Pressure Group members attend NHS Complaints Conference.

Westminster Briefing Group (1) On 7th October three members of the PHSO Pressure Group paid to attend an NHS Complaints Conference called ‘Westminster Briefing’.  westminster-briefing.Agenda   It was to be a day of presentation and discussion centred around the Francis Report’s 290 recommendations for improvement.  The fact that there so many recommendations shows the degree of change required.

Unfortunately, there was not as much opportunity for debate as they hoped and it was clear from the morning session that the speakers were not really primed to answer questions; especially hard hitting ones from people who had first hand experience of using the complaint process.

There was a feeling among the Group that the morning speakers were simply ‘going through the motions’ and this was reciprocated from the attending delegates (mostly complaint managers) who asked very few questions.  A notable exception were two representatives from Moorfields Eye Hospital who asked particularly relevant questions and showed a keen interest in the speakers presentations.  Fiona from the Pressure Group wrote to congratulate them afterwards, on having two representatives in the room who engaged in a way that presented Moorfields as a centre who genuinely cared about patient’s safety and rights. So we ‘complainants’ do more than just complain.

John Dale, a consultant and organiser of the National NHS Complaints Managers Group chaired the meeting.  Among the morning speakers were Paul Durham speaking on behalf of CQC and Sally Sykes who represented PHSO.  Both of these speakers talked about how their organisations were listening to complainants and taking change on-board, but it all sounded like jam tomorrow for members of the Pressure Group.  Interestingly, this slide from Sally Sykes presentation shows in the ‘third phase’ key issues which are presently under consultation with the Cabinet Office and PASC.  These changes require new legislation, so are PHSO jumping the gun or is this a done deal? SALLY SYKES PHSO SLIDE

Roan Dyson spoke about the services offered by POhWER, who help complainants ‘get their voice heard’. Unfortunately, they don’t take on case work, so their support is limited.   The most revealing fact to emerge from the morning session was that there were 88 different public bodies dealing with NHS complaints.  No wonder we are all confused!

Kim HoltThen in the afternoon, things picked up when Dr Kim Holt (Chair and Founder of Patients First) the whistleblower on the Baby P case, fully engaged the audience  as she talked about the dreadful plights of some of the whistleblowers she has worked with since starting her campaign for a full public inquiry four years ago. You can see her website here:  www.gov.uk/whistleblowing/overview

She explained that bullying is used to stop the whistleblowers and instead of the concern being investigated, the individual who raises the concern is investigated.  Bullying is mainly in the form of verbal abuse and suggestions that the whistleblower is mentally deranged. This will invariably lead to loss of career and stress related health problems for those brave enough to speak out.  Dr. Holt mentioned a paediatric surgeon who after raising concerns, was taken to court by the PDSA and is now no longer working.  There was also mention of another bullying case where someone literally had their head banged on a table. Dr. Holt said it was all down to poor clinical leadership and is calling for management to take proactive steps to deal with issues raised instead of adopting a defensive stance when things go wrong.

(You can see the slides to her presentation, along with those of the others speakers, by following the link at the end of this article.)

The next speaker was Kim Morley (Sapphire Specialist Epilepsy Nurse, Solent NHS Trust) who also had first hand experience of what it was like to be the victim of poor care.  She described how poor care made a person feel invisible, uncared for and cast adrift.   She also pointed out that when patients complain the people who caused the harm carry out the investigation and that as long as this continues there will be no justice.  Ms. Morley also mentioned a lack of diagnosis, which then denies the patient the treatment they require.  No diagnosis or strategic misdiagnosis has featured in cases within the Pressure Group causing unnecessary suffering for many years as people try to discover the real reason for their illness.

The last speaker was Ruth Evans (Patient Experience Network)   – she started by asking the direct question ‘What should a complaints system be like?’  Simple.  And ‘What does someone want when they complain?’  They want things put right.  She said Richard Branson’s organisation has a positive attitude to feedback/complaints, because it improves things; another positive speaker.  It is clearly the case that when someone makes an initial complaint they want a very simple response.  They want acknowledgement, an apology and some action taken to put things right.  It is the long fight for justice, when public bodies delay, deny and defend, which leads to permanent bitterness and litigation.

Dr. Holt won the prize from our group members though they all commented on how refreshing the afternoon speakers were and the real insight they shared of the painful journey one takes as either a whistleblower or NHS complainant.

