Improving public service: a matter of principle HC9...Improving public service: a matter of principle First report Session 2008-2009 Presented to Parliament pursuant to Section 14(4)

HC 9

Improving public service:a matter of principle

Improving public service:a matter of principle

First report

Session 2008-2009Presented to Parliament pursuant toSection 14(4) of the Health Service CommissionersAct 1993 (as amended)andSection 10(4) of the Parliamentary CommissionerAct 1967

Ordered byThe House of Commonsto be printed on11 December 2008

HC9London: The Stationery Office£14.35

© Crown Copyright 2008

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ISBN: 9780102958348

Improving public service: a matter of principle | December 2008 3

Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

The National Health Service

Complaint about Rotherham Primary Care Trust and South Yorkshire Strategic Health Authority(now Yorkshire and the Humber Strategic Health Authority) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Complaint about the Healthcare Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Complaint about a General Practitioner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Complaint about the Healthcare Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Complaint about Pennine Acute Hospitals NHS Trust and the Healthcare Commission . . . . . . . . . . 19

Complaint about a Dental Practice and a Dentist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Complaint about Heatherwood and Wexham Park Hospitals NHS Trust (now Heatherwoodand Wexham Park Hospitals NHS Foundation Trust), Berkshire East Teaching Primary Care Trust(now Berkshire East Primary Care Trust) and the Healthcare Commission. . . . . . . . . . . . . . . . . . . . . . . . 24

Complaint about Taunton and Somerset NHS Trust (now Taunton and Somerset NHSFoundation Trust) and the Healthcare Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Government departments, agencies and public bodies

Complaint about the Immigration and Nationality Directorate (now the UK Border Agency)of the Home Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Complaint about HM Courts Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Complaint about the Disability and Carers Service (now the Pension, Disability andCarers Service) of the Department for Work and Pensions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Complaint about the Learning and Skills Council for England . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Complaint about HM Revenue & Customs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Complaint about the Security Industry Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Complaint about HM Courts Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Complaint about Jobcentre Plus of the Department for Work and Pensions . . . . . . . . . . . . . . . . . . . . 51

Complaint about the Criminal Records Bureau . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Complaint about the Health and Safety Executive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Complaint about the Department of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Complaint about Jobcentre Plus of the Department for Work and Pensions . . . . . . . . . . . . . . . . . . . . 61

Improving public service: a matter of principle | December 20084


Foreword

As Parliamentary and Health Service Ombudsman,I provide a service to the public by undertakingindependent investigations into complaints thatgovernment departments, the National HealthService in England and a range of other publicbodies in the UK have not acted properly or fairly,or have provided a poor service.

My Office has two key strategic objectives. Thefirst is to help individuals who bring theircomplaints to my Office. I want to provide anindependent, high quality and accessiblecomplaint handling service that rights individualwrongs. The second key objective is to offer awider public benefit. I consider it a fundamentalpart of my role to use the learning from myOffice’s 40 years of handling large numbers ofcomplaints to help drive improvements in thedelivery of public services and to help informpublic policy. In order to do this I am committedto sharing as widely as possible the learning fromthe complaints I receive and to doing more to tellpublic bodies in my jurisdiction, including theNational Health Service, about the value ofdealing with complaints promptly and effectively.I also recognise the importance of makingpotential complainants, and those who supportthem, aware of my role and what I can achieve forthem. For these reasons, I am publishing thesecase summaries which are the second set in anongoing new series1 of published summariesabout complaints that I have investigated.

I have chosen these cases because they clearlyillustrate good or poor practice in dealing withcomplaints from members of the public. Inparticular, the cases demonstrate how thingsmight have been handled differently if the public

body concerned had had in mind theOmbudsman’s three sets of Principles:Principles of Good Administration, Principlesfor Remedy2 and Principles of GoodComplaint Handling.

These Principles are broad statements of whatI believe bodies within the Ombudsman’sjurisdiction should be doing to deliver goodadministration and customer service, includingoffering remedy when things go wrong. ThePrinciples cover:

• Getting it right

• Being customer focused

• Being open and accountable

• Acting fairly and proportionately

• Putting things right, and

• Seeking continuous improvement.

I fully appreciate that when public bodiesdeliver public services on a large scale, thingswill go wrong from time to time. What is key ishow the public body then puts right themistake. The Principles are not a checklist tobe followed mechanically, but they do set outa framework for public bodies to have in mind.This will enable them to deliver a first classservice to the public and offer the rightapproach to putting things right when theygo wrong.

1 First in the series was Remedy in the NHS, June 20082 http://www.ombudsman.org.uk/improving_services/good_administration/http://www.ombudsman.org.uk/improving_services/remedy/

Improving public service: a matter of principle | December 20086

The Principles of Good Complaint Handling3 isthe third in the series of Principles. They werepublished in November this year, and build on thePrinciples of Good Administration and Principlesfor Remedy. The Principles of Good ComplaintHandling set out how public bodies shouldmanage complaints properly so that customers’concerns are addressed and dealt withappropriately. Complaint handling should be ledfrom the top, focused on outcomes andaccessible to the complainant. All too often I seecases where the complaint handling falls short ofthese entirely reasonable expectations. Mr S wasleft feeling frustrated and outraged following hisexperience with the Security Industry Authority,which sent his application form for a doorsupervisor’s licence to someone else (page 45).The Authority initially failed to explain theircomplaint process, failed to keep accuraterecords and did not put things right quicklyand effectively.

In the case of Mrs Y (page 14), a GP Practice failedto act on a Consultant’s letter, and compoundedthat by not responding to Mrs Y’s complaintabout that matter, having initially insisted thatthey had dealt with her complaint.

Complaints are also a valuable source of feedbackfor the public body. Handled well, they providean opportunity for public bodies to improve boththeir service and their reputation. That meansaddressing individual complaints but also fixingunderlying problems and using the feedback andlearning to improve performance. Moreover, goodcomplaint handling can save time and money andmay result in fewer complaints.

The cases in this report come from a range ofpublic bodies within my jurisdiction, including the

National Health Service. They show the Principlesin practice, for example what we mean by ‘Actingfairly and proportionately’, or by ‘Being open andaccountable’. In the case of Mrs C’s complaintabout continuing care funding for her friend,Mrs J, for example (page 9), we considered thatthe Trust and Strategic Health Authority had notacted fairly since their portrayal of health needsdid not provide evidence of Mrs J’s healthcareneeds drawn from all the available and relevantevidence; and had not been open or accountablesince they had not clearly explained how thefunding decision had been reached and whatevidence had been used.

The Principles show what can happen when thingsgo wrong and what can be done to preventmistakes happening again in the future. The caseshighlight where the Principles might have beenused to good effect to improve the outcome forthe complainant. I would like to emphasise thatwe have chosen these cases only to illustratewhat we mean by the Principle concerned.

Many of the cases highlight where public bodiesfail to put things right properly and do not takedecisions based on all relevant considerations.When Jobcentre Plus suspended Mr K’s incomesupport payments following a request from himto pay him by cheque, they left him withoutmoney for three weeks (page 61). They rightlyconsidered the question of a financial remedy forMr K, but then did not consider the full impact oftheir actions on him.

The three sets of Principles represent commonsense and good practice but I hope they also gofurther than that, to drive a shared understandingabout what makes for good administration andexcellent service and complaint handling in public

3 http://www.ombudsman.org.uk/improving_services/complaint_handling/


bodies and the National Health Service. I hopethat using the case studies to illustrate thePrinciples will help prevent mistakes of the pastbeing repeated and will encourage public bodiesto use the Principles of Good Administration,Principles for Remedy and Principles of GoodComplaint Handling to offer a better service tothe public. Complainants often say that theyhope that others will benefit from theircomplaint. I share that hope. This set of casesummaries is intended to enable others tobenefit from the learning from these individualcomplaints, as public bodies translate thatlearning into a better service for all.

Ann AbrahamParliamentary and Health Service Ombudsman

December 2008

8 Redress report | November 2008

Flawed consideration of an application forretrospective continuing care funding

Background to the complaint

Mrs J was admitted to a nursing home on10 November 1999 following a fall inSeptember 1999 in which she fractured her hip.She also suffered from dementia and transientcerebral ischaemia (temporary neurologicalproblems caused by interrupted blood flow). Shewas transferred to a second nursing home inNovember 2003 and remained there until shedied on 5 September 2004.

Mrs J’s friend, Mrs C, applied for NHS continuinghealthcare funding on Mrs J’s behalf in April 2003.The Local Review Panel of Rotherham PrimaryCare Trust (the Trust) considered Mrs C’s claim. Itconcluded that Mrs J was not eligible forcontinuing care funding from 10 November 1999to 3 August 2004, but from 4 August 2004 hercondition ‘became more unstable and complex’and she was thus eligible for funding from thatdate until her death. Mrs C appealed to SouthYorkshire Strategic Health Authority (theAuthority) about the decision. The ContinuingCare Appeal Panel, held on 22 November 2004,upheld the decision of the Local Review Panel.

In January 2005 Mrs C complained to theOmbudsman about the Authority’s decision. Weinvestigated and recommended that theAuthority thoroughly review Mrs J’s case. TheTrust subsequently completed a portrayal ofMrs J’s healthcare needs and a second LocalReview Panel was convened to reconsider Mrs C’sclaim. The Panel concluded that Mrs J did notmeet the eligibility criteria for continuing carefunding before 4 August 2004.

What we investigated

In May 2007 Mrs C complained again to theOmbudsman that Mrs J had not been assessedfor continuing care funding at any time she wasresident in the nursing homes. She said that theTrust had not compiled a robust and accurateportrayal of Mrs J’s healthcare needs and, inparticular, that the summary of needs had giveninsufficient attention to the end stage gangrenefrom which Mrs J suffered, and which requiredthe involvement of a tissue viability nurse.

We considered whether the Trust’s reviewprocess met the following expectations set out inthe Principles of Good Administration:

• ‘Getting it right’ (acting in accordance with thepublic body’s policy and guidance – publishedor internal).

• ‘Being open and accountable’ (being open andclear about policies and procedures andensuring that information, and any adviceprovided, is clear, accurate and complete; andstating criteria for decision making and givingreasons for decisions).

• ‘Acting fairly and proportionately’ (ensuringthat decisions and actions are proportionate,appropriate and fair).

In the context of retrospective continuing carecomplaints this is taken to mean that there willhave been:

• a robust portrayal of health needs, drawn fromall the available and relevant evidence;

• a fair, proportionate and reasonable process ofassessment/review which is inclusive ofrelatives and carers;


Complaint about Rotherham Primary Care Trust andSouth Yorkshire Strategic Health Authority (now Yorkshireand the Humber Strategic Health Authority)

• consideration of the person’s individualhealthcare needs by an appropriatelyconstituted and qualified panel, andcomparison of these healthcare needs to theeligibility criteria; and

• a decision conveyed to the claimant thatclearly explains how it was reached, theevidence used and the rationale.

We examined all the relevant documentation. Wealso took advice from an experienced nurse withconsiderable experience of continuing carereviews and assessments.

What our investigation found

We found that the needs portrayal did notprovide evidence of Mrs J’s healthcare needsbetween 2000 and 2002, and significant eventsrecorded in the portrayal concerning tissueviability and nutrition from 31 March 2004 werenot reflected in the summary and did not appearto have been considered by the Panel. There wasno reference in the Panel report to any of thecontemporaneous records to support thestatement that Mrs J was not eligible for fundingbefore 4 August 2004. We found that Mrs C hadnot been given a clear explanation for how thedecision was reached, the evidence used and therationale for the decision.

In summary, the Trust’s review process was flawedand for that reason we upheld Mrs C’s complaint.The investigation was concluded in May 2008.

Outcome

As a result of our recommendations:

• the Trust agreed to apologise to Mrs C for nothaving thoroughly reviewed Mrs J’s case; and

• Yorkshire and the Humber Strategic HealthAuthority (as the Authority’s successor) agreedto ensure that a robust re-review of Mrs J’s casewould be undertaken.

10 Improving public service: a matter of principle | December 2008

Principles of Good Administration

The following Principles of GoodAdministration were referred to in this casesummary:

• ‘Getting it right’ (acting in accordance withthe public body’s policy and guidance –published or internal).

• ‘Being open and accountable’ (being openand clear about policies and procedures andensuring that information, and any adviceprovided, is clear, accurate and complete;and stating criteria for decision making andgiving reasons for decisions).

• ‘Acting fairly and proportionately’ (ensuringthat decisions and actions areproportionate, appropriate and fair).

Flawed investigation of a patient’s complaintabout a dentist


On 18 June 2004 Mr G attended a dental practice(the Practice) for a routine examination. He sawDr L, whom he had not seen before. By Dr L’saccount, during the examination she noticed thatMr G was suffering from sensitivity in the lowerleft part of the mouth, and that the filling in thelower left second permanent molar tooth (LL7)may have been leaking. She advised Mr G that itneeded replacing. Mr G returned for the plannedtreatment on 5 July. Dr L anaesthetised the lowerjaw, but before the dental work began, Mr G toldDr L that the sensitivity was in the upper left partof his mouth, and that this was where he hadunderstood dental work was going to take place.Dr L found that the upper left part of the mouthwas sensitive to cold air, and she administeredanaesthetic in the upper left part of the mouth.She replaced a filling in the upper left secondmolar tooth (UL7), but did no work on the LL7tooth. By Dr L’s account she indicated to thereception staff that a further appointment wasneeded for the work on the LL7 tooth.

Complaint to the Practice and to the PrimaryCare Trust

In July 2004 Mr G complained to the Practice thatDr L had administered an unnecessary anaestheticin his lower left mouth. In her reply, Dr Lexplained that she had done so because duringthe 18 June examination she had found that thefilling of the LL7 tooth needed replacing. She saidthat Mr G had first mentioned sensitivity in theupper left part of his mouth on 5 July. Dr L saidthat rather than go ahead and restore the LL7

tooth on 5 July, she had administered anaestheticto the upper left part of his mouth and repairedthe UL7 tooth instead. Mr G complained to thePrimary Care Trust, disputing Dr L’s account ofevents.

Complaint to the Healthcare Commission

Mr G then complained to the HealthcareCommission (the Commission), which took advicefrom its Dental Adviser (the Dental Adviser). TheDental Adviser referred to the General DentalCouncil’s publication Principles of PatientConsent and the National Health Services(General Dental Services) Regulations (theRegulations). He took the view that providing awritten treatment plan to all patients returning toa dental practitioner was a professionalrequirement under the guidance in Principles ofPatient Consent, and that providing a writtentreatment plan was a requirement for all dentistsunder the Regulations. The Dental Adviserconcluded that Dr L had failed to obtain Mr G’sconsent on 18 June to repair the lower filling andhis consent to administer anaesthetic in thelower part of his mouth. In reaching this finding,the Dental Adviser considered Mr G’s dentalnotes for the consultation of 18 June, in which itwas recorded that he had complained ofsensitivity in the lower part of his mouth and thata filling had been prescribed for the LL7 tooth.He also noted Mr G’s assertion that what he hadactually been complaining about was pain in theupper left area. The Dental Adviser concludedthat although it was ‘one word against another’,it was his professional opinion that Dr L had not‘adequately secured’ Mr G’s consent toadminister the anaesthetic as Mr G was ‘probablyunaware that Dr L had prescribed a filling’ in thelower part of his mouth. The Commissionaccepted the advice of the Dental Adviser and


Complaint about the Healthcare Commission

upheld Mr G’s complaint. It recommended toDr L that she apologise to Mr G and suggestedchanges to her working practices.

