Can the EHRC hold the Ombudsman to account for the appalling treatment it dishes out to those who have already suffered a trauma? Open letter from Colin Rock.
Dear Equality and Human Rights Commission,
As a bereaved parent and for nine years of an unresolved NHS negligence case I have been treated disgracefully by the PHSO against the provision of Equality Acts, and the definition of a Disability. I have become aware that this is not unusual and many others through online contacts have revealed the same dreadful experience. The people involved at PHSO hold an appalling attitude to complainants and the trauma they may have suffered.
It is 9 years since my son died as a result of NHS negligence in his Care. The negligence case is still unresolved, but the NHS Trust BSMHFT has now admitted weakly that they did not follow correct procedures at the start of my son’s illness. The PHSO first told me there would be ‘no useful outcome to an investigation’ then secondly that ‘the outcome (i.e.my son’s death) would ‘probably have been the same even if the correct care had been provided’. What alien land do they occupy?
Quite apart from the discrimination my son suffered from his GP and at BSMHFT, my claim now would be against the Health Services Ombudsman (PHSO) who has ignored and extended this trauma by its language, accusations, assumptions and ignorance of procedures. The PHSO continually refuse to entertain complaints against themselves, extending previous victims’ nightmares indefinitely.
Unfortunately other young persons have suffered the same as my son and have died needlessly and avoidably; potentially if the PHSO had listened-to and understood NHS problems then by taking positive steps at the time the problems were apparent. Denial and NHS protection must be their aim. Complainants are left ‘wasted’ in PHSO’s path.
Very unfortunately The PHSO does not understand Disability, Equality, Customer OR Patient Rights, or their own staff problems.
Ex-equality commission Dame J Mellor has been allowing this for her entire time at the PHSO and shows not the slightest recognition of the problem. You really need to act now to stop this madness at PHSO.
CC: Rob Behrens – Ombudsman
A case study in ‘managing expectations’. Please read and note. This has to stop.
17 February 2017
I realise that you will depart the PHSO as Ombudsman very soon. I haven’t written to you before but feel compelled to do so in order that you may glimpse what it feels like to be in my shoes. I hope you can take the time to read just a small amount of what has happened since I first complained about a Trust locally in October 2011.
Firstly I would like to open with a couple of sentences which highlights on the PHSO website what you have meant to this organisation as you leave office, it’s as follows:
‘With her at the helm, the ombudsman service has opened its doors to more people than ever before, providing justice to the very many people who have been failed by public services’.
I would like to say that this was the truth, but I am afraid that would be a lie. The most traumatic thing I have experienced along this journey is the complaint handling system itself.
When I complained initially to the Trust regarding my husband’s lack of treatment it wasn’t a letter of complaint, my first letter to the Trust, and I have it with all my correspondence which spills out into many arch lever files, was a letter begging for the correct help. The Trust were the ones who forwarded my letter for local investigation not I. I now know that was because the word Ombudsman held no fear for the Trust. That was back in October 2011.
I was never one to openly complain, never written a letter of complaint in my life until that moment. What a lot I learned from that point to present day.
I won’t bore you with the details, I know my files are still marked as ‘saved’ and for the time being haven’t been destroyed, as is the usual procedure after a year has passed, though that may have since changed as rules often do. It’s the feeling I want to convey. I’m only a simple person, I haven’t been blessed academically, I haven’t written anything which could be considered moving, thought provoking or even mildly amusing, all I’ve written since 2011 is the truth and how it unfolded and how the system, the very system that I believed was put there to help the likes of me, let me down. I want to tell you more than anything how that felt.
When my complaint was just the letter written in October 2011 crying out for the help and assistance for my husband and therefore our family, I was at my wits end. I had to flee my home to a friend’s house five minutes’ walk from all I knew. This done to give me the rest needed to continue to fight for my husband who was in psychosis, brought on by the serious and enduring illness that we knew to be Bipolar Effective Disorder. My husband had always worked without a break all his life for a total of 37 years, he was a ‘functioning’ person who suffered with this illness. He was successful and always provided. He also helped bring down funding with his work in renewable energy for Exeter University, a sum of £350,000, quite an achievement for a man with no formal qualifications to his name. Just a hard worker who did financially better the harder he worked.
The Trust spent around six months on their local investigations which in the end didn’t give justice to our family. Whilst that investigation was underway and my husband was still under the Trusts care mistakes kept happening, even as I alerted the Trust when these became apparent. When I posted that letter I Cc’d it to several people including my then MP. At that point my husband wasn’t brain damaged and the catalogue of disasters kept growing – terrible things, things that were so out of character and yet no one listened to me. I had to watch as he destroyed himself, set fire to himself, our home, overdosed and I couldn’t do a thing as he had the right to stop me being his carer whilst in psychosis. I had been with this man since 1982 and nothing like this had happened until he suffered a breakdown in 2004, and things did change, his illness became chaotic. Still no one listened to me.
I got the phone call from the PHSO in the spring of 2012 and heard the voice of Ms C asking me to listen – she told me that it was important that I understood what she was going to say next, she continued ‘I need you to know that we take what you are saying very seriously’, she paused and I stopped verbalizing the nightmare of the past year and she said those words again. I wept like I had never wept before, maybe my nightmare was soon to be over someone was listening.
That feeling, I can relive it, I can feel it as I write, it was overwhelming a wave of emotions from inside and outside my whole being and the universe, and it was electrifying and draining all at once. I sobbed not knowing where these strange noises were coming from. Ms C at that point said, ‘Mrs Steele, there are no words, there are just no words’. I was done. I felt relieved I could help my husband now, save our only asset our home, which was now uninsured. Despair left me that day, and it felt like hope was returning and that a guardian angel had appeared and was there to help me through the next phase, my family was going to be saved. That is what the PHSO did for me that day, and for the next few months.
I worked very hard gathering evidence for the investigation, and I mean hard, especially as I found all the paper work difficult. I went to night school to learn how to use computers and to type whilst working a full time job. The normality of my work was the only thing that was normal and un-chaotic. I worked hard because I believed the light at the end of the tunnel was in view. Our son was still at home, a seventeen year old and his spirits visibly lifted, which in turn made me stronger.
Mr C was assigned to investigate and that investigation started in the summer of 2012. Mr C and an aide visited me at the rented home, and my husband at our family home, which by this time was in ruins. I alerted Mr C that my husband wasn’t himself, I had been told by doctors that this was because of ‘psychomotor retardation’ in the depressive stage of his illness. I told Mr C that it looked more like my husband had suffered a stroke as his walking, talking and cognition was very much impaired, I even said he may think my husband intoxicated, his balance was poor and he fell a lot. I had to wait until October that same year before I could get answers as to why this physical change had happened as that is when I was awarded Power of Attorney, which I had to complete myself with witnesses as I didn’t have the money to pay for solicitors.
I also had been fighting the Bank regarding loans that were given as my husband was in a wheel chair sitting in the burned out home with bandages to his feet and hands and in receipt of ESA. My husband had accrued, in repayment terms, £23,000 of debt. I fought that whilst all the investigations were going on and won, without a solicitor. I was motivated by the fact the PHSO where here to help our family, it lifted me and carried me through all the work I was doing, gathering evidence, fighting banks and befriending the bailiff agency who were instructed to take our truck away as my husband had also been in court for ‘out of character behavior’, he had run after someone with a bread knife and had to pay court costs, which of course he couldn’t pay, he didn’t know what day it was. The bailiff spoke candidly about his own mother and how she too suffered with Bipolar and what this meant for him.
My husband has never driven since the life changing incident, or swam, or ran. I had to fight to prove he had brain damage, and that I did. I then had to prove when the damage happened and how, and I got the answers. The PHSO didn’t do this, I did. I gave your organisation every piece of information that I worked for and I never missed one six hour day of my job, I worked and studied until three, four in the morning I was running on adrenaline. I passed all my exams too, which may have been easy for some, but for me at my age was difficult.
I received Mr C’s final report on the day I was moving back home, on 23 July 2013. I had gutted the house into skips, with our son, swept it, painted it through and organised cheap carpets and curtains, beds and new furniture, well new to us. I did this in the Easter and half term breaks that year. I’m five foot and I threw scorched three seater settees down the steps of our home. I did it because I believed in our system, it was on my side. I was on a roll. I got the final report, and boom! It was not what I expected. It told only half the story. The words ‘scope of the investigation’ was used.
On reading the report I found that evidence had been left out, important evidence. Nothing was said about my husband having worked for 37 years without a break, bringing down funding for Exeter University through Defra for his work in renewable energy, having worked with a Doctor of Chemistry in the North East and turning around a project favorably. The report simply said, that my husband had not worked for some time and honed in on drug and alcohol problems that in truth were relatively recent in the scheme of our twenty nine years together and proven to be part of the illness when in mania. The report was a subliminal character assassination. I knew the truth, but anyone else reading that report would have thought my husband a total waste of space the whole of his adult life. The report made no mention of the brain damage that I had uncovered eight months before Mr C’s final report and to whom I’d given the scans and evidence as I received them from my GP.
On receipt of Mr C’s final report I was then told ‘the rest of the complaint will have to start again at local level’. Mr C delivered that whammy with ease. I was in shock. The ombudsman must be right, after all they are on my side. The more I looked at the report the angrier I got, and no Dame Mellor, it has nothing to do with me managing my own expectations correctly, this was a total affront.
The second local investigation started the same week, as I wrote to the Trust involved on 29 July 2013. That went on at local level for a year, and the BS I had to read was so amazing I laughed as I cried.
The PHSO picked up the ‘rest’ of my complaint in May/June 2014 but didn’t start proceedings until September that year apparently there was a rise in the number of complaints the PHSO were handling. I got the second final report from Mr. L investigator, on December 1st 2015. It took two and a half years for the second investigation start to finish, and the three year deadline for litigation had passed.
As you are aware the Ombudsman is the final arbiter, and the only way forward is judicial review, which on both investigations I was turned down for as I had no new evidence. It didn’t matter that the evidence I had already given wasn’t used, there was still no new evidence to be presented. I handed it to you on a plate, not knowing that with nothing left to give I’d be emotionally raped in the worst possible way and left for emotionally dead.
If it hadn’t been for my new found computer skills, this sixty year old woman wouldn’t have had a clue how to go about finding others who also had suffered at the hands of the Ombudsman. I uncovered collusion with the PHSO and the Trust involved, to the point I truly felt emotionally and physically abused.
Had I not found the pressure group headed by Della Reynolds, PHSO the Facts, I believe I would have gone seriously downhill mentally. I was saved as others had stories of the same corruption within our establishment. It wasn’t just me on my own saying those things, others confirmed my beliefs.
Part of my complaint in two areas are on the PACAC website, they own the copy right to that part of my complaint, they own my words, and yet they haven’t looked at my case, as they ‘cannot look at individual cases’. The CQC who sent out two officials to visit me cannot look into individual cases, neither can Jeremey Hunt or the Department of Health. It would appear there is a lot of hand washing going on within these departments and to hell with what this practice is doing to victims and their families. We, the people, are of no concern to the establishment and it shows. Thirty of our cases from our pressure group have been sent to the MET Police siting Misconduct in Public Office against the PHSO. It took the police nearly eight months to find legislature from a 1993 Act that says that your organisation is unable to share the details of investigations carried out by the PHSO. That means the office of the Ombudsman is above the law, and is undisputable. Surely things have to change?
I cannot thank you for the service the Ombudsman provides, because sadly the service only added to the pain and suffering in a way you will never be able to imagine. The pain of losing who my husband once was to what he has become is almost easy in comparison to what the PHSO did to our family and my husband’s character. Our grandchildren will be told the truth, they will be shown the deceit within the pages of those reports, and I will not rest until it has been put right.
I don’t blame NHS front line staff per say, I blame the culture within the NHS and the CEO’s whose job is to protect the ‘good name’ of the Trust and who flit from one appointment to the next and who run Trusts like businesses rather than a service. I blame the ‘safeguarding of the establishment mentality’ above all else and the obvious impunity afforded with these top positions. Matrons! a thing of the past, but sadly missed.
My husband won’t be able to drive again, swim again, take his grandchildren out on his own, even look after them for an hour or two independently, we won’t visit the places we wanted to in our retirement, he hasn’t earned a living since the incident in 2012.
