APPG listen to catalogue of poor complaint handling.

Private EyeAPPG for Patient and Public Involvement in Health and Social Care held their first evidence session on Wednesday 17th June which was organised in collaboration with the Patients Association.  They heard harrowing stories from six witnesses who had all suffered devastating trauma as complaints made about poor NHS care were dragged through a Kafkaesque process which had the single aim of damage limitation.  In all cases PHSO were named as a significant part of the problem.

Maggie Brooks explained her five year ordeal of trying to find out why their mother Elsie Brooks died an avoidable death following keyhole surgery to repair a hernia.  This appalling case appeared in the recent ‘Private Eye’ article attached and shows collusion between all authorities to deny the facts.  It is clear they have covered up the truth, but as Maggie pointed out, as soon as you say the words ‘cover up’ you are treated like a conspiracy theorist and fruitcake.  Yet five years later, following an NHS investigation, an inquest and a PHSO report which upheld their case, they still don’t have answers to vital questions.  Barking, Havering and Redbridge NHS Trusts have continually held back medical records and other evidence which would reveal where the mistakes occurred.  Maggie told John Pugh MP and chair of the APPG,

“We thought that PHSO would take it seriously that the Trust withheld records, but they just published the draft report as a final report anyway.  I wish we had never got involved with PHSO.” 

In summing up Mr. Pugh identified three key points:  Firstly the fact that the incident occurred at all was a failure point, secondly that the Trust were defensive from the start and used a trained barrister as their customer care representative.  Finally, that the Trust were allowed by the Ombudsman to call the shots by failing to release documents and that this went unchallenged.

Baroness Masham of Ilton confirmed that the time delay caused by such long drawn out complaint processes prevented any real remedy, as people moved on and events were forgotten.  She emphasised that complaint handling must be immediate.

Nic Hart then spoke about the tragic case of his daughter’s death from anorexia.  There was a total lack of communication between the primary care team who had done such a good job of returning her to a degree of health following a hospital admission and the discharge care team who then failed to monitor her progress.  He too experienced a cover up of the facts as he probed deeper in order to prevent similar events from ever happening again.  He concluded that;

You cannot trust NHS staff to self audit.  It must be external and records must be sealed immediately after an incident.

All parties found PHSO to be ineffective in bringing remedy or identifying the true facts despite many months of investigation.  In one case the complaint was artificially split between the LGO and PHSO but there was no dialogue between the two bodies and ultimately LGO produced no report, yet PHSO continued to look at isolated aspects of the case which needed to be seen in the round.

 Fragmenting cases appears to be common at PHSO, but this prevents any understanding of how all the factors combined to produce the tragic consequences.  No understanding = no learning.

Some witnesses reported that they now suffered from PTSD due to the intransigence of the complaint process and the denial of acknowledgement and closure. All had suffered long drawn out processes which required them to live and re-live their original trauma.

Richard von Abendorff, the final witness, put forward some suggestions for reform:

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

John Pugh MP and all members present, agreed that the complaint system was inadequate, unsafe and required reform.  There will be further meetings and representatives from NHS England, GMC, NMC and CQC will be giving evidence.  The PHSO Pressure Group will also be invited to submit oral evidence to the APPG as part of this investigation.

This recent blog post from Mick Martin  M.D. at PHSO, may shed some light on why the present Ombudsman system is failing to drive reform in NHS complaint handling.  Mr. Martin stated that:

There is a lot of confusion about our role, so to be clear:

  • we investigate cases so that we can make decisions on complaints, not to make up for poor investigations at local organisation level;
  • we press public organisations to learn from and improve their ways of working, we can’t make that happen;
  • we work hard to obtain a remedy for people when they have experienced injustice, we don’t favour them when we are investigating their case or advocate for them, and
  • we provide invaluable insight on things that keep going wrong, we don’t provide solutions.,-changing-how-we-work./_nocache

This gives the impression of a powerless body, struggling against the odds to put things right.  Providing insights on things that keep going wrong, but doing nothing to ensure improvement and learning is a pointless waste of money.  The Ombudsman has the power of a high court judge, but apparently the bite of a poodle.  As Tim Farron so eloquently pointed out in the previous Parliament,

“The Ombudsman should be a watchdog not a lapdog. “

Below is an account from the Patients Association from the same meeting.  We are very grateful to PA to be included in this APPG inquiry and look forward to attending the next meeting.

