The evidence PACAC didn’t want you to see.

PACAC evidenceOn Tuesday 12th July PACAC held an evidence session following the Ombudsman’s report investigations-into-unsafe-discharge-from-hospital.  Only those in the know turned up as no date was given on the PACAC website and due to a ‘system glitch’ advance notification was not sent to those on the mailing list either.  Consequently, the newly resigned Dame Julie Mellor was able to sit back with ease to listen to the unfolding debate.  You can see it here:   Oral evidence session 12.7.16

In traditional finger-wagging style the Ombudsman blames the NHS and Social Care for not working in an integrated way without a hint that this is directly due to a series of government acts which have served to divide social care from the NHS to allow for marketisation.  The Ombudsman shares nine harrowing stories and uses emotive language such as ‘untold anguish’ which just goes to show that they can do empathy when it suits them. This report follows on from a similar one in 2011 and clearly there has been no improvement since the NHS received the benefit of their last ‘shine a light’ expose from the Watchdog.

If the Ombudsman was really concerned about poor hospital discharge she has a direct route to tackle it – robust investigation, followed by sanctions requiring action plans for those Trusts found culpable.  She could come down hard on the poor hospital discharge and now that PHSO work hand in glove with LGO they could tackle both sides of the problem in an integrated fashion.  But this is not what the Ombudsman does and we have the evidence to prove it.  First-hand cases where PHSO have turned a blind eye to unsafe hospital discharge, allowing it to continue unchecked until the next report comes round.

We submitted evidence to PACAC to that effect.  This overview from the Pressure Group wasn’t published until after the start of the meeting, although it was submitted at the end of June.  None of the witnesses could have read it in advance and I doubt many read it afterwards.

Another group member submitted their own first-hand experiences of PHSO’s casual disregard for poor hospital discharge.   Teresa Steele‘s was accepted by PACAC on 7.6.16 but removed on 13.7.16.    It would appear that true accounts of ‘untold anguish’ ignored by Dame Julie Mellor and her team, are of no interest to PACAC, the witnesses or the wider public.

The narrative so carefully maintained by Dame Julie Mellor and her government supporters in PACAC is that the Ombudsman cares, the Ombudsman wants to see improvements and that something is being done to prevent future suffering.

 None of it true, but then truth is such an overrated commodity.

 

Editor’s update:  25.7.16

Eventually, redacted versions appeared on the PACAC website, too late to make any difference.  You can see them here:  PACAC inquiry evidence

The evidence that PHSO cry only crocodile tears is revealed in this FOI request.  Unsafe hospital discharge records  Although the new report acknowledges the level of harm caused by unsafe hospital discharge, PHSO do not store this information on a searchable database.  It is not a ‘key word’.  In order to identify hotspots or improvements it would be necessary to manually search each case file.  This does not look like an organisation with any genuine intention to make improvements in this area and PACAC do not look like a parliamentary body with any intention to pull them up on this fundamental failure. Like a Russian show trial in reverse, PACAC continually take the guilty and find them innocent.

 

 

Ombudsman Reform – MP Briefing Meeting.

Draft legislation for the new Public Service Ombudsman will be released for debate in parliament this spring.  Very few MPs are aware of these proposals or the opportunity this presents to finally deliver an effective and accountable Ombudsman service.

Please send this flyer  to your MP along with the proforma letter and invite them to attend the MP  Briefing Meeting on 23rd February in Committee Room 7, HoC starting at 3.00pm.  If your MP agrees to meet you there, then please come along too.  We need MPs to be our voice in parliament when this debate goes through the House.  To ask questions and scrutinise the legislation in committee.  Please alert your MP to this important legislation.  Even if they are unable to attend, it will raise awareness.  Let’s not allow this opportunity to slip through our fingers. Flyer 2

Turn Up The Volume – Bristol Conference 16.10.15

Will Powell, Della Reynolds, Delilah Hesling, Julie Bailey, Alison Cameron, Jade Taylor.

Will Powell, Della Reynolds, Delilah Hesling, Julie Bailey, Alison Cameron, Jade Taylor.

By Della Reynolds, PHSO Pressure Group

Usually campaigners have to sneak in through the back door if they want to attend NHS safety conferences.  These ‘corporate’ events are generally packed with experts in complaint handling, but very short on experts by experience – those on the receiving end.  Without complainants in the room there is a tendency to turn human suffering into risk analysis.  phsothetruestory.com/2015/07/25/when-complaint-handling-becomes-risk-analysis-it-has-missed-the-point/

This was not the case with ‘Turn Up the Volume’ a conference organised by Steve Turner   http://www.carerightnow.co.uk/steve-turner/  specifically for NHS whistleblowers and campaigners; a platform for those too often silenced as ‘vexatious’ and hopefully the first of many.   Those in authority prefer to keep campaigners apart and preferably at each other’s throats.  Swimming against the tide is exhausting and the hope is that each of us will succumb to emotional burnout if they can just keep us isolated and ignored long enough.