A Senior Dento-Legal Adviser at DentalProtection (Mr B) wrote to the Commission onDr L’s behalf. He contended that some of theadvice given by the Dental Adviser was factuallyincorrect, and that the decision that Dr L had notobtained patient consent was not supported bythe evidence. At the time Dr L had examinedMr G, the Regulations relating to treatment plansdid not stipulate that a plan was necessary whena patient was transferred from one dentist toanother in a practice under a continuing carearrangement. The Regulations only required adentist to provide a plan if carrying out three ormore permanent fillings or any other specifiedtreatments. Mr B pointed out that the Principlesof Patient Consent had only come into forcearound one year after the events complainedabout. He argued that Dr L had neither astatutory nor ethical obligation to provide awritten treatment plan. However, it was unlikelythat she would not have told Mr G about thetreatment he was to undergo, having recordedthe outcome of the 18 June examination. TheCommission obtained further clinical advice andreplied, apologising for ‘the distress caused bythe provisions cited’. Its position remained thatthe ‘consent [was] not as robust as it could [havebeen]’.


Mr B complained to the Ombudsman that theCommission’s findings about the treatment planwere inaccurate and flawed, and its finding aboutconsent was incorrect and unjustified.

We investigated whether the Commission’sinvestigative process was flawed, and had led toan unreasonable decision. We studied the papersprovided by Mr B and the Commission, and tookclinical advice from our own Dental Adviser.


We found that the Commission did notadequately explore or explain why Mr G’s caserequired a written treatment plan, and that theadditional material used in the consideration ofthis aspect of this case (the Principles of PatientConsent) post-dated the June 2004 consultation.

We had concerns about the basis of theCommission’s conclusion about consent, as it wasnot clear why it had given more weight to Mr G’saccount than to that of Dr L. Given the absenceof a clear explanation – and the view of theCommission’s Dental Adviser that this aspect ofthe complaint rested on ‘one word againstanother’ – we did not consider that the basis forthe Commission’s conclusion was adequately orpersuasively explained. The Commission’sresponse to Mr B’s complaint about its report wascursory and superficial. Although it tookadditional clinical advice in response to hisrepresentations, its subsequent response did notaddress Mr B’s specific points. Moreover, althoughthat response was less critical of Dr L than before,the Commission’s recommendations to herremained unchanged. It was disappointing thatthe Commission did not take the opportunitypresented by Mr B’s complaint to resolve mattersbefore it came to the Ombudsman. Had theCommission shared a draft of the report withMr B – thereby giving him the opportunity tocomment – it is likely that the issues he identifiedwould have been brought to its attention much


earlier, and would have stood a better chance ofbeing satisfactorily addressed at the time.

The Commission’s investigation wasmaladministrative and we upheld Mr B’scomplaint. Our investigation was concluded inApril 2007.

Outcome

At our recommendation, the Commission agreedto:

• reconsider Mr G’s complaint and review itsrecommendations (and consider if any tangiblerecognition of its failings was appropriate forMr G or Dr L as a result); and

• apologise to Dr L for the failings we hadidentified.



The Principles of Good Administrationwere not referred to in our report but thiscase summary serves to illustrate thefollowing Principles:

• ‘Getting it right’ (taking reasonabledecisions, based on all relevantconsiderations).

• ‘Acting fairly and proportionately’ (treatingpeople impartially, and ensuring decisionsand actions are proportionate, appropriateand fair).

• ‘Putting things right’ (acknowledgingmistakes and apologising).

Inadequate responses to a letter from a hospitalConsultant about a patient’s medication and toa letter of complaint from the patient’s wife


Mrs Y’s late husband (Mr Y) was severely disabledwith a chronic obstructive pulmonary disorder (acondition that results from damage to thebreathing tubes and air sacs within the lungs). Hewas a patient of Dr Z at a GP Practice. InMay 2005 a hospital Consultant (the Consultant)wrote to the Practice, suggesting changes toMr Y’s medication. The Consultant’s SpecialistRegistrar saw Mr Y in August, when it transpiredthat Dr Z had not acted upon the Consultant’sletter. Mr Y’s prescription was changed after theSpecialist Registrar wrote to the Practice.

Complaint to the Practice and to the HealthcareCommission

In September 2005 Mrs Y delivered a letter ofcomplaint to the Practice about Dr Z’s failure toact upon the Consultant’s letter. Despite theintervention of the local Primary Care Trust, thePractice did not respond. In January 2006 Mrs Yreferred her complaint to the HealthcareCommission, which was unable to complete itsreview due to the Practice’s lack of co-operation.


The Healthcare Commission referred Mrs Y’scomplaint to the Ombudsman, who exercised herdiscretion to investigate the complaint as itstood. Sadly, Mr Y died in June 2006.

We investigated the Practice’s failure to takeaction on the Consultant’s letter and failure torespond to Mrs Y’s complaint about that. Weexamined the available documentation, and tookclinical advice from a General Practitioner.


Dr Z was responsible for ensuring that his Practicehad effective procedures for dealing withcorrespondence. Although we could not establishthe precise sequence of events, it appears thatafter receipt at the Practice, the Consultant’sletter was probably filed in Mr Y’s notes withoutbeing referred first to Dr Z. We concluded thatthe Practice did not have a robust procedure inplace to record and respond to such letters.

Our clinical advice was that it would have beendesirable for the Practice to have implementedthe Consultant’s suggested changes, and if thePractice had done so without delay, then thiscould have helped Mr Y’s breathlessness, reducedthe rate of exacerbations (a sustained worseningof the patient’s symptoms from their usual stablestate, which is beyond normal day-to-dayvariations and is acute in onset) and improved hisquality of life. It was unlikely, though, that thethree-month delay in changing Mr Y’sprescription altered his long-term prognosis.

Since 1996 GP surgeries have been required tooperate their own complaints procedures, in linewith national guidelines. Dr Z had ultimateresponsibility for ensuring the Practice had anacceptable procedure in place to handle andmonitor complaints and that staff were trained tooperate that procedure efficiently. We wouldhave expected the Practice Manager to managethe complaints procedure for Dr Z (as she doesnow). The Practice initially said they had replied


Complaint about a General Practitioner

to Mrs Y’s letter, but could not produce a copyof their reply. However, the Practice lateradmitted that, essentially, they had ignoredMrs Y’s complaint and did not reply. The PracticeManager’s evidence indicates that the letter wasfiled away without being date-stamped or seenby Dr Z. We criticised the Practice for notresponding to Mrs Y’s complaint and condemnedthem for misrepresenting the truth by initiallyinsisting they had replied to her complaint.

These failings left Mrs Y with little choice but topursue her concerns through other routes. Thisprolonged her dissatisfaction and distress at atime when she was naturally concerned for herhusband’s health. It also meant that she had towait longer than necessary for an independentexplanation about the impact of the delayedchange to her husband’s medication on his health.

During our investigation, Dr Z told us that his own‘lack of experience in the NHS ComplaintsProcedure’ led to his ‘totally inadequate andincorrect’ handling of Mrs Y’s complaint. Hewrote to her, apologising unreservedly for theunacceptable handling of her complaint, andoffered to meet her, to offer an honest andthorough account of his management of herhusband. He apologised that an oversight hadapparently delayed the start of Mr Y’s newmedication and concluded that the Practice hadlearnt from their mistakes. Having consideredDr Z’s letter, Mrs Y told us that she felt that hisapology was insincere and too late, and reiteratedher view that her husband might have livedlonger had Dr Z changed his prescriptionpromptly. She declined the meeting offer, sayingthat she would prefer a written explanation of hismanagement of her husband.

We upheld Mrs Y’s complaint and concluded ourinvestigation in August 2007.

Outcome

We recommended that Dr Z:

• write to Mrs Y, offering her a full and honestexplanation for the Practice’s failure to act onthe Consultant’s letter and her complaint; and

• pay her £250 in recognition of the distress andinconvenience the Practice’s poor complainthandling had caused.

We noted the action that Dr Z had taken (andplanned to take) as a result of Mrs Y’s complaint,in particular his intention to attend NHScomplaint handling courses and to set up aPractice system to ensure that the same mistakecannot recur. In support of that, werecommended that Dr Z ask the Primary CareTrust to consider his proposed action plan, tohelp him to make any changes considerednecessary in light of our findings, and toimplement and monitor it.

Dr Z agreed to implement our recommendations.



The Principles of Good Administration werenot referred to in our report but this casesummary serves to illustrate the followingPrinciples:

• ‘Being open and accountable’ (takingresponsibility for actions).

• ‘Putting things right’ (acknowledgingmistakes and apologising).

• ‘Seeking continuous improvement’ (learninglessons from complaints and using them toimprove services and performance).


Remedy for a flawed investigation and poorservice


In November 2002 Mrs S fractured her femur. Shewas admitted to St George’s Healthcare NHSTrust (the Trust) and underwent a dynamic hipscrew procedure (insertion of metal plate andscrews into the leg in order to allow healing ofthe fractured upper thighbone). In January 2003the Trust X-rayed the fracture; Mrs S says she wastold ‘it had mended ok’. A further X-ray wastaken in February; the doctor was said to bepleased with the fracture. In March Mrs S decidedto have private physiotherapy; in connection withthat she paid privately for an X-ray. It showed thefracture had not united.

Complaint to the Trust and to the HealthcareCommission

In November 2003 Mrs S complained to theTrust. She asked why no one had pointed outthat the fracture had not healed and why theX-rays had not picked up that the fracture hadnot mended. The Chief Executive replied inJanuary 2004. He said his Consultant OrthopaedicSurgeon had said that fractures unite once theyare healed and that X-rays sometimes suggestfractures have healed when they have not.Dissatisfied with that response, Mrs S wrote tothe Trust’s Convenor. The Trust’s final response ofMarch 2005 reiterated the Consultant’s previousadvice about X-rays.

Before Mrs S received the Trust’s final response,she complained to the Healthcare Commission(the Commission). The Case Manager reviewedher complaint and sent her a decision letter on

8 July 2005 saying that he had referred hercomplaint back to the Trust, and asked them toobtain an independent orthopaedic opinion onher X-rays. (The Trust were unable to do thatbecause Mrs S’s complaint had been discussed bythe whole orthopaedic team. The Commissionagreed to obtain an independent opinioninstead.)

In February 2006 the Commission asked aConsultant Orthopaedic Surgeon (the ClinicalAdviser) if the Trust’s explanations to Mrs S were‘accurate and adequate’. The Case Manager senta second decision letter to Mrs S on 11 April,saying that Mrs S had received correct andappropriate surgical treatment, but that he hadconcerns about how the Trust had communicatedwith her and supplied information to her. TheCase Manager said that the Clinical Adviser had‘commented that he believed [the X-rays] weresuggesting a good progress regarding healing ofthe bone but sometimes a computerisedtomography (CT) scan may be needed to ruleout any abnormality in the healing process’. Heconcluded the Trust had ‘respondedappropriately with regard to the interpretationof your x-rays’. Mrs S replied that her concernshad not been addressed; she asked forconfirmation of whether her X-rays did, or didnot, show a break. The Commission agreed toreview its previous decision and sought clinicaladvice from a second Clinical Adviser.

A final decision letter was sent to Mrs S inApril 2007 by the second Case Manager, whorelayed the second Clinical Adviser’s opinion thatfractures of the type Mrs S had suffered tookabout three months to heal solidly butsometimes took a lot longer. He said the secondClinical Adviser had explained that an X-ray takenin December 2002 showed ‘the fracture remainsin excellent position’ and that the X-ray taken in

Complaint about the Healthcare Commission


January 2003 showed ‘the position of thefracture remained the same. He noted that …one would not expect the fracture to be healedat this point. He stated that the reason for theX-ray was to see if the fixation remained secureand the fragments remain the same [sic]position relative to each other’. The second CaseManager said a further X-ray taken inFebruary 2003 ‘confirmed the results were thesame as shown on the film taken onJanuary 15 2003’. He stressed that Mrs S’s fracturehad healed appropriately.

The second Case Manager conveyed to Mrs S thesecond Clinical Adviser’s advice about: thevisibility of fractures and fracture healing onX-rays; why X-rays might not show breaks; and CTscans. He also informed her that the fracture hadbeen clearly visible on all the X-rays reviewed bythe second Clinical Adviser. He said ‘in theopinion of the adviser, the reason for taking thefilms had been to check the position of thefracture and only secondarily (at that earlystage) to assess healing … the reason you wereadvised that things were going well … wasbecause they were, but this related to themaintenance of the fracture position’. Thesecond Case Manager concluded that there wasnothing further that the Commission could do (orthat the first Case Manager should have done),and proposed to take no further action.


Mrs S complained to the Ombudsman inMay 2007 that after two reviews by theCommission she had still not received answersabout whether the Trust’s X-rays showed a break,or why the Trust failed to identify that herfracture had not mended. She also complainedthat the Commission’s reports contradicted each

other, and was unhappy about the length of timethe reviews had taken. Mrs S said the delays hadprolonged the inconvenience and distress she hadsuffered.

We investigated the Commission’s handling ofMrs S’s complaint, to assess whether itsinvestigation process was flawed, its service pooror its decision wholly unreasonable. We alsolooked at whether it took an unreasonably longtime to review her complaint.

During the investigation we examined all therelevant documentation and obtained specialistadvice from a Consultant Orthopaedic Surgeon.


The Commission’s decision letter of April 2007included a detailed interpretation of the Trust’sX-rays, and stated that Mrs S’s fracture was visibleon them all. We therefore disagreed that theCommission had failed to answer her questionsabout whether or not the X-rays showed thebreak. Neither did we agree that theCommission’s reviews had failed to address whythe Trust did not identify that Mrs S’s fracturehad not mended: the same letter confirmed thatthe X-rays would not have been expected toshow that it had healed, and that she was toldthings were going well (in January andFebruary 2003) because they were. The secondClinical Adviser provided clear and detailedadvice about the course of healing of fracturesand about the interpretation of the X-rays, andcorrectly identified that the fracture had mendedappropriately.

However, we criticised the Commission’sconclusion that there was nothing further that itcould do, or that the first Case Manager should


have done. The Commission should haveobtained its own clinical advice at the outset inresponse to Mrs S’s complaint (rather than firstasking the Trust to do so). That failure meant thather concerns were not resolved at the earliestopportunity, and so prolonged the inconvenienceand distress she suffered. The Commission’sdecision letter of 11 April 2006 did not give Mrs Sa clear answer about whether her X-rays showeda fracture. Furthermore, having previouslyidentified that the Trust needed to take furtheraction to address her concerns about the X-rays,the Commission now concluded that the Trusthad responded appropriately. We therefore foundthat the decision letters of 8 July 2005 and11 April 2006 appeared contradictory. TheCommission took an unreasonably long period oftime (29 months) to complete its reviews andprovide Mrs S with a response that addressed herconcerns.

In summary, the Commission’s investigativeprocess was flawed and its service was poor, andthese failings amounted to maladministration.Furthermore, the Commission did notdemonstrate it met the standards of behaviourexpected of it, as outlined in the Principles ofGood Administration (‘Being customer focused’– keeping to its commitments, including anypublished service standards; ‘Being open andaccountable’ – giving information that is clear,accurate and complete; and ‘Putting things right’– putting mistakes right quickly and effectively).

We partly upheld Mrs S’s complaint andconcluded our investigation in June 2008.

Outcome

At our recommendation, the Commission agreedto:

• apologise to Mrs S for the failings we hadidentified; and

• pay her £200 as compensation in recognition ofthe inconvenience and distress its delay inresolving her complaint had caused her.



