Can James Titcombe force PHSO to face their own failures – for all our sakes?

James Titcombe                                                                        Sent via email 8th July 2014

Dame Julie

The Parliamentary and Health Service Ombudsman,

MilbankTower, Millbank,  London SW1P 4QP

Our meeting on Friday 4th July 2014 

Dear Dame Julie,

Thank you for meeting  with me on 4th July, which I attended with support from David Behan.During this meeting, you agreed that you would undertake a review and respond to the  concerns I have raised about your organisation and the decision not to investigate  Joshua’ s death following my referral in 2009.

It was agreed during  the meeting that it would be helpful if I wrote to you to summarise a clear list of the key questions which I would to review and respond to.These are as follows.

1)      The process and basis  for refusing to investigate Joshua’s death 

At the time of Ann Abraham’s decision, the Coroner had refused an inquest and therefore my family and I had nowhere else to turn to ensure that my son’s death was  properly investigated.

Could you set out  for me and my family, the reasons why PHSO decided not to investigate Joshua’s death when I  referred my complaint in 2009?

I  would like this response to consider and acknowledge that the case advisor (Harriet Clover) assigned to review Joshua’s case had recommended that the case should proceed to an investigation. Her reasons included recognition that the trust had failed to investigate  Joshua’s case adequately, that my family and I had not received an adequate response to our questions about the events that led to Joshua’s death and a concern that the failures were systemic in nature.These are important points to emphasise as previous responses to my concerns have not acknowledged this.

2)      Interactions between Ann Abraham and Cynthia Bower 

The decision not to investigate was made after at  least two  meetings between Ann Abraham  and Cynthia Bower.  Kathryn Hudson gave evidence to the Grant Thornton investigation relating to a conversation she had with Ann Abraham relating to one of these meetings. Kathryn Hudson’s evidence(confirmed by other documents), referred to a ‘meeting’  in  which Joshua’s case was discussed whereby a ‘suggestion’ was made that PHSO ‘might not investigate’ if CQC would take ‘robust’ action. Despite this, when I asked for an explanation, I was told in writing by PHSO that such a conversation did not take place.This letter was written when Kathryn Hudson was still working at PHSO.  During our meeting on Friday 4th July, you informed me that Kathryn Hudson was involved in the preparation of this letter.

  1. Can you clarify what conversations took place between Ann Abraham and Cynthia Bower in relation to Joshua’s case, including what was discussed during these conversations and the accuracy of the information previously provided to me about this matter by your office.
  2. Can you please provide clarification surrounding the handwritten note referred to in the Grant Thornton report which Ann Abraham made prior to her meeting with Cynthia Bower on 12th August 2012, in which it is clear  that she intended to discuss Joshua’s case?
  3. Can you please clarify why this note was  not disclosed to me when I made my initial DPA request and whether or not you believe it should have been provided to me either at the time, or subsequently when your organisation became aware of the note at the time it was provided to Grant Thornton.
  4. This note has still not been disclosed to me,  please can you now provide it.
  5. Do you accept that  the evidence given by Kathryn Hudson and Ann Abraham to Grant Thornton regarding  the nature of the conversation between Cynthia Bower and Ann Abraham conflicts and can you please explain this.

3)      PHSO’s understanding regarding what actions CQCwould take 

One of the main reasons Ann Abraham gave for declining to investigate Joshua’s case was the role of CQC.  As you know, the case advisor had recognised that the issues surrounding Joshua’s death had not been properly investigated and was concerned that the issues involved were systemic.

  1. Please can you explain why no letters or any other kind of documentation exist which confirm what action CQC had agreed to take prior to Ann Abraham’s refusal to investigate Joshua’s case?
  2. Given that the evidence clearly shows that PHSO were  aware of systemic concerns at the maternity unit at FGH and the ‘need for a wider investigation into the quality  of maternity services at the trust’ was acknowledged by Ann Abraham, please can you advise what steps were taken by the PHSO to ensure appropriate action would be taken by CQC before declining to investigate Joshua’s case?
  3. Please can you advise if you believe that the  steps taken to communicate  the concerns and the reasons for not investigating  Joshua’s case were sufficiently communicated to CQC at the time the decision not to investigate was made?
  4. Evidence provided by senior CQC staff (confirmed in the Grant Thornton report), suggests that CQC staff apparently interpreted Ann Abraham’s decision not to investigate  Joshua’s death as a ‘reassurance ’that things were‘ ok’.  Please can you clarify how you believe this misunderstanding happened and what lessons have been learned from these circumstances?
  5. Do you accept that had the Ombudsman investigated Joshua’s death properly at the time, the  course of events at Furness General Hospital (FGH) may well have been different and that problems at the maternity unit at FGH could have been exposed and addressed sooner?
  6. Do you acknowledge that as a consequence  of Ann Abraham’s decision not  to investigate Joshua’s death, my  family and I have had to fight a prolonged and arduous battle to establish the truth about why my son died? Can you please clarify whether or  not you feel the decision not to investigate was reasonable given that thec ase advisor had accepted that my family and I had not received an adequate response to our questions about Joshua death?
  7. During our meeting, Is hared with you an email written by  CQC staff on 20th August 2009,  in which it was stated  ‘I have heard by a roundabout route that the Ombudsman aren’t investigating [Joshua’s case]’.Are you able to  provide any explanation regarding  this memo and how CQC may have been given an impression that PHSO would not be investigating  Joshua’s case at this time (a number of months before my family and I were  informed of the provisional decision).