It was a delight to share a table with Will Powell, certainly not burnt out after 25 years of campaigning.  This extraordinary man has taken on every part of the establishment and used every means available to obtain justice for his son Robbie who died unnecessarily 25 years ago.  He knows the full level of collusion and corruption which keeps the truth hidden and the guilty protected.  Julie Bailey was also present and able to offer advice from her years of experience working to promote change through the ‘right channels’.  She pointed out that when the pressure builds this will be defused by a disingenuous promise of action.  Some crocodile tears will be shed along with the ubiquitous ‘lessons have been learnt’, but behind the words, she warns, no action is taken.  Everything goes on as before.

Two questions which emerged time and again were:

  • Who do you go to?
  • When will we see some action? 

As campaigners for reform of the Ombudsman the PHSO Pressure Group know for certain that there is no point taking your complaint to the Health Service Ombudsman.  They are just gatekeepers with a big shovel and a deep hole.  PHSO will not investigate whistleblower cases and neither will CQC.  Although PHSO are now investigating more cases they still allow serious and unsafe practices to continue unchecked by failing to find maladministration.

Whistleblowers are particularly vulnerable as they have no direct route to remedy and often the raising of serious patient safety issues is demoted to nothing more than an employment dispute.  Many brave people took to the stage to tell their stories and how they clung on to decency when the world turned against them.    Jenny Fecitt and Tracy Boylin had their lives destroyed when as NHS employees they spoke out about unsafe practice.  Both managed to pull back from the brink and have now set up Patients First a campaign for openness & transparency and a just culture in health services to encourage others to speak out.

Joan Pons Laplana is still working within the NHS and his concern for patient safety has caused him to speak out on a number of occasions.  Consequently he has had to move jobs 15 times in 15 years.  He told us that once you speak out you are labelled a trouble maker and then you have two options; either keep quiet or move jobs.  He quite rightly pointed out that the next Mid Staff scandal is quite likely happening as we speak.  CQC have found ¾ of trusts to be unsafe, 33 trusts have no permanent CEO and 60% of NHS staff agree that care is not good enough.  Creating low staff morale could all be part of the plan for privatisation if you agree with Youssef El-Gingihy a GP who wrote,  ‘How to dismantle the NHS in 10 easy steps’. www.zero-books.net/books/how-dismantle-nhs-10-easy-steps  First you destroy the present system and then save the people from catastrophe by introducing a private alternative.  I can’t be the only person regularly receiving private healthcare mail through my letterbox as they gear up for the nirvana to come.

Maria Paviour  www.mariapaviour.com/home an NHS whistleblower victim herself, has looked into the psychology related to bullying in the workplace.  According to estimates only 1% of the population are psychopaths – the kind of personality best suited to bullying and 3% are the everyday heroes who have the courage to speak up.

Psychopath definition:  A person with an antisocial personality disorder, manifested in aggressive, perverted, criminal, or amoral behaviour without empathy or remorse.

With only 1% likely to posses this personality type how is it that this behaviour has become a widespread management technique in the NHS?  Maria Paviour suggests this all stems from the pressure applied to individuals by aggressive target setting. She accepts that most people have good values, but says this isn’t enough as target achievement at all costs creates pressure to fit in with the cultural norms. Psychopathic slide

Chris Day Director of Engagement from CQC also commented on dysfunctional cultural norms when he described many organisations as having a ‘can’t fail’ attitude which requires them to distort the facts.  The pursuit of target achievement above all else was a key factor in the Mid Staffs inquiry.  I’ve put my own thoughts on the link between target setting and pervasive defensiveness in the NHS here: phsothetruestory.com/2015/10/21/fantasy-targets/

Wendy Addison was reduced to sleeping on the streets and begging for food due to the fall out of her whistle blowing in South Africa.  As the Finance Director of a major company she spoke out over fraud and paid a heavy price.  /wwwspeakout-speakup.org/#/  She survived, grew stronger and set up Speak Out – Speak UP to help other whistleblowers come forward.  She spoke about FRAUDSEC  which is an encrypted web platform which allows people to blow the whistle anonymously.  www.smh.com.au/it-pro/business-it/whistleblower-app-fraudsec-features-anonymising-encrypted-messaging-20150504-1mzc51.html

Jenny More and Christina Taylor from ‘Your Voice Matters’,http://www.yourvoicematters.org.uk/  have been campaigning for improvement to care homes for the last five years.  Both have been personally affected by poor care and poor accountability and told horrific stories including that of a blood soaked nightie disappearing after an elderly parent was assaulted by a care worker.  Nothing was done.  The PHSO Pressure Group have been campaigning for the last two years to improve accountability through reform of the Ombudsman.  Our stories run in parallel.  Jenny noted that regulators often failed to find the truth (CQC), that politicians were disinterested and if there was media coverage they were gagged from speaking the truth.  All in it together.  Jenny, Christina and the team at Your Voice Matters have put their lives on hold to fight for the rights of this very vulnerable group.

