Mid Cheshire Hospitals NHS Foundation Trust

7. Mr X complains about the care and treatment provided to his daughter, Miss Y, by Mid Cheshire Hospitals NHS Foundation Trust (the Trust). He complains:

• There was a delay in prescribing omeprazole to Miss Y • there was a failure to renew open access • staff were dismissive, defensive and confrontational during the complaints meeting • he was accused of being aggressive and this was added to records • there was poor communication from staff who informed omeprazole was ready for collection when it was not.

8. Mr X states the impact was that:

• Miss Y was left without omeprazole for six days, which left her visibly distressed and struggling to retain feed • Miss Y has experienced delays in growth and walking • Miss Y suffered with constipation and blood in her stool causing her pain • it caused physical and mental distress to Mr X and his wife which caused hospital admissions and an inability to carry out normal daily activities such as work which caused a loss of income.

9. Mr X would like an outcome of an apology, service improvements, financial remedy, a recording of the complaints meeting and for it to be considered whether the word aggressive can be removed from medical records.

10. What follows is a brief summary of events leading up to the complaint. We do not include all details as both parties to the complaint are aware of these.

11. In mid-December 2024, Miss Y was experiencing symptoms of vomiting and was struggling to retain feed.

12. Mr X contacted his GP by telephone to discuss this, and the GP scheduled an in-person appointment.

13. The GP assessed the symptoms and contacted the Trust for further advice who advised it warranted further assessment and Mr and Mrs X brought Mrs Y to the hospital the same day.

14. At the hospital, Miss Y was assessed and reflux was found to be the cause. Miss Y was prescribed carobel and 48-hour open access was given to the parents.

15. Carobel didn’t work and six days later omeprazole was prescribed and Mr X collected this directly from the ward.

20. When we look at a complaint we first consider what are the relevant standards or guidelines to inform what should happen. Next, we go on to consider the version of events from all parties. We do so to identify if care fell so far below a standard to be considered a failing (often referred to as ‘maladministration’). We recognise not all failings will be maladministration and some could be shortcomings. Where we identify this, we will make that distinction.

21. If we identify a failing, we consider the impact and injustice on the aggrieved and if we can link this to the failing. We refer to this as ‘flowing’ from the claimed injustice. We must be able to link this to reach a full decision.

22. Following this we then look to establish what the organisation has done to put matters right for the failing (the ‘remedy’). We also note that not every failing will be maladministration. On occasions this could be a shortcoming. Where we identify so we will make this distinction in our decision making.

23. If we consider more could be done, we may make a range of recommendations. Though we consider the individual circumstances of each complaint, it is for the Ombudsman to determine remedy that is fair, proportionate and reasonable.

24. Having done so, in some instances we cannot link the events complained about with the negative impact Mr X has claimed, in other instances we have found the Trust has already done enough to put right the impact of these events.

Omeprazole and poor communication

25. Mr X says that there was a six delay in prescribing omeprazole to Miss Y. He also complains that during this time there was poor communication from staff as he was incorrectly informed omeprazole was ready for collection.

26. The following guidance is relevant here to inform us what should happen: NICE Gastro-oesophageal reflux disease in children and young people: diagnosis and management’ (2019)

27. NICE guidance on reflux disease in children and young people states that the following stepped-care approach should be used: ‘review feeding history and then offer a trial of thickened formular’.

28. From the medical records we can see that when Miss Y was brought to the hospital, she was assessed and there were no red flags to her health. We can see Miss Y’s feeding and behaviour was monitored and then she was given feed thickener.

29. Our adviser says that the use of feed thickener and monitoring instead of prescribing omeprazole at this point was entirely reasonable management and appropriate to the symptoms Miss Y was having.

30. Once discharged, Mr X says that he called the hospital the following day and informed them that the thickener wasn’t working. Mr X says he was told that the prescription for omeprazole would be completed the same day for him to pick-up. Mr X says this did not happen.

31. The Trust says that Mr X called the hospital the day after this and was informed an omeprazole prescription could be given but not today due to being out of hours and not listed as a critical medication which would mean an out of hours pharmacist could be contacted. The Trust says it informed Mr X that the prescription would be chased the following day.

