Lessons learned after NHS report

The case of the man, known only as Mr L, was highlighted in a damning report released yesterday by the Parliamentary & Health Service Ombudsman into NHS handling of complaints nationally.

Mr L, who suffered from severe learning difficulties, died on August 4, 2008 after initially having been admitted to the L&D to have a polyp removed from his stomach.

He was discharged but readmitted the next day and had a tumour removed from his colon.

Despite some improvement, his condition worsened and he died several days later.

Mr L’s parents, Mr and Mrs W, formally complained to the L&D that they felt excluded from his care despite being experts in their son’s needs.

They said that had they bee asked they could have told consultants that he only wanted to go home because he didn’t like being in hospital.

Instead he was discharged because his specialist needs were not understood by staff.

Mr and Mrs W said: “Even when we kept telling the bursing staff that we thought he was worse we were ignored.”

The couple were only informed of Mr L’s second round of surgery at the eleventh hour and were not told what the procedure involved.

Unaware of how ill their son was, Mr and Mrs W were upset that they were not able to be with their son when he died.

Their devastation was confounded when an L&D consultant later wrote to Mr L’s doctor saying that he “could not tell what was going on” and described Mr L as “mentally sub-normal”.

The consultant later apologised.

Following the case, the L&D issued an apology to Mr and Mrs W and paid them £3,000 for the injustice caused.

The Listening and Learning report into complaints made to NHS trusts in 2010-11 found that the most ‘straightforward matters’ are still not being dealt with by NHS trusts ‘adequately’.

In all, 33 complaints were made to the L&D, six fewer than the previous year, with the Ombudsman intervening in one case.

Four investigated cases were reported on and all four of those complaints were upheld.

But the L&D said that steps have been taken to ensure that mistakes like those complained about in the case of Mr L will not happen again.

A statement released yesterday said: “The Luton and Dunstable Hospital can confirm that, following an investigation by the Parliamentary and Health Service Ombudsman, the hospital wrote again to Mr L’s parents to reiterate its apology for the failings in its services.

“The hospital has learned from this case and has undertaken several initiatives to promote awareness so that staff are aware of the needs of patients with learning disabilities and to ensure that it provides the best standards of care. This includes setting up a service improvement group with staff, patients and carers as well as providing training for staff to ensure that they are aware of the need to involve patients’ families when making decisions about patients who have learning disabilities.”

Complaints made to NHS Luton went up last year from 15 to 21.

None of those complaints were upheld.