Not everyone was a campaigner or whistleblower.  Jonathan Hazan, the chief executive of Datix http://www.datix.co.uk/ told us about the on-line data base for recording clinical incidents with a view of reducing them.  He informed us that 80% of the NHS use Datix though some are finding the form filling too time consuming.  Surely this depends on the outcome; form filling for the sake of it is onerous, but form filling to save lives should be a different matter.  Recording the data should only be the start of the process and Jonathan confirmed that the most effective model then used independent, external investigators to follow up incidents.  He confirmed the futility of self-evaluation, yet this is exactly what we have through much of the NHS complaint handling process.

James Munroe is CEO of Patient Opinionhttps://www.patientopinion.org.uk/ a trip advisor style website for NHS issues.  James accepts that Patient Opinion is for the everyday niggle rather than a major incident as service users and service providers are put in touch with each other to iron out service delivery issues.  There is a valuable sense of ‘victim empowerment’ in this project; that patients can have a voice and be heard directly by those with the ability to make change.  James reiterated the conclusion of the Francis report into Mid Staffs.  Feedback is important, it must be acted upon and people should be able to see what changes have taken place as a result.  Patient Opinion is independent of the NHS, but unfortunately, dependent for funding on NHS trusts signing up to the service which can create a conflict of interests.

Dr Umesh Prabhu and Kim Manley both spoke about improving workplace cultures.  Both agreed that it should be person centred and that the patient is at the heart of the process.

“We must never lose sight of the fact that patients are human beings – culture is what you do when no one is looking.”

So after a very long and eventful day did we find answers to our recurring questions?

  • Where do you go to?       We go to each other; the only people with the ability to listen with honesty and compassion.
  • When will we see some action?   When we take some, for those in power are content to push this issue round in circles for many more years to come.

A fantastic and inspiring day.  Some great contacts made and Steve Turner is to be commended for providing a platform and bringing us all together.  This may be the start of something big.  Perhaps an umbrella organisation enabling campaigners to work and support each other more effectively, for it is certain that change rests on our shoulders.

More information on the conference here: http://www.carerightnow.co.uk/turn-up-the-volume-resources-2/

NHS Heart of Darkness paper:   (Well worth a read).

www.dropbox.com/s/eiqd5szi5gheb8j/jbe%20article%20the%20nhs%20-%20sticking%20fingers%20in%20its%20ears%20humming%20loudl.pdf?dl=0

 

 

 

 

 

 

 

Yet another meeting about poor NHS complaint handling.

logo-rs-apphgWhen I attended the All-Party Parliamentary Health Group (APPHG) Meeting entitled ‘Patient complaint: a duty to listen and learn’ on 24th June, I was reminded of the old joke,

“How many psychiatrists does it take to change a light bulb?”  “Only one but the light bulb has to want to change.” 

As one meeting on the poor state of complaint handling merges into another and yet another, it struck me that you could ask a similar question;

“How many meetings does it take to change the NHS complaint process?”   

The primary problem is one of insidious defensiveness and this particular ‘elephant in the room’ was not mentioned by any of the panel consisting of;   Anna Bradley, Chair of Healthwatch England,  Dame Julie Mellor, Ombudsman PHSO, Michael King, CE for Local Government Ombudsman and Paul Hodgkin, Founder of Patient Opinion.

How entrenched is defensiveness within the NHS?  There was a time when no one would question, let alone criticise care given by a clinical professional.  Nowadays we are more confident to ask the questions, we just don’t get any answers.  It is only human to rebuke criticism, but fear of litigation adds a whole new dimension to the problems of accepting fault within the NHS.  There should be a simple model of complaint handling as outlined by Roy Lilley, from NHS Managers;

“Dealing with complaints isn’t that difficult. Listen, sympathise, don’t justify, make notes, agree a course of action and follow through. Six simple steps I’ve been banging on about for ages. Equip and empower the patient-facing front-line of care to handle complaints and say ‘sorry’ is a simple way to make sure they don’t become grievances.” 

http://myemail.constantcontact.com/Sorry-they-ve-said-it-.html?soid=1102665899193&aid=H5U8jleGbjM

If only it were that simple, but the NHS has a history of scapegoating those who fail to protect the system (whistle blowers) and woe betide any member of staff who slips up.

Who does defensiveness serve?  Generally speaking it serves the people at the top, who can put forward neat data charts with sound bite summaries to prove they are worth their salaries without any messy ‘reality’ getting in the way.  The Francis report confirmed that one of the primary issues in the Mid Staffs scandal was a desire to keep bad news from the Minister.  It serves those in leadership to cover up the holes in funding, staffing and training rather than expose the fact that patients will suffer when the system is overstretched and underfunded.  Which begs the question;

If the leaders are served by a cover up culture then who is to lead the reform? 

How do you begin to change a culture of defensiveness which is embedded within every aspect of NHS practice like the letters in a stick of rock?