I am still working full time, cleaning at a school next door. I am able to attend appointments with my husband and support him in my job, returning home in break times to make sure all is well. The prospect of cutting my working day is no longer an option, so there is little time left to spend with my husband before his cognitive decline becomes even more marked. At least I can hold my head up high until the day of reckoning comes when my husband is assessed for the switch from DLA to Pips. It’s all an adventure though isn’t it? It’s all a game and I want you to remember your part in it, because God forgive me, I’ll never forgive the Ombudsman.
Mrs Teresa Steele
GMC – double standards regarding responsibility to investigate.
Professor Stephenson on BBC Today programme 5th September stated when a patient is harmed by a doctor’s actions the GMC are absolutely obliged by an act of parliament to investigate. I brought to the attention of the GMC the death of my husband for an investigation whom was prescribed off-label IV therapy treatment by a doctor without informed consent, my husband died unnecessarily due to a doctor’s dangerous prescribing. I’ve just received a response from GMC who said they will not investigate or take any action. The GMC tell me the wording of Professor Stephenson may have been a little ambiguous on this point. It would appear that the ‘absolutely obliged’ would only apply to a Junior Doctor harming a patient through strike action. Now we see the true colours of the GMC, as an arm of the establishment.
General Medical Council
10 October 2016
Private & Confidential Mrs Barbara Smith
Dear Mrs Smith
Complaint about Dr D.
I am writing in response to your recent letter dated 19 September 2016,where you raise some concerns about comment’ made by Professor Terence Stephenson on · the BBC Today programme on 5 September.
I am sorry that you feel these comments were not in line with the decision not to investigate your complaint about Dr. D. I was very sorry to read about the loss of your husband Peter, this must have been a very difficult time for you. I can understand why you complained and that you feel strongly that Dr D. was at fault.
You specifically complained about the drug Dr D prescribed to your husband during a PCI angioplasty. We considered this but decided that this would not warrant an investigation or any further action by us. I see that in our letter of 1 August 2016 we explained our decision and why we had come to it and I enclose a further copy of this. I am afraid I cannot usefully add anything to what has already been explained there.
I know you are disappointed by our decision but II hope you can understand how we came to it and why we did not investigate or take any action.
In relation to Professor Stephenson’s comments, it is worth pointing out that the focus of his interview on the Today programme was our advice to doctors In training considering strike action, and his comments need to be considered in that context.
The message he was seeking to convey was that if we were presented with evidence that an individual doctor’s actions during the strike may have directly led to a patient or patients coming to significant harm, we would be obliged to investigate and if necessary take appropriate action. We·accept that the wording he used may have been a little ambiguous on this point,and we are sorry for this and any confusion caused. While we carefully assess the information which we receive as part of every complaint made to us about a doctor,we only carry out a full investigation if the specific concerns raised could question the doctor1s fitness to practise. n other words if the allegations were true,there would be a risk to patient safety if the doctor was aUowed to continue practising without any restrictions. Not every complaint made to us crosses that threshold for investigation.
While we carefully assess the information which we receive as part of every complaint made to us about a doctor, we only carry out a full investigation if the specific concerns raised could question the doctor’s fitness to practise. In other words if the allegations were true, there would be a risk to patient safety if the doctor was allowed to continue practising without any restrictions. Not every complaint made to us crosses that threshold for investigation.
I appreciate that you are likely to be disappointed by this response and that we are not investigating your complaint but I hope this reply clarifies our position and the comments made.
Headof Corporate Review Team
Service charters may come and go, but the dire performance of PHSO never changes.
Dear sirs and madams
I am asking that each board member reads this.Your remit is to ensure the proper working and reputation of the PHSO. I am writing to tell you – from experience – how badly it is failing the public. It is borne out by many others which are publically shared, and I add my voice to that.
Many, many of us are cynical that ombudsmen generally do not do what they are supposed to and seem to be a show and sham. I have had experience of this several times: I don’t think I’ve ever had a good outcome and yet every time, where there has been one, the independent assessor or adjudicator has found fault with the ombudsman for their handling.
This case is no exception.
I know you don’t handle individual cases but I want to know you understand the general circumstances. I feel that due to what I have endured, it is only fair to me that this is heard.
After some years of being suddenly and wrongly divested of my main income, and using up the other procedures to complain about it – literally struggling to survive – I came to the PHSO, my last resort. They took a year and have still not finished.
-They assessed the case without the very substantial supporting document attached
– They changed assessor several times, wherein my case was slowed and confused and I was told several conflicting things
– even though my form clearly stated the tribunals system as part of the case, they firstly told me (wrongly) that this is not their remit; and then a year later, after a dreadful conclusion that despite causing my near demise there was no fault to be found, they ask me to return to my (not helpful) MP and fill in another form.
– They changed the goalposts about review criteria: all were met but they seemed not to want to review, and then inclined not to find any fault with their rather protracted handling.
– often what I have written does not in any way match what the PHSO writes back – it seems that staff have comprehension issues or are deliberately side stepping them.
I believe they already had decided not to award against this case. I asked for my papers under freedom of information and there were several suspicious signs, as well as showing that the case had been assessed with most of the papers missing.
We are aware – only too well – that you are not a customer champions, which is needed. The PHSO is a customer frustrator and aggravator, elongating cases, maladministering them, with very poor staff understanding; it is a body which needs taking to task.
I find that the myths you try to bust are true – it is the worst that the public believes, and more. (does it not worry you that these myths are rife enough for you to address them this way?)
I have often seen evidence of collusion and deliberate evasion. I am part of organisations which share this information so I know it is not happening to just myself. Having exhausted the internal complaints and reviews, and feeling once again that I am not being listened to, I have turned to yourselves.
Please note that this is an open letter, for there are many issues of public concern.
We are not able to have disputes fairly heard; we leave with a greater sense of frustration (and time wasted) than of justice.
The remit is also very narrow, ensuring that for instance in this case that the Adjudicator’s office of the HMRC is the only focus (who actually did many things wrong, none of which were upheld) but that the tier below – the original issue – is not seen by you. I’ve had to multi complain regarding this one matter, always being told that someone else needs to be applied to, all with narrow guides and time limits – yet this side broke their own charter and promises so many times.
It has made a difficult time far worse – and this latest letter of bad news from the PHSO couldn’t come on a worse on more significant day, which you have again spoiled.
I require not only a response, but an overhaul of this and all ombudsmen.
How to make a complaint about PHSO service delivery? Make it once, make it twice, stay on track, don’t look back, hang on in, through thick and thin. Well done Colin for persistence in the face of utter obfuscation from PHSO.
Dear Sir or Madam,
Please note that I am still waiting for attention to my complaints about your responses to me and about the way you pursue your work entirely out of line with published Principles of good complaint handling.
As you know I have been strenuously verbal about this throughout the whole period of our correspondence now amounting to seven years of frustration, resultant illness, and wasted taxpayers’ money for nil learning or benefit received. It it very likely that your delay in recognising the negligence has resulted in similar cases known to the media.
I registered an official complaint through your feedback system in December 2013. New complaints have been raised since. You have so far failed to respond to complaints through investigation -although promised by senior staff (Ms. A. John etc.) and despite my having enquired about follow-up numerous evidenced times.
Also, having enquired about the system for making complaints and typical response times, I have had no acknowledgement that this will be completed to any time scale, or given any redress to the points raised – outlined in brief here:
- In current dealings you have not explained why you perversely continue to uphold defendant evidence proved unreliable in investigation, or why such faulty NHS anecdotal response takes priority over evidenced events.
- In entire dealings, you have not dealt or responded to your repeated use of false evidence (as above), bullying, mocking, ignoring, and obfuscation to intimidate and wear down victims of NHS negligence, in your agenda for easy complaint closure.
- Part of that agenda indicates you have violated Disability and Equality Acts to ensure disabled complainants receive inferior treatment. This may also have impact on compliance with Human Rights for fair hearing and justice.
- You have been unwilling to reveal your sources of professional advice or how they were selected by untrained caseworkers, yet have openly admitted that you use NHS sources in defence of NHS complaints.
- Your caseworkers give interpretations and make assumptions showing their biased and untrained selectivity.
- In my current case you have identified one maladministration (by BSMHT) which lead to actual negligence in medical case management. It is the obvious conclusion that it contributed to my sons death through that negligent care and I have shown this with cumulative evidence of probability. You make no recommendation in conclusion however on its effect.
- In my current case you have also identified improper NHS investigation (by GP) leading to a grossly extended effort by me to try and obtain understanding by you of the negligence, and evidently still not understood in 7 years of exhausting and debilitating effort. The GP is shown to have deceived and I submit that this strongly indicates a general negligence.
- In enquiry you have maintained that complaints against the PHSO are best served by being handled by the antagonist PHSO department, showing no quality or independence in systems. In high probability this has led to repetitive errors in your practice and judgement, and has led to extended frustration and conflict in investigation and settlement contrary to purpose or need. I claim this is intentional by policy to break complainants effort.
I take your lack of response to complaints so far to be deliberate effort to undermine complainant’s cases, demonstrating much of the above.
I have to regard my NHS complaint with the death of my son through negligence by his Solihull GP Practice and Mental Health Trust, unresolved, until these points are seen to be dealt with. You have now shown both have been deceitful in their respective defences. But this is indicative of the quality of care received before my sons death.
Now both parties have admitted maladministration of some type, but you have not considered the effects of this in judgement or assessment of their various deceits now evident, nor identified root case linked to effect – being my son’s death.
These complaints are not signed off with me although you have apparently colluded with defendant parties to mitigate satisfaction in outcome – but no such consideration is given the complainant. I have rejected the last outcome as incomplete and have separately given reasons why. I regard my PHSO complaint as remaining open until such time as you choose to deal with complaints about the PHSO in an transparent, respectful and quality manner.
My experience is that caseworkers and reviewers have real difficulty identifying issues. Each of these will have to be dealt with and it might help you and others if I put your quality of service issues separately e.g via Freedom of Information requests giving case examples where appropriate.
Quality issues: Please record my complaint, and issue a complaint number in acknowledgement.
Despite all the ‘listening’ and ‘learning’ from the PHSO spin machine, it looks like business as usual from the Ombudsman.
From the day you inaccurately defined the main elements of my complaint and published them before checking they were correct, you have given me the distinct impression that the PHSO will carry on regardless with its own “agenda” in its own way even though this directly contradicts the claims you make about your service on your website. You have watered-down, trivialised and even omitted totally most aspects of my experiences.
You may or may not have come across the notes PHSO produced from a meeting in Dec 2014 it held with organisation calling itself “PHSO – The Facts” – a title which is self-explanatory. PHSOTF brought together a series of problems people had reported from their dealings with the PHSO in their attempts to reach a satisfactory outcome. They were presented to the PHSO in a logical, well-reasoned and evidenced format. From the notes, PHSO gave the impression that it had acknowledged these problems and as a first step towards improving the service rewrote its service charter. Sadly 18 months on it still only exists as a draft and the consultation period has long since closed so there is no further opportunity for anyone to comment. As I have said above, its philosophy is not yet apparent in PHSO’s methodology.
This obvious lack of enthusiasm does not make it look like the PHSO is committed to any real degree of reform, which is backed up by the fact that my own experience has been identical to many of the issues raised at the 2014 meeting so clearly nothing has changed. Your draft report was a mile off the mark (as I have explained) and given your intransigence over the ToR, I cannot for one minute imagine you will rewrite the draft to give it the correct balance and emphasis. Furthermore it will not auditable which is a key element of ANY process (see below).
When you publish your next report, it is by definition final. There is an internal appeal process I know, but being internal it cannot possibly meet the criteria associated with true independence.
I would be far happier if when making the proposition you have below, you give me an absolute assurance that you will deal with each and every one of my concerns either within the report itself, or perhaps in a side-letter. I have to say that my expectation is that you will not, leaving me with a complaint that I barely recognise with nothing further I can do about it.
The families from the Hillsborough tragedy have fought for 27 years for justice for their loved ones. Those in the system covered up the truth, told deliberate lies and engaged in cruel victim blaming in order to avoid responsibility. Many more of us have suffered the same when we have made complaints about public bodies. The system is broken, it does not deliver justice and remedy to the wronged citizen. The Cabinet Office is currently drafting new legislation for a reformed Ombudsman. This could be a step in the right direction or it could be just cosmetic tinkering; new name, new logo, same old poor service delivery as before.
If you are concerned about reform of the Ombudsman then please send your concerns to Mr. Penrose at the Cabinet Office who is currently in charge of drafting the new legislation. Many voices with one clear message. We have had enough.
