on in the past few months, I hope that I can draw the Minister specifically on how the Government's proposed reforms will address specific issues that are raised by Mrs. Hawkins' complaint about her mother's treatment. In particular I should like to try to penetrate what the Joseph Rowntree Foundation, speaking in the context of local government reorganisation, described as a British "obsession" with institutional change and to understand how the proposed institutional changes will make a practical difference to the way the complaints system works and the attitudes that the various players within it adopt.

Nothing that any complaints system can do will reverse the pain and suffering that Mrs. Scott endured alone in her final hours; no compensation can ever put right the fact that Mrs. Scott's family were not with her when she died, nor were they even aware that her condition was serious. Moreover, it was not with a view to obtaining compensation that Mrs. Hawkins embarked upon the assault course that the current NHS complaints procedure represents. Instead, it was an attempt to establish the truth and, as the facts began to emerge, to try to ensure that appropriate action would be taken to ensure that the errors and failures that were exposed could not be repeated.

At the end of a process that has lasted nearly four years, Mrs. Hawkins remains totally dissatisfied. She is dissatisfied with the conduct of her complaint, the follow-up action, or lack of it, by the trust and the apparent inability of the system to ensure that the shortcomings of the individuals involved in Mrs. Scott's care were properly addressed.

Briefly, because we do not have time to go through the details of Mrs. Scott's treatment, I will outline the salient facts. Mrs. Scott was admitted to Eastbourne general hospital following complaints of abdominal pain and diagnosed as suffering from constipation and a urinary tract infection. She was about to be sent home from the accident and emergency department when Mrs. Hawkins arrived, expressed concern about her condition and insisted on a further examination. As a consequence of that examination, Mrs. Scott was admitted to the hospital and a care plan was drawn up for her, although it is not at all clear that that plan was followed beyond that point.

Throughout Mrs. Scott's stay in the hospital, clinical and nursing notes were maintained in a grossly inadequate fashion. It was impossible to identify the authors of some of the notes—for example, some were recorded on sheets without the patient's name. Despite significant changes in her condition, including a very significant drop in her blood pressure, no entries were recorded in her nursing notes on 30 June—the day before she died—between just after midnight and 8 pm, despite the requirements of the care plan.

Much of the investigation that followed focused on contradictory entries made in Mrs. Scott's records during the evening before she died and the lack of clarity about whether she had been administered the painkiller Tramadol once or twice. The ombudsman eventually concluded that the notes recorded by doctors and nurses of events occurring at different times were in fact notes of the same event. There were serious cases of misrecording.

As Mrs. Scott's condition deteriorated, it was clear that a more senior doctor should have become involved in her diagnosis and treatment, but none did. If the ombudsman's report has correctly deduced what happened, Mrs. Scott was given only one dose of Tramadol at 8 pm in the evening and, when she died some five hours later, she would almost certainly have been in extreme pain. It may well be that, because of Mrs Scott's age, weight and general condition, surgical intervention would ultimately not have been successful, but it is absolutely clear from the reports that it should have been considered and that it was not. Because of shortness of time, I shall not quote from the reports, but it is clear that there was a catalogue of failures by the hospital and the staff involved in recognising and acting upon the obvious deterioration in Mrs. Scott's condition.

Like all hon. Members, I have had to deal with many constituents who have had experience of the NHS complaints system at every level. We also often have the opportunity to see matters from a different perspective from that of the complainant by talking informally to NHS staff and managers. I want to extrapolate the general issues from Mrs. Scott's case.

The focus, as I understand it, of the Government's proposed reform of the complaints system—clause 109 of the Health and Social Care (Community Health and Standards) Bill, which contains a regulation-making power that means that we shall not see the detail for quite some time yet—is on changes to the independent review panel stage of the procedure. That is clearly a welcome reform, because there seems to be universal dissatisfaction among complainants with that stage of the procedure and a clear feeling that the word "independent" is a misnomer.

