Source · PHSO decision

Northumbria Healthcare NHS Foundation Trust

Ref: P-002047 Statement Decision date: 23 June 2023 Jurisdiction: NHS in England Closed After Initial Enquiries

The Trust did not accurately autopsy her father's body, causing anxiety about organ mix-up and exacerbating her grief.

Outcome

AI summary
The complaint was closed. The Trust already accepted its failing and apologised for the autopsy mistake, which was deemed sufficient.

The complaint

4. Mrs O complains the Trust did not accurately autopsy her father’s body.

5. Mrs O says this caused her anxiety about whether her father’s organs had been mixed with another dead person, and added to her distress while she was grieving.

6. Mrs O would like an apology and for the Trust to accept it got things wrong.

Background

7. The Trust did an autopsy three days after Mrs O’s father died.

8. Mrs O and her family saw there was an error on the coroner’s report because it included information about a gall bladder. Her father had his gall bladder removed around 18 months earlier.

9. The coroner’s office notified the Trust of this and it corrected the error.

Findings

12. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of the events.

13. Mrs O complained to the Trust on 29 June 2022 and got a final response from the Trust on 11 October.

14. Our ‘Principles for Remedy’ say, ‘where maladministration [fault] or poor service has led to injustice or hardship, public bodies [organisations] should try to offer a remedy [solution] that returns the complainant to the position they would have been in otherwise’. It says an appropriate range of remedies includes ‘remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures to prevent the same thing happening again; training or supervising staff; or any combination of these.’

15. We can see the Trust accepted its administrative error in the autopsy report and apologised to Mrs O in its complaint response.

16. The Trust assured Mrs O that autopsies are done on only one person at a time and there would be no possibility of organs being accidently mixed up.

17. The Trust also confirmed the pathologist corrected Mrs O’s father’s autopsy report.

18. Our ‘Principles of Good Complaint Handling’ say that to put things right organisations should ‘provide an apology, explanation, and an acknowledgement of responsibility, as well as remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures, policies or guidance to prevent the same thing happening again; training or supervising staff; or any combination of these’.

19. We are satisfied the actions the Trust has taken are in line with our Principles. This action has also given Mrs O the outcomes she wanted. We thank Mrs O for bringing her concerns to our attention.

Our decision

1. The Parliamentary and Health Service Ombudsman has carefully considered Mrs O’s complaint about Northumbria Healthcare NHS Foundation Trust (the Trust). We are sorry to hear of Mrs O’s concerns about the autopsy the Trust did on her father.

2. We think the Trust has done enough to put things right by accepting the failing, apologising for the mistake it made with the autopsy and for the impact this has had on Mrs O. We are not asking the Trust to do anything more.

3. We can clearly see this has been a difficult experience for Mrs O. We hope our explanation below gives her some reassurance.

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Decision details

Reference
P-002047
Decision type
Statement
Jurisdiction
NHS in England
Decision date
23 June 2023
Outcome
Closed After Initial Enquiries
Responsible body
NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST

Complaint summary

AI
Summary
The Trust did not accurately autopsy her father's body, causing anxiety about organ mix-up and exacerbating her grief.

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Data from PHSO under Open Government Licence.