John Penrose MP
Dear Mr. Penrose,
Thank you for your letter of 21st March 2016 in which you state that,“I think we both agree that any reforms to the Public Service Ombudsman sector must include robust governance and accountability structures.” Although I welcome this agreement, there is nothing in the current proposal to reassure me that the new Public Service Ombudsman (PSO) will be any more accountable than the last. This government does not have a good track record regarding the promotion of effective accountability structures. The closure of the only body with oversight for administrative justice, the AJTC in 2013 against expert advice, the rise in court fees, the reduction in legal aid and the introduction of punitive charges for tribunals do not demonstrate a government keen to deliver recourse to justice. Recent events at Mid Staffs, Morecambe Bay and now Southern Health demonstrate that in fact citizens must devote significant resources, over prolonged time periods, if they are to achieve any level of justice and remedy.
For decades the public have suffered from light-touch regulation where effectively public bodies hold themselves to account. Regulators suffer from a combination of ‘regulatory capture’ by their ‘stakeholders’ and lack of effective, statutory powers to enforce change. The Parliamentary and Health Service Ombudsman which occupies the space of a regulator, is a prime example of this. The Cabinet Office has regular bi-monthly meetings with the Ombudsman so no doubt you will be aware that this body considers its primary stakeholders to be those organisations who fall within their remit for investigation; the citizen complainant almost an after thought. The Ombudsman has no binding powers and must negotiate with public body legal teams to ensure compliance to investigation findings. This rather sets the Ombudsman up for the kind of bullying tactics well known to legal departments, who have only one duty; to protect their client. The Ombudsman is then faced with the dilemma of finding in favour of the citizen only to see the findings ignored or challenged in court; both humiliating and costly. Yet there is nothing in the new proposal to strengthen the powers of the PSO so that this new body can, with confidence, challenge and enforce change based on investigation findings.
The rise in Misconduct in Public Office complaints is a symptom of public frustration with ineffective regulation. You may be aware that we have 31 cases of MIPO lodged with the Metropolitan Police against PHSO, with more to follow. The provision of effective routes to justice is a cornerstone of democracy and we take great pride in our British values of liberty, tolerance and fair play. Yet in this country thousands have endured the devastation caused by unremedied injustice. A sobering thought on the day the Hillsborough families finally received a just verdict after 27 years.
With reference to holding the Ombudsman to account Robert Gordon considers the most effective way would be to establish a statutory board with a non-executive Chair to monitor and give oversight.
“I am clear that the PSO should be established as a corporate entity, with a statutory Board. There should be a clear division of responsibility between such a Board with a non-executive Chair, responsible for the overall strategy and effective operation of the organisation, against agreed strategies, plans and performance targets and the office holder (the Chief Ombudsman) invested with statutory powers of investigation.” (106 Gordon review)
Contemporary governance such as this has repeatedly failed to detect serious issues before they become national scandals such as that at Kid’s Company and the failure of the BBC regarding the activities of Jimmy Savile and other sexual predators. The boards charged with oversight inevitably claim to have been ‘kept in the dark’ and the composition of the board is subject to skewed appointment and bias. On the subject of appoint Mr. Gordon recommends that;
“I am clear also that the position of Chair should be a Crown appointment, with the approval of Parliament, and that non-executive members of such a Board should be appointed by Parliament. “ (107 Gordon review)
Crown appointments are essentially political appointments, resulting in the new Ombudsman being appointed by the party in power and those to keep watch similarly so. Is this what you refer to as ‘robust governance and accountability structures’?
You will no doubt be aware that the Ombudsman is currently under investigation by Sir Alex Allen. Ann Clwyd MP, who is recommending the introduction of an Independent Commissioner for NHS complaints, commented this week in an article in the Health Service Journal.
“Ironically, perhaps it is the PHSO that remains the object of anger and ridicule by many who want to appeal against those unsatisfactory investigations by hospitals. Although it has increased the number of cases it investigates since 2013, thousands are left dismayed by the PHSO’s refusal to consider their case on appeal, and critical of the competence of its investigations where they do take place.
Confidence in the PHSO is now at a very low ebb indeed, with the departure of senior staff under a cloud; a conduct investigation of the PHSO herself and the unusual drafting in of Bill Kirkup to take over serious health investigations. Reform of the Ombudsman system is long overdue.” (Ann Clwyd 22.4.16)
The resignation of Mick Martin, the Deputy Ombudsman following evidence of collusion in a sexual harassment cover up, is not the first dark cloud to cast a shadow since the appointment of Dame Julie Mellor in 2012. In 2014/15 the NAO identified a significant overspend in PHSO accounts which was previously unknown to either the Audit Committee or the Unitary Board. This led to an automatic qualification of their accounts and was described by Oliver Dowden, member of PACAC as, ‘insufficient management oversight’.
In September 2014 the NAO carried out a ‘Procurement Investigation’ regarding the employment of Rosemary Jackson Consulting to carry out ‘Governance Development Coaching’ on a three year contract at a cost of over £50,000. Although Ms. Jackson was a previous colleague of Dame Julie Mellor, who took a personal interest in the appointment, no conflict of interest was declared. Ironically, the Governance Coaching was designed to embed a similar management structure to that outlined by Robert Gordon for the new PSO.
“The Ombudsman has introduced as part of the development of the corporate business strategy a number of changes to PHSO’s senior management structure and governance. The two most fundamental of these changes are the creation of a new corporate Board of Executives and Non-Executives which makes decisions on strategy and policy, considers performance and provides stewardship of resources and values and the appointment of a Chief Operating Officer responsible for the day to day management of the organisation, as Accountable Officer to the Ombudsman.” (Luke Whiting – PHSO data officer 10.1.14)
In March 2016 the PCS Union took a vote of no confidence in PHSO management.
This present sorry state of affairs has been facilitated by a failure in political oversight, the total autonomy of the Ombudsman to carry out her affairs as she sees fit and the absence of any means of effective accountability for members of the public. The current proposal to establish a politically appointed statutory board to deliver oversight and accountability is woefully inadequate. This cosmetic tinkering will do nothing to restore public confidence.
Steps must be taken in the new legislation to ensure that the Ombudsman can effectively be held to account by both parliament and the citizen. Only the public are unfettered by alternative agendas and political control. PHSO the facts represent service users, informed members of the public and we have been requesting for some time a place at the table, not just a place on the tick list. New thinking is needed to prevent PSO from falling into the same scandalous mire as the present Ombudsman. We are willing and able to provide our unique insight. We look forward to sharing our proposals for reform of the Ombudsman in a meaningful discussion with the Cabinet Office in the near future.
Phso the facts
We learn from HSJ that there is to be an inquiry at PHSO into the recruitment of Mick Martin, Deputy Ombudsman and the handling of the revelation that he was complicit in a sexual harassment cover-up whilst at Derbyshire Healthcare Trust. deputy-ombudsman-complicit-in-cover-up This inquiry is to be carried out by Sir Alex Allan, a senior civil servant who could well be a ‘safe pair of hands’. Alex_Allan.
We believe that this inquiry should be transparent given the many criticisms of PHSO. It should not be held behind closed doors with only the final outcome announced when the heat has died down. If you agree that the transparency of this process is in the public interest, then please send the letter in the link below to Bernard Jenkin, Chair of PACAC via your MP. Letter to Bernard Jenkin – re: PHSO Inquiry
The ‘not in my remit’ game
or how those in authority avoid accountability (Part Two)
Contact NHS England because you are concerned that the Ombudsman failed to identify the true nature of your complaint and they will just contact the Ombudsman and believe everything they say. What a waste of time and money.
January 29th 2016
Dear Mr Finch,
I am emailing further to my email on 19 November 2015. Please accept my apologies for the delay to replying to you.
In our previous correspondence, we agreed that we would contact the Parliamentary and Health Services Ombudsman (PHSO) for details of their investigation into your complaint so that we could better understand what has happened and be in a position to advise you of your options going forward. We have now done this, and have sought advice from Jane Cummings in our reply.
The report we received from the PHSO indicated that it was their view that your clinicians had assessed you thoroughly, and concluded that it did not appear that there had been a failure to investigate your medical condition or provide treatment. Instead, it was the unusual nature of your symptoms that resulted in there not being any effective treatment identified to resolve the matter.
Given that there has been a gap between this report and your letter to ourselves, all we can suggest is that you continue to liaise with your clinicians so that suitable treatment can be found. The PHSO report suggests that you clinician agree with you that there is a problem with your symptoms, but that there is a difference of opinion on the cause of those symptoms or what treatment is indicated. This matter will only be resolved in collaboration with your doctors.
I appreciate that it is most likely not the outcome you are seeking, however I hope this information is helpful.
Customer Contact Centre Case Manager
PO Box 16738
The ‘not in my remit’ game
or how those in authority avoid accountability (Part One)
The Government are very good at sharing out responsibility – they call it things like ‘localism’. The suggestion is that you should give the decision making (and therefore hold to account) those who are closest to the action. All well and good, but when Government maintain control of ‘fiscal responsibility’ then they can crash the system and walk away with clean hands. The 2012 Health and Social Care Act allows them to do just that.
27 January 2016
Ms Larissa Georghiou
Ministerial Correspondence and Public Enquiries
Department of Health
Dear Ms Georghiou
Thank you for your letter dated 25 January which I received today and in which you clarify that there is little that our Department of Health or our Ministers can do to help in matters concerning serious issues that arise for patients who receive poor care from our NHS that results in a serious outcome.
You inform me that the Health and Social Care Act of 2012 ensures that the health services are ultimately the responsibility of NHS professionals. The act putting clinicians, rather than politicians, in control of healthcare, thus making NHS organisations independent of the Government, making them autonomous in their decision-making and that this will continue to be the case. You again state that the PHSO is also entirely independent of the Government, and for the moment any concerns I have regarding any corrupt practices within this organisation are of no concern to the Prime Minister and his ministers.
It is the people who have sovereignty over any reigning force, and in a truly democratic system it would be unacceptable to ignore this fact. The information in your letter indicates that I cannot go to my MP for answers.
With regard to the conclusions above, I’d like to ask:
- What powers do our ministers, and our Department of Health, hold?
- If there are powers, where did they get it from?
- In whose interests are the powers exercised?
- To whom are you accountable?
- If we, the public, are not satisfied how do we get rid of you?
I would also like to apply those questions to our PHSO. But maybe that will have to wait until the next PACAC submission.
Thank you for supplying the address of the local CAB office should I wish to seek legal aid, though I already do know of its whereabouts and have had cause to use this facility on one occasion, and found them overworked, understaffed and not always able to deliver the correct information, though they were very empathetic, but they too have to work within the constraints of our bureaucracy, (brick walls), and I believe that is where the problem lies.
Our NHS, I use the prefix ‘our’ because I believe that it is the people’s health service, and most people would say they understand that this service is in crisis. One could surmise that the act of 2012 that you highlight, was brought about to let government off the hook, on the other hand it could be argued that it gives greater power to the NHS, (leaving them to carry the can on every front, from staffing levels to financial restraints).
This concludes that our Department of Health and our ministers cannot help in the concerns I have raised. Thank you for that clarification.
Mrs Teresa Steele
David Behan, CQC replies to Will Powell’s request to support a call for a Public Inquiry into historic cases. Looks like the answer is NO. None of the remedies listed will help families previously affected find closure, so perhaps a legacy unit is the answer? http://phsothetruestory.com/2015/12/18/the-historic-complaint-dilemma/
Thank you for your emailof 11 December 2015.
I have sympathy with the position you find yourself in. I know this is an issue you have been raising for many years. I accept that in the past families such as yours, who have experienced loss or serious harm of a loved one due to a failure in care, may, due to historical weaknesses in the complaints and investigations framework, not have been assured that the full truth had been established and lessons learned. Recognition of this issue following reports such as the Mid Staffordshire NHS Foundation Trust Public Inquiry has led to a series of changes, including the introduction of duty of candour and fit and proper person requirements, and the setting up of a new safety investigations body for the NHS.
Sir Robert Francis QC looked at requests for a public inquiry during the Freedom to Speak Up review, and concluded that it was doubtful that such an inquiry “would do more than raise expectations only for them to be dashed”. This is a position that CQC supports. The focus for CQC has to remain on care quality and improving care quality.
Any decision as to a public inquiry is one that is ultimately taken by the Prime Minister. CQC’s position continues to be that if such an inquiry was to be established we would contribute and cooperate fully.
Thank you once again for writing to us.