• ‘Being customer focused’ (keeping tocommitments, including any publishedservice standards).

• ‘Being open and accountable’ (givinginformation that is clear, accurate andcomplete).

• ‘Putting things right’ (putting mistakes rightquickly and effectively).


Complaint about care and treatment after twooperations were cancelled and about poorcomplaint handling


Mr V was being treated by Pennine AcuteHospitals NHS Trust (the Trust) for sleep apnoea(a condition where the patient stops breathingduring sleep) and a Consultant Surgeon (theSurgeon) put him on a waiting list for examinationunder anaesthetic. On 13 September 2002 heattended for the surgery, but was sent home. Thiswas because the anaesthetist deemed him to bea high risk and required that he undergo a formalpre-operative assessment, including anechocardiogram, and because he would need aHigh Dependency Unit (HDU) bed. By the timeMr V was discharged, he had been without foodor drink for about 20 hours.

On 4 October 2004 Mr V attended forpre-operative assessment, but his medical noteswere unavailable. He said he tried to tell the staffabout the tests that were required but they didnot listen to him. When Mr V attended for therearranged operation on 14 October, staffidentified that he had not undergone therequired tests. An echocardiogram was carriedout but, as an HDU bed was not available, theoperation was cancelled. On 11 November Mr Vsaw the Surgeon, to discuss the problems he hadfaced, but felt rushed and the issue of relistinghis surgery was not resolved. Mr V’s progresscontinued to be monitored, and in April 2003 a‘watch and wait’ policy was adopted in respect ofhis future treatment.

Complaint to the Trust and to the HealthcareCommission

In November 2002 Mr V complained to the Trust.In reply, the Trust explained why the operationshad been cancelled and apologised for theinconvenience and anxiety caused. In March 2003Mr V complained to the Trust, via hisrepresentative. He wanted to know why he waskept at the Trust on 13 September for so long;why staff had ignored what he told them aboutthe tests required by the anaesthetist; and whyhe waited so long on 14 October when similarstaff had dealt with him on 13 September. Mr Valso complained about the Surgeon’s attitudeduring the November consultation, which hadleft him feeling unimportant and angry. TheTrust’s response did not cover all the issues.

A local resolution meeting took place inOctober 2003, but Mr V remained unhappy. TheTrust issued their final response in March 2004,apologised for their complaint handling, said thatthe complaints system was being externallyreviewed, repeated their previous explanationsand said they could do nothing more. The Trusttold Mr V that he could request an independentreview (but not that he had to do so within28 days of the local resolution ending). After areview had been requested on 29 July, the Trusttold Mr V’s representative that it was too late forhim to request one.

Mr V complained to the Healthcare Commission(the Commission). Its recommendations to theTrust included that they give Mr V a moredetailed explanation for the Octobercancellation, and tell him about the steps beingtaken to improve their complaint handling. Nofurther action was taken on the complaint aboutthe Surgeon. Mr V was dissatisfied with theinformation later provided by the Trust.

Complaint about Pennine Acute Hospitals NHS Trust and theHealthcare Commission



In August 2006 Mr V complained to theOmbudsman seeking explanations for the failingshe had experienced, and financial redress for theimpact that pursuing his complaint had had onhim.

We investigated the Trust’s cancellation of Mr V’soperations and his subsequent care; the eventsthat occurred at the pre-operative assessment;and their complaint handling. We alsoinvestigated Mr V’s complaint that theCommission had not investigated all his concernsand had ignored his evidence.

We looked at all the relevant documentation, andtook clinical advice from an experienced Surgeon.


We found that it was unreasonable that Mr V hadwaited so long at the Trust in September 2002before being told that his operation had beencancelled, and that the delay could have beenavoided if his medical records had been reviewedearlier. The Trust apologised to Mr V for thisfailure and improved their systems as a result. Theanaesthetist did not record his decision that Mr Vwas a high risk, and why. If Mr V was a high riskand needed an HDU bed, the Trust had failed toorganise this before admission. The lack of anadequate record of why the operation wascancelled and the failure to get a statement fromthe anaesthetist meant that the Trust could notprovide a clear reason for the cancellation.

It was unreasonable that Mr V’s medical recordswere unavailable for the pre-operative assessment(the Trust have since improved their systems). TheTrust said that the lack of medical records had no

impact on the quality of the assessment andMr V’s ongoing care, but also said this meant noechocardiogram was performed, leading to thecancellation of the October operation. Theseviews were contradictory and we criticised theTrust for their unclear explanations. There was alack of planning before Mr V’s Octoberadmission, and a delay in telling him that theoperation had been cancelled.

It was not possible to determine what occurredat the consultation with the Surgeon. As he hadpreviously apologised to Mr V for thecommunication breakdown, we did notinvestigate the matter further.

The Trust’s complaint handling was poor. Theirresponses to Mr V were delayed and did not fullyanswer his concerns. He had difficulty contactingstaff to discuss his complaint and there wasconfusion about the review. The Trustmisunderstood Mr V’s complaint, believing it wasmainly about system failures, whereas he wantedto know why he was a high anaesthetic risk. If theTrust had given Mr V clear explanations aboutthat the complaint may not have reached theOmbudsman. In summary, the Trust’s failingssignificantly impacted on Mr V’s life in terms ofdistress and inconvenience and we upheld hiscomplaint.

The Commission failed to obtain independentclinical advice on Mr V’s complaint, although itraised clinical issues. It failed to scrutinise theTrust’s explanations, and so unfairly presumedthat they had given Mr V an adequate andaccurate account of his care and treatment.Mr V’s concerns that the Commission’s decisionletters were unfair and biased wereunderstandable. It would have been better forthe Commission to have confirmed with Mr V thecomplaint to be investigated (the Commission


now does this). Its review focused on the changesin practice at the Trust rather than on the facts ofthe complaint. Furthermore, the lack of clinicaladvice affected the quality of explanation givento Mr V and the appropriateness of itsrecommendations. We found that theCommission’s complaint handling wasmaladministrative, and denied Mr V anindependent review of his complaint. We upheldthe complaint.

We concluded our investigation in July 2007.

Outcome

The Trust and the Commission agreed toimplement the following recommendations:

• The Commission and the Trust were toapologise to Mr V for the failings we identified.

• The Trust were to pay £250 to Mr V in light ofthe serious failings in their complaint handling;and to report back to the Ombudsman on howthe lessons learnt from this case have been fedinto their practices and procedures.

As the Commission was already working with theTrust to improve their complaint handling, nofurther recommendations were necessary.

Principles of Good Complaint Handling

The Principles of Good Complaint Handlingwere not referred to in our report but thiscase summary serves to illustrate the followingPrinciples:

• ‘Being customer focused’ (ensuring peoplecan easily access the service dealing withcomplaints; listening to complainants tounderstand the complaint and the outcomethey are seeking).

• ‘Being open and accountable’ (providinghonest, evidence-based explanations andgiving reasons for decisions; keeping full andaccurate records).


Inappropriate dental care and inadequatecomplaint handling


On 20 February 2006 P, then aged seven, wastaken to a dental practice (the Practice) by hisfather, Mr A. He was seen by Dr H who carriedout fillings to two baby molar teeth. Mr Aremained with his son during treatment. Ataround lunchtime, P began complaining of pain tohis lip. The inside of the mouth was lacerated.Mr A returned to the Practice with P, where hewas examined by Dr H and a colleague (theSecond Dentist). He was referred to hospital, andexamined by a Consultant. P needed stitches.

Complaint to the Practice and to the HealthcareCommission

The same day, Mrs A complained to the Practicethat she believed the laceration had been causedby a drill used by Dr H when treating P. In hisreply, Dr H said he believed that the lacerationhad been caused by P biting his lip while it wasanaesthetised. He explained that the SecondDentist had pointed out the shape of P’s teethimprinted over the wound. He was sure that thelaceration had not been caused in the Practice.

On 28 February 2006 the Practice Manager toldMrs A that Dr H was returning to Germany. InMarch the local Primary Care Trust (the Trust) toldMrs A that Dr H had not left a forwarding address,and suggested that she might involve theHealthcare Commission (the Commission). Mrs Aduly referred her complaint to the Commission inMarch. In response to Mrs A’s complaint and asubsequent request by the Trust, P was examinedby the Dental Reference Service (part of the clinical

governance arrangements for NHS dentistry). TheDental Reference Officer concluded in his report of10 April that the restoration was confluent (meaningthat the fillings were placed in the two teeth as onefilling), and he advised that the restoration wouldneed to be replaced to allow for individual toothmovement. He also identified further visible decayat two other baby molar teeth. Later, Mrs A toldthe Commission that P had developed a massiveabscess in the teeth that Dr H had filled, which hadthen been removed under general anaesthetic.

Because of the perceived complexities caused byDr H’s relocation abroad, the Commission askedthe Ombudsman to accept Mrs A’s complaint forinvestigation. The Ombudsman agreed to do so.


We investigated whether the laceration to P’s liphad been caused by Dr H’s drill; whether thefillings installed by Dr H were substandard; andwhether the Practice had handled Mrs A’scomplaint appropriately.

We studied the available documentation,including P’s dental records, and discussed thecomplaint with Mrs A, Dr H and the PracticeManager, and contacted the Dental Nursepresent on 20 February, along with the SecondDentist. We asked the Consultant for his opinionand studied the medical records taken for P whilehe was under his care. We also saw thephotographs of P’s lip taken by the family andsought clinical advice from two Dental Advisers.


The laceration to P’s lip was significant. TheConsultant thought the trauma was ‘considerable’

Complaint about a Dental Practice and a Dentist


compared with bite injuries he had seen, but wasnot absolutely certain that the injury was causedby a drill. Our own clinical advice was that if theinjury had been caused during the appointment,the wound would probably have bledsignificantly. That would have been very apparentat the time, or at least sooner than a few hourslater; it was ‘most likely’ that P had bitten his lip.The Second Dentist believed he witnessedimpressions of P’s front teeth on his lower lip. Wecould not reconcile the different opinions and,on balance, we could not be certain that P’s injurywas not self-inflicted.

The standard of care provided by Dr H to P wasnot wholly appropriate. Our clinical advicehighlighted that it was ‘poor quality dentistry’ tohave installed confluent fillings, and it was notedthat there was a justifiable need for X-rays to betaken before the fillings were installed (whichwould almost certainly have picked up the decayfound by the Dental Reference Service).

Although the Practice Manager told Mrs A thatDr H was leaving the Practice, we saw noevidence that Mrs A was told what action shecould take under the NHS complaints procedureif she remained dissatisfied with the Practice’sresponse to her complaint. The Practice’s Code ofPractice for Patient Complaints advises patientsto approach the Patient Advice and LiaisonService if they are not satisfied. Whilst thatsignposting was helpful, the Code of Practice wasmisleading and inaccurate as it did not advisepatients of their right to contact the Commissionif dissatisfied with the Practice’s response to theircomplaint. Mrs A could have been advised moreappropriately about what to do next.

We concluded our investigation in February 2008,and partly upheld Mrs A’s complaint (we did notuphold the complaint about P’s lip laceration and

upheld the complaints about the care providedto P and the Practice’s complaint handling).

Outcome

The Practice agreed to amend their Code ofPractice to reflect the provisions of the NHS(Complaints) Regulations which advise on theCommission’s role.

Dr H agreed to:

• review the Ombudsman’s report and reflect onthe learning points identified;

• send Mrs A a written apology for theshortcomings in his restorative dentistrypractice; and

• identify an appropriate person under hisworking arrangements abroad and share ourfindings and conclusions with them as part ofhis ongoing appraisal, and learning anddevelopment process.



• ‘Being open and accountable’ (publishingclear, accurate and complete informationabout how to complain, and how and whento take complaints further).

• ‘Seeking continuous improvement’ (using allfeedback and the lessons learnt fromcomplaints to improve service design anddelivery).


Complaint about the care and treatment of anolder person and about subsequent complainthandling


In March 2003 Mrs U, then aged 83, collapsed andwas admitted to Wexham Park Hospital (WexhamPark), managed by Heatherwood and WexhamPark Hospitals NHS Trust (the Trust). She sawDr G, who suspected a cardiac condition. Hearranged for a 24-hour ECG (electrocardiogram)and an echocardiogram. Mrs U was discharged,although her niece (Mrs T) said she was weak andhad dizzy spells. A few days later Mrs U wasadmitted to Heatherwood Hospital(Heatherwood), also managed by the Trust. Ahead scan found no abnormalities. Mrs U wasdischarged, but collapsed on 17 April, fracturingher ankle. She was readmitted to Wexham Park,where Dr G diagnosed possible drop attacks(short blackouts that result in falls) andprescribed Epilim Chrono, an anticonvulsantmedication.

Mrs U had ankle surgery at Wexham Park on20 April 2003 and her leg was put in a cast. Shewas transferred first to Heatherwood and then,on 3 May, to Upton Hospital (Upton), managed byBerkshire East Teaching Primary Care Trust (thePCT) for rehabilitation. Mrs U was due to have anout-patient appointment with Dr G on 20 May,but a week earlier Upton had cancelled theappointment (and did not schedule a furtherappointment) because she was an in-patient withthem and was therefore under the care of aconsultant on the ward. (At the time, Mrs T wastold that the appointment had not been

cancelled and that Mrs U had not been offeredanother appointment because she had failed toattend the clinic on 20 May.)

In June 2003 Mrs U was transferred back toWexham Park, having developed a vascular ulceron her ankle. Her cast was removed and thewound was found to be infected. Mrs U wastreated with intravenous antibiotics. A swab forMRSA was negative. She went back to Upton on10 June. A further 24-hour ECG was carried out on1 July, whilst Mrs U was still largely confined tobed. A swab for MRSA then proved positive andMrs U was readmitted to Wexham Park. She waslater transferred back to Upton, and discharged inmid-July. By Mrs T’s account, Mrs U’s dizzy spellsand weakness continued. She was suffering fromhair loss and a bad taste in her mouth; possiblyside-effects of her medication. Mrs U went for anEEG (electroencephalogram) at Charing CrossHospital in August, the results of which areunknown. However, Mrs U’s GP contacted Mrs Ton receiving the results, having diagnosed a heartproblem. An ECG taken in September showedMrs U had a complete heart block (noconnection between the atrial and ventricularbeats of the heart). The Royal Brompton Hospitalfitted her with a pacemaker and she remained onEpilim Chrono until some time in October.

Complaint to the Trust and to the PCT

Mrs T complained to the Trust in September 2003about delay in diagnosing Mrs U’s heart condition,the prescription of Epilim Chrono and the lack ofreview of the medication. She was dissatisfiedwith the Trust’s response and made additionalcomplaints about delay in placing Mrs U’s EEG

Complaint about Heatherwood and Wexham Park HospitalsNHS Trust (now Heatherwood and Wexham Park HospitalsNHS Foundation Trust), Berkshire East Teaching Primary CareTrust (now Berkshire East Primary Care Trust) and theHealthcare Commission


results on her records, the care of the anklewound, the development of MRSA, and thearrangements for the May 2003 out-patientappointment. A local resolution meeting tookplace in June 2004, after which the Trust toldMrs T that some of her complaints had not beenanswered at the meeting, because they involvedUpton. The Trust asked the PCT in July 2004 for aresponse to the issues that related to Upton, andsent a final response in October.

