NHS Complaints Advocacy Case Studies

Although most people using the health service are happy with their care and treatment, things can sometimes go wrong. If you’re not satisfied with the service you’ve experienced from a hospital, doctor, dentist, local surgery or any other NHS provider, you are entitled to complain about it. 

Below are some case studies of members of the public who have used Healthwatch Warringtons Advocacy service and their experiences.

(Their names have been changed to protect their privacy)

Making a difference for themsleves

Case study 1

Pauline (not her real name) was referred to the advocacy service for support with a needs assessment under section 9 of the care act, she met the criteria due to having been deemed (by the referrer) to have ‘substantial difficulty’ in being involved in the process and with no one willing or able to assist her at the time. 

Her circumstances were that, following an accident at his home she had been admitted to hospital as the result of a life changing injury.  At the point of discharge, it was acknowledged that she could not return to her home.  This was because it was not suitable for a wheelchair user and prior to the accident it had become cluttered and was in a neglected state, needing major repairs.  She was therefore discharged to a care home as an interim measure. 

Advocate met with Pauline at the care home regularly over the period of 2 months.  During the meetings options were explored, in terms of both care needs and housing requirements.  It was clear that Pauline didn’t require any support from the care staff as she was able to meet her own care needs.  However, she was unable to access the community independently.  She was not able to manage her food and drink simply because she had no access to an adapted kitchen or the community to purchase groceries.

Advocate established Pauline’s wishes which were to regain some independence and leave the care home as soon as was practical.  Advocate sourced a service to register her with social housing property pool (and facilitated this by taking a mobile phone into the care home).  Advocate supported Pauline to explore and consider the adaptions needed to return to her own property, such as adapted bathroom, adapted doorways, adapted kitchen, through floor lift.  The local authority had previously supported with clearing his property but there were also repairs outstanding. 

Following a discussion with Pauline, the advocate requested the local authority commission some hours for a personal assistant (PA) to support Pauline to access the community and to explore the practicalities of returning home or selling her home and moving to a suitable property.  The PA could also support Pauline to manage her property pool bids as Pauline had no access to technology in the care home.  The advocate also supported Pauline to ask the local authority to make a referral to OT to consider home adaptions and wheelchair services for an electric wheelchair assessment.

Case study 2

Edgar (not his real name) was in his 90s and living in his own home.  He was referred to the advocacy service in relation to a section 42 enquiry under the care act.   He met the criteria as she was assessed as having ‘substantial difficulty (by the referrer) and with no one appropriate or willing to assist him to consider the safeguarding concerns and any outcomes he wanted from the enquiry.

At the time of the referral Edgar was in a respite placement, partly due to concerns around a ‘carer’ who was managing his money.  There had been further concerns around the behaviour of the ‘carer’ and (her partner) raised with the local authority by members of the public in the months leading up.

Advocate met with Edgar, initially in the respite placement, but he did not acknowledge some of the concerns raised, and felt that the ‘carer’ was a ‘good person’ and said that he ‘completely trusted her’.  However, during the discussions about the safeguarding concerns, he explored some events and issues that he said had worried him.  He was able to say that he did not want to return home with the support of the ‘carer’ and that he wanted to spend the next part of his life in a care home, he had identified one he had seen previously, and advocate supported him to say he wanted to move there.  After he moved, the advocate visited, a few weeks into his stay, he had a comfortable room overlooking a garden, and he told the advocate that he was ‘much happier’ than he had been at home.  Saying ‘there is always someone to talk to and they look after you here’

Making a difference for Family

Our ICAS service was contacted by Mrs. E as she had sent a letter of complaint to the trust on behalf of her late father.  Mrs. E was confused by the complaints system and asked for support from an advocate.  Mrs. E and her advocate discussed her concerns, and the advocate supported Mrs. E to draft a letter of complaint to the hospital.

Mrs. E received a response and was not satisfied that her concerns have been addressed.

The advocate supported Mrs. E in attending a local resolution meeting.  This raised further concerns and questions for Mrs. E about the care and treatment her father received.

