Complaint Process

It is very important to us we try and share with you what we went through on our journey.  This way you can see what ‘could’ happen, what ‘does’ happen and find ways to avoid this happening to you, or be ready for it, forearmed, so you are aware of more options in advance than finding yourself suddenly in any similar situation and having to fight for this information, which is highly stressful whilst at the same time caring and worrying for a vulnerable elderly relative.  They were ‘surreal’  situations we found ourselves in.  We want to save you that.

 

PLEASE NOTE: YOU CAN READ DOCUMENTS ACCOMPANYING OUR COMPLAINT PROCESS AND OTHER DOCUMENTS UNDER “READ OUR DOCUMENTS” above and to the right of this text.  DOCUMENTS DIRECTLY RELATED TO THE BELOW INFORMATION WILL HAVE A LINK IN BLUE AND BE MARKED “Document’ followed by the name of the document.

 

1. HOSPITAL – BROOMFIELD, CHELMSFORD (MID ESSEX HOSPITAL SERVICES NHS TRUST)

Complaints

We complained to the Trust very early on about the care and the treatment mum and we as a family were receiving.  Despite chasing this complaint we did not receive adequate engagement with us for an unacceptably long time, 18 months.   We were going through other and ongoing poor care situations at the time and this was one complaint that ran alongside others and in total spanned our first letter in 2009 and intial meeting in 2010 until final apologies in 2013.  We went through over 20 meetings, with the Chief Executive, Deputy Director of Nursing, Head of Nursing and others and numerous emails back and forth until we finally had full acknowledgements and admissions of failures in care and service delivery.

 

We still had not finished this process even when mum, Reneé, had passed and it continued after this.  You can read letters from the Trust under Our Documents and below.

As with all our complaints, we had an Independent Complaints Advocacy Services (ICAS) advocate present many times, there was many investigations, then acknowledgements, then apologies.  We went on to then question why and how.  After this we wanted to know has been done, what is being done and what will be done in response to our complaints.  And – we wanted to be engaged in, included and involved in improvements and change.  We questioned all areas that were highlighted by our complaints – communication, attitude, culture, access to information, discharge procedures etc.  During our the time of complaint process a Patient Experience Team was founded.  At this time Katie Warren was refused to be a volunteer at the hospital, you can see documentation relating to this under Our Documents.

 

We developed our “Journey of Care Information System” nicknamed by Broomfield “JOC” over and from the many meetings we had with the Trust.  We  were told it would be implemented to appear on all wards walls or outside wards and its aim was to cover information provision at the time and point of need.  We were delighted.   It was not implemented.  We have apologies for this.   We were very disappointed.  We have been since however and are still engaging with the Head of Patient Experience, Communications and Public Engagement to help drive forward positive change.  You can read documenation under Our Documents and below.

 

Duration of this process: 2009 – 2013

Number of complaint meetings and meetings to instigate change: 22 (twenty-two) – Many accompanied by ICAS – plus numerous letters, emails and leading to ongoing phone calls with Head of Patient Experience, Communications and Public Engagement on a regular basis.

Outcome:  Apologies, acknowledgements, refused compensation, enegagement with Mid Essex Hospital Services NHS Trust to drive forward change.

See Document – Apology Letter 2011 Delays in Replying to Complaints.

See Document – Broomfield Final Apology Letter 2013

See Document – Broomfield Letter 2013 Journey of Care Confirmation.

See Document – Broomfield Hospital 2013 Re Journey of Care Information System U-Turn.

See more of our documents under “About us” – “See Our Documents”

 

2.  HOSPITAL – WILLIAM JULIEN COURTAULD, BRAINTREE (MID ESSEX PRIMARY CARE TRUST SUBSEQUENTLY CENTRAL ESSEX COMMUNITY SERVICES)

My mum was moved with our permission and with our strict conditions, agreed to, to this hospital for assessment and rehabilitation before she was allowed home to live with us, her express wishes.  She received poor care, our family was not listened to in raising concerns and conditiions were not adhered to.   And we were treated with a lack of respect and not communicated with, we felt as if ranks were being closed around us.  We had a meeting at this hospital, where we were not given the information we should have had despite all that had previously happened to mum and us.  We had advocates present from ICAS and the Independent Living Advocacy (ILA).  We felt my mum was given food she coulnd’t eat, she was not communicated with effectively, she was left in bed when she could have been sitting out because adequate equipment was not provided, she was deemed doubly incontinent – she wasn’t, the call button was not with her and was too short to reach her adequately, no-one listened to us. We were terrified.


