Opinion

When things go wrong with NHS care – and taking steps to put them right

Health service errors can have devastating consequences for patients and their families, says clinical adviser to the Parliamentary and Health Service Ombudsman Barbara Cannon

Earlier this year we heard that Southern Health NHS Foundation Trust failed to investigate the deaths of more than 1,000 patients with mental health problems. This reminded me just how important my work is as a clinical adviser to the Parliamentary and Health Service Ombudsman, which makes final decisions on unresolved complaints about the NHS in England.

I joined the organisation five years ago and have worked as a mental health nurse in the NHS for more than 25 years. I have had a fantastic career, worked alongside first-class professionals who put their patients first, and I am proud to be part of our NHS.

Unfortunately, I also learned very early on in my career that, like all human beings, doctors and nurses occasionally make mistakes and dont always take steps to put them right.

As a young nursing student, a man died on the ward I

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Earlier this year we heard that Southern Health NHS Foundation Trust failed to investigate the deaths of more than 1,000 patients with mental health problems. This reminded me just how important my work is as a clinical adviser to the Parliamentary and Health Service Ombudsman, which makes final decisions on unresolved complaints about the NHS in England.

I joined the organisation five years ago and have worked as a mental health nurse in the NHS for more than 25 years. I have had a fantastic career, worked alongside first-class professionals who put their patients first, and I am proud to be part of our NHS. 

Unfortunately, I also learned very early on in my career that, like all human beings, doctors and nurses occasionally make mistakes and don’t always take steps to put them right.

As a young nursing student, a man died on the ward I was working on, and the staff did not care for him as they should for someone who was at the end of life. This compounded his family’s grief; not only had they lost a loved one but the doctors and nurses did not treat them with sympathy or respect.

I was shocked. This has always stayed with me, but as a clinical adviser to the ombudsman I can now help to make sure patients and their families are treated fairly.

I, and each of my fellow clinical advisers, continue to work in the NHS so remain at the forefront of best practice. We normally take just one day a week to provide advice to the investigators.

When we work on a case we do not offer our opinion but make judgements according to current best practice and guidelines. We look at the records, compare that with guidelines then see if a gap emerges between what happened and what should have happened, and how this can affect a patient and their family.

I recently advised on a case where a young man with a history of drug, alcohol and mental health problems died in uncertain circumstances. Our investigation found that he had previously attempted suicide on several occasions and we identified shocking failures in his care.

The man’s family initially complained to the trust but the hospital’s response was a masterclass in how not to handle a complaint. They dragged their heels, taking months to answer the questions, and when they did it was obvious they had failed to thoroughly investigate the issues. 

The impact on the family took me back to my student days, but this time the final outcome was different. As a result of our investigation and recommendations, the trust apologised and agreed to take measures so it did not happen again.

But it is not just families who benefit. We often identify recurring themes in our casework and publish systemic reports of national significance that offer excellent opportunities for learning for the whole system, such as our reports on sepsis, midwifery supervision and regulation, and end of life care.

Our most recent publication – A review into the quality of NHS complaints investigations – highlights major shortcomings in the way hospitals investigate avoidable harm and death similar to the events at the Southern Health trust. It shows just how far the NHS still has to go to deal effectively with these issues.

At the Parliamentary and Health Service Ombudsman we investigate about 4,000 complaints a year. About 80% of these are about the NHS in England, and the rest are about UK government departments and other organisations.

The ombudsman has added a new dimension to my professional life in mental health. More importantly, it has given me the opportunity to make a difference when things go wrong in our NHS and make improvements that benefit us all.

Barbara Cannon is a community mental health team leader at Oxford Health NHS Foundation Trust 

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