Mrs. E was satisfied with some of the changes implemented following her complaint but there were other areas that she felt had not been addressed.

The hospital has implemented changes as a result of Mrs. E’s complaint, which included:

  • Due to not using passwords when required the trust has ensured all staff have completed ‘Information Governance Training’.  At the time of the complaint, 68% of staff on the ward had received this training.  The trust state that within 3 months following the complaint they are going to ensure 100% of staff on the ward are compliant. 
  • The trust acknowledges that communication was ‘not as good as it should have been when (client’s father) was transferred from Ward (no.) to Ward (no.).  Therefore, as a result of their investigation, they have appointed a family liaison lead to ensure family members are kept up to date.
  • The trust state that due to this complaint their investigation has identified a lack of information communicated during handover.  They have now added ‘infection’ to their handover sheets to ‘ensure this is discussed’. 
  • Monthly matron walkarounds have now been implemented with infection control and domestic supervisors. 
  • The trust has as a result of this complaint also implemented a ‘Matron Listening Surgery’ to ensure patients, visitors and staff can ‘raise and share concerns for immediate discussion and investigation’.  These times will be listed on the Ward notice board. 

The advocate supported Mrs. E in making an application to the PHSO which was declined.  The client was aware this was a possibility but wanted to ensure she “had done all I can for my dad”.  

Feedback from Mrs. E:

“I could never thank you enough for your help and support and all your kind words”

Mrs. K and Mr. D no longer live together, but she has Power of attorney over his affairs and supports his care needs due to his numerous health conditions including arthritis, mental ill-health, and dementia. Mrs. K is in her mid-60’s and Mr. D is in his late 70’s.

During 2019 and 2020 Mr. D’s health had deteriorated. He was due steroid injections in March 2020 to keep him mobile. She had attempted on numerous occasions to get him help from his GP at Grove Medical without success being told they weren’t doing them because of lockdown but they didn’t arrange for an alternative provision. Mr. D needs steroid injections whenever he feels pain and when he keeps falling. On average he needs the injections every four months. His legs were getting worse, and he kept falling over.

Mr. D spent 20 days in the hospital from 8 October to 29 October after many falls. They checked him out with x-rays and blood. The health professionals could not believe he had not been referred to the hospital about the state of his legs. The professionals emailed the GP about this as did Mrs. K. The surgery was also contacted by the social worker & ambulance service regarding his care. None of these communications made any difference.

A community nurse attends Mr. D for Depo injections every month and Mrs. K couldn’t understand why the GP felt he couldn’t do a home visit for the steroid injection.

Mrs. K had tried discussing Mr. D’s care with the surgery direct, asking the doctor to call her in November 2020. Eventually, when Dr. P Venkataramanan phoned her where she says, he shouted at her when she challenged him about his care of Mr. D. She reiterated that Mr. D kept falling and he needed the injections to keep moving. The GP’s response was that he had other Mr. D’s as well to care for, ‘why does she not put him in a care home’? He then told her he would not be coming out to carry out the injection. She was shocked by his reaction causing her upset and raised blood pressure.

By December 2020 and after many falls, Mrs. K took Mr. D and saw another doctor at the practice. Unfortunately, due to so many falls, the GP couldn’t give him the injection as there was an injury to his knee. He made a referral to the hospital on 1 December 2020 for his arthritis which came through with a date for late April 2021.

A complaint was submitted via NHS England as Mrs. K felt she had been unable to make her voice heard when contacting the surgery. NHS England contacted the practice and asked them to provide a resolution. Mr. D finally had the steroid injection in April 2021 although his son had to take him, which isn’t easy.

Mrs. K says that Mr. D finally got his injection to his knee only with the intervention of the Advocate and complaint to NHS England. However, the failure of a referral some years ago for his arthritis, issues with getting the steroid injections, and many falls, means that the deterioration of his knees has gone too far gone to operate.


Find out more

If you would like to find out more about, this statutory service providing help under the Mental Health Act, Mental Capacity Act, and the Care Act, independent advocacy, as well as ICAS service – get in touch.