Today we publish our report: ‘Groundhog Day 2’

‘Groundhog Day 2: An Opportunity for Cultural Change in Complaint Handling?’ focuses on ongoing issues with how Welsh Health Boards handle complaints.

It builds upon “Ending Groundhog Day: Lessons from Poor Complaint Handling”, published by our office in March 2017.

It shows that the lessons highlighted by our office in 2017 remain relevant today.

The case examples included in this Report demonstrate that all too often, Health Boards respond to complaints defensively rather than seeing them as an opportunity for learning and improving the services they deliver.

The themes identified in the Report point to areas were learning and improvement is urgently needed to improve the patient and complainant experience:

·       A lack of openness and candour

·       A lack of objective review of clinical care and treatment

·       Timeliness and quality of communications

·       Robustness and fairness of investigations undertaken by Health Boards.

The Report emphasises that the introduction of the ‘Duty of Candour’ on health organisations in Wales, effective from 1 April this year, presents a fresh opportunity for cultural change. The duty mandates health organisations to be open, transparent, and honest when patients experience harm during healthcare. This cultural shift aims to promote candour and systemic learning from mistakes.

Commenting on the Report, Public Services Ombudsman for Wales, Michelle Morris, said:

During my first year as Ombudsman, I have been struck by the similar pattern of complaint handling failings which my office has identified in cases involving Health Boards across Wales.

Although most health care across Wales is delivered in an excellent and professional manner, inevitably, sometimes organisations make mistakes.  In 2022/23, we found that Health Boards made mistakes and should put things right in between 22% and 41% of our complaints about these bodies – depending on the Health Board area.

When mistakes happen, we expect health bodies to respond openly and honestly to patients and their families. This does not always happen. In fact, we have seen an increase in complaints about poor complaint handling by Health Boards.

For example, we often see that, when Health Boards respond to complaints, they have not objectively assessed the care and treatment provided. In another example, even when, following investigation, the facts of a case clearly show that the Health Board made a mistake, we see that organisations do not acknowledge this in their complaint responses. These failings have real impact on patients and their families, often compounding the trauma caused by mistakes in care and treatment.

We trust that the Duty of Candour will have a positive and transformational impact on the way in which complaints are handled within Health Boards. However, if we see in our complaints that the Health Boards are not taking the Duty into account as they should, we will continue to call it out.

Miss X, the complainant in one of the cases highlighted in the Report (202102028) said,

My father’s death has been deemed to be the result of the Health Board’s failings over a period of 4 days. At least 5 interventions were deemed to have been missed over that time that may have prevented his death. Knowing that even one opportunity to save his life was missed is devasting. There are no words to describe how I feel knowing this happened repeatedly and though no-one can be 100% certain, it was described as highly likely he would be here today had even one of those opportunities been actioned.

My initial complaint to the Health Board was answered before a legal cause of death had even been established by a coroner. …. The process was impersonal and when I asked about appealing the decision, I was told that I only had three months .… It very much felt like a David and Goliath situation.

I should have been grieving and instead I had to endure further submissions of evidence, rebuttal of health board statements and recounting experiences where their own policies were not followed.

The outcome [of the Ombudsman’s investigation] was devastating in that it confirmed my worst fears, yet reassuring that I had been right not to give up. If the outcomes in this report prevent one death or stop one family going through what we have experienced in terms of distress, trauma and at times, simple exhaustion, it means that the injustice to my father will not be forgotten and dismissed as simply unfortunate.

I would encourage anyone who makes a complaint and feels the response is inadequate to contact the Ombudsman. Only if families keep challenging will this Health Board be held accountable for not investigating complaints fully and objectively.

Read the Report here.