On that note you may wish to listen to David Drew speaking on Radio 4’s Midweek about his horrendous nightmare following his decision to blow the whistle regarding concerns for patient safety at Walsall Manor Hospital, where he worked as Head of the Paediatric department .bbc.co.uk/programmes If you want to cut to the chase his part starts at 11.41. He speaks of the culture of closed groups and once more makes the point that the perpetrators are the very same people who investigate the complaint.  This is unacceptable. You can get his book, ‘Little stories of life and death’ here: http://www.amazon.co.uk/Little-Stories-Life-Death-NHSwhistleblowr/dp/1783065230/ref=sr_1_1?s=books&ie=UTF8&qid=1414175857&sr=1-1&keywords=david+drew

We have seen it in Mid. Staffordshire, Rotherham and of course in the Saville affair.  When those in authority fail to listen and respond appropriately to complaints then nothing is done to halt the horror and many more suffer as a consequence.  It is not good enough for those who failed to say, ‘lessons have been learnt’ for these are hollow words, too easily spoken.  The fact that Dr. Kim Holt and Dr. David Drew are having such a tough fight to obtain a public inquiry into whistleblowing, demonstrates a government who is unwilling to learn from these many failures.

head up bum Link to slideshows from the day:  https://dub114.mail.live.com/mail/ViewOfficePreview.aspx?messageid=mg9mujqpNa5BG05AAiZMHWHA2&folderid=flinbox&attindex=0&cp=-1&attdepth=0&n=99258138

 

 

 

Can Oliver Letwin deliver an Ombudsman service fit for the 21st Century?

PHSO Pressure Group at cabinet office

Della Reynolds, co-ordinator of PHSO Pressure Group at the Cabinet Office.

On 7th October the PHSO Pressure Group attended a stakeholders meeting held at the Cabinet Office to discuss complaint handling and the role of the Ombudsman. We were invited by the Rt. Hon. Oliver Letwin and present at that meeting was Robert Gordon CB and his team.  Mr. Gordon has had a distinguished career in the Scottish Office where, among other things, he helped to set up the devolved Scottish Parliament.  http://www.inspiringscotland.org.uk/who-we-are/board-of-directors/robert-gordon

Mr. Gordon has been charged with researching the current Ombudsman landscape and reporting back to the Cabinet Office with suggestions for reform.  We were delighted to be able to speak directly to him and his colleagues.  This was a valuable opportunity to discuss the service user’s experience and share a little of our ‘gold-dust’. Our initial concern was that the inquiry process would deliver nothing more than a re-branded version of a fundamentally flawed process.  It will take more than a common portal and shiny new logo to restore public confidence in the Ombudsman.  There is sufficient evidence in the public domain (Mid. Staffs, Morecambe Bay, Morrish family)  to demonstrate that this service is not fit for purpose and requires fundamental reform.

Once the Cabinet Office conclude their inquiry, with the help of Mr. Gordon, they will be drafting new legislation.  The original legislation has been in place for 47 years and quite possibly has never served the public in all that time; it is therefore vital that we use this opportunity to create an Ombudsman service which meets the needs and expectations of the public in the 21st Century. At the core of this legislation there must be measures to provide effective accountability for users of this service.  The total discretion enjoyed by the Ombudsman to date has no place in a modern democracy.  We are aware that the Ombudsman must be the final arbitrator, but allowing this body to exclusively handle all complaints about its own service creates an Alice in Wonderland scenario where the omnipotent Queen of Hearts simply makes up the rules as she goes along.  If you need proof, look no further than this year’s annual report where the Ombudsman states that from upwards of 27,000 complaints handled they only had to review their decisions 0.2% of the time.  Any organisation which believes that it has a 99.8% accuracy rate needs a reality check.

Mr. Gordon’s suggestion for robust accountability was to set up a monitoring board of ‘independent’ members who would scrutinise the Ombudsman’s performance against key indicators.  It is not too difficult to see the obvious flaws in this plan.  Firstly who are these ‘independent’ people and who appoints them?  There seems to be a cartel of like-minded people who are willing to sit upon each other’s boards and do little more than maintain the status quo.  PHSO currently have a Unitary Board, chaired by the Ombudsman herself and stuffed full of PHSO employees,   http://www.ombudsman.org.uk/__data/assets/pdf_file/0014/21614/Annual-Report-About-Us.pdf plus an Audit Committee led by Sir Jon Shortridge KCB http://www.ombudsman.org.uk/about-us/who-we-are/the-board/audit-committee and it is questionable whether either of these committees do any more than rubber stamp the decisions put before them.  The suggestion was made by the PHSO Pressure Group that board members for any panel which is designed to hold the Ombudsman to account should be drawn from recognised campaign groups and charities such as the Patients Association, AvMA and the PHSO Pressure Group itself, to include fierce critics such as James Titcombe and Julie Bailey.

 If you really want to know how an organisation delivers then ask those who have received.  

Hopefully, this possibility will be investigated by Mr. Gordon and his team.  Other suggestions for accountability included giving the Public Administration Select Committee (PASC) the powers it needs to hold the Ombudsman to account for poor service delivery.  Currently PASC cannot pursue any individual complaint nor can it ask questions of the Ombudsman relating to individual complaints.  To say that the Ombudsman is accountable to parliament for service delivery is unrealistic given that PASC is so severely handicapped.

