My normally healthy 94-year-old mother died in hospital in January 1997. For almost three months before, following a nasty fall in her kitchen, she suffered acute pain in her shoulder to the point where her normal activities were severely restricted and life became barely tolerable.
Her GPs - five of them in seven visits - came when called, but did nothing beyond prescribing more and more painkillers. Her live-in carers told me the doctors' visits were fleeting and that they seldom made a physical examination. They did not listen to what the carers had to say and delayed ordering a follow-up X-ray until it was too late to be relevant.
On her admission to hospital - with severe dehydration - just two weeks before her death, the shoulder was routinely X-rayed and discovered to be both broken and dislocated. Because no treatment had been prescribed, the shoulder bone had slowly, agonisingly, died.
I could not believe that this measured up to the standard of caring attention the NHS aims to provide, and after her death I decided to instigate an inquiry and complaint. Two years later I am still waiting for completion of the process, which I have pursued through all its various stages.
The Citizens Advice Bureau directed me to the local community health council, where I found a sympathetic ear and much practical advice. I then visited my mother's GP to express my dissatisfaction. The doctor showed me the door.
Next I wrote to the head of the practice asking for an explanation of the delay in seeking follow-up X-rays after my mother's fall and why there had been no serious investigation of her complaints of constant and increasing pain. I also sought an acknowledgement of the inadequacy of the service provided and, more importantly, an assurance that the practice would make every effort to ensure such neglect of an elderly patient would not occur again.
I was offered a meeting with the entire practice chaired by an independent facilitator appointed by the health authority. In the event, only two members of the practice turned up, neither of whom had visited my mother until her last weeks. I found their attitude so defensive, and their responses so limited, that I asked for an independent review panel to look into the case.
The findings of the panel resulted in some helpful recommendations. Although never explicitly admitting inadequacy of care, my mother's practice in effect admitted it by agreeing to assign a specific doctor to each elderly patient to allow progressive monitoring, and promising to work to improve their doctor-patient relationships. They also offered to try to speed up communication processes with the X-ray department at the local hospital.
Because the GPs had offered no answer to my question about what had been revealed by the initial X-rays, I had - on my own initiative - also written to the head of the hospital's X-ray department. He responded with an apology that his technicians had failed to spot my mother's fractured shoulder, explaining that when she visited the hospital she had complained of pain in her elbow, and that was the area that had been X-rayed. This was news to me.
In order to reduce the chance of delays and errors occurring again, the X-ray department has now granted open access to local GPs, reducing the delays for appointments and paperwork, and all technicians have received instructions on referred pain so that they will be more alert in future to the need to X-ray areas other than those giving immediate pain.
The GPs, working with the X-ray department, have also extended their 'reforms' to include a follow-up home visit to any patient aged over 70 a week after an accident or fall. All this marks a great step forward and such service improvements go some way towards reconciling me to my mother's suffering.
But I remained concerned and requested that my case be taken to the final level - direct appeal to the health service commissioner.
While acknowledging 'serious concerns' about many points raised by my mother's case, the investigational manager based her decision on assumptions which I believe are of questionable validity. The treatment my mother received would have been the same even if the doctors had known from the start that the shoulder bone was broken, the subsequent necrosis 'could not have been prevented' and there was no evidence that my mother's broken bone - and subsequent prolonged suffering - 'caused her decline and eventual death'.
Is three months of pain from an untreated broken bone not enough? Where else should one look?
I wrote yet another letter of complaint and received a letter from the commissioner's office saying that my complaint is being reviewed.
Red Letter Day - 18 September. I have just been told that the deputy health service commissioner considers my mother's case worthy of further investigation. The process will take time but, mercifully, the system works, and I am quietly grateful.