Essex Partnership University Foundation Trust (19 015 337a)

Statement Closed after initial enquiries Hospital acute services 06-Feb-2020

Summary: The Ombudsmen will not investigate Mrs X’s complaint. The Ombudsmen consider Mrs X’s complaint about events at Essex Partnership University Foundation Trust in 2017 is late, and we could not say the Trust should have detained Mr Y in 2017 and 2019. Also, the Ombudsmen do not consider there is a significant injustice to Mrs X to warrant an investigation of Southend Clinical Commissioning Group’s continuing healthcare assessment of Mr Y.

Western Sussex Hospitals NHS Foundation Trust (18 017 535a)

Statement Upheld Hospital acute services 30-Jan-2020

Summary: Ms A has complained about a Trust and a Council in relation to a delay in discharging her father in law, Mr B, to a care home. The Ombudsmen find fault with the Trust in not making required referrals. However, we do not find fault in relation to the delay in diagnosis of dementia or the issuing of a behaviour warning. In addition, the Ombudsmen do not find fault with the Council in relation to a delay in finding suitable care homes, but it should have provided the family with a copy of Mr B’s initial needs assessment.

Croydon Health Services NHS Trust (18 010 646a)

Statement Upheld Hospital acute services 22-Jan-2020

Summary: The Ombudsmen found fault with a Hospital Trust’s communication with a patient’s family about discharge arrangements. However, there was no fault with the decisions to discharge the patient back to her own home or subsequently to a rehabilitation placement. The Ombudsmen also found fault by a Council not completing a carer visit for 15-hours after the patient returned home. This caused the patient and her family distress. The Council and the Trust have agreed to the Ombudsmen’s recommendations to ensure learning is taken from the complaint and ensure the faults do not happen again. They will also apologise to the complainant for the distress caused by the faults identified.

Dudley Group NHS Foundation Trust (18 009 105a)

Statement Upheld Hospital acute services 15-Jan-2020

Summary: The Ombudsmen consider Dudley Group NHS Foundation Trust’s (the Trust) communication with Mr C about Mrs D’s prognosis was poor which caused confusion and distress. Also, the Trust’s lack of care planning for Mrs D on discharge to two care homes caused Mr C uncertainty. Trinity House Care Centre’s diabetes care plan lacked detail and did not escalate Mrs D to a GP in a timely manner which caused Mr C distress at witnessing his mother suffer pain and distress. The Ombudsmen consider Dudley Metropolitan Borough Council’s (the Council) safeguarding investigation and safeguarding adults review caused Mr C uncertainty and distress. The Council, the Trust and Summerhill Surgery’s complaint handling compounded Mr C’s distress.

Croydon Health Services NHS Trust (18 005 311a)

Statement Upheld Hospital acute services 02-Jan-2020

Summary: The Ombudsmen found fault by the Council and Trust with regards to the care and support they provided to a woman with ongoing health needs following her discharge from hospital. The Council and Trust will apologise to the woman’s daughter and pay a financial remedy in recognition of the impact of these events on her.

Croydon Health Services NHS Trust (18 005 311b)

Statement Upheld Hospital acute services 02-Jan-2020

Summary: The Ombudsmen found fault by the Council and Trust with regards to the care and support they provided to a woman with ongoing health needs following her discharge from hospital. The Council and Trust will apologise to the woman’s daughter and pay a financial remedy in recognition of the impact of these events on her.

Torbay and South Devon NHS Foundation Trust (19 004 170a)

Statement Not upheld Hospital acute services 03-Dec-2019

Summary: The Ombudsmen find no fault in the care a Hospital Trust, Council-funded Care Home and GP Surgery provided to an older patient following hip surgery. The patient’s hip became dislocated but, in view of the wider situation, there is no indication this was missed because of poor care.

Torbay and South Devon NHS Foundation Trust (16 015 030a)

Statement Not upheld Hospital acute services 20-Nov-2019

Summary: The Ombudsmen found fault with the care provided to a woman with complex needs by several health and social care organisations. This included failure to arrange assessments and reviews, failures in transition planning and failure to make appropriate safeguarding referrals. This fault meant opportunities were missed to explore whether the woman had additional care needs. This also resulted in distress and uncertainty for her sister, who is pursuing the complaint on her behalf. The organisations concerned have agreed to take action to remedy the injustice to the complainants.

Royal Devon & Exeter NHS Foundation Trust (16 015 030c)

Statement Not upheld Hospital acute services 20-Nov-2019

Summary: The Ombudsmen found fault with the care provided to a woman with complex needs by several health and social care organisations. This included failure to arrange assessments and reviews, failures in transition planning and failure to make appropriate safeguarding referrals. This fault meant opportunities were missed to explore whether the woman had additional care needs. This also resulted in distress and uncertainty for her sister, who is pursuing the complaint on her behalf. The organisations concerned have agreed to take action to remedy the injustice to the complainants.

Kings College Hospital NHS Foundation Trust (17 000 791b)

Statement Closed after initial enquiries Hospital acute services 07-Nov-2019

Summary: A man complained about the care of his late mother by a council and NHS organisations. He said she received poor stoma care from agency carers and district nurses and inadequate arrangements for care following a discharge from hospital. The Ombudsmen find that the council and an NHS Trust failed to ensure his mother received the stoma care she needed. This caused her distress and embarrassment and also caused the family distress. The council will explain how it will improve stoma care in future. The NHS Trust did not follow the recommended discharge plan or visit as often as it should have. This did not cause harm to the woman concerned but it caused distress to her family. The NHS Trust has already made satisfactory service improvements. The council and NHS Trust will apologise and pay a financial remedy. Other elements of the complaint were not investigated.