Complaint to the Healthcare Commission

Mrs T then complained to the HealthcareCommission (the Commission). Because Mrs U’smedical records were confirmed as lost by theTrust, the Commission could only view thelimited records from Mrs U’s GP and the RoyalBrompton Hospital. Its subsequent report toMrs T addressed all of her complaints, apart fromthe appropriateness of carrying out a 24-hourECG test when Mrs U was immobile. TheCommission upheld a number of Mrs T’scomplaints and recommended that the Trustreview their policies and systems for bookingfollow-up orthopaedic appointments andtracking clinical records.


Mrs T complained to the Ombudsman inJanuary 2007 that she had not received adequateexplanations about Mrs U’s care and treatmentfrom the Trust, the PCT and the Commission. Shewas also concerned that the Commission couldnot make findings in some areas because of theloss of Mrs U’s medical records. Mrs T wanted toknow what had gone wrong with Mrs U’s care andtreatment and wanted the Trust ‘taken to task’

for the delays in investigating her complaint andfor losing the medical records.

Because of the loss of Mrs U’s medical records,we decided to investigate the substance ofMrs T’s complaints against the Trust and the PCT,as well as the Commission’s handling of hercomplaint. We investigated ten issues of concernto Mrs T which were that:

• the Trust delayed diagnosing Mrs U’s cardiacproblem;

• the Trust inappropriately prescribed ananticonvulsant, which was not monitored orstopped when Mrs U was diagnosed withcardiac problems;

• the Trust delayed placing Mrs U’s EEG resultson her medical notes;

• the Trust and PCT failed to cancel Mrs U’sMay 2003 appointment;

• Trust and PCT staff failed to examine Mrs U’sbroken ankle at regular intervals;

• a 24-hour ECG was carried out on Mrs U whenshe was immobile;

• Mrs U’s ankle wound became infected withMRSA;

• the Trust lost the medical records during theCommission’s investigation;

• the Trust’s investigation of Mrs T’s complaintwas unhelpful and slow; and

• the Commission’s investigation andexplanations were unsatisfactory.


The only clinical evidence available was containedin letters from the Trust and PCT to Mrs U’s GP,and the records relating to her treatment at theRoyal Brompton Hospital. Limited clinicalinformation was contained in the Trust’s letters toMrs T. We took clinical advice from a ConsultantPhysician and a Senior Nurse, both with expertisein the care of older people. The guidance wetook account of included the National ServiceFramework for Older People (March 2001), andthe NHS Modernisation Agency’s Essence of Care(revised in April 2003).


There was no evidence before late August 2003that Mrs U had any significant cardiac problems,that her early treatment and investigations wereinappropriate, or that she had a cardiac problemfrom the outset that was undiagnosed. The EpilimChrono should have been stopped when herheart condition was identified. The Trust said thatthe prescription was reviewed at that point but, ifso, that did not explain why the prescriptioncontinued for a month. A delay in placing Mrs U’sEEG results on her medical records may havecontravened the NHS code of practice on recordsmanagement, but we could not say more withoutseeing the records. In any event, a delay wouldnot have been clinically significant.

There was evidence that Upton had cancelledMrs U’s May 2003 appointment, and that she hadnot been removed from the clinic list. The Trustexplained that they would not have made afurther appointment automatically becauseMrs U remained under the care of Upton, whichwould have indicated the timescale for afollow-up review upon discharge. A reviewappointment was said to have been arranged for15 September at the request of the ward staff,

but we could not confirm that. The failure toarrange a follow-up appointment for the plastercast to be checked was a significant failing. AsMrs U was transferred to Upton shortly aftersurgery, responsibility for carrying out theappointment lay with both the PCT and theTrust. We could not be certain what checks werecarried out and when, but the cast was notremoved until over a month after surgery. Thesefacts, taken with Mrs T’s account that Mrs U hadcomplained of pain and a smell coming from hercast, strongly indicated that the checks wereinadequate.

It was not inappropriate to carry out the ECG testwhen Mrs U’s movement was restricted, as theresults would show the same heart rhythm andrate. Without the records we could not commentdefinitively on the testing for and managementof the MRSA infection, but the screening andisolation procedures appeared reasonable. Theloss of Mrs U’s medical records was a seriousfailing which had significant consequences for theinvestigation of Mrs T’s complaints by both theCommission and the Ombudsman. The Trust’sresponses were slow and often contained littleinformation, with few apologies or explanationsfor the delays. Mrs T was not told by the Trustuntil late in the proceedings that Upton wasmanaged by the PCT.

The Commission’s investigation was reasonable. Itwas slow to conclude, but that was partlybecause of matters beyond its control. Thedelays, in themselves, did not amount tomaladministration. The Commission failed toaddress Mrs T’s question about the 24-hour ECGtest, which was unhelpful; our investigation hasremedied that injustice.

What injustice flowed from the service failingsand maladministration identified? The failure to


examine Mrs U’s ankle appropriately led to herdeveloping an ulcer; the failure to monitor herprescription following the diagnosis of her heartcondition meant that she may have taken thedrug for longer than necessary; and the loss ofthe clinical records deprived Mrs T ofcomprehensive answers to many of hercomplaints. The Trust’s poor complaint handlingmeant that she did not receive a satisfactoryresolution locally and had to involve theCommission and then the Ombudsman, causingadditional inconvenience and delay.

We concluded our investigation inNovember 2007, and upheld Mrs T’s complaintsagainst the Trust and the PCT. We did not upholdher complaint against the Commission.

Outcome

As a result of our recommendations, the Trust:

• re-examined the monitoring of Mrs U’smedication and gave Mrs T an explanation;

• reviewed the handling of Mrs T’s complaint andinformed her about how the lessons learntfrom this case were used in their review oftheir complaint handling process; and

• apologised in writing to Mrs T for the failings intheir complaint handling.

In addition, the PCT provided Mrs T with anaccount of the lessons learnt from the failure toexamine Mrs U’s ankle wound in an appropriateand timely manner.

Principles for Remedy

The Principles for Remedy were not referredto in our report but this case summary servesto illustrate the following Principles:

• ‘Putting things right’ (considering fully andseriously all forms of remedy, such as anapology and explanations).

• ‘Being customer focused’ (understandingand managing people’s expectations andneeds).

• ‘Seeking continuous improvement’ (usinglessons learnt from complaints to ensurethat maladministration or poor service isnot repeated).


Complaint about the handling of a complaintregarding the alleged abuse of an older personfollowing a hospital admission and about theHealthcare Commission’s review


In February 2005 Mrs C, aged 79, was referred toMusgrove Park Hospital, having been unwell for afew weeks. She was extremely weak, unable tostand without assistance and her feet were veryswollen and painful, owing to a related goutcondition. She was diagnosed with bilateralhydronephrosis (swelling of both kidneys owingto a backup of urine); and bilateral nephrostomies(insertion of a tube through the skin into thekidney to provide urine drainage) were performedthe next day. A suspected malignant lump wasalso found within Mrs C’s pelvic region. However,she contracted an infection and she wasconsidered too weak to undergo furtherinvestigation.

Over the next eight days Mrs C told her husband,Mr C, of several instances of poor treatment bystaff: being refused help to use the commode;being ordered out of bed; being scolded forleaning on her bed for support; and being orallyharangued and roughly handled by a member ofstaff during the night. After that last incident,Mr C contacted the Patient Advice and LiaisonService, and the ward Matron then met withMrs C the same day and agreed to speak to thestaff concerned. The Matron turned down Mrs C’sdaughter’s request to stay the night. Mrs C diedearly the next morning.

Complaint to Taunton and Somerset NHS Trustand to the Healthcare Commission

In March 2005 Mr C complained to Taunton andSomerset NHS Trust (the Trust); his letter focusedon what he described as at least three instancesof ‘deliberate abuse’ towards Mrs C. In April 2005the Trust replied, apologised for the distresscaused, and said that the care afforded to Mrs Chad been below standard and that the Matronand Ward Sister were working to improve, andthen maintain, standards. Mr C was unhappy withthe response, including the involvement of wardstaff in investigating the complaint, and remainedso following a meeting with the Trust inMay 2005.

In June 2005 Mr C complained to the HealthcareCommission (the Commission). Its report wasissued in November 2005, and made fourrecommendations to the Trust. Mr C said that theCommission had failed to address the complaintthat his wife had been abused. Correspondencebetween Mr C, the Commission and the Trustcontinued (Mr C also met with the Trust again inMarch 2006). In September 2006 the Trustapologised for the fact that they had, in breachof their Employee Relations Policy, not involvedthe Human Resources department in consideringthe complaint. In November 2006 theCommission issued its second report, confirmingthat finding, and said that it saw no scope forfurther action.


Mr C then complained to the Ombudsman. Ourinvestigation looked at both the Trust’s and theCommission’s handling of Mr C’s complaints. Inhis complaint to the Ombudsman Mr C said thatthe lack of resolution to his complaint continued

Complaint about Taunton and Somerset NHS Trust (nowTaunton and Somerset NHS Foundation Trust) and theHealthcare Commission


to cause him considerable distress and that ‘Ihave the lasting memory of unnecessarysuffering inflicted on my wife by those who werepaid to care for her’. He also referred to the timetaken and expense incurred in pursuing hiscomplaint.

During the investigation we considered evidenceprovided by Mr C as well as relevantdocumentation from the Trust and theCommission. We took clinical advice from aSenior Nurse.

In reaching our findings on this complaint wetook into account the Trust’s complaints policy.We also considered the Department of Health’sguidance to support the implementation of theNational Health Service (Complaints)Regulations 2004 and their March 2000 guidanceNo secrets: guidance on developing andimplementing multi-agency policies andprocedures to protect vulnerable adults fromabuse (this latter guidance set out therequirement to have such a policy backed up bytraining for staff).


We found that, despite the Department ofHealth’s guidance, the Trust had no policy inplace, in 2005, for managing concerns related toadult protection/vulnerable adults.

We found that the Trust’s involvement of theMatron and other ward staff in the investigationof Mr C’s complaint complied with their internalcomplaints policy.

We found that the Trust had been responsible fordelays in their handling of Mr C’s complaint andin their responses to the Commission.

We found that the Commission failed to confirmits understanding of the complaint with Mr C anddid not, as a result, identify his main complaint:that the Trust had not properly addressed thecomplaint about abuse.

We found that the Commission did not considerthe appropriate national guidance in investigatingMr C’s complaint as it did not identify the lack of,or question the Trust about the existence anduse of, a policy for managing concerns related toadult protection/vulnerable adults.

We found that the Commission wronglyinvestigated Mr C’s complaint about the Trust’sfailure to follow their Employee Relations Policydespite it being a staff disciplinary matter andnot, therefore, within the remit of the NHScomplaints procedure. By doing so theCommission caused confusion and further delay.

The investigation concluded in April 2008. Weupheld the complaints about both the Trust andthe Commission. Mr C was caused distress andinconvenience by the failure to consider hiscomplaints fully, properly and within a reasonabletimescale.

Outcome

As a result of the Ombudsman’srecommendations the Trust:

• wrote to Mr C to apologise;

• agreed to provide the Commission (in itsregulatory role) with evidence about theirperformance against response times forcomplaints (the Trust having reorganised theircomplaints department since 2005). TheCommission would also monitor performance


going forward and information arising fromthat would be copied to Mr C and theOmbudsman;

• developed an action plan to ensure theimplementation of their Adult Protection/Vulnerable Adult Policy (which was agreed bythe Trust’s Board in December 2007); and

• put funding in place for a new post of AdultProtection Supervisor.

As a result of the Ombudsman’srecommendations the Commission:

• wrote to Mr C to apologise; and

• paid him £150 compensation for the distresscaused by its failures.



• ‘Putting things right’ (apologies andcompensation).

• ‘Seeking continuous improvement’ (usingthe lessons learnt from complaints toensure that maladministration or poorservice is not repeated; recording and usinginformation on the outcome of complaintsto improve services).


Remedy for unreasonable delays andmishandling of an asylum application


Ms A and her sister entered the UK inAugust 1998 and applied for asylum. Theyattended separate initial asylum interviews at theImmigration and Nationality Directorate (IND) inOctober. In July 2000 IND noted that Ms A’saddress had changed, but on 17 August they senta statement of evidence form to her formeraddress, to be completed and returned by31 August. (IND sent a statement of evidenceform to Ms A’s sister at her correct address onthe same day.) In September Ms A’srepresentatives sent IND the completedstatement of evidence form, which they saidMs A had received after the 31 August deadline.IND did not link the form to the file.

On 11 September 2000 IND refused Ms A asylumon the grounds that she had not returned thestatement of evidence form by the deadline. On19 September they issued the refusal letter andan appeal form. Ms A’s representatives asked INDto reconsider their decision because thestatement of evidence form had been sent tothe incorrect address. They enclosed an appealform (which IND received on 25 September). InJanuary 2001 IND acknowledged they had sentthe statement of evidence form to the wrongaddress. They notified Ms A that their decisionof 11 September 2000 was withdrawn, and invitedher to withdraw her appeal, which she did. INDreceived the withdrawal form on 12 February, butdid not update their systems to show that theappeal had been withdrawn.

(Meanwhile, in November 2000 IND hadconducted an asylum interview with Ms A’s sister.They refused her asylum claim in January 2001.

Her subsequent appeal was heard inDecember 2001 and allowed in January 2002 – onhuman rights and asylum grounds. In February2002 IND granted her indefinite leave to remainin the UK as a refugee.)

IND interviewed Ms A in July 2001 and refusedher asylum application on 2 August. The fileshould then have been sent to an enforcementlocation to serve refusal, enforcement andappeal papers, but it was placed in a holdinglocation instead. There is no record of anysubstantive action on Ms A’s case betweenAugust 2001 and May 2003 when IND’s AppealsProcessing Centre called for her file. It appearsthat the previous appeal was considered to be‘reinstated’ even though the decision and theappeal had been withdrawn. In August 2003Ms A’s Member of the European Parliamentwrote to IND about the time taken to processher asylum application. IND did not respond.

Despite the fact that IND had not yet served theformal notice of the refusal of Ms A’s asylumapplication, in January 2004 they served her withnotice of a decision to issue removal directionsagainst her. In February a local councillor askedIND for an update on Ms A’s case, but again theydid not respond. In June IND sent a bundle ofappeal papers to a firm of solicitors with noinvolvement in Ms A’s case. The substantivehearing of Ms A’s appeal took place in August,when the Independent Adjudicator dismissed theappeal on asylum and human rights grounds.Ms A was granted permission to appeal. Theappeal was heard in March 2005, and remittedfor another hearing in June. In July her appeal wasallowed by an immigration judge on asylum andhuman rights grounds. On 18 July IND decidednot to challenge the decision.

Complaint about the Immigration and NationalityDirectorate (now the UK Border Agency) of the Home Office


From 30 August 2005 a new policy wasintroduced (under the Government’s Five YearStrategy for Asylum and Immigration) wherebypeople recognised as refugees would initially begranted a period of five years’ limited leave toenter or remain in the UK. On 23 September INDasked Ms A to provide passport photographs andto confirm various details. They received aprompt response and on 4 October they issued astatus document granting Ms A leave to remain inthe UK for five years, in line with the new policy.

In December 2005 Ms A’s MP wrote to ask theMinister why Ms A had only been granted fiveyears’ leave, when her sister had been grantedindefinite leave. The Parliamentary UnderSecretary replied, apologising for the delayhearing Ms A’s appeal and explaining that thesisters’ asylum claims had been decidedseparately and assessed on the basis ofinformation submitted in each case. He explainedthat Ms A could only be granted five years’ leave,in accordance with the asylum policy effectivefrom 30 August 2005, but could apply for furtherleave a month before her current leave was dueto expire.