Duration of this process: 2011 – 2012

Meeting with CECS:  4

Outcome:  Apologies, acknowledgements, taken to see Braintree Community Hospital that replaced this hospital to see remedied what we had highlighted in our concerns and complaints, offered £1,000 compensation – originally refused as legal action was pending.

With legal action now settled PROVIDE previously CECS have honoured their offer of £1,000 as a gesture of goodwill in recognition of a number failings in the quality and provision of care provided, that CECS did not always get the care right, on occasions failed to taillor the care to Renee’s needs and acknowledgement that the care did not meet the expeccted standards in a number of areas in William Julien Courtauld Hospital, Braintree.

PROVIDE are now engaging with us supporting the aims of WhereIsTheCare.co.uk and using us as another channel of information to make change and feeding back to us improvements.

See Document – CECS Apology Letter 29.08.13 inc Gesture of Goodwill Payment

See Document – CECS now Provide Gesture of Goodwill Payment Accepted in 2015

See Document – Provide Apology Letter from Charge Nurse 2012

See more of our documents under “About us” – “See Our Documents”

 

3.  ADULT SOCIAL CARE – ESSEX COUNTY COUNCIL

You can read the failures in services provision to mum and us as a family in this document.  It is long.  Citing: support not consistently being provided to our family, unacceptability in making the family feel patronized and in not working together to make decisions, and to not include carers (with client’s permission) in decisions, consistent support not provided in helping family draw up a care plan, the OT did not consider a range of options and risks, failure to respond in a timely manner to family’s original complaint, unacceptable attitudes by social service staff, links should have been greater with health colleagues, distress caused to the family etc.  We had 12 meetings, finally meeting the Executive Director of Adult Social Care Liz Chidgey at the time.  There are various documents for you to read regarding this complaint under Our Documents.

Many and serious failings were made – apologised for and acknowledged.  This process took all the strength we had, Katie Warren breaking down time and time again and starting a meeting with a minutes silence to remember her mum (then passed) and all that happened to her that shouldn’t have done.  Putting her photo in the middle of the table to remember who we were talking about, not a number, a person, a vulnerable person – and a family they didn’t listen to.  She put her mum’s little soft slippers on the table, to ‘remember’ how the family had to nurse her better and demand competent care, after being looked down on, and how mum was left to not be able to walk for the last year of her life through the pressure sores received within a residential care home and how all concerns raised went unheard.

We were accompanied in these meetings by 2 different ICAS advocates.

 

Duration of this process: August 2011 – February 2013 Many accompanied by ICAS advocates

Number of Meetings: 12 (2 with Acting Executive Director)

Outcome:  Admissions of failure in service provision, inappropriate outcomes to 2 Safeguarding of Vulnerable Adult alerts (SOVAs), apologies, accepted £7,100 as a goodwill gesture in recognition of all the aforesaid failures in service provision to Reneé Dewey and family.  They will continue to support the Journey of Care work with MEHT and will establish an ongoing relationship with Katie via AA.  This relationship has not continued.  We were directed to Commissioning, who did not wish to use us as a channel of information/feedback for them, saying there was no process in place to do so.

Until a change of post we were working together to drive forward change with Councillor Anne Brown – the then portfolio holder for social care, health and wellbeing who we were pleased was using us as another channel of information to improve service after meeting her on our care stand in High Chelmer, Chelmsford, where we were speaking with the public about elderly care.  Current portfolioholder Dick Madden, acknowledges the work that WhereIsTheCare are doing. Adult Social Care and Anne Brown continue to support us with her statement of support.  James Bullion, Head of Adult Services confirms Adult Social Care will engage with us to help informally resolve complaints and will continue to take our feedback.  Formal complaints can be addressed through the Complaints Process, or your local councillor or one of the portfolio holders as appropriate.

In addition it was requested and agreed that a statement be made by the Executive Director of Adult Social Care on the front of mum, Reneé’s Adult Social Care case files to be read in entirety before reading further, to be read in conjunction with Katie Warren’s statements and Minutes of Meeting held with Liz Chidgey and the family.  Liz Chidgey’s full statement can be read under Our Documents: it says that appropriate practice was not followed in relation to safeguarding investigations, that the outcome of a SOVA involving Katie Warren should have read unsubstantiated, that significant shortfalls occurred in the complaints handling process, that appropriate practice was not followed in realtion to safeguarding investigations causing Katie Warren unnecessary distress on two occasions, and it is acknowledge that aspects of the case recording from the case file were inappropriate and negative towards Katie Warren which is not appropriate practice.  A full and open apology has been given to Katie Warren and her husband.  All apologies can be read under Our Documents including Katie Warren’s statements mentioned here.  You can read some of these inappropriate and negative comments, please see Our Documents page.