You could start at the top and give a big stick to Jeremy Hunt so that he can hold CEO’s and managers to account for poor complaint handling.  You could beef up the CQC inspections and name and shame NHS Trusts and individuals.  However, this would most likely drive the culture of cover up even deeper, as people fear for their livelihoods and reputations.  Cover up thrives in a culture of fear.   http://www.theguardian.com/commentisfree/2015/feb/17/jeremy-hunt-nhs-bully-in-chief-health-secretary-staff

Or you could start at the bottom and get local complaint handling right.  Anna Bradley from Healthwatch England informed us that there were currently 152 local healthwatch groups monitoring complaint handling and service delivery.  This independent body is also busy making close links with MPs to enable them to better support their constituents and no doubt to promote their plan that a properly funded advocacy service is provided to all complainants under the Healthwatch banner. (Point 2 of  7 point action plan delivered to Jeremy Hunt in June 2015)    http://www.healthwatch.co.uk/resource/every-complaint-matters-seven-point-plan-nhs-and-social-care

Most complainants shouldn’t need advocacy if the process is simple, timely and honest. 

Or you could rearrange the regulatory bodies to make a more efficient, single portal which speeds the complainant through to the appropriate body in a ‘no wrong door’ approach. A recent Cabinet Office review has proposed that a new  ‘Public Service Ombudsman’ post is created with a Chief Ombudsman overseeing a number of other services such as LGO, Health Service and Housing.  This proposal is most likely to get the go ahead and will require a whole raft of meetings, consultations and written papers; but will it deliver any improvement?

People change the culture and the people have to want to change.  

The NHS is a massive, top down, control and command bureaucracy.  You only get whistle blowers in a Kafkaesque environment; anywhere else they are just staff members giving feedback.  The system has become a self-serving machine which uses its legal teams to close down complaint; internal or external.  Just reorganising the regulators isn’t going to impact on such deep rooted protectiveness.  This recent article from James Titcombe published in HSJ (1st July) shows how far the NHS has to go before the staff share the same kind of open culture enjoyed by the aviation or nuclear industries.  He describes an anecdote repeated by some clinicians he met of staff members using disclosure of incidents as a threat.

“A very common IT system used to report safety concerns in the NHS is Datix. I was told that a phrase which has now emerged is “I’ll Datix you”, used as a kind of threat in argumentative situations where there is some disagreement or heated discussion.”

http://m.hsj.co.uk/5086847.article

 

Lord Philip Hunt was the only person in the room who highlighted the pervasive issue of defensiveness when he asked the panel;

When are we going to have the discussion on the culture of defensiveness?  We have to stop beating people up and create an open culture.  It’s led by ministers from the centre and we need to move away from the blame culture. 

In response to this Paul Hodgkin, founder and former Chair of Patient Opinion replied that he did not believe that cultural change would come from parliament or from any of the reforms on offer.  He said that it was impossible for bureaucracies to deliver good complaint handling and that change would come from the public as they used technology to gain a ‘web-based voice’ which could not be ignored.  He had spoken earlier of citizen power gaining strength through technology and that this would forge an alternative complaint handling mechanism which cut through the layers of processing to deliver the feedback directly to the people who could effectively use it.  For this purpose he had developed the website ‘Patient Opinion’ which works like an NHS Trip Advisor, giving feedback directly to those responsible, who are able to reply on-line and deal with a grievance before it becomes a full blown complaint.  https://www.patientopinion.org.uk/

A step in the right direction, as is a similar scheme to use technology to take control of your own medical information.  ‘mynotesmedical’ a start up idea presently looking for funding. http://www.mynotesmedical.com/

No real progress will be made until we move away from the top down delivery model of the NHS and introduce a proper partnership with the patient and their family.  This requires mutual trust and the best way to achieve this is to invite more complainants to the endless meetings so that the voice of the patient is heard and we can work together for all our sakes.  We know what we want, what works and what doesn’t work, but far too often we are not part of the reform process.

Just like the elephant in the room, we too are invisible.

 

 

 

 

 

 

APPG listen to catalogue of poor complaint handling.

Private EyeAPPG 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:

  1. There must be proper independent investigations.  Organisations should no longer be able to hold themselves to account.
  2. Lessons should be learnt.
  3. There is presently no investigative body with the power to compel change and to monitor compliance with action plans.
  4. There must be adequate expertise.  Lay people cannot be expected to manage complex clinical and legal complaints.
  5. There must be accountability at all levels.
  6. 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.

http://www.ombudsman.org.uk/about-us/our-blog/meeting-the-demand-for-our-service,-changing-how-we-work./_nocache

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.

APPG: Evidence heard on Complaints Handling from Patients Association Newletter:

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.

 

 

Can a leopard change its spots?