As I understand it, the intention is that the yet-to-be-created Commission for Healthcare Audit and Inspection should take the lead role in conducting the independent review stage. I have mixed feelings about that proposal. It seems to me that CHAI's intended principal role is to improve standards of clinical governance through audit and support of systems. Its role in the independent review process will facilitate rapid feedback from findings in individual cases to improve the system, which is a good thing.

I am slightly less comfortable about CHAI having a lead role in the resolution of an individual complaint. That proposal seems to sit a little uncomfortably with the broader role envisaged for CHAI. To my mind, that is akin to asking the Audit Commission to manage appeals against local authority housing allocation decisions, and that would involve two separate issues being merged into one. My conclusion is that, if CHAI is to be involved at that stage of the complaint procedure, its involvement will have to be carefully defined to ensure that its principal role of extracting and ensuring the implementation of general lessons from an individual case is not compromised by—and, does not compromise in turn—the other important objective of the complaints procedure, which is to ensure an acceptable outcome from the point of view of the individual complainant.

My real concern, which I want to put to the Minister today, is that the problem lies further back in the process—in the development of a deeply defensive culture among NHS staff and managers. Perhaps inevitably in the context of an ever-more litigious society, that, if anything, seems to be getting stronger. Complaints are seen as wholly negative. There is a sense of closing ranks among staff. Complainants such as Mrs. Hawkins, who are essentially seeking information and reassurance that individual inappropriate behaviour has been identified, are treated from the outset as potential litigants. Apart from being extremely wasteful, the creation of an adversarial atmosphere around the complaints process from the outset creates a danger that, at the very early stages of the process, defensive postures will be struck and defensive statements will be made. They will become entrenched and effectively obstruct a more objective analysis later.

In short, I suggest that often during the local resolution stage of a complaint, which is as far as most complaints ever go, there may be a tendency to try to put the matter to bed, rather than to open it up and explore it more fully. That leads to complainants feeling obstructed by the lack of transparency, to staff often taking up positions that they feel obliged to repeat and reinforce later and to mangers focusing on an explanation that will prevent the complaint progressing to the next level. It requires a great deal of energy to pursue a complaint through the system and there is the suspicion that the focus of the first stage is sometimes on providing an explanation that will deter even the moderately strong from further inquiry. Many complainants find deeply offensive the implication from the outset that they may be seeking compensation. I suggest to the Minister that there needs to be a way of clearly separating complaints that are focused on the pursuit of compensation, or that might reasonably lead to a compensation claim, from those that clearly are not.

Another specific concern underlined by Mrs. Scott's case that I want to raise, is the securing of evidence in the context of the long time scales of the complaints procedure. Many local resolution procedures currently take a very long time. There is clearly a need to set a maximum time scale so that, if matters are to proceed beyond the local resolution stage, that can happen at a time when the incident is still relatively fresh in the memories of those involved. One of the striking and alarming things in Mrs. Scott's case is the lack of proper record keeping, which was compounded by the inability of key members of staff to remember the salient incidents in her treatment—no doubt a function of the pressure under which NHS staff operate. Surely there is a case for the taking of early statements from the clinical staff involved in an unexpected death or other untoward incident.

The other deeply unsatisfactory aspect of Mrs. Scott's case is the inability of any of the bodies involved in the complaints process—the trust itself, the independent review panel or the health ombudsman—to obtain a response from a staff nurse, a key member of staff, despite communicating with him at the address on the register held by what was the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. It appears that the system does not have the ability to enforce co-operation with the complaints process and, with the increased volatility of staff in the NHS and the increasing use of agency staff. That seems to me to be cause for serious concern.

Finally, complainants—Mrs. Hawkins included—find it difficult to understand why the independent review panel is unable to apportion responsibility for an incident even when the conclusions of the report are clear in that respect. The independent review panel is specifically not permitted to make recommendations for, or to instigate, disciplinary action against individuals. That is supposed to be a function of the employing trust in response to the report. In this case, there was no follow-up by the trust in relation to the shortcomings of individual identified members of staff. It is clear that CHAI would have a role in auditing procedural changes arising from a report into a complaint, which is certainly positive. Will the Minister tell us whether it would also have a role in ensuring a proper response by the trust at the level of the individual?

