Written evidence from A6 (PHS 20)
Public Administration and Constitutional Affairs Committee
Parliamentary and Health Service Ombudsman Scrutiny 2019-20 inquiry
[DVT subsequently diagnosed privately 37-days after attending A&E, with no injury found to explain the 5 ½ week deterioration during the time from onset to diagnosis, albeit without a single NHS test during that time despite two GPs noting ‘suspected DVT’ 11 days prior to my accessing the diagnostic test privately which diagnosed the DVT, the NHS being on Black Alert at Addenbrookes with my GP advising me not to attend A&E and failing to provide access to competent or equitable care].
PHSO’s EN-15432/0064 11 June 2013 response failed to investigate the 16 September 2012 complaint, despite that complaint being advised as logged as my formal complaint by PALS. PHSO EN-15432/0064 failed to investigate GP, OOH, A&E, PALS, failures in care during the further 16 days after the complaint, that it took to access a diagnostic test for my acutely symptomatic proximal DVT, despite that complaint being made and acknowledged by PALS, [and a separate copy provided as a print-out to my GP [Name redacted] on 17 September 2012. [GP] did not provide a referral to EAU3/TTT despite his observing the swollen limb on 21 Sep 2012 and commenting on [Doctor K’s] ‘suspected DVT’ note from the evening before, after he had been unavailable due to Cottenham Surgery being closed without any voice message due to staff training]. My GP noted ‘suspected DVT’ on 20 Sep 2012 ([Doctor K]), and 21 Sep 2012 ([GP]), yet neither provided any referral to exclude or diagnose a DVT until [Doctor R] on 2 Oct 2012 AFTER the DVT had been diagnosed by a hip and knee surgeon who had NOT been present at the time of diagnosis, and who had not provided access to Haematology or any competent oversight. [Doctor R] failed to date her 2 Oct 2012 EAU3/TTT ‘suspected DVT’ referral made after the DVT had been diagnosed privately, (logged on my GP record 2 Oct 2012, records accessed August 2016 after much stymying, including reporting [Doctor T] to GMC (GMC did not investigate or followup, but the patient records were finally provided to me after some further delay for ‘processing’ and ‘summarising’ though they did contain another - male - patient record for a key date (18 Sep 2012), with a different name, date of birth, different address, different medical presentation and different NHS number)). NB the DVT was diagnosed at 5:37pm at Spire Bupa Cambridge Lea and I was given heparin and warfarin in the corridor at 8pm by a nurse, and told to attend my GP the following day, after 37-days of asking GP, NHS NHS Direct, OOH, PALS for help, 37-days after attending A&E. PHSO 11 June 2013 Decision Letter by [Caseworker M] EN-154532/0064 determined that it was acceptable to:
Leave a patient in pain without tests for 37-days, deterioration.
Fail to provide access to crutches or diagnostic care.
For GP, OOH, NHS Direct to fail to respond to a formal written complaint.
For NHS Addenbrookes A&E to apparently amend records retrospectively.
For NHS Addenbrookes to fail to respond to a complaint in a time frame where there was an opportunity for prompt care to reduce further harm, versus it taking a further 16-days after multiple GP visits and phoning NHS Direct near-daily, to access a test even AFTER two GPs had noted ‘suspected DVT’ but refused access to NHS care, and 37-days after attending A&E.
On 16 September 2012 at 12:20 I made a written complaint to PALS at Addenbrookes. The nature of the complaint was that: 1/ I had attended A&E at Addenbrookes on 26 August 2012 following deterioration after a minor onset on 25 August (when having completed a 27 ½ minutes parkrun at Cambridge parkrun I had noticed a slight right calf pain that interfered with the lower leg).