Ms A complained to the Ombudsman inApril 2006 that she had applied for asylum at thesame time as her sister, but that as her sister’scase had not been subjected to the same delays,she (her sister) had been granted indefinite leaveto remain. Ms A said that IND had treated herunfairly and that their mistakes had put her in aworse position than her sister.

We investigated whether IND had delayeddeciding Ms A’s asylum application, and whetherthe time taken to process her successful appeal

and grant her leave to remain wasmaladministrative (as this spanned the criticalperiod when the policy changed).


IND sent the statement of evidence form to anincorrect address and delayed attaching it toMs A’s file, which resulted in an incorrect refusaldecision. They failed to issue an asylum refusaldecision, with associated enforcement and appealpapers, following the refusal decision of2 August 2001; processed an appeal which hadbeen withdrawn because of a failure to updatetheir systems; dispatched appeal papers to anincorrect representative; and did not reply tocorrespondence. IND also served a removalnotice on Ms A when they had not yet served adecision relating to the application. Takentogether these errors amounted to a seriousfailure on IND’s part to get it right or to becustomer focused, two of the Principles of GoodAdministration. That was maladministrative.

We did not uphold Ms A’s complaint that INDhad unreasonably delayed implementing theappeal decision. They knew the appeal outcomeby 18 July 2005 and took 49 working days to askfor the information needed to prepare the leaveto remain document. Although IND took longerthan the average time taken to request theinformation (and longer than would be goodadministration), we did not regard the time takenas being so excessive as to be maladministrative.

The injustice to Ms A flowing from IND’smaladministration was that she suffereduncertainty and anxiety, and would have beengranted asylum significantly earlier than she was,and granted indefinite (rather than limited) leaveto remain. IND contended that the time taken to


deal with Ms A’s application was not unusual andthat there was no guarantee of a successfulappeal even if they had dealt with the applicationsooner. While we recognised that, over theperiod in question, IND had difficulty dealingwith the number of asylum cases they received,the fact was that Ms A’s sister’s application tookthree and a half years to determine, while Ms A’sapplication took over seven years. Ms A’s appealwas ultimately successful; we saw no persuasiveevidence to suggest that an earlier and morestraightforward sequence of events would haveled to a different outcome.

We concluded our investigation in April 2008and partly upheld Ms A’s complaint.

Outcome

To remedy the injustice to Ms A, IND agreed to:

• apologise to her for the way they had handledher case and make a payment of £250 torecognise the inconvenience she suffered;

• grant her indefinite leave to remain in the UK;and

• reimburse the difference between the fees formaking an application for citizenship in 2004(which is when Ms A would have been able toapply) and the current fees (provided Ms Aapplied within a year of being grantedindefinite leave to remain).



• ‘Getting it right’ (acting in accordance withthe public body’s policy and guidance; andtaking proper account of established goodpractice).

• ‘Being customer focused’ (dealing withpeople helpfully, promptly and sensitively).

Commenting on a draft of the Ombudsman’sreport, Ms A said ‘let me take this opportunityto express my heartfelt thanks for yourthorough investigation of my complaint. … I lookforward to the successful completion of thismatter and start[ing] a new chapter in my life’.


Complaint about a breach of confidentiality byHM Courts Service as well as their subsequenthandling of correspondence, a complaint and arequest for compensation


In August 2006 Mr and Mrs M moved housebecause they had been threatened by the secondof two defendants against whom Mrs M hadbrought civil proceedings. A decision had beentaken not to prosecute that defendant in relationto the alleged threats and Mrs M haddiscontinued her case against that defendant (butnot the other). However, Mr and Mrs M believedthat the threat against them remained, which ledto their decision to move.

Mr M wrote to HM Courts Service (HMCS),following a telephone call to them the previousday, supplying his new address on theunderstanding that it would not be disclosedoutside the court or its staff, nor passed to eitherof the defendants or their representatives.

In September 2006 Mr M receivedcorrespondence at his new address from thesecond defendant’s solicitors. Mr M raised thiswith the court. The defendant’s solicitors saidthat a member of court staff had provided themwith the address.

Complaint to HM Courts Service

Mr M wrote to HMCS to complain. They said thatno order had been made not to disclose theaddress, that they could not locate any memberof staff who recalled disclosing it, nor find anyevidence that they had done so. They also saidthat they had written to the defendant’s

solicitors asking them not to give the address toanyone.

Mr M complained to the Area Director, relayingthe advice he had been given before disclosinghis address and saying that he had not been toldthat a court order would be required. He sought£18,000, covering damages from stress as well ascosts.

In October 2006 Mr M reported beingthreatened close to his new home. HMCS wroteto Mr M and said that they could only make apayment if he had suffered financial loss as adirect result of an administrative error. They hadseen no evidence that the solicitors had passedon his new address or that the court had giventhe address to them. They said the decision tomove house had been Mr M’s and he hadprovided no evidence of further incidents sincehis move. A judge had seen the letter requestingnon-disclosure and had made no order.

Mr M wrote again and said that his claim regardedthe court’s breach of confidentiality (not anassumption of the information being passed on),that he had been threatened again and that,without a court order, HMCS had nowimplemented non-disclosure of the address.HMCS replied to Mr M saying that there was noevidence that his address had been supplied tothe solicitors via the court and that any claimfrom him could not be considered without this.

Mr M wrote again; HMCS said they would replyby 22 December 2006. In December 2006 theywrote to his MP and said that Mr M’s claim forcompensation had been refused as it did notmeet the criteria for payment. They said thatthere was nothing to prevent the address beingdisclosed when the solicitors rang the court, but

Complaint about HM Courts Service


they had now removed the address from theirsystem as a gesture of goodwill.

On 28 December 2006 Mr M received a lettersaying that HMCS were seeking legal advice,which would take 28 days. Mr M complained thatHMCS were breaching their service standards andhad changed their position on several points intheir letter to his MP, including now admitting topassing on the address. In January 2007 HMCSreplied to Mr M and said there had been nomaladministration by their staff.

In June 2007 HMCS gave Mr M’s details to a bank.In August they apologised for this and said theyshould have contacted Mr M first.


In August 2007 Mr M complained to theOmbudsman. We investigated Mr M’s complaintsthat HMCS:

• committed a breach of confidentiality bydisclosing his address;

• provided contradictory accounts of theiractions in responding to his complaint;

• provided several different reasons for refusinghis claim for compensation;

• failed to make him aware of the correctcomplaints procedure; and

• failed to meet service standards in replying tocorrespondence.

Mr M said that the actions of HMCS had nullifiedattempts by him and his wife to secure theirpersonal safety by moving house. He said that

they were fearful for their wellbeing and had aminimal quality of life.


We found that HMCS failed to ensure that theadvice they provided to Mr M was clear, accurateand complete. He was given misleading adviceand he, not unreasonably, believed that hisaddress would be kept confidential. Having failedto advise Mr M correctly, HMCS then breachedhis confidentiality by disclosing his address to thesolicitors. We did not find that they disclosedMr M’s address to any party other than thesolicitors and the bank.

We found that HMCS failed to deal with Mr Mobjectively and consistently by not reaching theirfinal conclusion (about whether they had passedthe address on to the solicitors by telephone) atan earlier stage.

We found that the criterion which HMCS used tojudge whether to pay compensation remainedessentially the same: did Mr and Mrs M incurfinancial loss as a result of an administrative errorby court staff? We did not, therefore, find thatHMCS were maladministrative in that respect.

We did not find any evidence that HMCSprovided Mr M with their complaints procedureand it would have been good customer servicefor them to have done so. However, this did nothinder Mr M’s ability to pursue the matter andthey referred his complaints to the correct officewithin reasonable timescales. We did nottherefore find that this omission caused anyinjustice to Mr M.

We found that it was reasonable for HMCS tohave decided to seek legal advice in order to give


Mr M a proper response and this inevitablycaused a delay. However, they sent Mr M clearholding letters in the interim. We did not findthat any delay in handling correspondenceamounted to maladministration.

We found that Mr M had very real concerns forhis family’s safety and that his distress wasexacerbated by maladministration on the part ofHMCS. We also found that Mr M had beencaused additional frustration by their handling ofthe issue of whether they had disclosed hisaddress to the solicitors.

Our investigation report, issued in February 2008,partly upheld Mr M’s complaint.

Outcome

As a result of our recommendations HMCS madea compensation payment of £500 to Mr M andsent him a written apology for the shortcomingsidentified in our report.



• ‘Being open and accountable’ (ensuring thatinformation, and any advice provided, isclear, accurate and complete).

• ‘Acting fairly and proportionately’ (dealingwith people and issues objectively andconsistently).


Decision to reduce disability living allowanceaward taken without proper consideration of allthe relevant facts


Following a stroke in 1998, Mrs N received thehighest rate care and higher rate mobilitycomponents of disability living allowance fromSeptember 1999. The award was made on thebasis that she needed assistance during the dayand help with going to the toilet at night.

In October 2004 Mrs N completed a form torenew her award from March 2005. Mrs N saidthat, periodically, she had epileptic fits, and thatfive nights a week she needed help with going tothe toilet once a night. She also said that sevennights a week she needed help turning in bed andchanging her sheets or night clothes. TheDisability and Carers Service asked MedicalServices to assess Mrs N’s mobility and careneeds. The doctor examined her in October. Hewas asked to write down on the form what Mrs Nhad told him in her own words. He said that shetold him ‘I move from room to room with theabove said wheelchair’ and ‘Sometimes if I can’twt for someone to come & help me to go totoilet I try to move a bit to micturate near thetoilet…’ (pass urine near the toilet) and ‘I am notincontinent’. He wrote that Mrs N told him thatat night-time she needed watching in case shegot epileptic fits, but needed no help with toiletneeds; and that she was mentally competent, andcould not do anything for herself. He listed themedication that Mrs N took, but not how oftenshe had to take it. Nor did he say when Mrs Nhad last fallen, a question to which he was askedto respond. The doctor wrote that, in his opinion,Mrs N could not turn over, or move position inbed and that, although she needed help with her

toilet needs at night, she did not require suchhelp or help for any other purpose.

In December 2004 a decision-maker consideredMrs N’s application, awarded her middle rate carecomponent and refused the highest rate because:‘Although I accept that Mrs N has epilepsy andsometimes experiences a fit during the night, Ido not consider that she would be at substantialrisk of danger as she would be in her bed’. Mrs Nwas notified of the decision and her appealrights. Mrs N’s daughter (Ms E) told us that hermother did not appeal because she hadentrusted supervision of her financial affairs toher (Ms E). She had set up a bank accountspecifically to deal with her mother’s benefitsand care-related bills, and provided that theaccount was in credit she did not inspect theentries thoroughly. Ms E said that at the time thedecision letter had been sent, she had beenworking abroad regularly.

In the summer of 2006 the Independent LivingFunds (which provide grants to help severelydisabled people to live in the community) toldMs E that her mother’s funding had to stopbecause Mrs N no longer received the highestrate care component. On 19 June Ms E asked theDisability and Carers Service to look again at hermother’s award, and they sent Mrs N a form tocomplete. She noted on the form that sheneeded help with going to the toilet once anight, five nights a week; and additional help,once a night, five times a week. A decision-makerassessed that Mrs N’s help with going to thetoilet amounted to prolonged attention andawarded the highest rate care component andthe higher rate mobility component from19 June 2006, but refused to backdate the awardas Mrs N had not notified them within onemonth of the ‘change’ in her circumstances.

Complaint about the Disability and Carers Service (now thePension, Disability and Carers Service) of the Department forWork and Pensions


On 4 September 2006 Ms E appealed against thedecision not to backdate her mother’s award. Shesaid that Mrs N’s condition would not go away,that she had always needed help at night and thatshe (Ms E) would have accepted responsibility forthe reduction in her mother’s benefit were theIndependent Living Funds not asking for £8,845 tobe repaid. She enclosed a letter from hermother’s GP saying that: ‘Over the years Mrs Nhas gradually deteriorated and has required24 hour care … this care has been extended tonight time cover, essentially as she isprogressively incontinent’. The Disability andCarers Service told Ms E that they could notreview the December 2004 decision because thetime limit for appeals had expired.


In October 2006 Ms E complained on hermother’s behalf to the Ombudsman that theDisability and Carers Service had not taken intoaccount all relevant factors when reducing herdisability living allowance. As a consequence, shebelieved her mother was not receiving her properentitlement. Moreover, the Independent LivingFunds were seeking repayment of a substantialsum of money.

We investigated the way in which the decisionwas taken to reduce Mrs N’s disability livingallowance award.


There were significant shortcomings in the waythat the decision to reduce Mrs N’s disabilityliving allowance was taken. The Disability andCarers Service failed to recognise that themedical report provided by Medical Services was

clearly not fit for purpose: it was not free ofmedical jargon, and attributed to Mrs N anexpression – ‘to micturate’ – it seems unlikely shewould have used; it was illegible in parts; thedoctor had not fully answered all the questionshe had been asked; and it included unexplainedinconsistencies in the assessment of Mrs N’sneeds. Despite all this, the report was notreferred back to Medical Services for rework asprocedures require. As a result thedecision-maker had inadequate and incompleteinformation on which to make a decision, andfailed to take all relevant facts into account whendoing so.

The decision was made solely in relation towhether Mrs N was in substantial danger at night.But another relevant criterion for night-timeneeds for the highest rate care component iswhether the person needs prolonged or repeatedattention in connection with their bodilyfunctions. That was patently relevant to Mrs N’ssituation (and was the basis of her 1999 award).Her difficulties were the result of a stroke, wherethe advice available to decision-makers is thatsomeone’s condition is unlikely to improve a yearafter the event. Crucially, the issue of night-timeneeds for help with bodily functions was clearlystated in Mrs N’s application and covered in themedical report. We found no evidence that anyconsideration was given to these relevant facts.

One of the Principles of Good Administration is‘Getting it right’, which includes an expectationthat public bodies should, among other things,follow their own policies and procedural guidanceand make proper decisions, giving due weight toall relevant considerations. In this case, the failureto send back the medical report for rework,together with the failure to take into account allrelevant facts in coming to the decision, fell so


far short of reasonable expectations that itamounted to maladministration.

‘Putting things right’, including putting mistakesright quickly and effectively, is another of thePrinciples. The Disability and Carers Servicemissed an opportunity to put matters right whenMrs N appealed against the decision not tobackdate the new award. Although Mrs N did notspecifically ask for the matter to be looked at onthe grounds of official error, there are goodgrounds for officers to have recognised thepossibility of such an error and to have addressedit. By that time, Mrs N was considered eligible forthe highest rate care component from June 2006on much the same grounds as in 1999. This,together with the contents of the GP’s letter,should have suggested strongly that theDecember 2004 decision might need reviewing.This, too, was maladministration.

The injustice flowing from the abovemaladministration was that Ms E suffered worryand uncertainty, while Mrs N was denied a properconsideration of her application.

We concluded the investigation in August 2007and upheld Ms E’s complaint.

Outcome

At our recommendation the Disability and CarersService:

• apologised to Ms E and her mother;

• retook the decision of December 2004 in thelight of all the relevant facts (theysubsequently awarded Mrs N the highest ratecare component from 16 March 2005, and paidher arrears of £1,326.40 and £89.79 interest); and

• awarded £100 compensation to Mrs N and £250to Ms E.



• ‘Getting it right’ (acting in accordance withthe public body’s policy and guidance –published or internal).