The complainant has little scope to address the situation, as Mrs. Hawkins found out. The professional disciplinary bodies—the General Medical Council and so on—can investigate complaints only when the conduct complained of is sufficiently serious to warrant striking off a member from the register. In other cases, it is for the trust alone to carry out appropriate disciplinary procedures.

I welcome the Government's commitment to reform the NHS complaints procedure. I ask the Minister to address specifically a number of questions that arise from Mrs. Hawkins's case, but which have a much more general applicability. In doing so, perhaps she could confirm to the House how the proposed new system will address those issues. Will she tell us who will be responsible for setting down procedures for documenting events surrounding unexpected deaths or other untoward clinical incidents, including the taking and preserving of statements from the staff involved? Do the Government intend to introduce an obligation on persons registered with professional bodies to co-operate in the NHS complaints procedure? In short, I should like an assurance from the Minister that it will not be possible for a nurse who worked for an NHS trust to leave it and, while remaining registered with the UKCC, simply to ignore communications from the trust, the independent review panel and ultimately the health ombudsman regarding his or her role in an incident that is under investigation.

Will the Minister confirm that CHAI will have responsibility for auditing the process by which NHS trusts respond to its findings, and to those of independent review panels, during the local resolution of complaints? That includes findings relating to individual members of staff and disciplining those individuals. Can she tell the Chamber how she intends to ensure that the complaints process is focused on the complainants' objectives, as well as on the need for the system to learn from mistakes? In particular, how does she intend to end the defensive culture, which is inappropriate for the large majority of cases where, provided the complainant gets a satisfactory response from the process, litigation is not in prospect?

How does the Minister intend to ensure openness in the early stages of investigating a complaint? I should like to know whether the Government will address what is viewed by complainants as a grossly unfair bias in the system whereby the trust under investigation has the opportunity to review and comment on a report by the ombudsman prior to publication, but the complainant, who has been living, eating and drinking the details of the case for four years and is at least as well versed in them as anyone else, is not given such an opportunity. Finally, will the complainant have the ability to initiate the independent review panel process independently of the trust, or will the process still be something that only the trust can initiate?

Mrs. Hawkins has been engaged for the best part of four years in seeking to achieve a satisfactory conclusion to her complaint about the treatment of her mother and the events leading up to her death. The impression that she has is of a system incapable of getting to the truth behind those events and designed to protect those responsible for the serious lapses in Mrs. Scott's care from facing the consequences of their actions. Although Mrs. Hawkins feels that the system has failed her personally, it is her sincere desire that some good should come of her mother's death by exposing the weakness in the system. It is with that intention that she has dedicated herself over such a long period to pursuing this case.

Mrs. Hawkins will welcome, as I do, the fact that the Government are willing to make changes to the NHS complaints system. I hope that the Minister will be able to give me and, through me, Mrs. Hawkins an assurance that she will take on board the lessons from the case—I am happy to give her the full details and copies of all the reports—as she frames and shapes a robust and practical system for dealing with similar complaints in future.

1.18 pm

I congratulate the hon. Member for Runnymede and Weybridge (Mr. Hammond) on securing the debate. As he said, it is particularly prescient in respect of tomorrow's Second Reading and the publication of the document about reforming the complaints procedure.

The hon. Gentleman raised some very important points, and not just in relation to his constituent's case. I am aware of that case, however, and I shall try to deal with some of the related issues. The hon. Gentleman raised points about the operation of the service and, fundamentally, the culture of the service in dealing with complaints. We need to change not just institutions and structures, but attitudes and the way in which complaints are viewed throughout the service. That applies both to individual instances and to trends of complaints, which can tell us things about the service more generally. The service can learn from mistakes. Things will go wrong in any organisation that treats 1 million people every 36 hours, and sometimes they will be extremely distressing for the individuals involved, so it is incumbent on the NHS to learn from such incidents wherever it can.

