The latest report from the health service Ombudsman urges NHS trusts to look at two problems areas revealed by the latest round of investigations. Failures by inexperienced staff in accident and emergency departments and poor handling of complaints are the two consistent themes that have appeared in earlier reports and there appears to be little improvement.Four of the investigations revealed decisions made by inexperienced clinical staff in accident and emergency departments, where diagnosis was incorrect . In one case a mistaken diagnosis led to a delay in providing treatment which could have saved a patient’s life. Instead, he was sent home and suffered a fatal heart attack the following day. The cases underline the need for sufficient support and supervision of more junior clinical staff, and adequate liaison between accident and emergency and other specialties.
Eleven of the investigations related to failings in the way in which complaints were handled by NHS bodies. There were several cases that illustrate the fact that a poorly handled complaint amplifies the dissatisfaction and distress of people who have concerns about the care provided to them or their family. In two cases Trusts failed to identify and interview key witnesses. In one of these cases the Ombudsman found that a Trust had not taken reasonable steps to trace the junior doctor who had treated the complainants’ baby. The Trust said that they were unable to contact the doctor, having not found her details on the UK medical register. The investigator, however, was able to trace her through one short telephone call to the General Medical Council registry office.