Hospital complaint- Clinical governance

[LovelyBath77]

I had a difficult experience in hospital a few years ago, something serious and unusual was missed and could have died. At the time I made a complaint and got a very defensive letter back from the hospital. However at the time I also had a letter from someone called the head of clinical governance for surgery, asking if I wanted to speak further with them

I thought at the time it was not looked into thoroughly but do you think this means it was?

Well it depends what the head of clinical governance has done with the complaint. They may have done a thorough investigation, they may have been passed your complaint, glanced at the notes and rung you for a chat.

I used to work in clinical governance (not surgery) and there were only two of us in the dept. Me and the head, and they pretty much looked at everything and passed smaller stuff to me.

It would have been looked into. Complaints usually passed on to the relevant teams for investigation. It is standard practice to offer a face to face meeting to make sure all questions/complaints have been addressed.

If you are still unhappy with their response or have unanswered questions, I would contact the head of clinical governance and arrange a meeting.

If you talk to them you can ask what they've done.

Difficult to say. Complaints should be signed off by the Chief Exec, but the Head of CG for surgery should be the person that further comments/queries should be directed to. It doesn't necessarily dictate the calibre of the response. But it does indicate where the buck stops locally.

You should have had information on "what happens next" if you're not satisfied with the response.

Please don't think I'm poo-hooing you at all, but what makes you feel that it wasn't investigated properly? (I work with complaints and investigations, and trust me, some are better than others!)

it was years ago now, 4 years. I was too ill at the time with complications to do anything more. Was sent home with intussusception as an adult (rare bowel obstruction) without proper tests. Hospital letter said things like 'such facilities are not always available' and I 'seemed healthy'. Anyway I just wondered whether this meant it was looked into or not.

I guess the tone of the letter in response made me feel it was seen as fine' and didn't give me faith it had been taken seriously.

Very difficult to conclusively say.

Personally I'd contact the Trust and find out whether there was an investigation and what the terms of reference were.

The "facilities are not always available" would ring some slight alarm bells with me. It would also be useful to know how they concluded that further investigations were not clinically indicated (including who assessed this, their level of training and adherence to local guidelines/policies)

I saw a doctor in the night who asked for the surgeons to see me in the morning, it seems the next day they evaluated I might have a cancerous polyp and let me go home and have an outpatients flexi sig, as my signs seemed OK. However was bleeding rectally and the type of obstruction presents with bowel sounds, so wasn't picked up. By the time I had the test I was then rushed into surgery, with ischematic bowel and sepsis.

There was also an issue as the tumour was found previously in a test, which they didn't check out. (didn't get my notes in A and E). The letter blames me for this 'if you had informed us of this you may have been treated quicker'. but I wasn't aware.

This would mean that the department doctor referred it to the Head of Clinical Governance to notify them of a potential claim. However, in simple terms, you have three years in which to make a claim, counted from the date upon which you first became aware that you had suffered injury as a result of medical negligence (if indeed you believe you did suffer as a result of negligence). from your original post it would seem you would be out of date to make such a claim.

However, you can ask what was done at the time to ensure it didn't happen again and that you'd welcome an apology.

I didn't claim for negligence, although did speak with someone at the time who wanted to take it on no win / no fee.

Do you think it's too long ago to ask now, it was in 2012? Oh, and also what do terms of reference mean? and why do you think the head of clinical gov want to speak with me about it?

To be fair, intusseption can be incredibly hard to diagnose and it may be that all appropriate clinical tests were done and no further tests indicated at that time.

The general public usually fail to understand that rare conditions or conditions that present in an unusual way can be incredibly hard to diagnose. We can't go around doing whole body CTs on everyone who walks through the door.

Having said that, you're still unhappy with the response and there may be more to it in your case. I would try and drill down on exactly which aspects of care are bothering you most and which questions you specifically want better answers too and write a letter setting it out clearly and asking to set up a meeting.

Twatchops has it exactly. Some conditions will be missed not because of negligence but because they are very rare and hard to diagnose. CT scans are not without significant risk because of the amount of radiation they impose.
If you really still want answers four years later, contact PALS to discuss and ask for someone to go through your notes to help you understand how the clinical decisions were made. Do think about what specifically you are unsure about. It doesn't sound like negligence- although ambulance chaser law firms will take on anyone on no win no fee basis (although there are time limits). It is spurious negligence claims that are, in part, the responsible for stretching NHS finances to limit.

Thank you for the replies, yes it is helpful. I am glad I didn't claim for negligence in the end.

I have since written to let the surgeons know how I'm getting on (I had quite a few complications afterwards, due to bowel obstructions and adhesions, and needed an emergency op elsewhere and they had;t got the discharge summary) and I had a lovely reply where they told me they were sorry they had;t explained everything to me (adhesions cause further problems for example) so feel a bit better. i guess in a way i knew as you say, it was rare and felt after maybe by complaint had caused problems for them. (it was a senior consultant set me home). Hopefully it is all OK.