David Behan Chief Executive
Open letter from Will Powell to David Behan, CQC calling for a public inquiry regarding historic NHS complaint investigations. Will has been campaigning for over 25 years and is still without justice. Since that time many others have joined a growing group of active campaigners who are determined to fight against NHS cover-up. These cases have become historic through neglect and the families concerned have dedicated their lives to fighting for justice and closure. Could a public inquiry be the answer – or perhaps a legacy unit attached to the new Public Service Ombudsman in 2016? Something must be done to end this suffering.
From: Will Powell
Sent: 11 December 2015 13:53 To: ‘David.Behan@cqc.org.uk’
Cc: ‘firstname.lastname@example.org’; ‘email@example.com’
Subject: Support for a Public Inquiry into Historic Cases!
Open email to Mr David Behan CQC Mr David Behan CBE Chief Executive Care Quality Commission Finsbury Tower 103–105 Bunhill Row London EC1Y 8TG
Dear Mr Behan,
I refer to the correspondence that we exchanged in 2013 regarding my serious concerns about, inter alia, historic NHS complaints and whistle-blowing and also the meeting we had that year. You can access our correspondence at: https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxyb2JiaWVzbGF3dHJ1c3QwMHxneD oyN2MxYmVmNzFkZjdkMDdi At our meeting on the 10th September 2013 I asked you specifically if you and/or the CQC would support my call for an inquiry into NHS whistle-blowing. You informed me that you would respond in writing. However, your letter of the 11th October did not address this issue. I therefore stated the following in an email dated 23rd October: “ I also asked at our meeting if you would support an inquiry into whistleblowers. You informed me that you would consider this request. I would be grateful for confirmation as to whether or not the CQC would support such an inquiry.”
You responded by letter dated 8th November and stated, inter alia: “I am sorry that I neglected to respond to your question regarding whether the CQC would support an inquiry into whistle-blowers.” “Any additional inquiry would need to be commissioned by the Secretary of State and would need to be able to demonstrate that it would add value to what has already been undertaken, with very clear terms of reference. If such an inquiry was established we would contribute and cooperate fully.”
I responded to you on the 20th November as you had again avoided to answer my simple question. I stated, inter alia: “In my email of the 23rd October 2013 I asked you directly whether you would support an inquiry into whistle-blowers ……………………………. However, you have not, in my view, given me direct answers to these two questions.” “I will therefore respectfully ask these questions again to avoid any future misunderstandings: 1. Would you and/or the CQC support an inquiry into NHS whistle-blowers? Can you please answer yes or no?”
You responded on the 20th December and stated, inter alia: “If an inquiry into whistle-blowers was announced, then yes CQC would be supportive and would contribute and cooperate fully. You will be aware that this is a decision for the Secretary of State to take and it is not for the CQC to be making such ‘calls’.The Mid Staffordshire inquiry and the Governments response to the inquiry have led to a strong debate on whistleblowing. Consequently, a core part of our new strategy is that we will be spending more time listening to complainants and whistleblowers as part of our inspections. We are looking at all options, including a thematic review or CQC investigation, or offering interviews to current and former whistleblowers and complainants as part of one of our new inspections. We are currently carrying out a review of our approach to whistleblowers and complaints, this review will look at how we respond to our own staff as well as how we respond to those people in services who raise their concerns, blow the whistle or complain.”
Before writing and meeting you I was fully aware that the CQC did not have the remit to initiate an inquiry into NHS whistle-blowing thus the reason I only asked whether or not you and/or the CQC would support my call for such an inquiry. I was very disappointed by your responses as they did not answer my simple question and, in my view, avoided the important issue I was attempting to raise, which is still outstanding in spite of the recent Speak-up Review. Since our correspondence I have submitted Freedom of Information requests, via WhatDoTheyKnow, to the CQC and NHS England regarding the investigation of individual cases. On both counts it has been confirmed that individual cases are not within their remit. You can access the FOI requests at: https://www.whatdotheyknow.com/request/can_the_cqc_investigate_individu#comment-58903 and https://www.whatdotheyknow.com/request/can_nhs_england_investigate_indi#incoming-708795
My MP was informed by the Chairman of the Select Committee on the Parliamentary Commissioner for Administration, in July 1993, that: “It is clear from the letter of the 16th June  that Mr Reid’s decision not to investigate Mr Powell’s complaint was made in exercise of the discretion given him by statute. At its inception the Select Committee decided that it would not in such cases act as a ‘court of appeal’ against the judgement ofthe Commissioner [Health Service Ombudsman]. I am afraid, therefore, that the Committee can be of no assistance to Mr Powell in his particular case. The question of principle raised is whether it is right for the Commissioner to have such discretion. I will ensure that this issue is considered in the Committee’s deliberations on its forthcoming report.”
Although this undertaking was given to a Conservative MP, who was later to become a Minister, at the Lord Chancellor’s Office, it was reneged upon and the Parliamentary Health Service Ombudsman continues to have discretionary power, to this day, which has been used on numerous cases, over the years, not to investigate serious NHS complaints for one reason or another. You can access my MP’s 1993 correspondence with the Chairman of the Select Committee at: https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxyb2JiaWVzbGF3dHJ1c 3QwMHxneDo2ODk0NWQzNzM4MDYzNDdj
As you are aware, in 1998-99 the Health Select Committee [“HSC”] initiated an inquiry, as a consequence of the perverse Court of Appeal judgement in Robbie’s case, which ruled that there was no post death duty of candour for doctors to tell parents the truth about their child’s negligent death or refrain from falsifying medical records. I was informed by the HSC that it could not intervene in individual cases notwithstanding they had been provided with cogent evidence of negligent fatalities, falsifying of medical records and historic NHS cover ups. Furthermore, there was no government authority or any other organisation with a mechanism to investigate NHS historic cover ups, which in turn exposed the ‘gap’ in NHS investigations that still exists to this day.
You will be aware that a recent inquiry by the Public Administration and Constitutional Affairs Committee’s resulted in the Secretary of State agreeing to set up the Independent Patient Safety Investigation Service [“IPSIS”]. As a member of the Expert Advisory Group it would currently appear that this new body will not be investigating historic NHS cover ups when it is set up in April 2016. However, that may well change with public opinion expecting otherwise. Please note that the Chairman of PACAC, Mr Bernard Jenkin MP, has pledged support for a public inquiry into historic NHS cases if IPSIS does not have the remit to do so. You will also be aware of Dame Julie Mellor’s public criticism of the NHS complaint procedures. I was astonished that Dame Julie publicly exposed this as her office has failed the public since its inception by condoning NHS cover ups and/or turning a blind eye to misconduct in public office within the NHS.
I am formally requesting whether or not you and/or the CQC will support my call for a public inquiry into historic NHS cover ups? I have copied this email to Dame Julie Mellor and Mr Bernard Jenkin MP. I would appreciate a response at your earliest convenience. Kind regards.
Mr William Cassie Powell
The PHSO Pressure Group would like to thank Oliver Letwin and the Cabinet Office for the invitation to meet with service users anxious to ensure that the new Public Service Ombudsman meets the needs of the people.
As PHSO continue to stonewall the public, the PHSO Pressure Group inform Bernard Jenkin and PACAC that they have no option but to take matters into their own hands.
19th September 2015
Dear Bernard Jenkin,
Much as we admire the work of PASC, (now PACAC) in establishing the new Independent Patient Safety Investigation Service (IPSIS) we remain dismayed at the appalling service delivery which continues unabated from Dame Julie Mellor and PHSO.
No doubt you are aware of the two recent stories in the Sunday Times which berated the Ombudsman for compounding the grief of parents with insensitive and bureaucratic procedures. Jeremy Hunt felt compelled, once again, to write a letter of rebuke to the Ombudsman herself. http://www.thesundaytimes.co.uk/sto/news/uk_news/article1606330.ece?shareToken=8d4835f6a871532b3dacd92f8a5c1dc4
Katherine Murphy said in this week’s Patient Association Newsletter;
“Bereaved families have to battle for someone to listen to their personal circumstances and to take the necessary action.”
“Patients feel completely let down by the PHSO who overlook or ignore evidence, take far too long to communicate with families, are dismissive and insensitive and leave patients feeling that they are in the wrong for raising a complaint.”
I am afraid to tell you that the promises of improvement made by Dame Julie Mellor and Mick Martin in your previous scrutiny meetings have been nothing but empty words. The Service Charter Project is in disarray; the #mythbusting project effectively labels honest criticisms of PHSO as nothing more than ‘delusion’ and the annual accounts are well overdue.
PHSO continue to stonewall the public with regard to publishing the ‘change programme’ recommended in your recent report and progress on the NAO inquiry into value for money. https://www.whatdotheyknow.com/request/phso_response_to_pasc_report_inv#incoming-684339
A similar blocked response was given to a request concerning the external audit of investigation reports recommended by the Health Select Committee.
Having stated that “Complainants deserve an Ombudsman they can have confidence in” public confidence remains at rock bottom.
This letter is not a request for any service from PACAC. We are aware that the select committee has no power to investigate individual cases or to hold the Ombudsman to account in any meaningful way. This correspondence is simply to inform the Committee that members of the Pressure Group have been forced to take matters into their own hands in an attempt to resolve their outstanding complaints. To that end we propose to submit to the Metropolitan Police a series of test cases which will provide evidence of ‘Misconduct in Public Office’ on the part of Dame Julie Mellor and her staff. Policy and procedure are breached on such a regular basis that we believe this to be deliberate and therefore a wilful neglect of duty to the public.
We will be attending Scotland Yard on Monday 5th October to officially hand in the first submissions, with more to follow. You can see the details here. http://phsothefacts.com/misconduct-in-public-office/ We are aware that this will add further pressure to the already overstretched Police and CPS service, but we have no other choice.
IPSIS is a significant step in the right direction with regard to NHS complaint investigations and improving patient safety, but if nothing is done we will have a poor second option in the form of an Ombudsman service which can provide only a desk exercise, conducted by lay people who are required to deal with complex medical matters.
Not good. Not good at all, and this will not restore public confidence.
P.S. Is there any chance you can request and publish the PHSO ‘change programme’ and commission the NAO audit? We need to see some progress here.
17th September 2015
Re: Robert Gordon Report – Better to Serve the Public:
Proposals to restructure, reform, renew and reinvigorate public services ombudsmen.
Dear Mr. Letwin,
There is a new political mood in the country. Yesterday at Prime Minister Question Time, Jeremy Corbyn, leader of the Opposition, asked questions provided by members of the public. Over 40,000 had responded to an email asking for suggestions. The voice of the people was heard in parliament and responded to by the government of the day.
If people have moved away from politics, it is due to the fact that politicians have for too long closed their ears and eyes to matters which concern us. Let us hope that this new mood of public engagement is taken up by parties on both sides of the house.
In that vein, members of the PHSO Pressure Group, phsothefacts are making a further request be directly involved in the consultation process to establish the new Public Service Ombudsman. You may be aware that the ExpertAdvisory Group of IPSIS (Independent Patient Safety Investigation Service) recently appointed Will Powell to contribute his expert knowledge of patient safety issues following his 25 year campaign to introduce Duty of Candour. IPSIS, clearly recognise the value first hand experience.
When I spoke with Joanna Clift just before the summer recess, it was clear that we would not be able to contribute further until public consultation was sought for the draft bill. Consequently, the draft bill would be constructed without the valuable insight of those most immediately impacted by poor Ombudsman design.
Steve Hilton talks of new ‘open policy making teams’ in his book ‘More Human’,
“It’s a fundamental re-orientation of policymaking, from a focus on bureaucratic needs and priorities to the real lives of the real people government is supposed to serve.”
Social media enables members of the public to share experiences of public bodies and their complaint handling processes. We are our own ‘Trip Advisor’ of dysfunctional organisations. In the spirit of ‘the Greater Good’ this letter will be placed in the public domain on phsothefacts.com awaiting your reply, which will then be duly posted alongside.
So, is the Cabinet Office ready to listen to the people, or is it just another closed bureaucratic machine?
