Hi Folkes
As promised my update on the latest meeting of the complaints review panel.
This month it was nice to meet some more fresh faces at our panel meeting including attendees from Health watch and Staffordshire County Council
We started the meeting at 14:30 and concluded at 16:30.
After the usual introductions We reviewed all the issues that had been highlighted over the past few months.
It was great to see that the Action Tracker was up and running for our panel, This system simply allows us to review on a monthly basis that all recommendations and actions have been carried out within a sensible time frame.
From this system the panel will be able to see fully if implementation of change is having a real world effect.
It came to my attention at the meeting that there was an ongoing review as to how all agencies would work together, This is a good thing as when the Police,County Council and the Trust have to share information to protect then the Protocols and Processes need to be robust and Transparent within all organizations.
I only hope this would ensure Safety to the public and evidence based decisions and make efficiency savings.
As always it comes back to team work and attitudes between different organizations.
We reviewed the first of the two complaints.
Unfortunately the Investigating Officers were not in attendance for either of the complaints being reviewed.
The panel feel that this left a situation where direct questions could not be asked, It has been decided that in future reviews the IO or representative must be present to receive credit and constructive criticism.
Complainant A had suffered a fall from a step in which she stated that she could hear a cracking noise to her ankle.
She had attended a local walk in center who had carried out a film Ex-ray to the injury.
It was established from the Ex-ray that there was no fracture to the ankle.
The complainant was given information at the time to rest up and visit her GP if the pain persisted.
The lady did visit her GP as she was having pain in the ankle and was provided with physiotherapy.
After a further time the condition did not improve and the complainant was sent for a more in depth MRI scan.
The Scan showed a fracture.
Although the whole situation has been painful and distressing to this lady there is unfortunately no one situation to blame.
The Ex-ray that was taken at the walk in center was also reviewed at the local hospital 2 days later, this is standard practice for the walk in center.
Upon both viewing of the Ex-ray no fracture could be detected.
I have received very sound medical advice from a very down to earth lady that it is possible to have a fracture in a bone that will not show up under Ex-ray.
It was apparent to the group that upon the persistent pain of the injury, the decision to undertake physio prior to an MRI was not helpfull to the condition.
It is exceptionally costly to MRI every suspect fracture at nearly £500.00 to the NHS however a clinical case by case decision should be made when necessary.
A further issue came to light in the Complaint Response where the wording of the findings of the complaint could have been wrote more sympathetically to the complainant, this is not the fault of the IO however the response to complainant was from the medical director.
The panel were not in a position to provide direct feedback to the IO however issues have been highlighted.
The second reviewed complaint was short but very complex.
This was a learning curve for me in damned if you do damned if you dont.
There are many people out there who struggle to write including myself, sometimes it can be difficult to get down in writing the base of your complaint in a coherent manner.
The complainant had issues with data sharing and was concerned that information was being provided to the NHS regarding her continual home moves,few toys around for the children to play with and that she refused to say who was the farther to the child.
The initial complaint letter showed little structure to the point of confusion, the complainant states that the health worker was making derogatory reports such as being "Manipulative" about her to social care.
I held concern that the complainant would even know the word "Manipulative", this is a word I have heard stated in many reports describing individuals including myself.
Upon the IOs investigation it was established that the health worker had not raised any referral to social care however a referral had been made by the child's school.
The issues at home as noted by the health professional were that there were "frequent house moves, Few toys around the home and refusal to accept help".
It is apparent from records that the mother is known to social care.
From the perspective of Joe Blogs I could not see any reason why home moves and specific amounts of toys should raise any concern of risk, neither could I see that a mothers choice not to immunize a child be considered either neglect or abuse.
It is a sad fact in our society that parents can kill there own children.
In the Baby P case there were trigger signs that gave away what was happening and unfortunately frequent home moves to evade are a trigger as so are few toys unknown fathers etc.
It is important if you are involved with social care for any reason you should be able to embrace the support and work with those staff and understand why they are there.
You could be the best parent in the world and the bruise your child could have could be innocent or could be a warning of something sinister.
Damned if you do Damned if you dont.
The public need the ability to see full transparency it should be the corner stone in how the police,social care and the NHS report situations and work together.
Fact and evidence based information alongside identified risks will gain a safer multi agency approach.
The NHS, Police and County Council have a duty of care to protect this requires communication.
The sad reality is that data sharing is not always happening properly, where some are sharing information that is sometimes not based on fact or the information has been assumed or created this is simply unacceptable and requires challenge and cultural change.