 The truth is that the Ombudsman is accountable to no-one but herself and we all know of the corrupting influence of ‘absolute power’.  

The use of the word ‘corruption’ makes politicians feel uncomfortable and Mr. Letwin shifted in his seat as he pursued this subject, questioning why this would be the case.  It is our belief that both PHSO and LGO are morally corrupt in that they have total disregard for the plight of individuals as they manipulate the evidence to find spurious reasons to close cases down.  Complainants, who have been denied evidence in drawn out complaint processes where public bodies have ultimately lied and covered up the facts, then find themselves duped once again by the shiny rhetoric on Ombudsman’s websites promising impartiality and remedy.  In 2013-14 only 11% of all formal complaints were upheld by PHSO to some degree following an investigation.

The Ombudsman’s office has never been staffed in a way that shows real commitment to honestly resolving cases.

A quick comparison with the Netherlands http://phsothetruestory.com/2014/08/08/compare-and-contrast-two-different-ombudsmen-services/ reveals that their Ombudsman service employs 70% of staff to carry out investigations and the vast majority are trained lawyers, whereas PHSO currently have only 30% of staff as investigators and none of them have either legal or clinical training.  The front-line staff at PHSO are being asked to take on 10x more cases this year to comply Dame Julie Mellor’s plan to ‘give more impact for more people’ by increasing the number of investigations.  The drive to improve ‘quantity’ has further impacted on the key issue of ‘quality’ with investigators required to take on up to 15 cases simultaneously.  Although PHSO have promised to address an investigation methodology which has been accepted by Mick Martin, Managing Director as ‘not fit for purpose’ this organisation moves at the pace of a three-toed sloth on sleeping tablets.

Only Churchill expects so few to do so much and the staffing levels and skill mix required for proper investigation must be urgently reviewed.  Currently PHSO have no option but to close down a large percentage of cases in order to prevent complete system breakdown. The Pressure Group put forward the idea of dividing the Ombudsman service into a designated Health Service Ombudsman for England in line with devolution.  This could then be staffed by experts in clinical care.  NHS England recently reported that complaints topped 3,000 per week http://www.which.co.uk/news/2013/08/nhs-england-complaints-top-3000-per-week-331968/ and Dame Julie Mellor has been promoting Ombudsman services across the media to encourage more people to come forward.  There can only be disappointment ahead as newcomers join a backlog of over 1,000 cases currently waiting in the system. PHSO cannot be trusted to put their own house in order.  Senior management appear to be caught in a torpor of indecision. Mr. Gordon must do more than consult with the usual suspects in order to carry out his review and the Pressure Group suggest that he would benefit greatly from discussing matters with representatives from the PSU staff union among others.

We are convinced that Mr. Letwin is set on reforming the Ombudsman landscape and in order to achieve this aim we urge him to discuss the way forward not with those who caused the problems but with those who have suffered from them.  The public. 

You can see the full summary presented by the PHSO Pressure Group to Mr. Letwin and Mr. Gordon here: http://phsothetruestory.com/2014/10/12/phso-pressure-group-go-to-the-cabinet-office/

Meeting with Mick Martin – Managing Director of PHSO

Mick Martin from his LinkedIn profile.

Mick Martin from his LinkedIn profile.

It was a week of promises.  The Scots were being offered a listening ear from Westminster and the promise of political reform.  ‘We are hearing you,’ was the message as the near-miss Scottish bid for independence shook those in power out of their usual stupor.

Similarly there were promises on the table at PHSO when I went to visit Mr. Martin, the new(ish) Managing Director.  Do not be fooled by his casual appearance in this photo.  Mr. Martin is a force for change.

He was ‘Quality and Service Integrity Director’ at The Post Office from 2009 – 2011. Integrity is something he will need in spades if he is to persuade the public that the Ombudsman can change its spots.  But high up the list of his top skills are ‘customer service’ and ‘change management’ giving him all the credentials he needs to drag PHSO into the modern age of customer focus.

I first met Mr. Martin at the Pressure Group seminar in June.  He concluded that meeting with his own thoughts from the day and convinced me then that he was a different animal to the run of the mill, shut you down, no action required, PHSO employee.  In fact I was impressed by all the management staff who listened attentively that day.  They listened, they talked among themselves and now, three months later. we were to hear the outcome of their deliberations.

We sat in his office in Millbank Tower.  If there was a view of the Thames it was obscured by the array of coloured post-it notes which dotted every available space in the room.  Red for action, green for consideration and yellow for …. joy?   There was no doubt that he had his work cut out.  He informed me that PHSO were changing, were listening and responding.  There was to be no more shut down for dissatisfied customers.  On-going customer care at the post-review stage would put an end to the  ‘no acknowledgement required’ rubber stamp. This was a very positive start I thought.  But can he deliver?