I shall deal with Mrs. Hawkins's case and then address some of the other points that the hon. Gentleman raised. I am certainly very sorry about the circumstances in which Mrs. Hawkins' mother died. I know that Mrs Hawkins was extremely unhappy with the care that her mother received at the Eastbourne Hospitals NHS trust before her death. Any death is extremely difficult for relatives to deal with. When it happens in hospital, however, and those close to the deceased believe that better care could have been provided, their distress can only increase. I certainly offer my condolences to Mrs. Hawkins and her family. I know that she feels let down by the complaints system, particularly given what happened following her complaint at the independent review stage and the ombudsman report stage, and I am extremely sorry that that is the case.

I understand that at its meeting on 30 April the board of what is now the East Sussex Hospitals NHS trust considered and approved a position paper on the progress and developments that had been made since Mrs. Hawkins's complaint. The paper detailed the ongoing actions that the trust was taking in response to the recommendations of the independent review panel, the ombudsman's subsequent report and the review of nursing at the hospital which Ray Greenwood carried out in response to the incident as long ago as 1999.

I cart update the hon. Gentleman on a few of the things that the hospital has done. Now that its medical assessment unit has opened, more senior medical staff are available on the unit for patient care. That has lead to better patient care and certainly to greater supervision of junior nursing staff, which was a real issue in this case.

The hospital's clinical governance committee has recently approved new policy and practice for minimum observation and monitoring of post-operative patients on wards, as well as guidelines for monitoring patients receiving intermittent opiate analgesia. Again, that means much better monitoring and supervision.

The committee has also approved new policies and procedures on nursing documentation. The standard of documentation was clearly not what it should have been. There are also new guidelines on the care of the dying, the care of the deceased patient and the bereaved, the management of incidents, and nutrition. All those elements were relevant in the case of Mrs. Hawkins' mother. There was also an issue about notes not being dated, timed or having appropriate signatures on them, and there is now a computerised nursing documentation system at the hospital to ensure that those things are done for all notes.

Another issue was what discussions had taken place with the relevant staff to ensure that they took the independent review panel's recommendations on board and learned from what had happened. I understand that a copy of the panel's report has been sent to, and discussed individually with, every member of staff involved in the incidents that occurred in the case of Mrs. Hawkins' mother. With effect from as long ago as 1 April 2001, general managers have been in place in every clinical directorate. They are instructed to ensure that statements are taken from everyone involved and that there is proper documentation.

I believe that the trust is now fully committed to learning the lessons from Mrs. Hawkins' complaint. A new chairman and a new chief executive are in place, and there is a real concentration on the issues that led to that unfortunate incident.

I want to deal now with the general matters that the hon. Gentleman raised and to set out the proposals for changing the complaints procedure. The then Conservative Government introduced the current procedure in April 1996. There was a commitment to evaluation, to see how the procedure was working and what could be improved. We maintained that commitment by undertaking an independent evaluation study. It took two years, so it was very lengthy. A listening exercise was also conducted.

The evaluation process produced several key messages. First, people were unclear about how to pursue complaints and said that the process was often difficult to use. They said that there was frequently a delay in responding and that there was too often a negative attitude to complaints—the defensiveness that the hon. Gentleman described. Many complainants did not feel that they got a fair hearing or that they got support at the appropriate times when they wanted to complain. One of the most powerful messages was that the independent review stage did not have the credibility that it needed; people did not perceive it as truly independent from the service.

Another complaint was that the process did not provide the redress that patients wanted. As the hon. Gentleman said, many people were not looking for financial compensation but for apologies and for an acknowledgement that something had gone wrong. Crucially, they wanted systems to be put in place to ensure that the same things did not happen to other people in future. No systems were in place to use the feedback from complaints to drive improvements in services. The evaluation was clear about what people wanted us to ensure would happen.