See Document – Apology Documentation Service Failures

See Document – Apology Letter 1 – Errors made and regarding complaint handling

See Document – Apology Letter 2 – Reiteration

See Document – Apology Declaration on front of Renee Dewey’s Case File Notes

See Document – Family’s Comments on front of Renee Dewey’s Case File Notes

See Documents – Renee Dewey’s Case File Notes – Comments Made and Families Replies

See more of our documents under “About us” – “See Our Documents”

 

4.  LEGAL ACTION TAKEN AGAINST 2 DEFENDANTS – RECEIVING PRESSURE SORES AS A RESULT OF NEGLIGENT CARE

a. Boucherne Care Home, Heybridge, Maldon (where Renee resided)

b. NHS Commissioning Board for the District Nurse Service (the visiting district nurse service to this home run by the then primary care trust, subsequently taken over by Central Essex Community Services (CECS), now Provide.

We raised complaints whilst in this care home about care here resulting in pressure sores down to the bone (subsequently healed by our intervention), we instigated a case conference, we questioned the owners/manager and district nurses and district nurse management, adult social care, GP, we had an ICAS advocate present.  No admission of obvious poor care.  We had to fight for explanations, competent care and nursing care.  Concerns were not listened to.  Later, we instructed Thompsons solicitors for negligent care resulting in avoidable pressure sores.  Legal action can take a long time and is a highly stressful time, living and re-living very painful memories.  We were made a low offer to settle out of court, we wouldn’t.  A directional court hearing was in place for June 2014, after which we were made, deemed by our solicitors, a reasonable offer.  Unfortunately the system is such that families are put in a position where they are effectively forced to agree to an out of court settlement.  It is a compensatory system, not one where anyone has to admit any blame or ends up with a legal judgement in a court of law.

 

Duration of this process:  December 2010 – July 2014

Outcome:  Out of court settlement

NHS Commissioning Board for the District Nurses.  Admissions of liability – failure to provide a care plan prior to the development of pressure sores, failure to provide a suitable pressure relieving mattress to alleviate these sores and failed to provide a care plan for the carers to follow and implement.  They apologised in writing for the failures of the Mid Essex Primary Care Trust and the staff concerned and they acknowledged the pain and suffering that Renee suffered.

We appreciate their apology.

Boucherne Care Home, Heybridge, Maldon – Negligence is denied, no admissions or apologies have been received from this home on whose premises this happened and to whom we gave our trust to look after Renee, despite a Expert Court Witness Report – Nursing which was not challenged, which will soon appear on this site for you to read.

They neither admit nor deny the nature, causation, or prognosis in respect of any injuries suffered by Reneé.

Denied: failure to carry out proper risk assessment, precautionary measures, to act with duty care and attention.

The Expert Court Witness Report – Nursing: disagrees*.  The independent expert’s opinion is that they failed to appropriately and accurately assess Reneé’s leve of risk particularly with regard to her inability to independently respond to pressure.

Please Note: BOTH PARTIES settled out of court in joint payout £14,000 each of a £28,000 settlement.

See Document – Apology Letter on behalf of Mid Essex Primary Care Trust by NHS Commissioning Board – Confirmation of Settlement Amounts from the Board and Boucherne Care Home

See Document *”Expert Court Witness Report – Nursing: Conclusions” under “About us” – “See Our Documents” (to follow)

See more of our documents under “About us” – “See Our Documents”

 

 

OUR ADVICE

If you feel you are receiving neglectful / abusive care.  Always raise concerns.  Take notes every day.  Get everything in writing. Ask to read records.  Get photos. Get Adult Social Care involved,  Get safeguarding involved.  Report it to CQC.  Chase them up. Get outsiders involved.  Call the Police.  Ask to speak with managers.  Get an advocate to help you.  Go to charities, organisations, agencies to help you.  Educate yourself on procedures, guidelines, the law.

If your vulnerable elderly person develops pressure sores, remember most are unavoidable – consult a solicitor and take legal action if appropriate.   If care is not improved when we raise concerns directly, and Adult Social Care and CQC are not being effective, we have to take legal action, very sadly, to force improvements in care and force review of procedures.   Publicise.

See our Article under “Articles” from the “Home Page” – WhereIsTheCare Article – What to Remember About Complaint Meetings

See Adult Social Care Article under “Articles” from the “Home Page” – Making Complaints provided for WhereIsTheCare

Go to Articles, Tips and Leaflets from the Home Page and search “Advocacy” for further help with complaints