Previous meetings with management at PHSO have led me to believe that senior staff share a collective delusion that all problems were in the past, all criticism can be countered by data and the simple act of investigating more cases will make everyone happy.  Happy customers, happy staff and happy politicians.  A bit like the pigs on Animal Farm they have become detached from the hard daily grind and partake of ethereal discussions using management speak.   If Mr. Martin is to achieve his objective of modernising this service he will have to start by removing those blinkers.

PHSO Staff Survey

PHSO Staff Survey 2013

The staff survey should have given them a bit of a clue that things aren’t working.  Trust in management appears to be at an all-time low.  They have a staff turn-over rate of 21% which must affect both speed and quality of investigations.

The Health Select Committee is due to report soon on their inquiry into NHS complaint handling and hot on their heels the Cabinet Office will deliver government proposals into changes to the Ombudsman landscape.   It would appear that PHSO is under pressure from all sides.  So what did Mr. Martin offer as a way forward?  He offered to listen.

Members of the Pressure Group do indeed hold the gold-dust of experience.  We know what it feels like to go through the sausage machine of the PHSO process and emerge mangled and bruised on the other side.  We know what went wrong and what is needed to put it right.  To all of this Mr. Martin will listen, then no doubt construct more post-it notes.  He won’t get it all right and he won’t do it all straight away.  However, I believe that he is a man of integrity and I am happy to take the olive branch of continued dialogue with a willingness for us to work together to improve this service for those who receive it and those who deliver it.  I’ll even bring my own post-its.

 

 

After months of waiting PHSO finally release details of their staff survey…

Our staff survey of summer 2013 showed that we had not done as well as we should have in bringing staff along with us and making sure they were fully informed and involved during the period of change. While the majority of staff were committed to our work and had a high opinion of their peers, job satisfaction and morale had declined since the previous survey in 2011. The overall staff engagement score fell from 73% in 2011 to 47% in 2013, although the two surveys were not directly comparable in all areas. We have implemented an action plan to address these concerns, with more regular staff briefings, more face-to-face communication and question and answer sessions with senior staff, as well as a network of ‘engagement champions’ to help promote two-way communications. We also plan to launch a new intranet in summer 2014.

We have started to strengthen relationships with our trade unions – the Public and Commercial Services Union and FDA, formerly the First Division Association. We are more actively consulting, informing and involving them in decisions that affect their members, particularly about pay.

During the restructure we gave staff support to help them deal with the personal impact of changes, including coaching, career guidance and use of the employee assistance programme.

We hope for improved results in our next staff survey and we intend to systematically measure our success in motivating and developing staff, including through full staff surveys every two years.

(from Annual Report 2013 – 14)    http://www.ombudsman.org.uk/a-voice-for-change/our-aims/aim-5-developing-our-organisation-so-that-it-delivers-our-aims-efficiently-and-effectively

Was it worth the wait?

 

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

 

 

PHSO Seminar; we talked, they listened, what next?

As members of the Pressure Group prepared for the seminar the news broke of the devastating case of the Morrish family and their scathing opinion of the PHSO investigation process.  It was all over breakfast t.v. and then again on radio 4 when John Humphrys put some rather probing questions to Dame Julie Mellor. ( http://www.bbc.co.uk/programmes/b047c310  starts @ 2.48) So this was the backdrop to our seminar and possibly the reason for the last minute shift away from Millbank Tower to the more obscure territory of EC1.

I must say from the outset that we were listened to and we were heard. 

IFF, the customer survey people ran the meeting and were flexible and accommodating.  Although we could have used more time, we were not rushed and all participants felt valued.  We split into two groups and the young man from IFF who led our table started off with the cheery smile of a children’s t.v. presenter.  As the stories unfolded his head sunk gradually lower and his smile waned.  Could this all be true?  Are people really treated with such contempt for the truth?  Although each of our stories are unique, they followed a familiar pattern of denial of the evidence, flawed decision making, failure to answer difficult questions and an inability to put the record straight.  The raw pain of those re-lived experiences soon surfaced through the everyday veneer; voices struggled to be heard through the clog of emotion which caught in the throat and tears were openly shed.

Unresolved injustice is an open wound.  

When the two groups gathered again to review the key themes another young chap from IFF read out a catalogue of poor complaint handling which could rival Schindler’s list.

  • System favours organisations
  • Evidence from public bodies taken at face value
  • No opportunity for redress, can’t put things right
  • Not enough cases get through
  • Systems favours professionals
  • Too much emphases on small details and not the big picture.
  • No advocacy for complainants
  • Not a clear process of how cases are assessed.
  • Lacks independence and objectivity.
  • Anonymous clinical advisors
  • Lack of independent clinical advice
  • Cover up of state fraud or corruption
  • Concerns on time lines – slow process
  • Lack of openness and transparency
  • Lack of  alignment to principles of care
  • Lack of accountability

IFF now compile a report to which we will all have access, then we have called for a follow up meeting to discuss the way forward.  This seminar marks the beginning of our journey with PHSO and not the end.  Despite our concerns that we didn’t say just what we meant to or in the way that we intended;  the impact of so much human pain in one room was inescapable.  As one PHSO employee said as we waited for the lift together after the meeting,

‘It’s different when you see the people’.

