The Health Service Ombudsman: NHS Failing Patients with Mental Health Problems

By John Tingle

Failings in National Health Service (NHS) care for patients with mental health problems is a worryingly persistent story in the English media. Many reports show harrowing and dramatic failings in NHS care provision for the mentally ill some of which result in avoidable deaths.The Health Service Ombudsman  (HSO) represents the final stage in the NHS complaints procedure and is an independent  office reporting  directly  to Parliament.The HSO carry’s out investigations into complaints  and makes the final decisions on those that have not been resolved by the NHS in England.In a recently published report the HSO reveals reveals unjust, shocking and tragic failings  in NHS care provision for patients with mental health problems.Some mental health care complaints figures are given in the report.In 2016-2017 there were 14,106 complaints made to NHS mental health trusts (hospitals) with ,65% being upheld or partly upheld by the local organisation.Case work data between 2014-15 and 2017-18 was analysed and five key themes showing persistent failings that the HSO see in complaints being made emerged from this exercise:

  • Diagnosis and failure to treat.
  • Risk assessment and safety
  • Dignity and human rights.
  • Communication.
  •  Inappropriate discharge and provision of aftercare.

The HSO also points out in the report that the other common factor in the cases examined is too frequent substandard complaint handling by the NHS organisation. This adds insult to injury, compounding the impact of failings.

Case studies

The HSO report contains several cases studies that reflect the recurrent complaint themes identified. The case studies presented are also examples of severe service failures where hopefully lessons can be learnt and that the same mistakes will hopefully not be repeated. Case studies  include:

Diagnosis and failure to treat: MS J

This patient died from Neuroleptic Malignant Syndrome (NMS), a rare but potentially life-threatening reaction to the use of a group of antipsychotic drugs or major tranquilisers called neuroleptics. The treating doctors did not consider NMS for her symptoms. They should have referred her for a physical medical opinion but did not do so. Staff did not carry out a creatine phosphokinase (CPK) blood test, which would have identified NMS. Her death was avoidable:

The HSO report conveys tragic events that should never have occurred had reflective and caring practice taken place. What makes the situation worse is that the failure themes identified  are common themes and have been seen for many years in numerous previously published reports from a host of other organisations.

Treating complaints as jewels of customer feedback

Health carers and NHS organisations should view complaints positively and as presenting welcome opportunities to improve practice. However, this is practically much easier to say than to do. Nobody likes to be complained against and in the light of a complaint being made against an individual human nature seems to click in and a defensive reaction to the complaint prevails which damages the whole process. The NHS does need to develop a culture which does not seek immediately to apportion individual blame for adverse events, complaints and needs to take a much more of a holistic view of what went wrong to encourage lesson learning and candour. There may be systemic failings in the care environment such as low staffing which contributed to the error and then to the complaint.

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