Misleading and inaccurate information abouteducation maintenance allowance led tofinancial loss


K was due to start a college course on11 September 2006. In early August her mother,Mrs Q, obtained the necessary forms andguidance notes in order for K to apply foreducation maintenance allowance (a weeklypayment of up to £30 to support people fromlow income households to continue in learning,administered by the Learning and Skills Councilfor England – the Council). Mrs Q understoodthat K needed to open a bank account; realisingthat that might take time to arrange (K waswaiting for a new passport to replace her expiredone, and she had no utility or council tax bills inher name), she rang the Council’s educationmaintenance allowance helpline to explain thedifficulty and to ask for advice. Mrs Q told usthat the helpline said that they could not acceptK’s application without a valid bank account.

In early September 2006 K and Mrs Q visitedseveral banks and building societies, to enquireabout opening a bank account, but each time thelack of proof of identity for K was a problem.Mrs Q rang the helpline several times to explainthe problem and was, she said, repeatedly told topersevere. By late September K had started atcollege and Mrs Q was supporting her financially.According to Mrs Q, she spoke to the helpline on1 October and was advised to submit theeducation maintenance allowance applicationstraight away. She was told that although theform would be returned because there were nobank account details, K’s application would beregistered and backdated on receipt of the bankdetails. Mrs Q submitted the application form on

2 October, together with a letter describing thedifficulties she had faced and the previous day’sadvice.

K received her new passport and eventuallyopened a bank account. The Council received thedetails on 18 October 2006 and backdated hereducation maintenance allowance to 2 October(where an application is received more than fourweeks after the start of the course, paymentsmay be backdated to the date on which theapplication was received or the start date of thecourse, whichever is later). When Mrs Q askedthe Council about backdating the educationmaintenance allowance to September, theyadvised her to appeal. She did so, describing thedifficulties she had encountered, and thehelpline’s contradictory advice. Her appeal wasunsuccessful.

Mrs Q approached her MP who wrote to theMinister in January 2007, pointing out that ifMrs Q had submitted the education maintenanceallowance application in September without thebank account details, the award would have beenbackdated to September. But, instead, she hadlost money. The MP said that if the Council wereprepared to backdate the allowance to the datethe form was received, regardless of whether itwas complete, applicants should be informed ofthat from the beginning. If claimants were notinformed, then the policy ought to be amended.The Council’s Chief Executive replied to the MP,saying that K’s payments could not be backdatedbecause there was no evidence to suggest thatshe intended to apply before 2 October 2006. Hedid not address the MP’s central point.

In February 2007 Mrs Q complained to theCouncil about the inaccurate information thehelpline had given her, and about the refusal tobackdate the education maintenance allowance.

Complaint about the Learning and Skills Council for England


In the meantime, the college contacted theCouncil to say that Mrs Q had asked them fordocumentation to support her claim that theinitial application had been made inSeptember 2006. They said a member of thecollege staff had spoken to Mrs Q many timesdating back to the start of the course, and wouldbe happy to talk to the Council. The Councilreplied that they would contact the individual ifthey thought it necessary. In the event, they didnot. The Council did not uphold Mrs Q’scomplaint. They said that as K’s application hadbeen received more than four weeks afterstarting her course, she was only eligible toreceive payments from the date of receipt.


Mrs Q complained to the Ombudsman inMay 2007, commenting that ‘In every otheraspect of claims for people on low income,emphasis is made on getting in the forms even ifyou do not have all the information to ensurepayments are not lost, but this is not the policywith EMA. I would like to see this changed’.

We investigated Mrs Q’s complaints about beinggiven misleading information concerning when toapply for education maintenance allowance, andabout backdating it, which had led to financialloss and inconvenience. (K received no educationmaintenance allowance for September 2006 andMrs Q incurred unnecessary out-of-pocketexpenses.)


We established that incomplete educationmaintenance allowance applications are notrejected, but are acknowledged and given a case

reference number. However, the helpline, websiteand the guidance notes led Mrs Q to believe thatK’s application would be rejected if submittedwithout bank account details. She was giveninadequate and misleading information, whichwas maladministrative. The Council’s reply to theMP indicated a degree of discretion not providedfor in the education maintenance allowancescheme. But, in any event, they made no attemptto examine the evidence offered by the collegeof K’s earlier intent to apply for educationmaintenance allowance, and so did not give dueweight to all relevant factors when consideringMrs Q’s complaint. The Council also failed toaddress the central point of the MP’s letter. TheCouncil’s maladministration meant that Kreceived no education maintenance allowanceduring September 2006, which Mrs Q had nochoice but to make good, while she had to makea number of telephone calls and write lettersunnecessarily.

We concluded our investigation in March 2008and upheld Mrs Q’s complaint.

Outcome

At our recommendation, the Council:

• apologised to Mrs Q;

• paid her £100 to remedy the distress andinconvenience caused; and

• paid £120 to K (as the education maintenanceallowance applicant) which was equal to theamount she would have received inSeptember 2006.

We recommended that the Council review thebackdating rules to ensure they met the scheme’s


policy objectives and were flexible enough topermit them to deal with exceptional andunanticipated circumstances fairly andappropriately. The Council said they weresatisfied with the flexibility of the scheme rules,but agreed to put in place procedures to create arecord of an application that would allow thebackdating of payments in appropriate cases.

We recommended that the Council ensure thatthe education maintenance allowance website,guidance notes and helpline staff explainedclearly to applicants that, if they encounter adelay in opening the necessary bank account,they should submit their application form inorder to safeguard their entitlement. The Councilsaid that the helpline ‘scripts’ now include thatinformation.



• ‘Getting it right’ (acting in accordance withpublished or internal policy and guidance).

• ‘Being open and accountable’ (being openand clear about policies and procedures andensuring that information, and any adviceprovided, is clear, accurate and complete).

• ‘Putting things right’ (acknowledgingmistakes, apologising, and putting mistakesright quickly and effectively).

• ‘Seeking continuous improvement’(reviewing policies and procedures).


HM Revenue & Customs recovered tax (whichhad been underpaid as a result of an error ontheir part) plus interest, failed to payentitlement to tax credits and failed to addresscomplaints


Mr P’s tax code for 2002-03 included a child taxallowance. In 2003-04 Mr P did not receive a newtax code and his employer used the 2002-03 code(a new code should have been sent, with theallowance removed, due to the introduction oftax credits in April 2003).

In May 2004 HM Revenue & Customs (HMRC)discovered that they had deleted Mr P’s previoustax record, so they established a new one andsent a new tax code (with the allowanceremoved). In December 2004 Mr P completed anonline tax self-assessment form for the 2003-04tax year but was unable to enter his previous taxcode (containing the allowance) onto that form,so his self-assessment showed an underpaymentof tax for that year. In January 2005 he contactedHMRC.

In February 2005 HMRC sent Mr P aself-assessment statement showing underpaid taxof £499.28. Mr P said that his tax only appearedunderpaid because he had been unable to insertthe correct code on the self-assessment form. InMarch 2005 Mr P claimed tax credits (his claimwas backdated to December 2004).

In April 2005 HMRC told Mr P that he shouldhave received a different code for 2003-04, hadunderpaid tax and that tax credits had replacedthe child tax allowance. Mr P asked HMRC toliaise with the Tax Credit Office (to whom hecopied his letter) in order to offset his unclaimed

tax credits against the underpaid tax. In May 2005HMRC said that he should pay the underpaid tax.

Complaint to HM Revenue & Customs

In May 2005 Mr P sent a formal complaint letterto HMRC and wrote to the Tax Credit Officeasking if he was eligible for tax credits fromApril 2003. In June 2005 HMRC said that a new taxcode should have been issued for 2003-04,offered to recover the underpaid tax by adjustingMr P’s 2005-06 tax code and told him to contactthe Tax Credit Office as he appeared to beentitled to claim from April 2003.Correspondence continued and in October 2005Mr P escalated his complaint to HMRC’s AreaDirector; he asked for the underpaid tax andunclaimed tax credits issues to be resolved and tobe paid compensation for inconvenience. HMRCsaid they would investigate.

In December 2005 HMRC wrote to Mr P,apologised and offered a compensatory paymentof £80. They said that the underpaid tax did notmeet the criteria for remittance, that they couldnot offset against tax credits, that the Tax CreditOffice had strict rules about when paymentsstarted and that the issuing of the new tax codein May 2004 should have alerted him to the factthat he was no longer receiving the child taxallowance.

In January 2006 the Tax Credit Office wrote toMr P and said that claims could only bebackdated by three months and that income taxliability and tax credit eligibility were separateand could not be offset. In February Mr P paid hisoutstanding tax bill with interest of £536.48.

Complaint about HM Revenue & Customs



In October 2006 Mr P’s MP referred his complaintto the Ombudsman, namely that: HMRC’s actionshad caused him to suffer financial loss. Weinvestigated Mr P’s complaints that:

• HMRC recovered tax plus interest from himwhich had been underpaid as a result of anerror on their part;

• he had not been given his full entitlement totax credit dating back to 2003; and

• HMRC had failed to fully address hiscomplaints.


HMRC acted maladministratively by deletingMr P’s tax code, which caused him actual financialloss. The deletion of Mr P’s tax records meantthat he did not receive a personalised claim formand other information regarding the introductionof tax credits. Had he done so, he would haveclaimed and received an award from April 2003.

We found that, although HMRC were technicallycorrect to charge Mr P interest on his underpaidtax, their delay in resolving his complaint allowedthe interest to accrue for longer than it shouldhave done.

We found that the standard of HMRC’s complainthandling was so poor as to amount tomaladministration. They failed to give Mr P theright information (for example, exact details ofthe tax credit backdating limits) and did notproperly manage his expectations (for example,by saying that he appeared to be eligible for taxcredits from April 2003). They also missed

opportunities to apologise and failed to act in ajoined-up manner when the issues he raisedcovered both income tax and tax credit matters.

We found that Mr P suffered actual financial lossand was caused additional worry andinconvenience as a result of HMRC’smaladministration.

Our investigation, which concluded inMarch 2007, fully upheld Mr P’s complaint.

Outcome

As a result of our recommendations, HMRCapologised and made the following payments:

• £608 (equivalent to Mr P’s tax creditentitlement between April 2003 and May 2004);

• £100 (for distress and inconvenience caused bythe deletion of Mr P’s tax record);

• £100 (for worry and inconvenience caused bydelays and poor complaint handling); and

• £40 (in lieu of the interest paid on theunderpaid tax).


The Principles of Good Administration werenot referred to in our report but this casesummary serves to illustrate the followingPrinciple:

• ‘Being customer focused’ (responding tocustomers’ needs flexibly, including, whereappropriate, co-ordinating a response withother service providers).


Licence application and personal details werereturned to the wrong person, and poorcomplaint handling


On 4 August 2006 the Security IndustryAuthority (the Authority) wrote to tell Mr S thathis application form for a door supervisor’slicence was incomplete. They enclosed hispayment, identification documents, and theapplication form of a third party, Mr A. Onreceipt, Mr S telephoned the Authority to askwhere his application form was. The Authoritysaid it appeared that his application had beenseparated from his documents and replaced withMr A’s application. Mr S asked to speak tosomeone who would take responsibility forrectifying the problem, but was told that no onecould tell him where his application was. Enquirieswould be made with the document handlingcentre. The Authority told Mr S that someonewould call him, but that he should call them if hehad heard nothing within two and a half weeks.

During August and September 2006 Mr S chasedthe Authority for progress. On 20 September heasked the Authority for the contact details ofsomeone who could resolve matters or tell himwhat was going on. He sent a letter of complaintto the Home Office. On 2 October a CustomerServices Manager (the Manager) telephoned Mr S.He said it was likely that the two applicationforms had been switched and that he was havingdifficulty contacting Mr A. Later in the month,the Home Office wrote to Mr S; they passed onthe Authority’s apologies for their poor serviceand outlined the Authority’s complaints process.

By the Authority’s account, they twicetelephoned Mr A in November 2006; he

confirmed that he had received another person’sapplication form. He agreed to return it. Nothaving received the form back, the Authoritywrote to Mr A on 28 November asking him toreturn it. Also on 28 November a CustomerServices Officer (the Officer) wrote to Mr S,apologising for the Authority’s error, and sayingthat they had located his form and were in theprocess of retrieving it. In a letter dated12 December the Officer told Mr S that they werehaving difficulty retrieving the form. During atelephone conversation with Mr S on14 December, the Manager summarised the letterof 12 December (which Mr S had not yetreceived), and said it seemed that the letters of28 November and 12 December contradictedeach other, and that the first letter could havebeen unintentionally misleading. The Managersaid he could not guarantee that Mr S’sapplication would be retrieved and advised himto submit a new one. He recognised the troublecaused to Mr S and that he had lost faith in thesystem.

On 29 December 2006 Mr S replied to theOfficer’s letter of 12 December. He said that hewas not satisfied with the explanation given, andcommented that the Authority seemed moreconcerned that he submit a new application thanthey were about the original mistake. Mr S saidhe had little confidence in the Authority’s abilityto protect his personal data but that, in spite ofthis, he was enclosing a new application form andappropriate fee.

On 9 February 2007 the Authority wrote to Mr Sto apologise for the inconvenience caused. Theysaid they had been dealing with moreapplications than their system had been designedfor, and ‘some isolated errors have occurred’. TheAuthority refunded Mr S’s £190 application fee.On 16 February the Authority wrote to Mr A

Complaint about the Security Industry Authority


again, asking him to return the application form.In March Mr S wrote to the Authority; heacknowledged the refund, but said that he couldnot accept that they took complaints seriouslyand that he had not been made aware of, or seen,their complaints policy and procedure. He alsocomplained that he had not been kept informedof progress, and that the Authority’s letter of9 February had not addressed all of his concerns.The Authority apologised to Mr S on 22 Marchfor the delay in replying to his letter of29 December 2006, for the error over hisapplication form, and for not calling him backmuch sooner. They accepted they had raised hisexpectations over the retrieval of his application.


Mr S complained to the Ombudsman inJanuary 2007 that the Authority had lost hisapplication form containing his personal details,and that he had not received a satisfactoryresponse to his complaints. He expressed greatconcern about the potential misuse of hispersonal information and said he had incurredunnecessary costs and worry in pursuing hiscomplaint.

We investigated the Authority’s handling of Mr S’slicence application and their handling of hissubsequent complaint. During our investigationwe listened to recordings of telephoneconversations between Mr S and the Authority.


Judged against the Principles of GoodAdministration, the Authority did not get it rightin this case. They should not have sent Mr S’sform to Mr A and vice versa, the most likely

cause of which was human error. The seriousnessof the error, at a time when identity theft ismuch in the media and can have wide-rangingeffects on victims, led us to find the Authoritywere maladministrative.

Having made a mistake, it was incumbent on theAuthority to put things right. However, theircomplaints process did not deliver the outcomeMr S sought, nor reassure him that the Authoritywere a reliable organisation. Despite being toldthat someone would contact him within threeweeks, Mr S was not contacted again (apart froma short standard email reply) until almost sevenweeks later. The lack of contact exacerbatedMr S’s frustrations and indicated to him theAuthority’s disregard of his legitimate concerns.There was no audit trail of evidence to showwhat action the Authority took to contact Mr Aor to resolve Mr S’s complaint. That lack ofrecord-keeping was poor administration.

The Authority failed to explain their complaintsprocess to Mr S. The Home Office outlined theprocess, but the Authority should have done thatthemselves. Mr S’s frustrations could have beenlessened had the Authority explained that hiscomplaint was following a defined process. Wesaw no evidence that the Authority addressedMr S’s comment that he had not been madeaware of a complaints policy. Public bodiesshould provide clear information about howpeople can complain, but we found no evidencethat information about the Authority’scomplaints process was widely available to thegeneral public or routinely given to complainants.Things improved after October 2006; theAuthority sought to address Mr S’s complaint anddemonstrate ownership of the problem; theykept him updated and the telephone calls werean attempt at good customer service. That said,


the Authority did unintentionally raise Mr S’sexpectations about the retrieval of his form.