Elizabeth and Jill attended the AvMA conference in Manchester on Tuesday on behalf of phsothefacts expecting to see Dame Julie Mellor,  give a progress report on improvements in complaint handling from PHSO.  Without warning or explanation she was replaced by Sally Sykes.  You can read their full report below.   Let us hope that Dame Julie still has the Health chat with Roy Lilley pencilled into her diary at the Kings Fund on 15th April as we have booked four front row seats.

sally sykes

Sally Sykes – PHSO

The Action against Medical Accidents Conference:

NHS Complaints – Putting Recommendations into Action.

24th March 2015, Manchester Piccadilly.

 Attended for PHSO the Facts by Jill Mizen and Elizabeth Gould

CAN A LEOPARD CHANGE ITS SPOTS?

 

When Sally Sykes Executive Director of External Affairs and Strategy at the PHSO sauntered in to the AvMA Conference in Manchester she was wearing a leopard-print coat.

Fitting attire for a representative of an organization that, despite its refrain of “Believe us, we’re changing for the better”, hasn’t changed at all. If you’ve ever engaged with the PHSO the tone would’ve been familiar.  Patronizing, disingenuous and mendacious; the nonsense dished up might have been last year’s leftovers.

The programme of the AvMA Conference had certainly changed. Dame Julie Mellor who had been billed to speak first was nowhere to be seen with no reason given. The running order had also changed as Ms Sykes arrived late and Chris Bostock, Complaints Policy Lead at the Department of Health stepped into the breach as the first speaker. He explained that the imminent Election means that discussion of the future has to be put on hold. His presentation therefore focussed on what had been achieved in NHS culture change since the Francis Inquiry.

The very good news for us is that Mr Bostock has invited PHSO the Facts to meet with him once the new administration has settled in – perhaps a month after the Election. Whilst his focus is policy relating to NHS complaints, we left him in no doubt that we considered the PHSO as not fit for purpose.

Next up Ms Sykes herself and all the usual platitudes. You’ll be pleased to know that:

“We are changing, and are interested in and listening to feedback”

“We want complaints to make a difference and help to improve public services for everyone” 

“We are leading improvements to the complaints handling system”.

Ms Sykes last presentation slide read “Thank you for listening” and “Any Questions?”  We held back.  Why provide a platform for Ms Sykes to deliver more PHSO PR spin?

The rest of the Programme involved speakers from the NHS and the private and the voluntary sector. All the presentations were thoughtful and interesting.

The Head of Complaints, PALS and Legal Services at Pennine Acute Hospitals NHS Trust, John Culshaw, described a complaints management system that, if it delivers what it claims, is a model of good practice. If there is anyone out there who currently has a complaint being handled by that Trust it would be good to hear if their practice does what it says on the tin.

The Chief Executive of Patient Opinion, James Munro, described the power of social media in bringing patients and providers together to share and act on patient feedback. If 104 year old Ivy Bean could use Twitter to compliment the staff in her Care Home, then none of us can plead that the technology is beyond us. But as Dr Munro recognized such communications are not a substitute for a formal complaints system; they are a complement.

We heard from a Patient Service and Experience Lead in an NHS Commissioning Support Unit, and speakers from the Care Quality Commission, the Patients Association, Verita Consultancy, and the AvMA.

Finally we heard from Julie Bailey founder of Cure the NHS who successfully campaigned for a Public Inquiry into the failings at Mid Staffs. Calm and dignified, her moving presentation documented “The Torture of the NHS Complaints procedure”.

It is difficult to believe that someone could have been so personally vilified in bringing the Mid Staffs failings to the public attention. Difficult to believe unless, like many of us in PHSO the Facts, you too have met walls of denial, defensiveness and delay; you too have been smeared; and you too have been accused of being vexatious, obsessive and intransigent.  We felt it was a privilege and an inspiration to hear Julie Bailey speak.

Like us Julie said that she was unconvinced that the PHSO were changing. And where was Ms Sykes to hear this? Long gone, back to London no doubt for more radio interviews, more gushing assurances about the PHSO as a listening organization. They may be listening but they are certainly not hearing us.

And as for the leopard and its spots?

Well the spots are essential to camouflage a stalking leopard. That’s not something that’s changing anytime soon.…and neither is the PHSO.

PHSO Pressure Group attend AvMA conference

AvAM meeting supported by Verita 5th March 2015.

Investigations Fit for a Modern Health Service.

Report written by Brenda Prentice:

 

Dr. Umesh Prabhu speaking at the AvMA conference.

Dr. Umesh Prabhu speaking at the AvMA conference.

The first speaker was (to my shame) unknown to me, Dr Umesh Prabhu. After making a mistake where a baby died he felt like giving up paediatrics, but was persuaded not to and instead devoted the rest of his career to improving patient safety.  I don’t think I have ever heard a more passionate speaker. He was a breath of fresh air and what a way to start the day. For those who want to know more about him please see http://lifeinthefastlane.com/umesh-prabhu-changemaker/

After rising through the NHS he was in a position where if he found clinicians not able to do their job, even if simply because they thought themselves ‘untouchable’ he got rid of them. I wanted to ask, how, given the employment laws, but he managed!