Hope you are all having a good week & take care in the Sun
Steve
As promised my update on the latest meeting of the complaints review panel.
This month it was nice to meet some more fresh faces at our panel meeting including attendees from Health watch and Staffordshire County Council
We started the meeting at 14:30 and concluded at 16:30.
After the usual introductions We reviewed all the issues that had been highlighted over the past few months.
It was great to see that the Action Tracker was up and running for our panel, This system simply allows us to review on a monthly basis that all recommendations and actions have been carried out within a sensible time frame.
From this system the panel will be able to see fully if implementation of change is having a real world effect.
It came to my attention at the meeting that there was an ongoing review as to how all agencies would work together, This is a good thing as when the Police,County Council and the Trust have to share information to protect then the Protocols and Processes need to be robust and Transparent within all organizations.
I only hope this would ensure Safety to the public and evidence based decisions and make efficiency savings.
As always it comes back to team work and attitudes between different organizations.
We reviewed the first of the two complaints.
Unfortunately the Investigating Officers were not in attendance for either of the complaints being reviewed.
The panel feel that this left a situation where direct questions could not be asked, It has been decided that in future reviews the IO or representative must be present to receive credit and constructive criticism.
Complainant A had suffered a fall from a step in which she stated that she could hear a cracking noise to her ankle.
She had attended a local walk in center who had carried out a film Ex-ray to the injury.
It was established from the Ex-ray that there was no fracture to the ankle.
The complainant was given information at the time to rest up and visit her GP if the pain persisted.
The lady did visit her GP as she was having pain in the ankle and was provided with physiotherapy.
After a further time the condition did not improve and the complainant was sent for a more in depth MRI scan.
The Scan showed a fracture.
Although the whole situation has been painful and distressing to this lady there is unfortunately no one situation to blame.
The Ex-ray that was taken at the walk in center was also reviewed at the local hospital 2 days later, this is standard practice for the walk in center.
Upon both viewing of the Ex-ray no fracture could be detected.
I have received very sound medical advice from a very down to earth lady that it is possible to have a fracture in a bone that will not show up under Ex-ray.
It was apparent to the group that upon the persistent pain of the injury, the decision to undertake physio prior to an MRI was not helpfull to the condition.
It is exceptionally costly to MRI every suspect fracture at nearly £500.00 to the NHS however a clinical case by case decision should be made when necessary.
A further issue came to light in the Complaint Response where the wording of the findings of the complaint could have been wrote more sympathetically to the complainant, this is not the fault of the IO however the response to complainant was from the medical director.
The panel were not in a position to provide direct feedback to the IO however issues have been highlighted.
The second reviewed complaint was short but very complex.
This was a learning curve for me in damned if you do damned if you dont.
There are many people out there who struggle to write including myself, sometimes it can be difficult to get down in writing the base of your complaint in a coherent manner.
The complainant had issues with data sharing and was concerned that information was being provided to the NHS regarding her continual home moves,few toys around for the children to play with and that she refused to say who was the farther to the child.
The initial complaint letter showed little structure to the point of confusion, the complainant states that the health worker was making derogatory reports such as being "Manipulative" about her to social care.
I held concern that the complainant would even know the word "Manipulative", this is a word I have heard stated in many reports describing individuals including myself.
Upon the IOs investigation it was established that the health worker had not raised any referral to social care however a referral had been made by the child's school.
The issues at home as noted by the health professional were that there were "frequent house moves, Few toys around the home and refusal to accept help".
It is apparent from records that the mother is known to social care.
From the perspective of Joe Blogs I could not see any reason why home moves and specific amounts of toys should raise any concern of risk, neither could I see that a mothers choice not to immunize a child be considered either neglect or abuse.
It is a sad fact in our society that parents can kill there own children.
In the Baby P case there were trigger signs that gave away what was happening and unfortunately frequent home moves to evade are a trigger as so are few toys unknown fathers etc.
It is important if you are involved with social care for any reason you should be able to embrace the support and work with those staff and understand why they are there.
You could be the best parent in the world and the bruise your child could have could be innocent or could be a warning of something sinister.
Damned if you do Damned if you dont.
The public need the ability to see full transparency it should be the corner stone in how the police,social care and the NHS report situations and work together.
Fact and evidence based information alongside identified risks will gain a safer multi agency approach.
The NHS, Police and County Council have a duty of care to protect this requires communication.
The sad reality is that data sharing is not always happening properly, where some are sharing information that is sometimes not based on fact or the information has been assumed or created this is simply unacceptable and requires challenge and cultural change.
Hope you are all having a good week & take care in the Sun
Steve
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