Following a number of concerns that had been raised about care on the Tawel Fan Ward at Ysbyty Glan Clwyd, Betsi Cadwaladr University Health Board commissioned an investigation into what happened. This was carried out by Health and Social Care Advisory Service Consultancy Limited (“HASCAS”). The investigation produced an overall report looking at the general issues raised about Tawel Fan, which was published in May 2018. HASCAS was also commissioned to produce individual reports into the experiences of 108 patients who had been on Tawel Fan during the relevant period.
The NHS Complaints Procedure (“Putting Things Right”)
In April 2013, the Welsh Government introduced a new procedure for NHS bodies to deal with complaints, known as “Putting Things Right”. This requires Health Boards to consider whether – if something has gone wrong – it has a “qualifying liability”. If it does, the Health Board must follow a process for considering whether it should offer appropriate financial redress to the patient (or their estate if the patient is no longer alive). More information about Putting Things Right can be found here: http://www.wales.nhs.uk/sites3/page.cfm?orgid=932&pid=50738
The 108 individual reports produced by HASCAS in relation to Tawel Fan are being treated as the Health Board’s responses, under Putting Things Right, to the concerns that have been raised about Tawel Fan.
The role of the Public Services Ombudsman for Wales
The Ombudsman considers individual complaints about maladministration and service failure by Welsh public bodies, including NHS bodies such as the Health Board. In order to uphold a complaint, the Ombudsman must be satisfied that there is evidence of maladministration or service failure on the part of the public body concerned and that this has caused an injustice to the person making the complaint, or someone they represent. If something has gone wrong, but the person has not suffered any injustice because of that, the Ombudsman cannot uphold the complaint. When deciding whether to investigate a complaint, the Ombudsman will consider what might be achieved by an investigation and whether it might be possible to settle the complaint.
The Ombudsman is independent of the NHS and his service is free to use.
Frequently asked questions
1. Who can complain to the Ombudsman?
If you have received one of the individual HASCAS reports about the care of your family member, then you may be able to complain to the Ombudsman. You would need to show that you are an appropriate person to make the complaint.
2. Is there anyone who can help me make a complaint to the Ombudsman?
The North Wales Community Health Council provides a free advocacy service to people who want to complain about the Health Board. They may be able to help. Their contact details are:
Postal Address: Unit 11 Chestnut Court, Parc Menai, Bangor, Gwynedd, LL57 4FH
Telephone: 01248 679284
Postal Address: Unit 1B and 1D Wilkinson Business Park, Clywedog Road South, Wrexham, LL13 9AE
Telephone: 01978 356178
3. The Health Board has offered me a meeting to discuss the report. Do I need to attend a meeting before complaining to the Ombudsman?
No. However, the Ombudsman would encourage you to attend a meeting with the Health Board, as this may help answer some of your concerns.
4. Are there any time limits for complaining to the Ombudsman?
Yes. The Ombudsman has decided to waive the normal time restrictions within which complaints must normally be submitted to his office. However, he would still expect any complaints about the Tawel Fan reports to be submitted to him at the latest within six months of the report being received by the family, unless exceptional circumstances apply. If you complain to the Ombudsman more than six months after receiving the report, you will need to explain why you were not able to do so earlier.
In any event, the Ombudsman would encourage complaints to be made to him as soon as possible after receiving the report and attending any subsequent meeting.
5. I have received a letter from the Health Board which states that it considers that there may be a qualifying liability and that it may offer me financial redress (also known as a “Regulation 33 letter”). Can I still complain to the Ombudsman?
If you have received one of these letters it will be more appropriate for you to pursue the matter through the Putting Things Right financial redress process. You will be entitled to free and independent legal advice.
6. What kind of issues can the Ombudsman consider?
The Ombudsman will not investigate just because you are unhappy with the decision set out in the report. You will need to explain why you consider the report is flawed. For example, if you do not consider HASCAS followed the right process in investigating your family member’s care at Tawel Fan (for example, whether HASCAS obtained and considered all the relevant evidence) that may be something the Ombudsman could look at.
7. What happens once the Ombudsman receives my complaint?
The Ombudsman will carry out an initial assessment to decide whether he will investigate your complaint. If he decides not to investigate, he will write to you to tell you why. Sometimes, a person’s concerns can be resolved without the need to investigate by the Ombudsman asking the public body to take some action. Again, if this applies the Ombudsman will let you know.
If the Ombudsman decides to investigate your complaint, he will write to you and the Health Board to set out the terms of the investigation. One of his staff may contact you by phone to discuss this. The Ombudsman’s investigations can usually be carried out on the basis of the documentary evidence provided by the person making the complaint and the public body complained about, but in a few cases, he may also need to interview those involved or carry out additional enquiries.
Sometimes the Ombudsman’s investigations are discontinued because the public body has agreed to take action to resolve the complaint. Otherwise, the investigation will be concluded with a written report. If the complaint is upheld, the report will contain recommendations aimed at putting things right for you and preventing the problem happening again. Both you and the Health Board will be sent a draft version of the report to comment on before any final decision is made.
8. What might the Ombudsman recommend to put things right?
If the Ombudsman concludes that the investigation or report is flawed, then he might ask the Health Board to provide you with a better explanation or carry out the investigation again. The Ombudsman will normally recommend that public bodies apologise if they get something wrong, and he may also sometimes recommend financial redress (but see point 5, above).
9. Can the Ombudsman look into why the overall HASCAS report differs in its conclusions about what happened from previous reviews (e.g. the 2014 Ockenden Report, Mortality reviews)?
The Ombudsman can consider how adequate the HASCAS investigation into your family member’s care was. However, it is not his role to adjudicate on the merits of the various overall reports.
10. How do I complain to the Ombudsman?
There is an online form on his website here: https://www.ombudsman.wales/
If you prefer, you can print off a version of the form from our website or obtain one from our Complaints Advice Team on 0300 790 0203. Please send the form to The Public Services Ombudsman for Wales, 1 Ffordd yr Hen Gae, Pencoed, CF35 5LJ.
When submitting your complaint, please include a copy of your individual HASCAS report and any other relevant documentation.