Dear Mr Martin,I am writing to express my repugnance at the way the PHSO has ignored the seriousness of Professor Mark Baker, Director of the Centre for Clinical Practice at NICE’s admissions in June 2014. I am sure like me you are fed up with reading his comments but will repeat them again:NICE CG53 issued in 2007 was “not fit for purpose” and there was “dangerous neglect” for patients diagnosed with CFS/ME, “it had been assumed there were specialists who knew what to do and there were not” http://www.forward-me.org.uk/25th%20June%202014.htm.In August, Russell Barr agreed to investigate what could be done; in November he had spoken to Gavin McBurnie the Director of Complex Investigations and Systemic Failure. Russell confirmed the problems I had raised definitely need sorting out. Once he had spoken further with Gavin he would send a confirmation email to ensure it could be easily seen how we would move forward, I am still waiting.The final straw was last Tuesday, we seem to have gone back to square one. Scott Riley rang from your Customer Care Team, he had been asked to look at my case to see what was happening. Guess this was after Della Reynolds the coordinator of PHSO the Facts spoke to Annette John. Annette thought that the PHSO were considering a systemic review into CFS/ME but it was unlikely to be this year. She was also surprised that I did not know what was happening about my personal case.Scott and I discussed my main concern, the systemic failure. I asked whether we were talking about the financial year or calendar year for the review to begin; if we were talking about the calendar year, the reason why patients diagnosed with CFS/ME were knowingly being left by the PHSO to suffer dangerous neglect needed to be confirmed.Scott, like the Systemic Review Team are based in Manchester and he would be speaking to them, but was not sure when he would get back to me as he was on holiday the following week. I am writing to you as I have heard nothing further, it always seems that whoever is needed to help make a decision is on holiday at a crucial point and I am fed up with what can only appear to be delaying tactics.I have read several reports following the Kirkuk Inquiry into events at Morecambe Bay Maternity Unit where mothers and babies died unnecessarily; James Titcombe and other members of MBIA have called for the resignation of Dame Julie Mellor. One comment “if this public body is ever going to radically reform its service delivery then the entire board and most of the senior management, (who let’s face it have stood by mute) must resign along with Dame Julie.”The PHSO brought me into the tragic situation trying to help resolve the systemic failure for patients diagnosed with CFS/ME in 2008. The only way forward is for people to work together, but I remain disgusted by the duplicity of the PHSO.However, I always like to have hope, it helps when dealing with the desperate people who have been diagnosed with CFS/ME and left to suffer because the NHS has not provided adequate medical care. The courtesy of a positive response from the PHSO without further delay is now needed. If the PHSO continues to not fulfil their promises then yes for whatever reason all that can be said is the PHSO is not fit for purpose and needs to be replaced.I look forward to hearing from you.Regards,Jill MizenMr. Martin’s response below looks like a standard proforma which just directs you round to another part of the system, where you start again with a person who knows nothing about your case. What a waste of time and money!“Martin Mick”
To: “‘Jill Mizen'”
Subject: RE: Systemic Review for patients diagnosed with CFS/ME – PHSO fit for purpose?
Dear Ms Mizen,
Thank you for writing to me personally and for sharing your concerns.
In order to ensure that you are properly looked after, I have passed your concerns to another member of the Customer Care Team who is looking into your case and will be in touch with you directly as soon as possible. If you wish to contact the team, you can email firstname.lastname@example.org or call 0345 015 4033 (option 3).
Sent by email – 22.12.14
Elaine Colville warns of the dangers of both PHSO and PASC ‘walking round in circles’ in an attempt to be doing something without actually holding anyone to account.Dear Mr Jenkin and Mr Martin,Over the last two years I have read much about the latest change initiative at PHSO including the ostensibly up-beat messages in last Friday’s blog http://www.ombudsman.org.uk/about-us/our-blog/making-a-difference2. Russell Barr, Director of Investigations, talks a good talk, as others before him. However, the Ombudsman’s continuing practice and use of deontic charges to indicate how the PHSO service ought to be at some indeterminate time in the future is becoming increasingly unacceptable.As a complainant with first hand experience of the service with an outstanding, festering grievance, I simply cannot buy into all the rhetoric. The scenario I can see is a PHSO content with the changes achieved, but still continuously trying to catch-up with itself, leaving extant control risks that go with its frenzy fundamentally unaddressed, and floundering on its main challenges; suffering too much paralysis as it conducts ever deeper analysis, creating the illusion of moving forward because “we are doing something”. The risk of walking around in circles is one of the main threats to PHSO.Also, tardiness will always haunt an organisation which is basically financially self-propelling; an institutional pertuum mobile – the internal perception being that there is no attractive external institutional alternative – hence fuelling the comfortable feeling of generous wiggle-room in explaining its raison d’être and all that ad finitum. This will continue to be the case until the same stakeholders who own, as well as depend on the PHSO, run out of patience and see that it is easier to build a new PHSO next to an old one; than it is to build a new one on top of an old one; and do just that.It is time for PHSO to manage the strategic risks – doing the right things in addition to doing them right. Both the PHSO and the PASC carry a heavy responsibility on the issue which cannot be delegated upward or downward, or passed on like a hot potato, or cosmetically solved by simultaneously blowing hot and cold from both sides of the mouth, an act not unbeknownst to political or politicised organisations. The biggest challenge is to find its extant risk appetite; and to learn to implement corrective action, and live by it.Yours sincerely,Elaine Colville________________
Mick Martin from PHSO promises James Titcombe that the Ombudsman will use discretion in favour of complainants in future. This will mean more investigations for historic cases and where legal action is involved. But will PHSO be able to deliver on these promises when they are already at full stretch?
24 October 2014
Thank you for your recent emails regarding several areas of our work. I am back in the office after some annual leave and am pleased to have the opportunity to respond.
The context for each of my answers is that PHSO is changing ·I have explained that we need to modernise many aspects of our work and we are now fully engaged in doing so ·it will take time to complete but it will be considerable. Whilst the answers below are specific to your questions, I would be delighted to talk you through what we are doing to respond to feedback and change the way we work.
You asked about our willingness and ability to take on ‘historic cases’. You will know that our legislation contains a requirement for us to consider whether or not to investigate complaints that come to us more than 12 months after the complainant was aware of the events they wish to complain about. We have always had discretion as to whether or not to apply this ‘time bar’ and the way in which that has been applied has changed over the years. The criteria we now apply to such complaints means that we seek to exercise our discretion as positively as possible. In considering the age of cases we therefore ask: Can we do an effective investigation that will resolve the issues raised given the time that has passed? What is the nature of the injustice highlighted by the complaint? Where the answer to these questions is yes ·we seek to use our discretion to investigate.
You have also asked about our position on investigating cases where families may be considering (or are actively) taking legal action in relation to the matters they wish to complain about. Here our legislation requires us to consider whether it is reasonable for complainants to seek any ‘alternative legal remedy’ that may be available to them. Our policy is not to reject cases simply because some aspects of it might require legal remedy but instead to consider what aspects of the complaint we can investigate. We recognise that things like full explanations of what occurred, learning, determining improvement activity and apologies are not remedies that the legal route would provide and so seek to extract from the complaint the elements we can investigate to potentially provide such outcomes.
Finally, with regard to your prompt about the recommendation we made in relation to your case and the need for Human Factors and Root Cause Analysis in local investigations, I was delighted with the work that Helen (Hughes) led for us in this area and we engaged with NHS England in order to progress it. We believe strongly that this is an area requiring timely concerted action. We have also decided to build on Helen’s work by undertaking a systemic investigation into complaints about Serious Untoward Incidents so that we can explore the impact of gaps in capability, identify best practice and highlight methods that could be valuable across the NHS. We will be using an external best practice investigative method to undertake this work and will be looking to engage with organisations and individuals in order to progress this piece of work. Please let me know if you would like to be involved.
I hope this answers your questions.
Here are the PHSO Pressure Group questions for Oliver Letwin.
Will we get direct answers or political spin?
Meeting with Oliver Letwin, Minister for Government Policy
24th July 2014
Issues with legislation:
The original 1967 Parliamentary Commissioner Act was designed primarily for Parliament to hold the Executive to account. There were fears at the time that this legislation would be ineffective in protecting the citizens from the abuse of power and these fears have since come to be realised.
“I suggest, however, that the bulk of the population do not normally come much into contact with the Central Government. Far more often it is with local government, with local representatives of the National Health Service and with other forms of local officialdom. However, under this Bill all these are specifically excluded from investigation by the Parliamentary Commissioner—perhaps for good reason, as the noble and learned Lord set out. But where the shoe pinches the general public most, no alleviation is offered under this Bill.”
(Parliamentary Commissioner Bill – Hansard – 20 Feb 1967)
Although the original legislation was augmented by the Health Service Commissioners Act 1993, the primary legislation controlling this body remains unchanged for well over forty years.
The Public Administration Select Committee (PASC) recently held two inquiries into the effectiveness of the present Ombudsman service. In their subsequent reports, ‘Time for a People’s Ombudsman Service’ and ‘More Complaints Please!’ they call for changes to legislation to prevent the Ombudsman being ‘stuck in time’ and to better meet the needs and expectations of the general public.
The Cabinet Office, under the guidance of Oliver Letwin, are now building on these reports with 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.
It is vitally important that any proposed changes to legislation following the outcome of the Cabinet Office inquiry are tailored to meet the needs of the service users and effectively protect citizens from the abuse of power. We cannot wait another forty years ensure that these needs are met.
Q.1 Given that there is no proposal to deliver the outcome of the Cabinet Office inquiry in this Parliament, would Oliver Letwin and his team consider setting up stakeholder meetings which invite campaign groups and other interested parties to add to the discussion and final legislation in much the same way as the Department of Health has for the proposed changes to regulation of Health and Social Care professionals? Previous users of the system hold the ‘gold dust’ of experience and knowledge.
Issues with accountability:
The PHSO Pressure Group have come to realise that the Parliamentary and Health Service Ombudsman is effectively unaccountable. This state of affairs leads to complacency, arrogance and poor service delivery.
In theory the Ombudsman’s decisions are held to account by judicial review. However, the total discretion enjoyed by the Ombudsman means that courts are reluctant to interfere with her judgement and this was demonstrated in the case
R v Parliamentary Commissioner for Administration , ex p. Dyer
In fact only one case has been successful pursued through the courts at judicial review which is that taken up by the Balchins in 1997 http://global.oup.com/uk/orc/law/public/endicott2e/01student/ch13/03cases/
Judicial review is costly, stressful and proven to be unsuccessful for members of the public. It is an inappropriate mechanism for holding the Ombudsman to account.
Technically, the Ombudsman is accountable to Parliament through the Public Administration Select Committee (PASC). However, this body has no power to investigate individual cases, cannot make binding recommendations or follow up complaints from members of the public regarding poor service delivery. In this respect the Ombudsman is entirely independent of government, MPs and civil servants.
Complaints about the Ombudsman
“The Ombudsman maintains a complaints procedure which gives guidance on how to complain to her if complainants are dissatisfied with the service provided by her office. The Cabinet Office, Treasury and the Department of Health have no locus in such complaints which are matters for the Ombudsman herself, and ultimately for the courts and/or Parliament as appropriate.”
The Health Select Committee (HSC) also monitors the work of the Ombudsman and in 2011 called for a complete overhaul of this ineffective body and a strengthening of legislation. Likewise, they have no powers to enforce this recommendation and to date it has not been implemented. http://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/news/11-06-28-clreoprt-substantive-/
- How does Oliver Letwin propose to make the Ombudsman service accountable to the public without the need to resort to expensive and quite possibly futile legal action?
These complaints are heard so often by PHSO staff that they have devised stock answers.
Wonder why so many people say the same thing?
|Suggestions for responding to dissatisfaction and disappointment|
|Complainant conduct||Possible responses|
|You think my complaint isn’t important enough?||
I didn’t really expect you to do anything about my complaint
- I am sorry you feel that way. If you would like, I can take a few minutes to discuss our role.
- I have considered your complaint and made enquiries. I appreciate my actions did not result in the outcome you were hoping for.
- We have fully assessed your complaint and we do not consider there is evidence that … acted unreasonably.
They (the relevant body) are lying to you/manipulating you/covering up
- I am satisfied with …. response and unless you have evidence that they have deliberately misled or misinformed me, our decision stands.
- So far I have no reason to believe this. I certainly welcome any evidence you can give me that supports your assertion.
- I have considered your evidence as well as the evidence provided by … and I can’t agree with your assertion, though I do acknowledge that this is your view.
- What do you base this claim on?
- The fact that you disagree with our decision does not mean ….. has acted unreasonably.
You are colluding with the Trust/department
- We do not take sides. We consider the available evidence and make impartial decisions
- I understand you are disappointed with our decision and I am sorry you see it this way. My role is to be impartial and, based on the evidence available to me, I cannot see that … has acted unreasonably.