 

Can Oliver Letwin redeem himself as the Complainers’ Champion?

Oliver Letwin behind barsIt would be easy to believe that Oliver Letwin did not so much grasp the mantle of Complainers’ Champion as have it thrust upon him in much the same way that disgraced Stalinist were encouraged to vacation in Siberia.  After all it’s not every politician who wants to be recognised as Minister for Complaints.

The truth is that Mr. Letwin has time on his hands since being replaced as Cameron’s policy advisor in April 2013, by Jo Johnson, brother of Boris, the British Kennedys.    It was thought that Mr. Letwin was too distant from the concerns of ordinary voters to write the next Conservative manifesto.  Educated at Eton and Cambridge, before becoming an academic, Mr. Letwin had little chance to develop an understanding of the lives of ordinary voters.  This may be the reason why, in July 2011 he called for public sector workers to be in fear of losing their jobs in an effort to improve productivity.  Fear of the Gulag could also have done the trick, but I dare say that even Mr. Letwin realised that this would be a step too far.

It is well known that Oliver Letwin is in favour of savage cuts to public services, which he sees as bureaucratic and inefficient.  In 2001, in the run up to the general election, he stated that the Tories would slash taxes by £20bn, putting money back into the pockets of the taxpayer whilst simultaneously devastating public services reliant on taxpayer funds.  It did not come to fruition at that time, but with austerity came the opportunity to legitimately slash public spending, without the subsequent tax rebates as I recall.

With cuts to public services there will inevitably be more complaints.  Front-line staff, over run by an impossible workload will inevitably make mistakes.  So is Oliver Letwin the right person to be overseeing a complete overhaul of the complaint process and the role of public sector Ombudsmen?    Having created the chaos which caused the complaints the aim would surely be to provide a watertight system which allows for efficient complaint disposal without leakage and scandal.  Job done.

Perhaps the idea is to privatise all public services putting them beyond the reach of freedom of information requests and data release, making the task of white-washing complaints a whole lot easier. In 2004 Mr. Letwin stated that the NHS will cease to exist after five years of Tory rule.  The big sell off has certainly begun, but five years was a tad optimistic for such a mammoth organisation to be turned piecemeal into profitable private companies.

But let us not dwell on the negative.  Mr. Letwin has the opportunity as Complainants’ Champion to become a national hero.  He has already agreed to meet with a coalition of campaign groups on 24th July to discuss the forthcoming inquiry.  Representatives from the PHSO Pressure Group, National Health Action Party and LGO Ombudsman Watch will meet with Mr. Letwin at Westminster to share their ‘gold dust’ knowledge of issues and solutions.  Complainants are primary stakeholders in the discussion process and intend to contribute throughout, in order to guide Mr. Letwin and the Cabinet Office in making the right choices.  The result could be legislation which actually provides protection for the citizen from the abuse of power.  Public sector Ombudsmen who actually believe that complainants are honest with valid concerns.  An end to bias, corruption and arrogant disregard for the public.  So, Mr. Letwin, are you able to deliver?

Coalition of Health Campaigns visit the BBC

Joint Press Release from PHSO the Facts and Heal the Regulators. 

Several senior journalists at the BBC international headquarters in the New Broadcasting bbc-logo-oHouse responded to invitations from two major campaigns, PHSO the Facts and Heal the Regulators, and met with their senior representatives in three separate meetings on Thursday 22 May 2014 (Super Thursday) regarding the Ombudsman and the regulators.

The journalists concurred with the two campaign groups that the high profile issues have wide public significance which affect all 65 million British people.  The serious issues are numerous, but can be grouped into three key ones:

1. The Ombudsman and the regulators have failed a large number of citizens

2. The Ombudsman and the regulators have failed a large number of professionals and practitioners

3. The Ombudsman and the regulators needs to be reformed (as stated in various reports from the Parliament, including the most recent one published by PASC, which suggested a People’s Ombudsman).

Senior professionals commented that in the history of campaigning, it seems that PHSO the Facts and Heal the Regulators are the only groups who managed to meet with the “heavyweights” in national press and media all in one day. The senior professionals felt that this milestone was achieved because the issues are of national importance and they hoped that the Prime Minister and Government Minister will soon be willing to meet with the campaign leaders as well.

Since Super Thursday (22 May 2014) at the BBC international headquarters, various national newspapers, TV stations and radio stations are becoming interested in PHSO the Facts and Heal the Regulators. We have a new meeting at the BBC (with another “heavyweight”) and a meeting with the Evening Standard next week.

