Trust put right problems with complaint handling but not with chest pain procedures

What happened

Mrs S said that an ECG was taken and she was told that it was normal, when she could see that it showed a rapid and irregular heartbeat.  She said a doctor did not come to see her and a nurse told her she would need to be admitted for more tests.  Mrs S knew that this was not the correct action for the problem she had.  She felt that the unit could not provide her with safe care so she discharged herself.

Mrs S complained to the Trust and said its first investigation into her complaint was unsatisfactory and had to be repeated, by which time the staff involved could not remember what had happened. Mrs S said the Trust had not done enough to put right either the problems in the care she received or in handling her complaint.

The Trust agreed with Mrs S that the first investigation was inadequate, and it carried out a further, more detailed and robust investigation. The second investigation identified a number of concerns. These included that the minor injuries unit did not have a clear protocol for managing patients with chest pain, and that the medical cover should be reviewed because there could be delays in getting a doctor to review patients.

The Trust produced an action plan setting out a number of ways in which it would improve the procedures for the minor injuries unit and complaint handling.

What we found

We felt that the Trust had done enough to put right the problems with the complaint handling. It had identified the need for a second investigation and had carried this out. It had improved its procedures and had learnt from Mrs S's complaint. However, we agreed with Mrs S that the Trust had not done enough to put right the problems with the care she received. This is because we found that the revised protocol for patients attending the minor injuries unit with chest pain was still not robust enough.

Putting it right

We recommended that the Trust explain how it will make sure that patients attending the minor injuries unit with chest pain or another acute medical problem are managed appropriately. The Trust agreed.