James Titcombe Sent via email 8th July 2014
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.
- 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.
- 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?
- 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.
- This note has still not been disclosed to me, please can you now provide it.
- 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.
- 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?
- 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?
- 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?
- 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?
- 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?
- 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?
- 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
- 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?
- 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?
- 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?
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.