APPG for Patient and Public Involvement in Health and Social Care held their first evidence session on Wednesday 17th June which was organised in collaboration with the Patients Association. They heard harrowing stories from six witnesses who had all suffered devastating trauma as complaints made about poor NHS care were dragged through a Kafkaesque process which had the single aim of damage limitation. In all cases PHSO were named as a significant part of the problem.
Maggie Brooks explained her five year ordeal of trying to find out why their mother Elsie Brooks died an avoidable death following keyhole surgery to repair a hernia. This appalling case appeared in the recent ‘Private Eye’ article attached and shows collusion between all authorities to deny the facts. It is clear they have covered up the truth, but as Maggie pointed out, as soon as you say the words ‘cover up’ you are treated like a conspiracy theorist and fruitcake. Yet five years later, following an NHS investigation, an inquest and a PHSO report which upheld their case, they still don’t have answers to vital questions. Barking, Havering and Redbridge NHS Trusts have continually held back medical records and other evidence which would reveal where the mistakes occurred. Maggie told John Pugh MP and chair of the APPG,
“We thought that PHSO would take it seriously that the Trust withheld records, but they just published the draft report as a final report anyway. I wish we had never got involved with PHSO.”
In summing up Mr. Pugh identified three key points: Firstly the fact that the incident occurred at all was a failure point, secondly that the Trust were defensive from the start and used a trained barrister as their customer care representative. Finally, that the Trust were allowed by the Ombudsman to call the shots by failing to release documents and that this went unchallenged.
Baroness Masham of Ilton confirmed that the time delay caused by such long drawn out complaint processes prevented any real remedy, as people moved on and events were forgotten. She emphasised that complaint handling must be immediate.
Nic Hart then spoke about the tragic case of his daughter’s death from anorexia. There was a total lack of communication between the primary care team who had done such a good job of returning her to a degree of health following a hospital admission and the discharge care team who then failed to monitor her progress. He too experienced a cover up of the facts as he probed deeper in order to prevent similar events from ever happening again. He concluded that;
You cannot trust NHS staff to self audit. It must be external and records must be sealed immediately after an incident.
All parties found PHSO to be ineffective in bringing remedy or identifying the true facts despite many months of investigation. In one case the complaint was artificially split between the LGO and PHSO but there was no dialogue between the two bodies and ultimately LGO produced no report, yet PHSO continued to look at isolated aspects of the case which needed to be seen in the round.
Fragmenting cases appears to be common at PHSO, but this prevents any understanding of how all the factors combined to produce the tragic consequences. No understanding = no learning.
Some witnesses reported that they now suffered from PTSD due to the intransigence of the complaint process and the denial of acknowledgement and closure. All had suffered long drawn out processes which required them to live and re-live their original trauma.
Richard von Abendorff, the final witness, put forward some suggestions for reform:
- There must be proper independent investigations. Organisations should no longer be able to hold themselves to account.
- Lessons should be learnt.
- There is presently no investigative body with the power to compel change and to monitor compliance with action plans.
- There must be adequate expertise. Lay people cannot be expected to manage complex clinical and legal complaints.
- There must be accountability at all levels.
- Action plans must go to board level.
John Pugh MP and all members present, agreed that the complaint system was inadequate, unsafe and required reform. There will be further meetings and representatives from NHS England, GMC, NMC and CQC will be giving evidence. The PHSO Pressure Group will also be invited to submit oral evidence to the APPG as part of this investigation.
This recent blog post from Mick Martin M.D. at PHSO, may shed some light on why the present Ombudsman system is failing to drive reform in NHS complaint handling. Mr. Martin stated that:
There is a lot of confusion about our role, so to be clear:
- we investigate cases so that we can make decisions on complaints, not to make up for poor investigations at local organisation level;
- we press public organisations to learn from and improve their ways of working, we can’t make that happen;
- we work hard to obtain a remedy for people when they have experienced injustice, we don’t favour them when we are investigating their case or advocate for them, and
- we provide invaluable insight on things that keep going wrong, we don’t provide solutions.