He talked of the importance of having ‘value based leaders’ and that he had 220 Patient Safety Champions now operating within his organisation.  This man has put words into actions and really should meet with Jeremy Hunt and Bernard Jenkin as soon as possible as they are still trying to answer the ‘how’ questions regarding reform of patient safety. He was a difficult act to follow and I didn’t envy the next speaker.

The next speaker was Chris Brougham the Director of Investigations and Training at Verita. She also advises Trusts on patient safety and wants to see a clear model for carrying out investigations and better training for the lonely job of investigating.  She was an interesting speaker and one who should be listened to by Trusts.

She spoke about being ‘open and transparent’ and said simply, ‘this is about telling the truth’.  Chris also talked of the front-line staff just going through the motions filling out ‘fish-bone’ charts to provide root cause analysis without any real idea of how to analyse the data.  Clearly training for front-line staff carrying out the initial investigation is badly needed and something that PHSO could tackle.  Chris also said that the Terms of Reference must be relevant to each incident, not generated from some central source and that it was vital that Trusts investigated those aspects most important to the complaint.  Obvious really.

Peter Walsh spoke next and talked particularly about the new duty of candour and Will Powell’s long fight to achieve ‘Robbies Law’ in the name of his son who died due to NHS negligence more than 20 years ago.  Quite a campaign!  Peter said that previously the system frowned upon cover ups, but tolerated them, forcing complaints to devote their lives to finding out the truth about their loved one.   Peter complained that there were different standards of duty of candour between the NHS and the Private sector which left loopholes. He was also concerned that the clinical investigation board presently under discussion at PASC would provide ‘legal privilege’ to all participants which he felt went directly against the new duty of candour.

I was lucky enough to be sitting next to a lady who said she was a trustee at AvMA, Suzanne Shale. She stood in for James Titcombe who was listed to speak but after the Kirkup report, he was emotionally exhausted.  We watched a film James had made of his complaint journey.  Coming from the nuclear fuel industry he could not believe that less time would be spent investigating the death of a baby than would be spent investigating a single rusty bolt.  With great composure he spoke of the dawning realisation that there was a cover up and the anger this generated when he had lost his baby son to negligence.   You can see this film here on Patientstories.org.uk and may wish to contact this organisation to put your own story forward.  http://www.patientstories.org.uk/films/joshua-story/  Suzanne then spoke passionately and with authority about his case and it was insightful.

The speaker Della and I were waiting to hear was Mick Martin the Managing Director of PHSO. I thought he looked strained and he was contrite. He didn’t try to defend the record of PHSO and readily admitted it was more difficult to effect change than he might have wished.  He suggested that ‘defensiveness’ is a natural reaction to a complaint and it should be expected.

He talked about the ‘journey to travel’ in relation to PHSO and the modernisation programme.  One of the aspects which will have to change according to Mr. Martin will be the way PHSO investigate in private as he said this was impossible in the modern world. That will be a relief to many, but I wonder if anyone has told the front line staff.

He spoke of new operational changes which meant that PHSO could be held to account.  One of these was PHSO’s decision to use external, independent reviewers to audit PHSO decision making.  He stated this as though the management of PHSO decided this was a good idea when in fact it was recommended by the Health Select Committee in their recent report.  In reality PHSO have been minimising their use of external reviewers with only three currently employed.  Another fact which may be of interest to some of you is that the work of PHSO is no longer unduly affected by the 12 month time limit, as they are using their discretion to allow more complaints to be investigated which would previously have been ‘out of time’.

We were able to ask questions of Mr. Martin at the end of the meeting and
Della asked where PHSO would find the new ‘indpendent’ external investigators for the audit process.  Mr. Martin replied that PHSO would recruit and employ them, so I think we can all see the obvious conflict of interests here.  He who pays the piper …..

A theme of the day was that human beings make mistakes and complainants need to forgive human frailty.  I added that I would be very happy to forgive but as ‘they’ were in arrogant denial that anything was wrong, there was nothing to forgive them for! Point was taken.

I also flagged up that conferences such as this should encourage more service users to attend by giving some free places.  All the other attendees had their costs covered but these events are expensive for complainants even with a reduced rate.

The day seemed to support us, the PHSO Pressure Group, we have many people agreeing that change must take place. We must keep pushing at the opening door.

A modern health service is one that values complaints

and really does listen to them.

 

 

 

PHSO Pressure Group attend Guardian live NHS debate.

Guardian pictureOn the 20th January two members of the PHSO Pressure Group attended the Guardian live NHS debate –

Behind the headlines:  Is there a future for the NHS?  

 

The debate was chaired by Denis Campbell, Guardian Health Correspondent and the panel consisted of Norman Lamb MP, Lib Dem Minister for Care and support,  Sir Bruce Keogh, NHS England Medical Director, Dr. Mark Porter, chair of the BMA and Julia Manning, CEO of think tank 2020 Health.