32. From the advice sought we understand that omeprazole would not be considered an emergency drug and therefore it is entirely reasonable that the Trust did not call an out of hours pharmacist to prescribe the medication. We also note that it is difficult to see which calls took place on which day due to a lack of medical records after discharge. Factually we note record keeping is not part of the investigation.

33. The following day omeprazole was issued for prescription and three days later Mr X collected the prescription directly from the ward. Omeprazole was given to Miss Y six days after she attended the hospital.

34. We understand that Mr X being incorrectly informed omeprazole was ready for collection would have been stressful and worrying and we do not underestimate how this must have affected him. On this occasion we do not consider this falls so far short to be considered maladministration more so this would be a short coming in communication and likely a human error.

35. We can see that the Trust have apologised for this and are making changes within their pharmacy team, where they will use a medication drop box at the front of the hospital. They have also planned for parents to receive a text when the prescription is ready for collection.

36. Taking all this into account, it appears the Trust has acted in line with our complaint’s standards as it has seen Mr X’s complaint as an opportunity to develop and improve its service and the Trust has apologised for the stress this would have caused Mr X.

37. We sought to understand the physiological impact of this better and spoke to our adviser. From that we understand that the six-day delay would not have caused physical harm to Miss Y. We understand omeprazole is not an urgent medication and there were no other concerns about Miss Y’s general health. We note (from the same advice) omeprazole often takes a couple of weeks to take effect and that it is very common for baby’s vomiting milk to be referred as an outpatient where they may wait many weeks to be prescribed omeprazole.

38. Our adviser explains there is no evidence of a link between the six-day delay in prescribing omeprazole and Miss Y experiencing delays in growth and walking or Miss Y suffering with constipation and blood in her stool.

39. Though we recognise a missed opportunity of a relatively short duration for a better outcome in prescribing omeprazole to Miss Y, from the clinical advice received there is no link to growth delays or walking and mobility issues. Similarly, we would not be able to link this to a loss of income as we have seen no evidence that suggests an indication this impact and injustice could be seen to ‘flow’ from the matter we have investigated as had the medicines been prescribed timely we recognise there is still a delay to them reaching their desired efficacy and we simply would not be able to determine their success of working or not.

40. In relation to Mr X’s complaint that he was incorrectly informed omeprazole was ready for collection and travelled to pick to up unnecessarily we would consider that this shortcoming has been addresses and the Trust has already done enough to put this right.

41. This is because when considering remedy, we rely upon our principles for remedy which guide us to thinking of a remedy that is fair, proportionate and reasonable. We also rely upon our severity of injustice scale. This is a scale of six levels of injustice ranging from low level occurrences of physiological or emotional impact leading up to level six where we may see permanent disability or avoidable death occurring.

42. Here we have identified a missed opportunity lasting a relatively short period of time no more than two weeks. This sits at level one on the scale where we would normally consider an apology alone is enough to remedy. Here we have seen an apology and learning taken which we consider is fair, proportionate and reasonable.

43. For these reasons we will not consider this complaint part any further.

Open access

44. Mr X says that he was initially given 48-hour open access to the ward and was told that this would be extended so that he would be able to return to the ward directly if Miss Y’s condition worsened. Mr X says that this was explained verbally but not documented and therefore this was not extended.

45. The Trust have recognised and apologised for this. Staff have been reminded about clearly documenting conversations and advice given so that there is a clear audit trail. The Trust has also updated its process on Open Access so that a slip will be given to parents on discharge which ensures it is correctly documented and the process of gaining Open Access is correctly explained.

46. From the medical records we can see that the Trust have noted 48-open access, but nothing has been noted on the documentation about the extension.

47. Our adviser has informed us that if the family were concerned about Miss Y’s condition or if her health began to worsen then Mr X could have still attended the hospital via the emergency department and therefore still access prompt healthcare.

48. This means that although there was a failure of record keeping as the extension of Open Access was not added to Mrs Y’s records (record keeping not part of this complaint we look into) it did not mean the family could not seek advice if they were concerned and therefore did not have a negative effect on Miss Y’s health.