What is unique about the two campaign groups, PHSO the Facts and Heal the Regulators, is that they are run by highly qualified, widely published and well-connected senior professionals. This is quite unique in the world of campaigning. This fact, combined with the fact that these two campaign groups promote compassion, kindness and wisdom, means that their work will flourish and last for decades to come. Compassion, kindness and wisdom will always exist and can never be destroyed, no matter how strong the bullying and victimisation.

 

 

Members of PHSO Pressure group attend D.o.H stakeholders meeting.

Stuart Finch from phsothefacts and Peter Walsh from AvMA

Stuart Finch from phsothefacts and Peter Walsh from AvMA

On 21st May two members of the PHSO Pressure Group attended the Department of Health’s stakeholder meeting to discuss the proposed legislative changes to the regulation of Health and Social Care professionals.

 

The regulatory bodies within the remit of the project include:

  • General Chiropractic Council
  • General Dental Council
  • General Medical Council
  • General Optical Council
  • General Osteopathic Council
  • General Pharmaceutical Council
  • Nursing and Midwifery Council
  • Pharmaceutical Society of Northern Ireland

The project also covers the legal regulation of the Professional Standards Authority, which oversees the work of all nine regulators.  None of these bodies come within the remit of the Parliamentary and Health Service Ombudsman.

Here is our summary of the meeting:

It is obvious that the healthcare professionals come to complaint handling from a different perspective when they use terms like ‘complaint disposal’ without flinching.  They give the impression that although the regulatory system isn’t perfect, by and large it works quite well dealing with the complaints that reach investigatory panels.  What they ignore is the dam which holds back huge numbers of valid complaints from coming anywhere near scrutiny.  They state with certainty that ‘not everyone can have an investigation’ without considering for one moment the damage caused by turning complainants away with no acknowledgement and no remedy.  
It became clear that the professional lady in our discussion group, who carries out some regulatory work for the GMC, approached the task with two certainties.  That the vast majority of healthcare professionals were competent and decent people and that the regulatory system operated with integrity.  On that basis, the only conclusion to be drawn was that the complainant was probably in error and her job was to look for that error and dismiss the case.  It could be that the complainant misunderstood the responsibilities of the healthcare professional; the complainant may be emotionally overwrought or possibly just vindictive and vexatious.  It was as if complainants acted like ‘hoodies’ just wandering round the regulatory system looking for trouble.
If you turn the whole thing on its head and start with the perception that the complainant is likely to be a genuine person who has a valid concern, then the spotlight for investigation falls upon the system and why this complaint has been escalated without resolution.  It also falls on the healthcare professionals; whether they managed expectations appropriately and delivered to a professional standard.  It just depends on which side of the table you sit on, which view you take.  So it was a good job we were there to put the other point of view.  Stuart has first hand experience of being turned down by every single organisation in his quest for justice and remedy.  As each new regulatory body was drawn from the hat and offered as a solution, Stuart was able to give the reasons they used to deny him an investigation and remedy.  I think this came as a bit of a surprise to some in our group.  
Peter Walsh from AvMA was in our discussion group, he stated that it was a waste of time to ask regulatory bodies to review their own decisions.  He wants the Professional Standards Authority (PSA) to have the power to investigate individual complaints and carry out reviews.   Peter stressed the importance of getting it right at the start of the process and the risk to patient safety if issues were not dealt with appropriately.  The PSA could have an active role in resolving individual complaints where people felt they had not received a fair hearing, if they were given the powers to investigate complaints. They also need the power to make binding recommendations for this to be effective. This could come through the proposed legislation and would be a major improvement. 
In the draft bill there is a ‘duty to cooperate’  clause which requires all regulatory bodies to share information.  Stuart and I had talked about falling through the gaps, where no single body had the remit to investigate your complaint and you were bounced around the system like a pinball machine.  The professional representative determined that the duty to cooperate meant that it would now be necessary for the regulatory bodies to work together and disclose information in order to resolve cases. She determined that with this in place the complainant could hold them to account if they refused to do so.  Simple as that.  She did not recognise the scenario I presented of regulatory bodies not cooperating but colluding together to prevent scrutiny of valid complaints and deliberately withholding key information.  She just did not believe that this would happen. 
As our group discussion drew to a close we talked about the issue of advocacy.  Peter Walsh was in agreement that all complainants need to be guided by an independent advocate and offered the services of AvMA. Many valid complaints are not given a fair hearing because the complainant has not provided a structured account of the events with key issues raised and supported with evidence.  Although we all agreed on this point, it was unclear whether this could be addressed by the proposed legislation. 
At the final plenary, Peter Walsh raised the issue of the five year rule which prevented older cases being investigated.   A lady from the midwifery council remarked on a case which had blighted their profession when a grieving parent continued to make complaints against a midwife ten years after the original event.  It was very unfair, in their opinion, for this person to be able to ask for another investigation when her matter had been dealt with.  They described the unnecessary stress this had caused to the midwife concerned.  Although it is understandable that a returning complaint must be a nightmare, the question has to be asked as to why the complainant returned ten years later.  Because she didn’t agree with the previous decisions, came the reply.  So for the mother, there had been no satisfactory outcome, no resolution and consequently no closure.  The professional solution is to firmly enforce a five year time limit which protects the professional staff from continued stress, but does nothing to alleviate the pain suffered by the complainant, who is now shut out of the system.  The real solution, for all parties, should be to improve the complaint handling service to find proper solutions at the outset.  No one wants to drag a complaint on for years.  We do it because the delay, deny, defend culture forces us to. 
More meetings will follow this initial gathering and we will be able to attend and continue to influence this legislation in the making.  
Your comments are welcome. 