In theory, the panel had 45 minutes to individually put across their personal answer to the question and then a discussion would take place where panel members answered questions from the audience.  https://membership.theguardian.com/event/behind-the-headlines-is-there-a-future-for-the-nhs-14848553423

We settled back into our seats to listen to the great and the good hoping for an opportunity to put our question to the panel in the second half of the debate.

Dr. Mark Porter, took pole position and kicked off with some pretty strong statements.  He confirmed that the provision of healthcare was the mark of a civilised country, however the NHS was starved of funds and the top down reorganisation had done nothing to improve the problems with delivering healthcare in this country.  His solution was to take marketing out of healthcare and give proper government funding.   This view was later endorsed by an on-line poll (and show of hands) from the audience who voted overwhelmingly for less private sector involvement in the NHS.

Sir Bruce Keogh, was the next to speak and put into context some of the problems facing the NHS which all came down to funding in one form or another.  They were, increased costs, increased demand, ageing population and greater expectations all compounded by lack of funding due to a global crisis. He said that a successful NHS needed to be based on values, driven by evidence and focused on outcomes.

Normal Lamb MP, spoke of an £8 billion gap in funding by 2020 and the pressure lack of funding put on delivery of NHS services.  He is a passionate mental health campaigner and believes that mental health issues should be on a par with physical health.  He termed the current provision as,’ health discrimination’.  He called for increased health prevention measures and improved integration of services to save money. Although Mr. Lamb spoke critically of government reorganisation in the NHS he did not vote against the Health and Social Care Bill in 2012.  He was also shown to be out of touch when he stated that TTIP would not affect the NHS which triggered loud responses of ‘rubbish’ from the audience.  Obviously if the government wanted to protect NHS from TTIP they could put a veto on it, but have consistently refused to do so, leaving it open to cherry picking from the USA.

Julia Manning, was the last to speak and talked of her first hand experiences supporting patients in her work as an Optometrist and her experience of social inequality through the work of her husband, who is a comprehensive school deputy head teacher in London. She also spoke openly about her own experience of being diagnosed with mental health issues when she was 22.  She found that there was a false divide between mental health issues and the physical symptoms she experienced as part of her condition.  As a result of her experiences she became a passionate campaigner for improvements to public health and founder of the think tank Health 2020.

The panel and invited guests managed to spend an hour talking among themselves and when the first question was taken from the audience all panel members were asked for their response.  Denis Campbell, the chair then asked supplementary questions based on these responses and the time crept away with many members of the audience, including ourselves, sitting with our burning questions and no opportunity to contribute to the debate.

In frustration,  I found myself calling out, ‘When it is our turn to speak’ and the panel finally wrapped up their personal discussion and started to take questions from the audience.  Unfortunately, this part of the debate was now rushed with audience members continually being asked to be ‘brief’.  Having drawn attention to our part of the room I was in due course handed the microphone and was able to put a question on behalf of the PHSO Pressure Group.  Given that money was the key focus of this debate I asked the following question:

The NHS Litigation Authority are sitting on a £21 Billion backlog in litigation payments, this money could be used for front line services.  Many people are forced to take legal action because the regulatory system lets them down.  When will there be a Parliamentary debate on the role of the Ombudsman? 

The answer from Mr. Lamb was that there was no debate presently on the table but in his opinion the new duty of candour would make a significant difference.  Julia Manning also commented that the move to put NHS records on-line for direct access by patients would also help complainants.  Neither of these really got to the heart of the question, but we planted a seed possibly.

You can see the whole debate here:   http://youtu.be/YVlSCtQQSA4?list=PLkfpKPZnlsI3psMLFAglchf46jbvGIzb5

Della Reynolds from PHSO Pressure Group with Julia Manning from Health 2020.

Della Reynolds from PHSO Pressure Group with Julia Manning from Health 2020.

Della Reynolds from PHSO Pressure Group with Sir Bruce Keogh.

Della Reynolds from PHSO Pressure Group with Sir Bruce Keogh.

Double scrutiny for PHSO.

Members of the Pressure Group following the PASC meeting.

Members of the Pressure Group following the PASC meeting.

On the 10th November members of the PHSO Pressure Group attended the annual PASC scrutiny meeting with Dame Julie Mellor and Mick Martin, the new Managing Director.  We sat in the public seating area at the back, taking notes and nodding in agreement at some of the searching questions from the chair, Bernard Jenkin and other members of the committee.  We noticed a new determination on the part of PASC to probe beyond the initial answer.  Even so, we felt that some of the responses lacked completion.  We were not in a position to cross-examine unfortunately, but we have been given the opportunity to ‘fill in the gaps’ with a written response to PASC which will be published on their website.

A copy of our response was handed directly to Mr. Jenkin yesterday following our meeting with Jeremy Hunt and has been sent by email to all members of the committee today.

