Summary
Mr Nic Hart complained to us about the care and treatment provided for his 19 year old daughter, Averil, by four NHS organisations. He also complained about how those organisations, a local Clinical Commissioning Group and NHS England handled his complaint about what happened to Averil.
We found that all the NHS organisations involved in Averil’s care and treatment between her discharge from hospital on 2 August 2012 and her tragic death five months later on 15 December failed her in some way.
We found her deterioration and death were avoidable.
We found that most of the NHS organisations which dealt with Mr Hart’s complaint failed to respond to his concerns in a sensitive, transparent and helpful way. Their investigations were not sufficiently thorough or joined-up. They did not provide Mr Hart with the answers he sought about Averil’s care and treatment. These failings led Mr Hart to feel profound frustration with the NHS organisations and exacerbated his and his family’s deep distress resulting from Averil’s avoidable death.
Sadly we can do nothing to remedy the injustice to Averil. We have however made recommendations to remedy the injustice to her family and to ensure each of the organisations and the wider NHS learn from the mistakes made in this case. We hope that our recommendations will mean that no other family experiences what Averil and her family experienced.