PHSO Pressure Group meet with Rosie Cooper MP

 

On 29th April two members of the PHSO Pressure Group met up with Rosie Cooper MP at Westminster to discuss the dire state of the present Parliamentary and Health Service Ombudsman.  We informed her that the continued failure of PHSO to deal with complaints fairly to provide justice and remedy was causing widespread suffering as people struggled to find closure.  When you have lost a loved one unnecessarily or suffered personal injustice you do all you can to prevent that happening to others in the future.  The Ombudsman, who should protect the public from the abuse of power and ‘put things right’ deliberately defends public bodies and NHS trusts by denying and manipulating the evidence to find no case to answer.  It is time for this to stop.

PHSO pressure group meet MP

Stephen Greck and Rosie Cooper at Westminster

Below is our follow up letter to Rosie Cooper MP explaining why there needs to be legislative reform of the Parliamentary Ombudsman and a complete overhaul of the current system.  We are also calling to be represented at the Cabinet Office inquiry into complaint handling and public Ombudsmen services.  Any inquiry into complaint handling should start and end with the complainant.

Dear Rosie Cooper MP,

Thank you for meeting with members of the PHSO Pressure Group recently to discuss the appalling state of the present Parliamentary and Health Service Ombudsman.  This body is not fit for purpose and has been corrupted from its original intention, which was to protect the citizen from the abuse of power.  Perversely, the Ombudsman serves to protect the public bodies from genuine complaints, resulting in a failure to address key issues and improve service delivery.  This was brought to public attention at the Mid Staffordshire Hospital inquiry, where none of the complaints were investigated by the Ombudsman during the period under review, including that presented by Julie Bailey.

The dire state of the Ombudsman service was recognised in 2011 by the Health Select Committee when they called a complete overhaul of PHSO.  http://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/news/11-06-28-clreoprt-substantive-/  Chair Stephen Dorrell stated that,  “The legal and operational framework of the Health Service Ombudsman should be widened so that she can independently review any complaint which is referred to her following rejection by a service provider.  The Ombudsman’s current terms of reference prevent her from launching a formal investigation unless she is satisfied in advance that there will be a ‘worthwhile outcome’. We have concluded that this requirement represents a significant obstacle to the successful operation of the complaints system. Patients should be able to seek an independent review of the findings of internal reviews by care providers; the terms of reference under which the Ombudsman works prevent her from properly fulfilling this role. This needs to be changed.”

We are a group of individuals who have all suffered injustice at the hands of the Ombudsman.  By coming together and sharing our experiences we can prove that PHSO deliberately deny or manipulate the evidence to avoid carrying out a full investigation.  Even those members of the group who have had investigations are not satisfied with the service.  The Ombudsman strategically focuses on minor issues and allows major breaches to go unattended, they are inaccurate in their reports altering the facts of the matter and any sanctions or action plans are minimal with little account of the suffering caused.  These action plans are then left unmonitored by PHSO as this is not within their remit and for all we know may never be implemented by the public body concerned.  The whole process is corrupt and allows public bodies to treat complainants with impunity knowing there is little chance of sanction by the Ombudsman.  There is no public confidence in the present Ombudsman service and we are calling for the complete overhaul recommended by never delivered in 2011.

The present Ombudsman Dame Julie Mellor is publically encouraging more people to make complaints as part of an initiative to raise the profile of PHSO, but this action is viewed by members of the Pressure Group as a slap in the face and gross hypocrisy when PHSO consistently fail to investigate the vast majority of complaints which are already presented to them. 

‘Older people should be encouraged to complain and should be taken seriously when they do. But my fear is that too many older people are suffering in silence.’ 

We may be ‘seeing the tip of the iceberg’, she said…   (Dame Julie Mellor, Mail Online 6.4.14)

Dame Julie Mellor’s statement in the same article that,  Complaints are a gift to the NHS because that is how improvements are achieved””  is particularly galling as many  offer similar ‘gifts’ to the Ombudsman only to have them returned unopened.  She certainly does not practice what she preaches and the data will confirm that.

In 2012-13 (latest available figures) PHSO received 4,889 complaints which needed to be reviewed.  For 3,914 (80%) no action was taken due to Ombudsman discretion.  Only 384 received a full investigation (7.9%) and 230 were upheld (4.7%).  For the vast majority making a complaint made no difference.   