We have now identified four key areas in which to move forward. First, we need to change the way in which the NHS and its staff view patients and handle complaints. That is a cultural, not a structural, change. We are working closely on that with the NHS university and the professional bodies to develop a number of training programmes on customer care and communications skills. Those programmes should ensure that everyone in the NHS, at all levels, will be more attuned to what patients want and will view complaints as requiring the provision of a first-class service, as for the rest of the business, rather than automatically seeing complaints as a personal attack and retreating into a defensive mode. The foundation of that change will be to ensure that the education, training and culture are right.

Secondly, we want to ensure that the NHS deals with complaints positively as an integral part of service delivery, and not as something on the outside that happens after the event, somewhere down the track, when things have become increasingly complicated. In that context, the introduction of the patient advice and liaison services, which now exist in 98 per cent. of trusts, will be a real step forward. PALS aim, as far as possible, to resolve complaints on the spot. They can bring people together, and they can get very senior clinicians to explain to patients some of the decisions that have been made. Many complaints arise from a lack of communication, from confusion or obfuscation, or because the clinician and the patient are not talking the same language. PALS can act as a facilitator in bringing people together.

An interesting figure that I saw recently was for the East Kent Hospitals trust, which experienced a 68 per cent. reduction in formal complaints in the six months following January 2002, when the PALS was established. That is an incredible result. I do not pretend that that can be extrapolated across the service, but it shows that PALS can help in such circumstances.

I know that we are running out of time, but I wanted to ask a specific question. The Minister said that all staff involved at the hospital had seen the IRP report and discussed it, but I presume that that did not include the staff nurse who could not be traced. Do the Government propose to place an obligation on professional staff to co-operate with inquiries into incidents in NHS hospitals, as a condition of remaining registered?

I understand the hon. Gentleman's concerns about that. I cannot give him an undertaking on that today, but I will write to him with details of what steps can be taken in that regard. It is an important matter: people should not be able to evade their responsibility by not co-operating.

First, we must get the culture right, and secondly we must get things right at the front end, with local resolution through PALS, and through the introduction of modern matrons. Thirdly, we want radically to reform the independent review element of the complaints procedure. That is why that element will pass across to CHAI. The hon. Gentleman made the important point that the complaints process should be clearly separated from that organisation's inspection functions, but I believe that by bringing those functions together under the same roof we will provide the opportunity for the complaints to inform clinical governance, the inspection process and the agenda for improvement.

We will set out in regulations how those separate functions will be administered. The details of what CHAI will do in relation to the independent review stage have yet to be formulated, but we envisage that it will have a range of options. It will be able to recommend to the organisation what it should do it may conduct a detailed investigation; or it may fast-track an issue through to the ombudsman if it is complicated and needs more serious review. CHAI will examine what needs to be done, by whom and in what time scale, and it will take a proactive approach. That will meet people's requirements for a truly independent part of the system that is outside the NHS, and it will take the matter seriously. If we get right the independent part of the process, that will increase credibility and trust in the system.

Fourthly, we must ensure that we learn from complaints about how to drive up standards. If we consider the pieces of the jigsaw—the new system of organisation of complaints, the statutory requirement for quality, the adverse incident reporting system through the National Patient Safety Agency, the National Institute for Clinical Excellence with its guidelines for treatment, the renewed emphasis on clinical governance and the reform of the system of professional regulation, which the hon. Gentleman raised—we can see that, together, they represent a real drive for quality. I believe that we will be able to achieve the required cultural change to complement the institutional change.

The hon. Gentleman raised important issues about whether CHAI could audit the process of trust responses. Clearly, patients need to know what has happened as a result of the decisions taken, and I will respond to him about that. We need to ensure that people have the opportunity to comment equally and equitably on ombudsman reports. Again, I will respond to the hon. Gentleman on that important point.

We have set out a time scale for the changes that we want to happen. Provided that our primary legislation is passed, we anticipate that the process will start in April 2004.

I also want to mention the independent complaints advocacy service—