This gives the impression of a powerless body, struggling against the odds to put things right. Providing insights on things that keep going wrong, but doing nothing to ensure improvement and learning is a pointless waste of money. The Ombudsman has the power of a high court judge, but apparently the bite of a poodle. As Tim Farron so eloquently pointed out in the previous Parliament,
“The Ombudsman should be a watchdog not a lapdog. “
Below is an account from the Patients Association from the same meeting. We are very grateful to PA to be included in this APPG inquiry and look forward to attending the next meeting.
This week the All Party Parliamentary Group for Patient and Public Involvement in Health and Social Care (for which the Patients Association provides the secretariat), has heard evidence from patients and their families who have been let down by the complaints system.
The NHS complaints system still exposes many patients to gruelling and unsatisfactory process, despite numerous high level calls for reforms. Research conducted by the Patients Association found high levels of dissatisfaction with the complaints process with patients frequently encountering unhelpful and defensive staff, complicated procedures to negotiate and sometimes dishonest replies. The findings show that some patients are so daunted by the procedures or worried about being seen as a trouble-maker by hospital staff, that they do not bring a complaint – despite having grounds to do so.
The first oral evidence session was held at Portcullis House, Westminster and was chaired by John Pugh MP, along with Rosie Cooper MP and Baroness Masham of Ilton. Oral evidence was provided by six members of the public who have been supported by the Patients Association.
Maggie Brooks opened the session with the story of her mother Elsie who died in December 2009 after failings in nursing care. Following an ineffective Trust investigation that took 16 months and brought no explanation to light, the Brooks family took their complaint to the PHSO in 2011.The initial PHSO investigation took over a year and the draft report upheld their complaint. However it failed to investigate the main aspect of their complaint and the investigator had not seen critical medical records.
Nic Hart gave a moving account of how his daughter Averil, died while in NHS care in December 2012 after a battle with Anorexia Nervosa. She received inpatient treatment in Cambridge, for Anorexia Nervosa, over a period of nine months. She was discharged from the unit, and started at the University of East Anglia two months later. She registered with the UEA Medical Centre for primary care, and after a delay of several weeks, she was also provided with secondary care by the Norfolk Community Eating Disorder Service.
By the time of the scheduled medical review, she had collapsed and had been admitted to the Norfolk and Norwich Hospital. Mistakes were made, and her condition worsened further; she was then transferred to Addenbrooke’s Hospital where she sadly died.
In late 2013 and early 2014 the complaints were submitted, explaining that there appeared to be numerous significant failures during Averil’s care; specifically that she had originally been discharged from hospital too early, that the transition to secondary care at university was poorly handled and that the secondary care itself was inadequate. It was hoped that these concerns would be fully investigated.
We also heard from a father whose son committed suicide, investigation into the complaint found no failings despite expert witness reports and evidence to the contrary. Two patients who were given treatment against their will by unidentified healthcare professionals even when one was allergic to the medication. Richard von Abendorff whose mother suffered a horrifically painful last three days of life because of the hospital’s multiple errors in her opiate pain control. His concerns of the complaints and wider investigatory process highlighted the ‘systemic’ failures but his persistence led to a Patient Safety Alert issued on the use of Naloxone. Further details of these cases can be found here
Many of the speakers described themselves as ‘naive’ when they first began the complaints process, believing that their case would be thoroughly and independently reviewed in order to uncover what really happened and why. However, they encountered many of the same problems including difficulties in accessing medical records, failure of hospital Trusts to provide accurate and complete records and a lack of independence and expertise of complaints bodies.
The patients and their families expressed a need for increased expertise, accountability and independence within the complaints process, and argued that the process would be greatly improved if it focussed on the complainant rather than acting as a defence for hospital Trusts.
Throughout the year, the APPG will be listening to evidence from a broad section of organisations, groups and individuals with expert knowledge and experience of complaints handling. The APPG will be especially focussing on organisations and individuals that have developed best practice guidelines and protocols for dealing with NHS complaints. Future sessions (to be held in September and October) will hear evidence from Clinical Commissioning Groups, hospital Trusts, regulatory bodies and other organisations with an interest in complaints handling.