4)      Internal  Review Process 

Following the rejection of my complaint in relation to the North West Strategy  Health (NWSHA), I appealed the decision and the review supported Ann Abraham’s decision not to investigate.Following this, I started a Judicial Review process which triggered a second external review which was highly critical of the decision stating it was‘flawed’.    The eventual investigation carried out led to national recommendations for change. PHSO have apologised for  this decision but what  steps have been taken to strengthen the internal review process to ensure that ‘flawed’ decisions are no  treviewed as  being satisfactory in the  future? Can you summarise any  learning PHSO have taken from these circumstances?

5)      My letter to Ann Abraham of 26th August 2010

I have attached  a letter I sent to Ann Abraham  of 26th  August 2010. On page 3 of this letter, I set out what I believe the consequences of the  decision  not to investigate Joshua death were, for the ‘NHS and other families in the future’.The first item listed states:

“Uncertainty as to whether or not all possible lessons from Joshua’s death have been taken locally,this means an increased risk to mothers and babies in the local area”. 

Do you now accept that this was indeed a consequence of the decision made not to  investigate Joshua death and  that risks to other mothers and babies at the maternity unit  at  FGH were only subsequently identified following an inquest and subsequent regulatory action more than a year later?

These concerns summarise the  issues and questions I feel that I have been asking you to respond to since  July  2013.  However, I have recently received a  large number  of documents from your organisation under the Data Protection Act(DPA) and would like to raise some additional concerns as follows.

6)      Pre-occupation with reputation 

  1. The initial assessment form following my referral of Joshua’s case to your organisation includes a risk assessment  which described the case as ‘high risk’ due to the potential for ‘media interest’. Do you agree that is it wrong to risk assess cases about potentially avoidable deaths in this way and that any risk assessment should be about risks to service users, not risk to your own reputation?
  2. Within recent documentation provided to me under DPA, I  have come across another risk assessment which states ‘medium risk’and describes my unhappiness with the decision not  to investigate Joshua’s case and concern from the Health Select Committee about the decision.The risk assessment summarises the risks as ‘a risk to our reputation’ and a ‘risk of litigation’.The‘mitigation plan’ involves ensuring correspondence from myself is passed through the Ombudsman legal services. Please can you clarify these circumstances and  explain if this type of risk  assessment will continue to be carried out in the future?
  3. Can you comment on the decision to refer all my correspondence to your legal team and clarify why this was done?

7)      Ability of PHSO to properly investigate cases of potentially avoidable death 

When we met,  MickMartin articulated that the methodology currently used to investigate cases of preventable deaths in health care by PHSO was not  ‘fit  for purpose’. Has this statement been made publicly and are you able to provide an action plan and time frame for when you hope these issues will be turned around?

Summary 

I passionately believe that any organisation committed to genuine change must first get some  key basic principles firmly  in place.The most important of which is being absolutely open, honest and transparent when things go wrong, or when significant change is needed. It is now my hope that  you will  ensure that the serious issues I have raised relating to the way the Ombudsman responded to my family  following Joshua’s death, are properly reviewed and that I will receive a full, open and honest response.

For the sake on my family,including my wife, parents,in-laws and my children (who will one day  see kto understand what  happened to their brother) I hope that your response to these issues will bring us some closure and reassurance that all necessary lessons from our experience have been taken by  PHSO  to ensure other families in future do not go through what  we have had to.

Yours sincerely,

James Titcombe

CcJeremy Hunt

David Behan

Bill Kirkup

 

 

One thought on “Can James Titcombe force PHSO to face their own failures – for all our sakes?

  1. Excellent searching letter James…and one which MUST be honestly responded to.
    I note PHSO MD Mick Martin has acknowledged “the methodology presently in use is not fit for purpose!”
    Its NOT, and what are you, (the PHSO process,)doing about it?

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