In conclusion, the Authority’s initial mistakecombined with an ineffectual complaints processamounted to maladministration. They did not getit right, nor did they make a good job ofattempting to put things right. They did not, atleast initially, acknowledge and apologise for theirmistake, or explain what had gone wrong; nor didthey act to put things right quickly andeffectively. An ineffectual complaints process isnot good public administration. Mr S was leftfeeling understandably concerned that hispersonal information had been sent to a thirdparty. He was frustrated and outraged. Acustomer’s perception of an organisation is notonly shaped by the way that organisation conducttheir usual business, but also by how theyrespond when things go wrong. As Mr S observedto us:

‘This to me is a classic example of whycomplainants become frustrated with thesystem(s) and do not bother to pursueissues or complaints … . My experiencesleave me with the continuing view thatthe SIA is very poorly managed.’

We upheld Mr S’s complaint and concluded ourinvestigation in February 2008.

Outcome

There was no evidence that the Authority’smistake was caused by a systemic fault, so wemade no recommendations in that respect. Wedid, however, recommend that the Authority:

• apologise to Mr S for not fully explaining theircomplaints process to him and for not

addressing this point in their response to hisletter of March 2007; and

• review their complaints process, and inparticular the need to make information abouttheir full complaints process publicly available,that complainants are routinely given theinformation about their full complaintsprocess, and that they keep a complete audittrail of their actions to resolve complaints.

The Authority implemented ourrecommendations.



• ‘Getting it right’ (acting in accordance withthe public body’s policy and guidance).



The Principles of Good Complaint Handlingwere not referred to in our report but thiscase summary serves to illustrate the followingPrinciple:

• ‘Being open and accountable’ (publishingclear, accurate and complete informationabout how to complain, and how and whento take complaints further).


Failure to act on a request to serve a third partydebt order on a specific day


Ms D obtained a county court judgment against adebtor who owed her £3,411.81. In June 2006 shesent the county court an application for a thirdparty debt order together with the £55 fee. Shewrote that ‘as it appears crucial to time theapplication carefully, I would want the actionplanned so that the judgment debtor’s accountis frozen on 1st of the month when funds aremost likely to be available’. She wrote again on3 July and reminded the court about the timingof the order. The court made an interim thirdparty debt order on 26 July and posted it thatday. It arrived on 28 July. The debtor’s bankaccounts were frozen, containing just £150.75. Thebank retained £55 for dealing with the order (asthey are entitled to do), and a final third partydebt order was made in October ordering thatMs D be paid the balance of £95.75.

In August 2006 Ms D’s father, Mr J, wrote twice tothe court to complain that they had not servedthe order on the date requested. When hereceived no reply, he wrote to the Court Managerand received a one line response saying that ‘thecourt cannot control the date an account isfrozen’. Mr J then wrote to HM Courts Service(HMCS) complaining about the lack and level ofresponse, adding that the response he hadreceived was at odds with the advice HMCS gaveapplicants about the need to consider carefullythe date on which a third party debt order ismade. In reply, HMCS said that the order was senton the day it was made and that ‘the court is notaware of the time it takes to identify theamount left in accounts in the various banks’.

They said there had been no maladministration,and so no compensation could be offered.

Mr J wrote back in October 2006. He said it wasnot true that the court could not control when abank account was frozen: the court could haveposted the order a day or two before therequested target date. He added that it appearedthe court had no regard for its own advice andhad made no attempt to follow Ms D’sinstruction. In reply, HMCS accepted that theassertion that the court could not control thedate an account is frozen was ‘somewhatdisingenuous’ as it had some control over the daythe order is served. They accepted that Ms D’srequest for service on a particular date had beenignored and that the order had been sent as soonas it was drawn. They offered £55 compensation.


Mr J complained to the Ombudsman in April 2007that HMCS had ignored Ms D’s instructions aboutserving the third party debt order, and that shehad lost the opportunity of the claim against thedebtor being satisfied.

Our investigation looked at HMCS’s handling ofthe third party debt order application, consideredthe adequacy of their leaflet Third party debtorders and charging orders and scrutinised theirhandling of Mr J’s complaint. During theinvestigation, we spoke with Mr J and madeenquiries of HMCS and the bank.


HMCS failed to take account of Ms D’s requestabout the date of service of the order. That wasmaladministrative. We were not convinced by

Complaint about HM Courts Service


their argument that sending a letter by postmeans that the date on which it will arrive is‘entirely in the hands of the Post Office’. Mostfirst class letters arrive the next working day, andit was therefore unreasonable of HMCS to fail toadopt that (or a similar) strategy. Even if the orderhad arrived on the second of the month, thatwould have gone a long way to meeting Ms D’swishes. If HMCS had felt unable to comply withher request, they should have told her. One ofthe Principles of Good Administration is ‘Beingcustomer focused’. This includes the need forpublic bodies to aim to ensure that customersare clear about their entitlements; about whatthey can and cannot expect from the publicbody; and about their own responsibilities. Inignoring Ms D’s request HMCS were not customerfocused.

‘Being open and accountable’ is anotherPrinciple. The information in HMCS’s leaflet aboutthird party debt orders fell well short of this; itdid not mention that applicants can serve theorder themselves, nor did it refer to the questionabout whether an applicant can ask for the orderto be posted on a particular day. The generaldisclaimer included in the leaflet (that it cannotexplain everything about court rules andprocedures) was not sufficient to compensate forthe lack of information about how a person canseek to ensure a third party debt order is servedon a certain date. That was important and shouldhave been covered by the leaflet. Taken together,these failings were serious enough to bemaladministrative. A further Principle is ‘Puttingthings right’. Part of this is operating an effectivecomplaints procedure which investigatescomplaints thoroughly, quickly and impartially.Mr J wrote five letters of complaint before hereceived a response which in any way addressedthe points he had made. That fell short of the

standard of complaint handling that Mr J wasentitled to expect and was maladministrative.

Did Ms D suffer a financial loss as a result ofHMCS’s maladministration? We found that noregular deposits went into the debtor’s accountsat around the beginning of each month, andnothing was deposited between 28 July and6 August 2006. Furthermore, as an order is notsent to the debtor until seven days after it is sentto the bank, the debtor in Ms D’s case would nothave known his bank accounts were subject to acourt order until on or after 4 August 2006. Wehad no reason to believe that, even if the orderhad been served as Ms D had requested, shewould have obtained any more satisfaction fromthe order than she did. Ms D did, however, sufferoutrage and distress. From the inadequateinformation in the HMCS leaflet and the fact thatthey did not otherwise explain her options toher, she was also unable to make a fully informeddecision about which route to pursue in trying toserve the order on the date she wanted. Mr J alsosuffered outrage and inconvenience because ofthe way his complaint was handled.

We partly upheld Mr J’s complaint and concludedour investigation in March 2008.

Outcome

At our recommendation, HMCS paidcompensation of £150 (instead of £55) to Ms Dand apologised for the outrage and distress theyhad caused her and Mr J.

We also recommended that the next time HMCSreprint their leaflet, they amend it to reflect thefact that applicants for third party debt ordersmay choose to serve those orders themselves,and that it states clearly what steps HMCS can


and cannot take to meet requests for service ona particular day or time of the month. HMCSagreed to review the information given to courtusers on this subject.



• ‘Being customer focused’ (informingcustomers what they can expect and whatthe public body expects of them).

• ‘Being open and aqccountable’ (being openand clear about policies and procedures andensuring that information, and any adviceprovided, is clear, accurate and complete).

• ‘Putting things right’ (operating an effectivecomplaints procedure, which includesoffering a fair and appropriate remedy whena complaint is upheld).



• ‘Being customer focused’ (dealing withcomplainants promptly and sensitively,bearing in mind their individualcircumstances).

• ‘Putting things right’ (providing prompt,appropriate and proportionate remedies).


Failure to appreciate the full scope of theinjustice caused by maladministration


Mr H had been working in Spain for many yearsuntil ill health forced him to give up his job andreturn to the UK in January 2005. In NovemberMr H was signed off by his doctor untilMarch 2006. Jobcentre Plus advised him to claimdisability living allowance (which he did on11 November 2005) and income support (which hedid on 5 December). Following his incomesupport application, Jobcentre Plus told Mr Hthat as he was aged 61 he should claim pensioncredit instead. Mr H said that he then claimedpension credit twice during January 2006 and thathis applications were lost in the system. Hecompleted another application in March and wasawarded pension credit, backdated to5 December 2005. According to Mr H, he had toincrease his bank overdraft because of the delayand incurred charges. (Bank statements for theperiod between December 2005 and March 2006show charges totalling £123.52 in the form ofinterest on amounts overdrawn.)

Mr H’s financial problems and ill health werefurther exacerbated when his son was killed whileabroad in February 2006. Mr H had to pay funeralcosts of more than £4,000, and was awarded asocial fund funeral payment of £989 by JobcentrePlus. Mr H appealed, as he felt he should havebeen awarded the full costs of the funeral.Jobcentre Plus then realised that they should nothave made a funeral payment: the funeral tookplace outside the UK and neither Mr H nor hislate son met the other entitlement criteria.

In the meantime, Mr H’s disability living allowanceapplication had been refused in January 2006.

Jobcentre Plus advised him to claim incapacitybenefit; that claim was also refused as he had notpaid enough National Insurance contributions inthe two years prior to his application. Mr Happealed, on the grounds that he had beenpaying contributions into the Spanish system.Mr H telephoned Jobcentre Plus in March todiscuss the refusal of his incapacity benefitapplication, and agreed to send them details ofhis earnings in Spain. Jobcentre Plus received thisinformation from Mr H in April and forwarded itto the International Pension Centre. They, in turn,requested further information from Mr H, whichhe supplied to his local job centre on 12 May.

Initial referral to the Ombudsman

In August 2006 Mr H referred his complaint tothe Ombudsman. We declined to investigate atthat time as he had not been through JobcentrePlus’s complaints procedure. We referred hiscomplaint to the Chief Executive of JobcentrePlus, giving her an opportunity to resolve theissues. In December the Chief Operating Officerresponded to Mr H’s complaint. He apologisedfor the poor advice Jobcentre Plus had givenMr H about income support and pension credit,confirmed that Mr H had since been paid pensioncredit arrears, and apologised for losing Mr H’sinitial pension credit application. The ChiefOperating Officer explained why the incapacitybenefit claim had been refused and provided anupdate on the progress of this in relation toMr H’s overseas contributions. He also apologisedthat the information that Mr H had provided inMay 2006 had not been forwarded to theInternational Pension Centre untilNovember 2006. He also provided an explanationfor Mr H’s funeral payment award and confirmedthat he would not be asked to repay it, as it wasdue to an official error.

Complaint about Jobcentre Plus of the Department forWork and Pensions



Mr H felt that the response from Jobcentre Plusdid not resolve his complaint and he asked theOmbudsman to look again at his grievances. Wedecided to investigate his complaint in July 2007.

We investigated Mr H’s complaint that JobcentrePlus’s response to him of December 2006 wasinadequate; that they were maladministrative infailing to compensate him for the bank chargesand other expenses incurred as a result of thedelay in paying him pension credit because oftheir misdirection (the costs of telephone callsand travel expenses to Jobcentre Plus and to hisMP’s office to resolve his difficulties); and thatthe £50 compensation payment they had madeto him was inadequate. Mr H said that hesuffered inconvenience, financial loss, and wantedcompensation for the charges and expenses hehad incurred, and recognition of the stress he andhis wife were under as a result of Jobcentre Plus’smaladministration.


Jobcentre Plus’s response to Mr H ofDecember 2006 gave a good explanation for theissues he had raised, and they accepted that theirfailings had led to some of the problems he hadencountered. The clarity of their explanation andacceptance of responsibility was very much inline with the Principles of Good Administration(‘Putting things right’). However, part of puttingthings right is also to provide a remedy whichfairly reflects the harm someone has suffered. Itis here that Jobcentre Plus fell down.

Mr H raised the question of overdraft charges inhis complaint. Jobcentre Plus considered thismatter as part of their compensation decision,

but then made no reference to it in their letter tohim. This omission amounted tomaladministration. Had Jobcentre Plus acted inaccordance with the Principle of ‘Being open andaccountable’, this would not have happened. Asfor the decision not to compensate Mr H for hisbank charges, his bank account was alreadyoverdrawn before he applied for benefit and thecharges were calculated in the form of interest onthe amount by which he was overdrawn.Although Jobcentre Plus reasonably concludedthat the timely payment of pension credit wouldnot have stopped him becoming overdrawn, theydid not consider whether timely payments wouldhave reduced the charges applied to his bankaccount. It is reasonable to conclude thatwithout the maladministration the charges wouldhave been lower; Jobcentre Plus’s failure toconsider that point was maladministration. Wefound that the other costs that Mr H wantedJobcentre Plus to reimburse (telephone and travelcosts) were not brought to their attention untilafter they made the compensation decision. Theycould not, therefore, have included these costs intheir consideration.

Jobcentre Plus did not take Mr H’s individualcircumstances sufficiently into account whendeciding to pay him compensation of £50. He wassuffering both from ill health and bereavementduring the very time when Jobcentre Plus mademistakes and delayed dealing with his claims.Mr H had also made clear to Jobcentre Plus thathe was under financial pressures, made worse bythe late payment of pension credit. There is noevidence that Jobcentre Plus took thesesignificant and relevant circumstances intoaccount, and so fell short of meeting thereasonable expectations as set out in thePrinciples of Good Administration (‘Beingcustomer focused’ and ‘Acting fairly andproportionately’). That was maladministrative.


In summary, Jobcentre Plus’s flawedcompensation decision meant that Mr H did notreceive a remedy which properly recognised theharm done to him as a result of theirmaladministration. We regarded £50 asinsufficient to recognise the worry, inconvenienceand trouble that Mr H was put to at a verydifficult time. Furthermore, Jobcentre Plus’smaladministration in considering the remedymeant that Mr H was put to unnecessary timeand trouble in bringing his complaint back to theOmbudsman.

We partly upheld Mr H’s complaint andconcluded our investigation in March 2008.

Outcome

At our recommendation, Jobcentre Plusapologised to Mr H and paid him:

• £200 in recognition of the worry,inconvenience, time and trouble he was put to;

• £20 to cover his bank charges;

• £70 towards his telephone costs; and

• £20 towards his petrol charges.



• ‘Putting things right’ (acknowledgingmistakes and apologising where appropriate;operating an effective complaintsprocedure, which includes offering a fair andappropriate remedy when a complaint isupheld).

• ‘Being customer focused’ (dealing withpeople helpfully, promptly and sensitively,bearing in mind their individualcircumstances).

• ‘Being open and accountable’ (statingcriteria for decision making and givingreasons for decisions).

• ‘Acting fairly and proportionately’ (ensuringdecisions and actions are proportionate,appropriate and fair).


The Criminal Records Bureau provided thecomplainant’s employer with an inaccuratedisclosure which wrongly attributed criminalconvictions to him


Mr L required a disclosure (a criminal recordscheck) in order to take up employment in thesecurity industry. He applied to the CriminalRecords Bureau (the Bureau) for a disclosure inMay 2006 through his employer. The Bureauchecked Mr L’s details against the police nationalcomputer, and identified an individual with thesame name and place of birth, and whose date ofbirth differed from Mr L’s only by one year. Theytherefore issued a disclosure for Mr L – which wassent to his employer – showing that individual’sconvictions.

