Care home misled complainant about amount of physiotherapy given to her son and PCT failed to properly investigate complaint

What happened

Mrs K complained to the Primary Care Trust (PCT) about her concerns. The PCT investigated the complaint and found some failings on the part of Voyage Care. However, the PCT did not agree with Mrs K about the number of missed physiotherapy sessions, did not attempt to consider the impact on J's health or consider whether Voyage Care should take some or all of the responsibility for the breakdown in communication that led to the ending of J's placement. The PCT also did not explain what action it had taken to address the failings it had identified. Mrs K brought her complaint to us and, when the NHS restructured, we referred it to the Clinical Commissioning Group (CCG) with an understanding that a new investigation would address shortcomings we had identified in the PCT's complaint handling.

The CCG conducted an internal audit of the complaint and concluded that J did not get the assessed amount of physiotherapy, but it was unable to gauge the extent of the shortfall. It also concluded that Voyage Care had overcharged the PCT for therapy sessions. The audit did not deal with responsibility for the breakdown in trust or consider the impact on J's health. The audit found the investigation had been delayed because of the good relationship between the PCT and Voyage Care.

The investigation had lacked thoroughness and a clear conclusion. The CCG apologised to Mrs K and outlined service improvements, but refused a request for financial redress.

Voyage Care refunded £640 for under–provided therapy sessions.

What we found

Both local investigations failed to calculate the amount of under–provided physiotherapy sessions correctly. Voyage Care contributed significantly to the breakdown in trust that ended J's placement.

We were critical of the thoroughness of the CCG's investigation and the measures it had taken to hold Voyage Care to account for its failings. We also criticised the CCG for failing to take account of the impact of the shortfall in therapy on J's health, and its failure to apportion responsibility for the breakdown in trust.

There were failings in the CCG's complaint handling that extended to dismissing Mrs K's concerns, and bias.

Finally, we criticised the CCG for not remedying the complaint and refusing financial redress.

As a result, we concluded that Mrs K was left not knowing how much difference these failures had made to J's health and wellbeing. She experienced loss of trust, distress, frustration and anger. The CCG's complaints process failed to take Mrs K seriously or reassure her that it protects the interests of vulnerable patients and their families.

Putting it right

Both bodies acknowledged and apologised for their failings and agreed to pay Mrs K compensation. The CCG said it would prepare an action plan to address failings in its complaint handling and agreed to take action to recover the full amount of the overpayment from Voyage Care.