What are you good for then?
- I appreciate your disappointment/frustration at our decision and why you may ask this question. You may wish to read our annual reports which explain what we have achieved over the years.
- I am sorry we were not able to do what you wanted us to do/had hoped we could do. The fact is (explain case details).
- I appreciate that you would have liked us to take up your case but our organisation is impartial; we are not advocates for complainants.
I am going to take this to the media
- That is for you to decide
- That option is certainly open to you.
HOW DO PHSO REVIEW STAFF SLEEP AT NIGHT?
All Stephen Greck wanted was a posthumous apology for his Mother’s poor care during her dying days. Instead, he suffered more pain from the denial of evidence and callous disregard for his concerns.
All in a day’s work for PHSO staff.
The Rt. Hon Oliver Letwin, ‘Complainers Champion’ simply doesn’t have time to reply to complaints himself.
Dear Mr Letwin,
Sir Greg Knight M.P. has trouble locating emails sent directly to his office. He also has trouble realising that this correspondence is asking HIM to personally take some action. Perhaps appearing on ‘open letters’ will sharpen his attention.
Dear Sir Greg,
On 3rd January an email was sent to you about the way the PHSO handles NHS complaints. Details were provided of the questions I had asked the Ministry of Justice:
- “what recourse does the ordinary citizen have in these circumstances? Is there any way the NHS and PHSO can be compelled to release documents that are inconvenient to themselves? If there is not, what plans are there to reform this shocking situation”.
16 January, your secretary Teresa Sothcott wrote my email was receiving attention which you would reply to in detail, in due course. [later stating that the email referred to had not been received]
The Ministry of Justice passed my request to the Department of Health and their response can be seen in the attachment. My comments to the response:
- The Ombudsman appointment is made by the Crown under the Parliamentary Commissioner Act 1967. The PHSO is accountable through the PASC. The Committee monitors the work of the Ombudsman through regular hearings and support.
I ask you to raise my questions with the PASC, who if they had the authority rather than just acting as a ‘monitoring’ service would be able to resolve my situation.
· It provides much information, but as is normal does not answer my questions. Instead it is suggested to contact the Information Commissioner’s Office.
I do not wish to follow yet another procedure, which does not provide justice for the ordinary person with a public body that normally finds in favour of the organisation whatever the evidence against it. Following enquiries, I understand the more successful option is to go straight to court for breaches of the Data Protection Act.
It would be appreciated if you would confirm whether there is anything you can do as my MP to help me.
Mrs Jill Mizen
If you are tired of playing wild goose chase with your M.P. then send your letter to email@example.com for inclusion on ‘open letters’. [Editors note: prompt reply received from Sir Greg Knight M.P.]
With no replies (yet) from any MP with regard to supporting our campaign to improve the Ombudsman service. We have taken to writing to MPs individually.
This heartfelt account from Brenda gives Jeremy Browne, MP for Taunton Deane, the chance to know the people behind the data. Angry people, let down by the regulatory system who are no longer lone voices to be dismissed and ignored.
We are a group who could become a ‘mob’. Be warned.
27th Jan, 2014
Over the last 23 years, you and previous MP’s have been unable to assist us in our search for help for our disabled son. With ‘hidden disabilities’ he often looked well but sadly with no pancreas he was not.
There is an interim report about to be published by the Local Gov Ombudsman which will probably find 11 administrative faults with Adult Social Care in Somerset, it will also find faults with the District Nurse service. But the Parliamentary and Health Ombudsman continues to find nothing wrong with Health service. I thought our case was unique but I now find we are far from alone in the unjust way we have been treated. There are some horrific cases and if they are not recognised there will be no lessons learnt! Not until there is a crisis like Morecambe Bay and Mid Staffs, then the mud flys.
As a parent now, perhaps you may have more sympathy for the situation our son found himself in. Blamed for everything that went wrong, he never got the help he was, eventually, assessed for. ‘He needs 24 hour live in care as he is in danger of a catastrophic event’, but 10 months after that assessment, nothing had changed and he did have a catastrophic event. Now it is us who are wrong to ask, why?
It seems the PHSO is corrupt by design. It was set up to protect systems and not to protect the citizens.
Our Pressure Group has come about by the suggestion of an MP. Will you please support us? You never know, one day it might be your child who is ill and blamed for it. With Andrew he was assumed to be an alcoholic, but at 15 when he first became ill I think I would have noticed. He was tee total, after his pancreas was totally removed he tried alcohol for the first time. ‘How can you drink that stuff’, he said and never tried it again.
PLEASE SUPPORT US, THE SYSTEM MUST CHANGE.
According to PSU, the union representing staff at PHSO “Assessment work involved a thorough review of the evidence, enquiries of the bodies involved, and the drawing up of detailed conclusions that were quality-assured by their managers.” Well perhaps that’s what it says on the tin, but read this letter to PASC for a reality check on the Assessment process.
To Members of the Committee:
Following the private meeting with PASC on 26th November 2013 (see news on this site) these questions were left with the committee for their consideration. When/if answers are forthcoming I will keep you informed.
Dear Mr. Jenkin,
Thank you for the opportunity to speak directly with members of the PASC committee. I value this time greatly. I am aware that with a number of people wishing to contribute to the subject, I may be unable to put all my key questions to the committee. I have therefore listed them below for your attention and response.
Repeated failure within the NHS complaint system.
A number of key reports (Keogh, Francis, Clwyd) have recently highlighted the scandalous way in which NHS complainants have been treated uncovering the culture of ‘delay, deny, defend’. Equally, the need for the total restructuring of senior management at CQC following further revelations of corruption and cover up, have implications for the Ombudsman’s office. Where was the Ombudsman during the many years it took for these issues to grow to scandalous proportions? Why didn’t the Ombudsman regulate? The Mid Staffordshire Inquiry revealed that PHSO did not investigate a single complaint regarding this hospital during the period of January 2005 to March 2009 although complaints had been received.
Q.1. When will PHSO be held accountable for its role in the NHS care and complaint scandal?
Lack of accountability.
The Parliamentary Commissioner Act of 1967 embedded Ombudsman ‘discretion’ at the heart of the regulatory system. This discretion effectively means that the Ombudsman is unaccountable to members of the public. With discretion to act according to her own agenda the Ombudsman cannot be considered to have acted ‘unreasonably’ when refusing to investigate a case, or dismissing an investigation at any point in the process. Consequently, it is impossible to hold the Ombudsman to account under the law via Judicial Review. Historically, only one case has ever been upheld against the Ombudsman’s office.
The artificial divide between ‘the house’ and ‘the government’ results in the Ombudsman being unaccountable to any member of Parliament whether they be an MP, Minister or committee member.
The Ombudsman handles all complaints made about their service ‘in-house’. They get to mark their own homework and unsurprisingly find that they are doing a jolly good job.
Q.2. How will PASC engage the enthusiasm of the Cabinet Office to make the changes in legislation required to secure proper accountability of the Ombudsman to both Parliament and members of the public?
Over the years a number of investigations have been carried out into the role of the Ombudsman within the regulatory system – all of which have found failures.
- 2003 Government Report: NHS Complaints Reform: Making things right stated that, ‘The Independent Review stage does not have the credibility it needs.’
- 2004 Dame Janet Smith: Fifth report of the Shipman Inquiry stated that there was, ‘Absence of accountability to an external body’.
- 2011 The Health Select Committee found that the Ombudsman service was not fit for purpose stating that, ‘Patients should be able to seek an independent review of the findings of internal review by care providers; the terms of reference under which the Ombudsman works prevents her from properly fulfilling this role. This needs to change.’
- 2012 PASC compiled a report entitled, Work of the Parliamentary and Health Service Ombudsman 2012 – 2013. Much of the evidence contained within this report condemned the Ombudsman for failure to carry out robust and independent reviews.
In all this time nothing has changed and here we are gathering more evidence and compiling more reports.
Q.3 How will PASC ensure that the outcome of this inquiry will lead to meaningful action and overcome the ‘bias to inertia’ which has existed so far?
Not sure who to write to at PHSO? Then use this handy list to find out who’s who. If you write to enough people perhaps someone will reply to you?
Post Holders Job Title
Amanda Harrington Interim Senior Investigation Manager (Health)
Andrew Medlock Head of Customer Services
Anne Harding Legal Adviser
Christine Moulder Casework Knowledge & Learning Manager
Christopher McAlpine Deputy Director of Customer Services & Assessment
Clint Taylor Head of Corporate Planning
Craig Turton Interim Senior Health Policy Manager (Projects)
Deborah Oliver Interim Director of External Affairs
Diane Reay Head of Media, Marketing & Internal Communications
Frank Garofalo Director of Operations
Gavin McBurnie Director – Clinical Advice
Graham Payne Director of Finance, Planning & Performance
Graham Williams Lead Clinical Adviser within CAD
Gwen Harrison Director of Investigations & Resolution
Helen Hughes Chief Operating Officer
Jack Kellett Director of Complex Investigations (Health)
Jennifer Elkeles Senior Investigation Manager
Katharine Stevenson Information and Records Manager
Linda Tomlinson Acting Deputy Director of Customer Services & Assessment
Lorna Stoddart Organisational Development Manager
Luke Whiting Head of Freedom of Information/Data Protection
Denise Bird-Newell Director of HR, People & Talent
Maria Leader Lead Clinician
Marie Cheek Director of Service Delivery
Marko Jovanovic Deputy Director of Parliamentary Investigations
Martin Jacobs Financial Controller
Mike Bird Interim Executive Director of Operations & Investigation
Mike Browne Interim Deputy Director of Media & Comms
Mike Procter Interim Executive Director Business Transformation
Neil Armstrong Casework Policy & Guidance Manager
Pauline Elliott Interim Deputy Director of Health Investigations
Rebecca Milner Head of Parliamentary Policy & Insight
Rob Davies Stakeholder Relationship Manager
Ros Page Head of Procurement, Project & Business Management
Sally Sykes Executive Director External Affairs & Strategy
Sara Wilcox Marketing & Communications Manager
Sarah Fox Ombudsman’s Casework Manager
Simon Collier Head of Learning & Development
Steve Brown Head of Assurance, Risk and Programme Management Office
Susan Lowson Lead Clinician – Health Investigations
Susan Thomson Head of Executive Office
Suzannah Beazley Head of Review Team
Tom Stoddart Head of ICT
If you thought that being able to contact the CEO of a publicly funded organisation (PHSO) was a basic right, then think again.
16 October 2013
I am writing in response to your email dated 20 August 2013 in which you expressed dissatisfaction with our handling of your request for information. Under our internal complaints procedure your complaint has been passed to me for review.
Background: Your information request
In your initial request dated 10 July 2013 you explained:
‘Please can you give me an address or telephone number where I can be sure to reach Dame Julie Mellor…’
That was the entirety of your request.
Background: Our initial response
In her email dated 1 August 2013 Ms Helm, Freedom of Information/Data Protection Officer, responded to your request. Ms Helm explained that:
- You could write to Dame Julie at:
The Parliamentary and Health Service Ombudsman
London SW1P 4QP
2. She was unable to provide you with Dame Julie’s direct telephone number as she considered this constituted Dame Julie’s personal information. Ms Helm explained that she was withholding this information under s40(2) FOIA 2000 and noted:
‘We acknowledge there is a public interest in allowing people to access to (sic.) the Ombudsman’s service, but as I explained Dame Julie cannot be personally involved in every case. Therefore the public interest test is met by providing the telephone number of Ombudsman’s service (sic.) to allow members of the public to speak to the caseworker who is best placed to assist them. The number for general enquiries is 0345 015 4033.’
Background: your request for a review
By email dated 9 August 2013 you expressed dissatisfaction with our handling of your request for information. You did not request a review in your email but you did note that:
‘It is not relevant to say it is ‘personal information’ because that is what I am asking for – a specific number for a specific person with a standing in the organisation; not a home telephone number.’
In your email dated 20 August 2013 you requested a review of Ms Helm’s handling of your request for information. In seeking that review you explained that:
‘I believe being able to contact top management with a certainty of getting a prompt, empathetic and reasoned reply is of utmost importance and interest especially where systemic failures are being experienced.’
I have reviewed our handling of your information request in light of the issues you have raised as set out above.
I consider that Ms Helm has acceded to your original request to the fullest extent possible. In relation to her decision to withhold Dame Julie’s telephone number I can confirm that Ms Helm’s analysis was correct. I am therefore satisfied that we have met our statutory obligations under information access legislation.