Solicitors acting for Mr L promptly wrote to theBureau, saying that Mr L was clearly not theindividual whose details were recorded on thepolice national computer, and that Mr L deniedany involvement in the convictions shown on thedisclosure. They asked for a fresh disclosure. TheBureau asked Mr L to complete a disputeresolution form, and to return it along withphotographs of himself, which he did. In lateJune 2006 they sent Mr L’s completed form and aphotograph to the police, and asked them toinvestigate Mr L’s claim that he was not theindividual whose details were on the policenational computer.

In August 2006 Mr L telephoned the Bureau. Hesaid that, having arranged with the police to havehis fingerprints taken for comparison with thepolice national computer, he had duly attendedhis local police station only to find that they wereunaware of such arrangements. The Bureau asked

the police to arrange a new appointment, whichthey did. A comparison of Mr L’s fingerprints withthose held by the police subsequentlyestablished that he was not the individual whosedetails were held on the police nationalcomputer. Having received that information fromthe police in September, the Bureau sent Mr L’semployer a new disclosure on 29 September.

In October 2006 the solicitors wrote to theBureau seeking compensation for the distressthat they said the issue of an incorrect disclosurehad caused to Mr L. The Bureau replied sayingthat the details shown on the police nationalcomputer had sufficiently closely matched Mr L’sown details, so that it had been reasonable to linkhim to that record. Furthermore, the otherindividual lived close to Mr L. The Bureauconcluded that they had not actedmaladministratively in issuing the disclosure asthey did, and so there was no basis on which theymight be expected to compensate Mr L.


Mr L complained to the Ombudsman inJanuary 2007 that the Bureau’s actions had led toinconvenience and distress. We investigatedwhether the Bureau had mishandled hisapplication for a disclosure.


The enquiries we made of the Bureau, followingreceipt of Mr L’s complaint, prompted them toreconsider their handling of his case. In theirsubsequent response, the Bureau said that it hadbeen apparent from the initial police nationalcomputer search that the fingerprints of theindividual whose convictions had been linked to

Complaint about the Criminal Records Bureau


Mr L were held by the police. They said theyshould, therefore, have arranged to have thosefingerprints compared to Mr L’s fingerprintsbefore issuing a disclosure. The Bureau said that ifthey had done so, Mr L’s employer would havebeen told from the outset that Mr L had nocriminal convictions.

We upheld Mr L’s complaint and concluded ourinvestigation in May 2007.

Outcome

As a result of our investigation the Bureauapologised to Mr L for the inconvenience thattheir oversight had caused him and paid himcompensation of £550.



• ‘Acting fairly and proportionately’ (offeringa remedy that is fair and proportionate).

• ‘Putting things right’ (paying compensationwhere it is not possible to return acomplainant to the position he or shewould have been in but formaladministration).


Remedy for a mishandled investigation into aserious accident and inadequate preparation forlegal proceedings


In August 2002 Mr F (then a boy) was knockedover by a truck reversing over a public footpathinto a yard owned by Company P. He sustainedlife-threatening injuries, for which he continuesto undergo surgery. The Health and SafetyExecutive (HSE) began an investigation. Theyobtained the physical evidence from the scene ofthe accident, gathered by the police, interviewedMr F and eye witnesses, and took statementsfrom employees of Company P, including thedriver of the truck.

In June 2004 Company P were interviewed undercaution in accordance with the Police andCriminal Evidence Act 1984. Before that interview,HSE said that they were not consideringproceedings against any individual officer orservant of the company. However, the officerassigned to the case told Mr F’s family inApril 2005 that Company P would be taken tocourt. HSE told the family that the case would beheard in court in November 2006.

Having heard no more, Miss B (Mr F’s sister)contacted HSE on 8 November 2006 but couldget no further information. The next day she wastold the case was not going ahead and that thishad been decided at a case conference (inOctober 2006), on the basis of Counsel’s opinionthat the evidence gathered did not pass theevidential test for prosecution. Mr F’s familycomplained to HSE.

The Head of Field Operations for the Londonarea met the family and their solicitor inDecember 2006. He wrote to Mr F’s parents withthe results of a review he had conducted. He saidthat HSE’s conduct of the investigation andsubsequent legal proceedings had beenunacceptable, as had the failure to liaise properlywith the family throughout the course of theinvestigation and subsequent aborted legalproceedings. He apologised unreservedly, andsaid he would work to ensure that this could nothappen again. The Head of Field Operationsadded that he had thoroughly explored thepossibility of reopening the investigation togather more evidence, but there was little chanceof gathering evidence which might support asuccessful prosecution.


In January 2007 Miss B complained to theOmbudsman that HSE’s apology was notsufficient redress for their inadequateinvestigation and their preparation forsubsequent legal proceedings. She soughtcompensation for the distress that HSE hadcaused her family. She wanted the compensationto reflect the effect of the maladministration onany future damages Mr F might receive, andreassurance that no other family would have togo through what they had suffered.

The focus of our investigation was whether theactions HSE had taken to remedy the injustice toMr F and his family were adequate in thecircumstances.

Complaint about the Health and Safety Executive



Our investigation established that Miss B’scomplaint to HSE had prompted them to take anumber of steps in an attempt to remedy hercomplaint, and to reduce the chances of theirfaults and failings being repeated. Actionincluded:

• an apology;

• developing proposals to make the best use ofenforcement to deliver health and safetypriorities, and to improve the efficiency andeffectiveness of investigation and prosecutionactivities;

• sharing the key learning points from Mr F’scase;

• ensuring HSE keep interested parties properlyinformed throughout the course ofinvestigations and subsequent legalproceedings;

• introducing a system to ensure thatinvestigation reviews are carried out andrecorded. Existing documents were revised togive more details about what reviews shouldinclude and what should be recorded, and toallow lines of enquiry and decisions to berecorded in a way which should ensure thereview meets its objectives;

• ensuring that HSE do not decide to prosecutewithout evidence to support a successfulprosecution, and that all reasonable lines ofenquiry are properly considered;

• introduction of an improvement programmefocusing on investigations and enforcement toraise competence levels; and

• introducing a new computer system withmodules to help track the progress ofinvestigations and the submission ofprosecution reports and their approval, and toensure that legal proceedings are properlymanaged.

Mr F and his family had a reasonable expectationthat HSE’s investigation into his serious accidentwould be thorough and competent, anddetermine whether or not health and safetylegislation had been breached (and that HSEwould pursue a prosecution effectively if it had).HSE failed them on every count.

Although HSE had taken steps to minimisethe chances of a recurrence of these failings,we upheld Miss B’s complaint that theindividual remedy offered by HSE to Mr F wasinadequate. Our investigation was concludedin October 2007.


Outcome

We recommended that HSE pay compensation toMr F.

The Chief Executive replied, saying that HSEregretted that they had added to the alreadygreat level of suffering in this case, and askingthat his personal regret be conveyed to Mr F andhis family for the mistakes made. He offeredcompensation of £2,000. We regarded that to bean appropriate amount.

We did not share Miss B’s view that redressshould take into account any effect HSE’smaladministration would have on any futuredamages (that would have involved considerablespeculation as to the outcome of anyprosecution of, or civil claim against, Company P).



• ‘Getting it right’ (considering all relevantfactors when deciding the appropriateremedy, ensuring fairness for thecomplainant).

• ‘Putting things right’ (considering fully andseriously all forms of remedy, such as anapology, explanation, remedial action orfinancial compensation).

• ‘Seeking continuous improvement’ (usingthe lessons learnt to ensure themaladministration is not repeated, and usingcomplaints to improve services).


Failure to ensure that accurate informationabout copyright was provided on a website


In 2003 a charity (the charity), whose aim is toprovide accurate information and advice to drugusers, made use of some photographic materialthat they found on a website sponsored by theDepartment of Health (the Department). On thewebsite, it was stated that all material was Crowncopyright unless otherwise stated and that Crowncopyright material could be used without chargefor health promotion purposes. There was noindication that the photographs were not Crowncopyright. The charity used some of thosephotographs on their own website.

The charity were later approached by aphotographer who claimed copyright of thephotographs, asked for payment of £5,098.83 andsubsequently issued court proceedings.

The charity approached both the Departmentand the Central Office of Information. Thecharity were referred to copyright information onthe website and were told that this was a matterbetween them and the photographer, and it wassuggested that they might wish to seek legaladvice. The charity subsequently paid the fee,settling out of court with the photographer.

Complaint to the Department

In October 2006 the charity made a formalcomplaint to the Department, which replied inNovember and said that, although they acceptedthat the charity had mistakenly believed theimages they used were Crown copyright, theycould not take responsibility for that. They also

referred to the copyright statement on thewebsite from which the images had been taken.

The charity made a further complaint, assertingthat nothing on the website had indicated thatthe images they had used were not Crowncopyright and that some of the copyrightinformation had been added more recently.

In January 2007 the Department replied and saidthat the website use statement had been on thesite since October 2003 (except for a period inFebruary to March 2006 when it had beeninadvertently removed). They maintained thatthey had no legal liability and that it had beenthe charity’s responsibility to contact the websiteto establish the copyright status of the images.The Department apologised for ‘gaps’ in theircommunications with the charity during 2006.The charity wrote again to the Department,restating their position and subsequently askedfor a meeting to discuss the issue. TheDepartment said that they had provided all ofthe information they could and told the charitythat they could make a complaint to theOmbudsman.


In March 2007 the charity’s complaint wasreferred to the Ombudsman. We investigated thecharity’s complaint that the Department failed toensure that accurate information about copyrightwas provided on a website that they sponsored.The charity said that, as a result, they hadincurred costs of £5,098.83.

The purpose of our investigation was not todetermine whether the Department had any legalliability in this matter but to decide whether theyhad been maladministrative. As part of our

Complaint about the Department of Health


investigation we obtained an archived 2003version of the website from which the charityhad taken the images for use on their ownwebsite.


We found that the 2003 version of the websitesaid that material was Crown copyright unlessotherwise indicated and that such material couldbe reproduced free of charge. None of thephotographs were labelled or captioned toindicate that they were not Crown copyright. Incontrast, the current version of the website doescarry warnings that no material should be usedwithout prior approval and indications of thecopyright owner of all photographs.

We found that the charity had carefully checkedthe copyright position on the website. If thewebsite had properly reflected the position andthus alerted them to the fact that thephotographs were not Crown copyright, theywould have checked further and obtained therelevant permissions or decided not to use thephotographs.

We found that the Department had beenmaladministrative by providing incorrect andmisleading information about copyright. This hadcaused the charity to incur the photographer’sfees of £5,098.83 for use of his copyrightedmaterial.

Our investigation, which concluded inDecember 2007, upheld the charity’s complaint.

Outcome

As a result of our recommendations theDepartment apologised to the charity andrefunded an amount equivalent to thephotographer’s fees.


The Principles for Remedy were not referredto in our report but this case summary servesto illustrate the following Principle:

• ‘Putting things right’ (offering a remedy thatreturns the complainant to the position thatthey would have been in were it not for themaladministration).


Mishandling of income support payments andinadequate consideration given to appropriateremedy


Mr K’s income support payments were paiddirectly into his bank account. On11 February 2006 he wrote to ask Jobcentre Plus topay him by cheque instead. He instructed hisbank to close his account and destroyed his bankcard. Jobcentre Plus did not receive Mr K’s letteruntil 14 February, by which time they had alreadypaid his income support payment for 13 Februaryinto his bank account, which he could not thenaccess. On receipt of Mr K’s letter, Jobcentre Plussuspended his payments, awaiting contact fromhim to find out if he was going to open a newbank or post office account. On 13 February Mr Kwrote to his MP asking what was happening withhis payments. He was referred to his localcouncillor as the reason for changing thepayment method related to his council tax. Mr Kwrote again to the MP. She contacted JobcentrePlus which immediately lifted the suspension andhand-delivered a cheque to Mr K for his incomesupport arrears.

Jobcentre Plus apologised to Mr K for what hadhappened and said that compensation would beconsidered. The compensation referral included aletter from Mr K to his MP, in which he describedthe effects of being without income support: noelectricity and hence no heat (in sub-zerotemperatures), light or hot water; and he couldnot afford food. He also pointed to his history ofheart attacks. Jobcentre Plus decided not toaward Mr K compensation; they accepted thattheir maladministration had interrupted hisbenefit payments, but felt that the level ofinconvenience did not merit compensation.

Jobcentre Plus’s file was noted: ‘This decisiontakes into account the observation that thematter could have been resolved at the firstpoint of contact from the customer followingthe benefit interruption. Benefit entitlementwould have been due on 20/02/06. I would haveconsidered it reasonable for the customer tocontact the department directly to establish[sic] position with his benefit entitlement asopposed to writing directly to his MP over aweek later’. (At interview, Mr K explained to usthat he had approached his MP rather thanJobcentre Plus, because on previous occasionsJobcentre Plus had ignored his letters until theMP had intervened on his behalf.)


Mr K complained to the Ombudsman inSeptember 2006 that Jobcentre Plus had left himwithout payment for three weeks, leaving himwith no heating, hot water, food and only coldwater to drink. He also complained aboutJobcentre Plus’s refusal to compensate him. Atinterview, Mr K told us that Jobcentre Plus’sactions had meant he could not properly take hisheart medicine which had to be taken with food;he had used candles for light; and he had losttouch with his brothers because he would notopen his door to them at the time because of hisshame at his poverty. He told us that JobcentrePlus did not ask him how their actions hadimpacted on him before making thecompensation decision.

Our investigation focused on Jobcentre Plus’shandling of Mr K’s request to change his paymentmethod, and their consideration of acompensation payment.

Complaint about Jobcentre Plus of the Department forWork and Pensions



Jobcentre Plus should not have suspended Mr K’spayments. Instead, they should have changed thepayment method first to ensure his paymentswould be made by cheque and if they wished toestablish his intentions about future paymentsthey should have asked him. Their decision tostop paying benefit into Mr K’s bank account butnot to start paying it by cheque wasmaladministration.

Jobcentre Plus were not at fault in making the13 February 2006 payment directly into Mr K’sbank account, as they had not by then receivedhis letter of 11 February.

In general we expect bodies to be given theopportunity to put things right as soon aspossible. In this case we accepted it wasreasonable for Mr K to have asked his MP for help(rather than contact Jobcentre Plus) because ofhis history of needing her intervention. It wasdisappointing that Jobcentre Plus did not askMr K why he chose to approach his MP for help,or to ask him how their maladministration hadaffected him.

We partly upheld Mr K’s complaint andconcluded our investigation in September 2007.

Outcome

As a result of our recommendations, JobcentrePlus:

• reconsidered their compensation decision(examining carefully the situation Mr K foundhimself in), and awarded him compensation of£400 in recognition of the distress andinconvenience he suffered; and

• apologised to Mr K for not offering him anappropriate payment earlier.

Jobcentre Plus also gave an undertaking that anamed officer would ensure a prompt responseto any future correspondence from Mr K. Theysaid they would send a holding reply to anyfuture correspondence within five days and a fullresponse within ten days, in line with their normalservice standards.



• ‘Getting it right’ (considering all the relevantfactors when deciding the appropriateremedy).

• ‘Acting fairly and proportionately’ (offeringa remedy that is fair and proportionate tothe complainant’s hardship or injustice).


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Documents

Improving public service: a matter of principle HC9...Improving public service: a matter of principle First report Session 2008-2009 Presented to Parliament pursuant to Section 14(4)