Deterioration overnight despite RICE self-care meant that I was advised to attend A&E. On 26 August 2012 I had been triaged to A&E Minor injuries and discharged without crutches or tests or followup. 2/ I continued to deteriorate, on 3 Sep 2012 NHS Direct advised that I needed crutches. I was unable to access crutches via my GP or via Addenbrookes, I was home alone with my husband away on business in USA from 27 Sep 2012. 3/ On 5th (GP appointment) and 6 Sep 2012 I asked my GP again for help, repeatedly. Without any help. 4/ On 14 September I deteriorated further and was unable to walk or drive, and my husband was still away. Overnight my condition deteriorated but I was refused a home visit by Union Lane Nurse [Nurse M] despite ‘urgent’ triage for my cold white leg, and I lost consciousness. On 15 September I called my GP, PALS, NHS Direct for help, and subsequently made the written complaint on 16th September 2012. [NB I saw my GP subsequently on 20 September where ‘suspected DVT’ was recorded by GP Union Lane [Doctor K], as my own GP at Cottenham Surgery Lewis House was unexpectedly closed for staff training on 20 September 2012. On 21 September 2012 I phoned Cottenham Surgery 6 times, but the receptionist refused me an appointment. [GP] said that he would sign a Bupa referral at that point, which he did on 21 September 2012. Bupa had a backlog of NHS-funded old people getting taxation-funded hip replacements so there was no ultrasound until 1 October 2012. Cottenham Surgery only referred me to Addenbrookes to have my ‘suspected DVT investigated on 2 October 2012, the day after Bupa had diagnosed the DVT. The doctor [Doctor R], Cottenham Surgery, did NOT date the referral form for ‘suspected DVT’ and did NOT attach any Bupa/Spire scans or documents nor the consultant letter. Nor did Addenbrookes do any scans or tests other than a blood test to check what dose of warfarin and heparin that Bupa had given me in the corridor at 8pm 1 Oct 2012, ie. the previous evening at Spire]. I complained in writing 16 September 2012 12:20pm, via email to PALS about
1/ The failure of Addenbrookes to investigate a deteriorating unexplained onset over (37-days, but at the time of the written complaint) 21 days on 16 September 2012.
I complained about
2/ the failure of my GP, and associated services, Cottenham Surgery and Union Lane out of Hours, to provide care over those 21 days.
That complaint was accepted as a formal complaint on 17 September 2012 at 11:22am by [Micro Legal Administrator R] at Addenbrookes by email. However the 37-days delay in accessing NHS care despite repeated attempts, resulting in (now permanent limb impairment, wasting and a clawed foot) harm, as the key complaint, was NOT acknowledged by the PHSO Complaint Response by [Caseworker M] dated 11 June 2013, EN-154532/0064. The response from the investigation by [Caseworker M] at PHSO, in her Decision EN-154532/0064 dated 11 June 2013 was that:
‘You complained about the care and treatment provided to you by the Trust’s Emergency Department and its Thrombosis Treatment Team (TTT) from September 2012 to March 2013’
• - NB I complained on 16 September 2012 about ED failings 26 August 2012, and I was next referred to Addenbrookes on 2 Oct 2012. So, I had no (Addenbrookes Trust) care during September 2012. I complained about the inability to access care for an undiagnosed acutely symptomatic proximal DVT via either Addenbrookes or via my GP, as I deteriorated. My DVT was diagnosed 1 Oct 2012 at Spire through Bupa, despite Drs [GP and K] on 20 and 21 September 2012 recording ‘suspected DVT’ but without excluding a DVT or making any NHS TTT Referral until after Bupa had diagnosed the text-book symptomatic DVT 37-days after I first presented to Addenbrookes A&E with unexplained deterioration following a trivial onset and RICE self-care overnight.
• ‘You complained that the ED staff failed to properly examine or correctly diagnose your symptoms when you visited on 26 August 2013’
• - NB. Letter was dated 11 June 2013. I had attended A&E on 26 August 2012 when I was discharged without crutches, follow up or physio.