That concludes my review of this matter. If you consider that I have not dealt with your information request properly you can raise the matter with the Information Commissioner. He can be contacted at:
And so it goes on…. You complain to PHSO, they carry out their own review, they find nothing wrong, you complain to PHSO, they carry out their own review, they find nothing wrong, you …
A very powerful letter from David Drew an NHS Whistleblower.
David Prior, chairman of CQC, told the Health Select Committee this week that a ‘chilling’ culture in NHS hospitals discouraged potential whistleblowers from speaking out. In response I wrote to him, agreeing and giving a description of my experience of such a culture at Walsall Hospitals NHS Trust from 2008 to 2010 which ended in my dismissal. I have not worked since. Here is the unabridged letter:
23 October 2013
Dear Mr Prior
Re: There has been a deafening silence from clinicians for too long.
Thank you for the evidence you gave to the Health Committee yesterday and its subsequent press coverage. I agree with your thesis that good clinicians speak up for patients and good leaders will encourage staff to speak up and will listen to what they say. Gold dust.
The Midstaffs experience and survey after survey shows that staff often do not speak up believing that no-one will listen or, even worse, they will suffer personally. This was my experience at a West Midlands hospital from 2008 to 2010.
I was the senior clinician in the paediatric department and by 2008 had been head of department for 7 years. I was removed as head of department in April 2008 for daring to suggest a consultant I was managing had problems with competence. There was agreement in the consultant body with my view. The Trust failed to engage with this.
In October 2008 I raised serious concerns about mismanagement of the department. A Royal College of Paediatrics (RCPCH) review later agreed that the Trust executive had inappropriately appointed managers with no paediatric qualification or experience who were managerially aggressive (I used the word bullies) and sidelined senior frontline staff. The context to this was a cost-cutting exercise to prepare for FT application and to pay for the new PFI hospital.
I expressed concerns about proposed swingeing cuts to the nursing establishment and proposed medical redundancies. If left unchallenged these would have (and partly did) result in an unsafe service. As important, a mismanaged redundancy programme resulted in the loss of some of our best nurses and the demoralization of those who stayed.
I also reported major problems with the child protection service which the Trust was not taking seriously. A child (Child K in the Local Safeguarding Children Board Serious Case Review) died following catastrophic mistakes in basic safeguarding. No serious attempt was made to address these mistakes. A nurse with no safeguarding experience was appointed internally to mitigate redundancy numbers. A subsequent appointee was bullied out of her post by managers. The CEO suggested she was not up to the job and that managers swearing at her could be excused as they were under stress.
Children were put at serious risk through changes to in-patient accommodation made without reference to clinicians. An antiquated ward heating system repeatedly broke down over 2 winters causing sick babies to become hypothermic.
Management failed to take these issues seriously. The CEO for example took 8 months to provide an unsatisfactory written response to my concerns about safeguarding.
In April 2009 as a result of this I was unceremoniously excluded from the hospital. Documents obtained by Data Protection Act showed the Medical Director claiming to NCAS that I needed excluding as I was obstructive, unmanageable, writing defamatory letters to a manager, thought to be psychotic, leaking information to the press about Child K, might interfere with any Trust investigation of my exclusion and posed a threat to staff and patients. If that sounds a bit crazy in itself it is exactly what the telephone transcripts show. He had not mentioned a word of this to me before excluding me and never did at any future date. Not a word of it was true.
The investigation into my exclusion concluded that I had no case to answer. The RCPCH review subsequently agreed that even if the allegations made against me had been true they did not warrant exclusion. I returned to work after 5 months.
There had been if anything a deterioration in the department in my absence. The consultant I had originally complained about was repeatedly being reported to the West Midlands Deanery for bullying, making trainees afraid to speak out, being unsupportive and not attending calls out of hours. The managerial bullying was worse. One consultant had found a new job and others were talking of leaving. I wrote a comprehensive disclosure to the CEO and said that if she failed to act I would consider my obligations under the Trust whistleblowing policy discharged and I would go outside the organisation. The Trust Chair then met me with my BMA rep and agreed to commission an independent review of the paediatric department through the RCPCH.
The 3 person review panel sat in early 2010. A report was written but only 2 copies printed. I was given one and the CEO the other on 26 March 2010. The following facts about the review are now clear:
- The 3 panel members were gagged by the Trust. The CEO of the RCPCH informed me of this recently when I wrote a formal complaint about the review. The panel members he told me were unable to help his investigation because of the gags.
- I wrote to the panel chair before the review started stating that I was a whistleblower, gave incontrovertible evidence of protected disclosures to the panel at interview and yet the report, without giving any evidence, said that I was not a whistleblower.
- The report was highly critical of Trust senior management. It was suppressed by the CEO. Even the Trust board did not see it. According to one non-executive director (transcript of appeal hearing) the board accepted the CEO’s claim that it was too confidential for them to see. The CEO told my ET (agreed transcript) when cross examined on why she had not let the board see it, “Because they didn’t ask”.
- Under the review’s instruction dissemination of its findings were left entirely to the CEO. I was disbarred from having any part in this. The CEO sent a highly selective summary omitting serious criticisms of senior management to a select group. The CEO specifically altered the review’s instruction of who should see its findings in this summary. As a result middle grade non-clinical managers saw the summary but even senior clinicians who were department heads were excluded. The CEO had recently escaped a consultant vote of no confidence so this was perhaps understandable.
- The review chair refused my written requests to see the RCPCH policy his panel was working to. The RCPCH Registrar likewise refused. Lately the RCPCH has relented and provided me with its policy, “A protocol for external clinical advisory team visits” which was given to the review panel. It is clear from this that there were serious breaches of the protocol including the signing of gags which put the whole process beyond further scrutiny.
- Part of the reviews methodology was to take notes of all witness interviews then destroy them after use. This is specifically contrary to RCPCH policy and again protects the review from scrutiny.
- At no future point was any panel member willing to attend either an internal disciplinary or an external legal proceeding to be cross examined on the review. The review, its conduct and conclusions were carefully and methodically put, by the Trust and the review panel, beyond scrutiny.
Immediately the report was given us the CEO asked me to agree to all its findings and required outcomes without caveat. I expressed concern about two specific issues: the dissemination of the review which I knew the CEO would want to suppress and an instruction about the expression of my Christian faith at work which had not been raised with me in interviews and which I guessed was based on mischievous complaints by managers I was in conflict with. I got an email by return from the CEO asking me to resign. I did not. I then received an appointment for a disciplinary hearing with date, time, place and the names of panel members. I can perhaps be forgiven for thinking this was “here’s one I prepared earlier”. The hearing was a blatant breach of Trust policy as no investigation had taken place. It was stood down by the CEO after BMA representations.
The review chair was then appointed (the interview committee consisted of the CEO and Trust chair with no medical representation) as head of the paediatric department. This was helpful in his planned career move from paediatric nephrology to management. He was aware that the CEO was suppressing the report but refused to do anything. His first act on taking up the post was to meet me and tell me that unless I signed up to the findings of the review immediately I would “soon not be working in the Trust.” The BMA advised me this was discriminatory as no-one else had been made to sign anything. I did not sign.
I was then called to a meeting with the CEO with my BMA rep present. The meeting was digitally recorded. The CEO told me she and the Trust board had decided my position was untenable. This according to a non-executive director was untrue; he knew nothing about it. “We’ve been kept in the dark David.”
The CEO offered me a 6 figure sum, well above my contractual entitlement, and a good reference if I left immediately. She told us that because the SHA was involved in the offer I would have to sign a gag. The BMA and I later made separate inquiries at the SHA (including its CEO) and we were told nothing was known about this offer.
The offer in any case was in breach of the instructions laid down for settlement in Maintaining Higher Professional Standards. I called it what it was, a bribe at tax-payers expense and refused it. As a result the disciplinary procedure was restarted against me. I was finally dismissed for “gross misconduct and insubordination” In December 2010 after what my BMA rep described as a kangaroo court.
I believe I was dismissed because of the serious concerns I raised about the paediatric department particularly from 2008 to 2010. I was an embarrassment to the CEO and Trust Chair especially after the review was so critical of senior management. There is a paper trail of my claims to be a whistleblower which the Trust and review panel preferred to ignore. The layers of secrecy around the review which was conducted by a RCPCH approved panel are inimical to a patient safety culture. What kind of a Trust board can accept a service review of a department for which it has governance responsibilities being kept from it? A supine board in my opinion. The review chair was specifically complicit with the CEO in suppressing the report his panel produced.
I did my best at all times as a doctor. I kept faith with my patients, my professional code and my conscience. At my disciplinary hearing the Trust solicitor is on record as saying.“This hearing is not about the loss of a job. It is about the end of a career.” This was followed by the disciplinary panel chair who was the Director of Nursing who added, “…and never being able to practice medicine again.” There was no doubt in their minds of the consequences of my dismissal. This may give a clue as to why medics and nurses are sometimes reluctant to speak up.
My book “Little stories of Life and Death @NHSWhistleblowr” includes this material but in a more narrative form and will be published soon. Meanwhile I will publish this letter on my blog in the next couple of days, not to embarrass you in any way but to raise the profile of NHS whistleblowing.
Letter sent today to Oliver Letwin MP the new ‘complainants champion’ Will he reply or hide behind ‘parliamentary protocol’?
I’ll keep you informed.
24th October 2013
Dear Mr. Letwin,
I have just watched with interest your oral evidence to the PASC inquiry concerning complaint handling and the Ombudsman service, which was recorded on 16.10.13. I was impressed by your determination to change the culture of complaint handling across the public sector; you must be a man who is prepared for a challenge. I wish you well.
May I offer one or two thoughts of my own to help you on your way? I am a complainant and as such I can give you an insight into using the complaint system from the other side. I had no intention of becoming a complainant and I had no idea when I made my complaint that I would still be complaining three years later. The first thing to bear in mind is that none of us have chosen to be here, we would all prefer to reclaim our lives and move on, but the failure of the regulatory system to provide justice and remedy unfortunately prevents closure.
In all cases a complaint starts with an event, often a traumatic event. People struggling to come to terms with the trauma use the state provided regulatory system in an effort to achieve justice, remedy and closure. To heal our own pain and to improve matters for those who follow after. The second thing to bear in mind is that the complaints which are received by MPs or by the Ombudsman represent only the tip of the iceberg. Many people fall out of the complaint system long before they get to this stage due to the intransience of the process. Complaining makes you ill. So a ‘handful’ of complaints received by those in authority represent a far bigger issue.
You talked at length about finding a better way into the complaint system and there was mention of a ‘common portal’. Finding you way in is not nearly as difficult as finding an independent, impartial and fair hearing once you are in the system. This is the main problem and is actually a national scandal. The Ombudsman serves a crucial role in any democratic society. They protect the vulnerable from the misuse of power. When this system fails, as ours has done, confidence in democracy is shattered. All the Ombudsman services regularly convert trusting and loyal citizens into cynical radicals, some of whom become active campaigners as a result. It is only a matter of time before a tipping point is reached.
The regulatory system works under the premise of ‘delay, deny and deceive’. The whole process is excruciatingly drawn out requiring the complainer to constantly relive their trauma through repeated reference to their case and the evidence which supports their case. The delay is deliberately built into the system in the expectation that many complainants will drop out in exhaustion. Where valid evidence is presented it is denied. No matter how compelling the evidence the regulatory process will deny it all. Where requests are made for information the complainant is deceived in order to protect the organisations. This is systematic, widespread and has been in existence since Adam was a boy, so I hope you know what you are taking on.
Those in authority have been ‘getting away’ with this deception for many, many years. So why interfere? Seems to be working perfectly well for those who are in authority. They are protected by a layer of bureaucracy, paid for by the taxpayer, which diverts all annoying complaints into a large waste disposal bin. Well the reason someone needs to interfere is because the secret is out. With social media, dissatisfied complainants are able to make contact with each other. By comparing cases the truth can be seen. The regulatory system is corrupt by design.
You talked of using the effective systems in place in the private sector, as if something inherent in ‘private’ prevents misuse of complaint processes. Let me tell you that this is not the case. My initial complaint concerned a private teaching centre. They simply closed ranks against me when I complained about the service received. The elements which ensure good complaint handling are loss of customer base and loss of reputation. It is as simple as that. I could not affect either of these for the centre, so they had no reason to deal fairly with my complaint. Where any organisation, private or public has a monopoly there is no fear of losing customers. Where there is no public forum to evaluate performance there is no chance of losing reputation. These are the two key issues here.