If you would like to see our scrutiny of their scrutiny then please follow this link. https://www.dropbox.com/s/pu9c062a7ni31jo/PASC%20response.doc?dl=0

Comments more than welcome.

Patients Association slams PHSO as not fit for purpose.

patients

We can only concur with the report released by the Patients Association this week.  The experiences listed here mirror those of the Pressure Group.  There have been promises of change but is this body capable of reforming itself? 

Patients Association Press Release

 18 November 2014  

  The Patients Association is an independent national health and social care charity established over 50 years ago and has a long history of campaigning to ensure that the voice of patients is heard within the Health and Social care system.

The PHSO is failing families, leaving them distressed and totally worn down, state the Patients Association who have seen worrying trends through their National Helpline.

The Patients Association raise concern that the PHSO which should be a catalyst for change is failing to challenge poor practice and bring about change in the NHS.

The Patients Association and the families are calling on the Public Administration Select Committee to address the failings of the Parliamentary and Heath Service Ombudsman and establish a truly independent, transparent and peoples Ombudsman.

The work of the Health Ombudsman is unaccountable and wholly ineffective according to families who have raised concerns about the system, say the Patients Association charity today (18 November).

The report highlights how families having turned to the PHSO in desperation and as a last resort, feel stonewalled by the PHSO during inadequate, untimely, secretive and unacceptably flawed and out dated investigation processes.

A new report highlights detailed cases where patients and their families have been badly failed by the Parliamentary and Health Service Ombudsman (PHSO). Each story is written personally by the complainant or by their family members.  All speak of how their interactions with the Ombudsman have compounded the grief and hurt they were already feeling through loss of loved ones or due to poor NHS care.

For nearly 3 years, the Patients Association have supported the parents of Sam Morrish, a three year old boy from Devon, who died after a string of NHS blunders.  Sam died in 2010, but it was only in the summer of this year that the Ombudsman pronounced on the case – Sam’s parents are heavily critical of the PHSO investigation process.

James Titcombe has publicly and repeatedly asked the PHSO to carry out an internal review into the decision not to investigate the death of his baby son Joshua.  James is quoted as saying “From Dame Julie Mellor, all we hear is the sound of silence.”

In another case, the family raised serious concerns about the care afforded to their daughter who died of anorexia, despite the family spending a year compiling a detailed dossier for the PHSO, it still took the Ombudsman over two months to appoint an investigator to their case.

In a further case, a woman died after keyhole surgery for a hernia repair, the family described the two year process with the Ombudsman as “gruelling and destructive”. They added “It has forced us to spend almost three years of our lives trying to limit the harm the Ombudsman’s so called investigation has done to us.”

Some patients have been led to believe that the PHSO is inappropriately preventing them raising concerns regarding inaccuracies and other errors in PHSO draft reports.  The PHSO is effectively gagging those families.  This is highlighted in the case of a child whose mother has devoted nearly 3 years challenging the PHSO on decisions made which were error based.  B’s mother was specifically prohibited from sharing the contents of a draft letter.

In another case the family of Jo Deering have been left feeling totally alone and unsupported as a result of the Ombudsman’s investigation.  Whilst detained under the Mental Health Act, Jo was granted extended leave.  She committed suicide whilst on leave but the Ombudsman refuse to investigate the decisions made that ultimately lead to Jo’s death.

Mr Holt was left devastated and insulted when on the recommendation of the Ombudsman the Trust offered him £250 compensation following the death of his wife Jennifer, due to a preventable fall.

Katherine Murphy, Chief Executive of the Patients Association said: “We wish we could say cases like that of Sam Morrish and those other families are a once in lifetime situation, but they are not.  We receive cases every week where people are distressed and even traumatised by the way their case has been mishandled by the PHSO”.

“The Health Ombudsman should be a court of last resort where uncorrected mistakes by the NHS can finally be put right, but the process is not fit for purpose and often ends up compounding the grief of families.  The quality, accuracy, objectivity, effectives, openness and honesty of its reports is shameful.”

Katherine Murphy added: “The PHSO cost to the public purse is around £40 million a year, but we have no idea how it really does its job. The total cost to society and families far exceeds the £40 million funding the Ombudsman receives. The emotional cost for families far outweighs the huge financial cost.”

The Patients Association has evidence of serious failings of the PHSO and says it’s time to hold them to account for those failings. The words spoken publicly by the PHSO that there needs to be more care and compassion in the NHS and an end to the toxic culture need to be matched with significant action.

We cannot expect Trusts in the NHS to handle complaints appropriately if they are confident that the PHSO will not find failings against them.   Radical reform in complaints handling is of paramount importance across the NHS and the PHSO.

The Patients Association is urging the Public Administration Select Committee and the Government to bring about that radical change and give the public confidence that complaints will be fully and professionally investigated.

Read the full report here:  file:///C:/Users/HP/Desktop/PHSO%20-%20The%20’Peoples’%20Ombudsman%20-%20How%20it%20Failed%20us%20-%20FINAL3%20(1).pdf