The Pressure Group are aware that from 2013 a new initiative, ‘More impact for more people’ has been implemented which is designed to provide more investigations and improve feedback to organisations.  We do not have confidence that this programme will deliver robust, impartial investigations and believe that it is simply a rebranding exercise where previous ‘assessments’ are relabelled ‘investigations’ in order to meet targets.  The reason for our concern is that following a FOI request PHSO revealed that only 30% of their staff currently carry out investigations whereas 54% are in management roles and the average time for completion of an investigation has fallen from 162 days to 39 days this year.  PHSO are attempting to do more for less and we cannot see how they can complete quality investigations of complex issues without a proper commitment to staffing and time allocation.  Only 42% of these new investigations are being upheld compared to 85% previously.  This would suggest that the extremely high threshold of evidence against the public body has simply been shifted to the investigation stage from the assessment stage.   This will not satisfy the complainant or put things right.

Continued denial of justice and remedy can lead to severe and on-going emotional trauma.  Without justice there can be no closure and many people who have already suffered a painful bereavement, continue to struggle with additional psychology damage due to the failure of PHSO to acknowledge and properly investigate their concerns.  The complaint methodology used by PHSO means that complaints as made are never actually addressed. To add insult to injury many Pressure Group members have experienced imperious, arrogant, patronising and dismissive attitudes from caseworkers. There is a high price to pay for society and for the NHS as people become ill due to the stress of a long and fruitless fight for justice.

The Ombudsman does not represent good value for money.  At £34m per annum each investigation (2012-13) costs just short of £87,000.  The Ombudsman is unaccountable to members of the public.  It is impossible to win at judicial review due to the total discretion enjoyed by the Ombudsman, so it is inaccurate to say that the Ombudsman is accountable under the law.  The Public Administration Select Committee (PASC) have no real powers to sanction the Ombudsman or hold her to account and they cannot intervene in individual cases.

PASC themselves accept that the Ombudsman service is ‘outdated’ in their recent report ‘Time for a Peoples’ Ombudsman’ and calls for a strengthening of accountability for PHSO by appointing a Minister for Complaints.  Bernard Jenkin MP, Chair of PASC stated that,

“We have to make these changes.  PHSO is part of our service to our constituents, and its way behind the times.  Our voters have a right to complain about public services when mistakes, misunderstandings and maladministration occur. We so often see that people complain not for their own benefit, but to ensure lessons are learned and the same mistakes are not inflicted on others. As we recently reported, the disaster at the Mid-Staffs hospital is a tragic example of what happens when the complaints system does not work.”

The report calls for changes in legislation to be decided by the Cabinet Office following their review of complaint handling and the role of the public sector Ombudsmen.

Guy Horsington, Private Secretary to Oliver Letwin stated in an email to phsothefacts that,

“As you are aware at the end of last year the Minster gave a commitment to explore further some of the issues that the Public Administration Select Committee (PASC) had raised by undertaking two further pieces of work:

  • to investigate how public services can make best use of complaints, and ensure complaints are welcomed as a valuable source of information about where improvements are required; and
  • to take a wider look at the role and powers of the public sector Ombudsmen.

Both pieces of work are being taken forward by teams based in the Cabinet Office, working with Departments and key stakeholders.”

The decisions made during the Cabinet Office Inquiry will be crucial to developing an effective Ombudsman service which works for the people to protect them from the abuse of power.  Complainants are ‘key stakeholders’ in this process and should be represented at the discussions.  Complainants have used the system from top to bottom and hold the ‘gold dust’ knowledge apparently valued by those in authority.  We are the end users and as tax payers we pick up the bill.  The PHSO Pressure Group are therefore requesting a seminar with members of the Cabinet Office and other key stakeholders so that we can contribute to the final decision. 

This should be in keeping with Oliver Letwin’s own views as he stated to PASC that,

‘Valuing complaints and supporting people who feel the need to complain should be at the heart of the values which drive public services.  The importance of leadership cannot be overstated.  Complaints must be valued from the very top of an organisation and seen as something to be welcomed.”  (PASC Report – More Complaints Please!)

So far, we have not felt ‘welcomed’ by Mr. Letwin or the Cabinet Office, but hopefully there will be a realisation that we have a great deal to offer each other.  The PHSO Pressure Group has first hand knowledge of the problems encountered by complainants and suggestions for ways forward.  I have enclosed a copy of our summary report which gives some information in this regard.  A full and detailed report will be sent via email.

Our hard work and experience could save a great deal of time for the Cabinet Office committee.  Improving services for complainants must start and end with the complainants themselves.

We hope that you and other MPs will see the value of our contribution as experienced and committed members of the public looking to improve complaint handling for those who follow in our footsteps.

Yours sincerely,

PHSO Pressure Group