You talked about changing ‘behaviour and attitudes’ as well as systems. All PASC committee members agreed that this was essential and that previous advice on this matter has been ignored. Tinkering with the system will not alter the outcome for the complainant. Monitoring processes is not the same as resolving issues. You talked about reading reports from the Ombudsman and stated that you were impressed by the work they carried out. Did you know that only 2% of all the complainants ever have their case investigated and consequently have a report written? Did you know that even within that 2% of ‘successful’ outcomes there is a high level of dissatisfaction with the Ombudsman service? The Parliamentary and Health Service Ombudsman is a national disgrace. They are not unaccountable to complainants and regularly ignore letters of complaint about their own service. The artificial divide between ‘the house’ and ‘the government’ effectively means they are accountable to no-one within Parliament either. This is a dysfunction which is built into the system and one you seem reluctant to address. Someone must step up and interfere with the ‘working of the house’ when ‘the house’ is currently protecting a dysfunctional organisation.
As for removing the MP filter, this is another red herring which takes up too much debate time when the real issue of failure to deliver justice and remedy goes unchecked on a daily basis. In my experience the MP was irrelevant and may even have been detrimental to my case. In my contact with other campaigners many agree that they were let down by their MP who showed little interest in their case. There are a few notable exceptions and where an MP has taken up the matter personally there is certainly more likelihood of a successful outcome. It should not be such a lottery.
Mr. Letwin, may I urge you not to simply rearrange the furniture on this particular sinking ship. There are many angry people who have been waiting a long time for remedy and they will not accept any half-baked report which does not address action on the fundamental issue of corruption within the regulatory system and the repeated denial of justice. There is a movement for change and every day new recruits are created by the institutional bias of the regulatory system. We are the ‘big society’ Mr. Letwin and we are fighting back.
An open letter from Jan Ooms, long-time campaigner for justice in the regulatory system.
No answer so far to this letter. Guess we will have to make our own minds up. Do you think that the Ombudsman abides by its own principles of good complaint handling?
27th August 2013
Dear Nicki Smith,
I am writing to you because in all the three years of fighting for justice, you are the only person who has ever apologised to me, and it wasn’t even your fault. I also noticed that in your email to Suzannah Beazley following my phone conversation, you put the status as ‘high’ giving the impression than I might be important. I am guessing that perhaps you have not been at PHSO very long?
I have enclosed the documents which refer to your previous connection to my case so that you can get your bearings. As you can see highlighted on HI0091, you stated that you did not think it unreasonable for Andy Comber to give me answers to my questions. I do not think it unreasonable either; after all one of your principles of good complaint handling is ‘getting it right’ and another is ‘being customer focused’.
You will see that I took your advice to write in and sent a letter to Andy Comber on 3rd June 2013. In this letter I pointed out the discrepancies between his analysis of the evidence and the statements in the appropriate policy documents. I have asked a series of relevant questions, none of which have been answered.
On 23rd July I wrote to his supervisor, Suzannah Beazley, where I asked her to follow up my letter of 3rd June in the hope of getting answers to my questions. I also informed her that I have new evidence to support my case that no review was ever carried out on the I.V. process. Now, a month later, I am still waiting for her response.
The third principle of good complaint handling is that PHSO are ‘open and accountable’ which involves, ‘providing honest, evidence-based explanations and giving reasons for decisions’. Suzannah Beazley appears to be in breach of this principle. It is also the case that your fifth principle involves ‘putting things right’. As in, ‘Acknowledging mistakes and apologising where appropriate.’ I have not had an acknowledgment or an apology. Is it the case that PHSO does not abide by these principles?
I have demonstrated through objective statements taken directly from policy documents that Andy Comber did not ‘get it right’ when he confirmed that there was no evidence of maladministration. I have received no evidence based reasons for his decision and why he ignored the evidence in front of him. I believe that Suzannah Beazley is in breach of policy by not replying to my correspondence and I wish to put in an official complaint about her.
There is little point writing either to Suzannah Beazley or Andy Comber, which is why I have addressed this correspondence to you. If nothing else I would like the answer to one question. Does PHSO abide by its own principles of good complaint handling?
Looks like ‘jobs for the boys’ at the latest PASC inquiry.
Thanks to Elaine for this submission.
On 29 July I asked the following point with the PASC:
“3. Formal Minutes 2013-2103 on ‘Declaration of Specialist Adviser interests’ dated 11 June 2013 record Dr Nick O’Brien’s recent past and current working relationship with the PHSO and the PASC. Would you please clarify to what ‘forthcoming inquiry’ Dr O’Brien is referring when he speaks to being hired to produce a policy position paper in April 2013”
In a reply later the same day I stated:
“As regards my third question on Dr O’Brien which you cannot answer it seems to me that there is, or may be, a prima facie conflict of interest if Dr O’Brien is acting in an advisory capacity for both the committee and the PHSO. Respectfully, therefore, can you get to the bottom of this matter”.
The following day I was told:
PASC’s Specialist Adviser to the Complaints inquiry
You have also asked about a potential conflict of interest in respect of PASC’s specialist adviser on the complaints inquiry. Advisers are appointed by Committees to support an inquiry by acting as a source of expert advice and knowledge. These people are experts in their particular field and as such it is likely that from time to time they will have been engaged in work that covers the same ground as an inquiry. It is made clear to advisers that they need to have in mind the fundamental role of assisting in the objective examination of evidence in order to reach conclusions.
In the interests of transparency, advisers are asked to openly declare their relevant interests. The Committee takes these into consideration when taking the decision on who to appoint and in this case were satisfied that Dr O’Brien was a suitable appointment for the complaints inquiry.
In respect of ongoing monitoring, advisers work closely with Committee staff and operate under the general direction of the Committee Clerk, whose duty it is to ensure that the Committee receives dispassionate and impartial advice. Conclusions and recommendations in the Committee’s final report on any subject will be formed by the Committee not only after having listened to the views of the specialist adviser, but having also taken advice from Committee staff and taking into consideration the broad range of written and oral evidence received during the inquiry”.
If you check out Nick O’Brien’s Profile on ‘Linkedin’ you will see he has long been a close adviser, even acts as her alter ego before the Council of Europe.
I simply cannot see how he can be at all considered ‘impartial’ as a Special Adviser to the PASC for the purpose of this current inquiry into the PCA Service – for which I submitted evidence that was published last week.
It’s just further cause for concern about the unaccountable PHSO and the cosy relationship with the PASC.
http://uk.linkedin.com/pub/nick-o-brien/36/3a7/75a Profile for Nick O’Brien confirms he works for both parties simultaneously. Can he be trusted to be open, transparent and robust in his analysis of the evidence, or is this just an inside job? Answers on a postcard to Bernard Jenkin.
Ever wondered about PHSO external assessors – read on to find out more.
Transcript of phone call dated 30/05/2013
Mrs TO called in response to our review acknowledgement letter. Mrs TO said that she would like all correspondence via email to save on postal costs. She asked me if I wanted that in writing. I said that it was unnecessary and advised that I would make a note of her request.
Mrs TO referred to her public interest issue and asked if we would be reviewing this, I explained that the review would be looking at her concerns about Suzannah Beazley and Sarah Fox. Mrs TO said that her public interest issue was never answered by the Welsh Ombudsman ….or Suzannah Beazley. I explained that the review would look at her concerns about Suzannah’s correspondence.
Mrs TO asked who will be looking into her complaint and whether Suzannah would be dealing with it. I informed Mrs TO that her case will be looked into by an external reviewer. Initially Mrs TO was happy with this. Mrs TO asked how many external reviewers we have. I confirmed that we have 4. Mrs TO asked if Suzannah Beazley knows the external reviewer. Confirmed that she does as they are employees of the PHSO.
Mrs TO began to laugh. She said that there is no point in having review then. She asked if Suzannah Beazley had any dealings with her request for a review. I explained that Susannah arranged to have her concerns reviewed under our internal complaints procedure. I explained that Suzannah is head of the review team. I also explained that she asked us to investigate her concerns about Suzannah and Sarah Fox which is what we are doing at the moment.
Mrs TO repeated ‘yeah, right, over and over and laughed. I explained that if she remains unhappy with our decision or handling after we have issued our response she could file for a judicial review. Mrs TO continued to laugh and say ‘ yeah, right’.
The call ended.
Will Dame Julie Mellor meet with the complainants?
Watch this space.
The use of ‘discretionary powers’ by the Ombudsman means that this body is effectively unaccountable. This letter from 1993 confirms that Parliamentary Committees will not intervene in the working of the Ombudsman’s office. They do however hold inquiries and write reports. 20 years on and all we have are inquiries and reports – never any action.
12th April 2013
Dear Dame Julie Mellor,
I am writing to you today because I am concerned that you are suffering from ‘doublethink’. In case you are not familiar with the term, let me explain that it is the act of simultaneously accepting two mutually contradictory beliefs as correct. I came to this conclusion as I watched you give evidence at the Public Administration Select Committee on 18.12.12.
It would seem that while you agree that there is a chronic and urgent problem in the complaints system you are unable to understand the part that PHSO plays in maintaining this state of affairs. You suggest on the one hand that you wish to be ‘shining the light’ on poor practice and yet you uphold only a tiny fraction of the cases which are presented to you. Using your own data (see attached report) it can be seen that in 2011 – 2012 you actively ‘resolved’ only 4.9% of the total number of cases submitted and those which found in favour of the complainant amounted to only 1.4% of the total. Is it possible that 98.6% of the people complained to you in error?
You state that you wish to see PHSO engage with more people, carry out more investigations and report back to more organisations and yet you turn 95% of complainants away at the door. What is the point of having more people complain when you don’t deal with the ones you have?
You state that it is the role of the Ombudsman to see if the evidence supports the case and if it does you use this evidence to feedback to service providers. But in the vast majority of cases you deny or ignore the evidence presented by the complainant. There are many recorded cases where the Ombudsman has found no maladministration, but the complainant has then been able to secure damages through court action using the same evidence. You don’t need me to tell you this, you know it is true and if you are uncertain then read through some of the witness statements from previous PASC meetings. It is all there to see for those who are willing to open their eyes to the truth.
You chide the service providers for not applying principles of good complaint handling, but you seem unable to realise that if the system is weak at the top (you) and there is no danger of sanctions (currently less than 2%) then there is no incentive for the service providers to put their house in order. They are happy to allow individuals to escalate their complaint knowing that when they come to you the vast majority will be turned away and those that are ‘resolved’ will most often find that their case is not upheld. You are the problem, the starting place and the solution. The Ombudsman must put its own house in order first.
You gave the statement that 64% of people are disillusioned about the value of complaining. You state that you want to restore confidence and show that complaining provides a remedy and brings results. But look at your own figures, over 95% of the people who complain to you went away with no remedy and no result. Over 95%.
You confidently claimed that 100% of recommendations are implemented, but when you find in favour of only 328 cases that does not represent a huge number.
In your annual report for 2011 -2012 you proudly state that you take complaints made about you seriously and use this information to learn and improve. Yet when reviewing complaints you found that only 0.4% of the total decisions needed to be looked at again. PHSO is therefore correct 99.6% of the time; a remarkable feat. You attribute this to a more robust decision making process and improved customer service. You state that, ‘as a result of learning from the complaints we receive …this seems to be reflected in a fall in the number of complaints about us.’ It is a shame that you don’t review the cases that were later proven through court action, you would have a lot more to learn. The fact that the review process is handled internally is a significant factor and should complaints about PHSO be sent out to an independent moderator I’m sure we would all see a different picture.
In case you wanted to look for yourself at a robust and evidence based review process, I have enclosed a file of papers which refer to my recent review at PHSO. You will be able to see that the Ombudsman dismissed thirteen pages of evidence which included statements from policy documents, statements made by Ofqual staff and the advice of a barrister as failing to be ‘objective’. Ofqual on the other hand provided no evidence in support of their claims and none was requested. Their version of events was taken at face value, no questions asked. For most rational people this would be termed ‘applying bias’.
I will be submitting evidence to the next PASC inquiry and have included it with this correspondence for your information. I suppose it is difficult to come to terms with the fact that the Ombudsman is denying justice to thousands on a yearly basis, causing huge emotional distress and allowing dysfunctional organisations to act with impunity, but that is the sad reality. It is obvious from the data that the glowing words are pure rhetoric.