49. When deciding on a level of financial compensation, we use our severity of injustice scale to guide what we may ask an organisation to provide. Injustices which fall at level one on the scale are ones where the complainant has faced ‘annoyance, frustration, worry or inconvenience and where the effect on the individual is of short duration’

50. We appreciate Mr X experienced four days of stress and frustration due to not having Open Access to the ward extended. We do not underestimate the frustration and stress he experienced at this time.

51. For these reasons we would place Mr X’s injustice at level one on our scale. When an injustice does fall at level one on our scale, we do not deem compensation to be appropriate. Even in consideration of the cumulative impact of this and the previous identified missed opportunity we do not consider both together go beyond level one.

52. We conduct precedent checks into all complaints we investigate to consider if there are wider organisation wide failings that then go onto inform our consideration of remedy. We note Mr X seeks service improvements in this area. We have not seen cause to consider the need for further organisation wide improvements here and therefore consider an apology is fair and proportionate.

53. Taking all this into account, it appears the Trust has acted in line with our complaint’s standards as it has seen Mr X’s complaint as an opportunity to develop and improve its service and it has been open and sincere. The Trust has apologised for not documenting the extension of open access. It has also explained how it has altered its process to ensure this does not happen again.

54. When considering this aspect of Mr X’s complaint, we consider that the Trust has already done enough to put right the impact of these events.

Staff behaviour

55. Mr X says that during the complaints meeting staff were dismissive, defensive and confrontational. Mr X also says he was accused of being aggressive on the phone by staff.

56. Having looked through the records, we have not found any medical records where it states Mr X was aggressive.

57. We have also listened to the recording of the complaints meeting and we do not feel staff failed to meet the expectations set out in the complaint standards of being ‘transparent, honest and open to development.

58. We understand that Mr X perceived the staff to be dismissive, defensive and confrontational and understand how this may be a subjective consideration.

59. We consider that the Trust has acted in line with our NHS complaint standards, it sought input from relevant staff, organised a complaint meeting where they were open and transparent and followed up with the written response.

60. In these situations, where there are conflicting accounts and conflicting perception of events, we are unlikely to reach a view as to whether there are failings.

61. Lastly regarding the outcome of seeking an amendment to medical records to remove the Trust’s account of Mr X being aggressive. This is an outcome the Ombudsman cannot achieve. We reference the NHS guidance on this: https://transform.england.nhs.uk/information-governance/guidance/amending-patient-and-service-user-records/

62. We note a patient or user has a legal right to ask for records to be amended but a Trust has no legal obligation to make those changes happen. This is because even in record keeping, if inaccuracies are present these still may be the rational and reasoning that led to a decision being made and thus both as a clinical and legal account those records would need to be present for audit. In this instance Mr X could request a foot note to be added to the records. The Ombudsman could not make a Trust change records.

Conclusion

63. We recognise this complaint and the circumstances around it have caused Mr X considerable distress and worry. We hope our report reassures Mr X that appropriate action has been taken to address his concerns. We thank Mr X for bringing his complaint to us.

1. We have carefully considered Mr X’s complaint about Mid Cheshire Hospitals NHS Foundation Trust (the Trust).

2. Mr X says in December 2024 the Trust failed to appropriately care for his daughter, Miss Y, both during and after her admission to hospital for reflux. He also complains that the hospital failed to renew Open Access, and that staff were defensive and confrontational during the complaints meeting and that he was accused of being aggressive.

3. We sincerely appreciate this must have been a very distressing time for Mr and Mrs X. We hope this statement gives Mr X reassurance we have thoroughly considered his concerns. We are grateful for the time and effort Mr X made in bringing his complaint to our attention.

4. We have carefully considered Mr X’s complaint and have seen indications of failings in some areas. Where we have seen the Trust has got things wrong, we think it has done enough to put right the impact this has had on Mrs Y and Mr X. We explain this is more detail below.

5. In some instances, we cannot link the events complained about with the negative impact Mr X has claimed and therefore, on those points, would take no further action.

6. In making our decision, we do not intend to diminish how stressful this time must have been for Mr X and his family.