• ‘we think that the care that the treatment provided to you by the Trust was reasonable… staff noted that your leg function was improving and recorded a reasonable assessment including a physical examination’... ‘our Advisor would not have expected ED staff to carry out an investigation into possible DVT’... ‘the ED notes of your visit do not record anything about crutches’. ‘You complained that you were not physically examined whilst under the care of the TTT [NB this was 37-days after the A&E examination, with no other Addenbrookes examination or tests] or given access to a consultant. The Trust said that you had been referred to TTT by your GP, having been previously seen by a private consultant [a private hip and knee surgeon at Spire for my LEFT knee as my right leg was useless and I wanted one functioning leg, the orthopaedic consultant over a week earlier]. The TTT nurse had not considered any further medical assessment necessary…. Medical oversight remained the responsibility of your GP. The Trust also said that you had been offered an appointment with the TTT consultant which you had refused…. The notes show that a medical history was taken at the start of your treatment and no contraindication to warfarin was recorded. From what we have seen it may be possible that this and the handwritten notes were amended retrospectively…’
• Regarding [Caseworker M’s] conclusion in 11 June 2013 EN-154532/0064 that:
• ‘In one of its decision letters the Trust told you that the TTT nurse had obtained all the relevant information needed before continuing the treatment that had been started by your GP….We therefore considered whether this possible omission indicated a more general failing in history taking or assessment. No other evidence suggesting inadequate history taking has been identified by our Adviser and in the absence of any other evidence of failings in the care provided by the TTT we cannot conclude that any wider failing occurred.’ - My GP had NOT started treatment. I had been given heparin and warfarin in a corridor at Spire Cambridge Lea Bupa at 8pm on 1 Oct 2012, without any Haematologist oversight, a week after I had an appointment with an orthopaedic consultant on 24 September 2012 Cambridge Lea Bupa Spire at 09:30am, where my left knee was specifically mentioned.. And my right limb swelling had been noted as ‘suspected DVT’ had previously been documented by two NHS GP on 20 and 21 September 2012, 20 September 2012 at Union Lane out of hours, [Doctor K] , and 21 September 2012 by [GP] at Cottenham Surgery - neither had excluded a DVT with any test. The notes relating to the diagnosis of the DVT were NOT provided to Addenbrookes at any point during my finger prick blood tests for INR on 2, 3, 4, 5, 6, Sep 2012, or my 8 Sep 2012 single appointment where Anticoagulation Nurse [Nurse 2] assigned my Haematology oversight to Spire Cambridge Lea Orthopaedic Consultant [Mr A], backdated 1 October 2012 to 1 January 2012, with the document date 8 Oct 2012. Inexplicably, Nurse Sleep/Clinic33 had by then amended a document which I accessed via SAR in 2014, showing the 1 October 2012 Heparin as administered by Addenbrookes. The same SAR showed that no scans or evidence of any injury were provided to Addenbrookes prior to 8 Oct 2012 when I was discharged to Spire care (without funding and with a Hip and knee Surgeon named as Haematology oversight on the 8 Oct 2012 Clinic33 document.
• Despite the original complaint including my GP, and [GP] being provided with a copy and asked to respond on 17 September 2012: there was no response from [GP], and his practice partner claimed in 2013 that he had emigrated to Australia. When he left the practice, the Medical Secretary found a Bupa Referral dated 10 September 2012, which had been in his drawer, which she handed to me in an envelope Autumn 2013. (that would have related to my repeatedly phoning and asking for help between 4 September 2012, and then more insistently after the deterioration with the cold white leg on 14-15 September 2012 overnight when [Nurse M] refused to provide a home visit or ambulance – [Mr S] listened to that recording in 2016 when they finally responded, but he refused to give me a copy of that recording where I cried and pleaded in pain for NHS help, whilst the bullying nurse ‘explained’ that my pain was ‘raynauds syndrome’ by telephone without any visual or examination of the limb).
• It is worth noting, that [Mr L] Complaints Manager at Addenbrookes noted in a Complaints letter that Addenbrookes had been unable to access the records from Spire, Bupa, or [Mr A] the Orthopaedic Consultant whom I had only seen once, a week prior to the ultrasound where my DVT was diagnosed in my thigh at my suggestion reminding ultrasound technician again that I had a parental history of DVT (in a slim, active, no varicose veins, parent), after Bupa had failed to find any injury to explain five and a half weeks of deterioration resulting in a useless, swollen, right leg, without dorsiflexion, and unable to weight bear, cold and discoloured. My conclusion is:
• It appears pointless to use taxation-funding to fund PHSO. Patients should instead be directed to legal services who might be better incentivised to help via the legal system.
• The truth is that getting truthful answers or closure*, is not accessible to the non-medic after serious harm. I have been left as a previous half-marathon runner, with an impaired right leg that is wasted, weak dorsiflexion, pain at rest and walking due to post thrombotic syndrome, and difficulty accessing RAL2 NHS prescriptions to mitigate the post thrombotic syndrome.
• The failings by PHSO Decision EN-154532/0064 contributed to further medical harm, by failing to give Addenbrookes, my GP, Out of Hours, NHS Direct, opportunities to learn from mistakes and to improve care:
• - * the most important being to make real time notes accessible to patients, so as to give patients real time information on what has been documented, so that people like me, in future, that they might re-present in time to preserve their limb function.