Health bosses reflect on 'lessons learned' after daughter couldn't say goodbye to her mum
Bosses at the NHS trust that runs the BRI and Weston General say they've learnt 'vital lessons' after the daughter of a dying woman wasn't told in time to say her final goodbye
Bosses at the health trust that runs the BRI and Weston General Hospital say they have learned vital lessons after staff failed to notify the daughter of a dying woman in time for her to say goodbye.
In another case, University Hospitals Bristol & Weston NHS Trust (UHBW) had to apologise and made improvements to keeping operating theatres available, after it failed twice to plan a patient’s surgery on time and then did not follow them up as an outpatient properly.
It also paid £500 compensation to a woman for distress caused when a midwife wrongly told an ambulance crew that she could make her own way to hospital, which led to the introduction of a new dedicated telephone triage system to stop it happening again.
These were three of the four cases partly upheld against UHBW by the Parliamentary & Health Service Ombudsman (PHSO) since April 2020, which were revealed in a report to the trust’s board to show how things had been put right to avoid similar mistakes in future.
The fourth involved factual errors and inconsistencies in its response to a complaint from a patient, which led to a “loss of faith in the answers provided and left the complainant feeling that she was not being taken seriously”. The ombudsman told the organisation to pay her £300.
The report to the board said all four cases were from 2020/21 and that not a single one had been upheld or partly upheld in the two years since then.
It said: “The percentage of cases upheld or partly upheld is lower for UHBW than for comparable acute trusts nationally.
“Whilst the data reflects that UHBW has good complaints processes, policies and standard operating procedures in place, there is still work to be done in respect of learning and culture.”
The PHSO, set up by Parliament, provides an independent service for handling complaints that have not been resolved by the NHS in England.
Once a member of the public lodges a complaint, the ombudsman initially decides whether no further action is required or to launch an investigation, with the result being upheld, partly upheld or not upheld.
The report said that since April 2020, the PHSO had carried out preliminary or detailed inquiries into 26 complaints against UHBW, whose sites also include Bristol Children’s Hospital, Bristol Eye Hospital, St Michael’s Hospital and the University of Bristol Dental Hospital.
None have been upheld in full, four were partly upheld, one was not upheld and 16 were closed with no further action, while one was settled before a full investigation with a £100 goodwill payment agreed by the trust and complainant.
The remaining four cases, all from 2022/23, are pending an outcome.
UHBW chief nurse and midwife Deirdre Fowler told the board on Thursday, June 15: “Because of the small numbers it demonstrates that our responses in general are robust in terms of the PHSO interest.
“Three of the four that were partially upheld show failings in communication.”
Referring to one of the cases, the board report said that while the ombudsman did not find any failings with an end-of-life patient’s care or treatment, it concluded that “staff failed to notify the patient’s daughter early enough for her to say goodbye and be with her mother when she passed away”.
The PHSO told the trust to write to the complainant to acknowledge that staff should have contacted the family sooner when the woman’s condition changed and that the trust should produce an action plan confirming how it would ensure relatives were kept better informed.
The UHBW report said: “A safety brief was produced in respect of timely contact of patients’ relatives.
“In addition, staff were instructed to speak to patients and their families about the patient’s wishes, including who should be contacted in an emergency, and for this to be recorded in the patients’ notes.
“A review of the handover process was also carried out by the ward sister, to ensure vital information such as patients’ and families’ wishes are included in all handovers.”
A failure to plan an operation for someone suffering from a condition called cholecystitis – inflamed gallbladder – on two occasions resulted in an apology to the patient’s husband for the “missed opportunity for surgery and the distress and uncertainty this caused”.
The watchdog told UHBW to put measures in place to prevent a repeat and the trust has since ring-fenced seven surgical theatre slots per week on day case theatre lists, which has improved the situation, the report said.
It said a case where the ombudsman found “failings in advice given to an ambulance crew by a midwife, stating that the patient could make her own way to hospital” led to an apology and better communication.
The report said: “As a result of this complaint, a new telephone triage system was introduced by the midwives, with a dedicated midwife on each shift to take calls from patients and ambulance crews.
“The maternity unit also obtained funding to open a new triage area away from the delivery suite, with a dedicated telephone triage area.”