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

This week the All Party Parliamentary Group for Patient and Public Involvement in Health and Social Care (for which the Patients Association provides the secretariat), has heard evidence from patients and their families who have been let down by the complaints system.

The NHS complaints system still exposes many patients to gruelling and unsatisfactory process, despite numerous high level calls for reforms. Research conducted by the Patients Association found high levels of dissatisfaction with the complaints process with patients frequently encountering unhelpful and defensive staff, complicated procedures to negotiate and sometimes dishonest replies. The findings show that some patients are so daunted by the procedures or worried about being seen as a trouble-maker by hospital staff, that they do not bring a complaint – despite having grounds to do so.

The first oral evidence session was held at Portcullis House, Westminster and was chaired by John Pugh MP, along with Rosie Cooper MP and Baroness Masham of Ilton. Oral evidence was provided by six members of the public who have been supported by the Patients Association.

Maggie Brooks opened the session with the story of her mother Elsie who died in December 2009 after failings in nursing care. Following an ineffective Trust investigation that took 16 months and brought no explanation to light, the Brooks family took their complaint to the PHSO in 2011.The initial PHSO investigation took over a year and the draft report upheld their complaint. However it failed to investigate the main aspect of their complaint and the investigator had not seen critical medical records.

Nic Hart gave a moving account of how his daughter Averil, died while in NHS care in December 2012 after a battle with Anorexia Nervosa. She received inpatient treatment in Cambridge, for Anorexia Nervosa, over a period of nine months. She was discharged from the unit, and started at the University of East Anglia two months later. She registered with the UEA Medical Centre for primary care, and after a delay of several weeks, she was also provided with secondary care by the Norfolk Community Eating Disorder Service.

By the time of the scheduled medical review, she had collapsed and had been admitted to the Norfolk and Norwich Hospital. Mistakes were made, and her condition worsened further; she was then transferred to Addenbrooke’s Hospital where she sadly died.

In late 2013 and early 2014 the complaints were submitted, explaining that there appeared to be numerous significant failures during Averil’s care; specifically that she had originally been discharged from hospital too early, that the transition to secondary care at university was poorly handled and that the secondary care itself was inadequate. It was hoped that these concerns would be fully investigated.

We also heard from a father whose son committed suicide, investigation into the complaint found no failings despite expert witness reports and evidence to the contrary. Two patients who were given treatment against their will by unidentified healthcare professionals even when one was allergic to the medication. Richard von Abendorff whose mother suffered a horrifically painful last three days of life because of the hospital’s multiple errors in her opiate pain control. His concerns of the complaints and wider investigatory process highlighted the ‘systemic’ failures but his persistence led to a Patient Safety Alert issued on the use of Naloxone. Further details of these cases can be found here

Many of the speakers described themselves as ‘naive’ when they first began the complaints process, believing that their case would be thoroughly and independently reviewed in order to uncover what really happened and why. However, they encountered many of the same problems including difficulties in accessing medical records, failure of hospital Trusts to provide accurate and complete records and a lack of independence and expertise of complaints bodies.

The patients and their families expressed a need for increased expertise, accountability and independence within the complaints process, and argued that the process would be greatly improved if it focussed on the complainant rather than acting as a defence for hospital Trusts.

Throughout the year, the APPG will be listening to evidence from a broad section of organisations, groups and individuals with expert knowledge and experience of complaints handling. The APPG will be especially focussing on organisations and individuals that have developed best practice guidelines and protocols for dealing with NHS complaints. Future sessions (to be held in September and October) will hear evidence from Clinical Commissioning Groups, hospital Trusts, regulatory bodies and other organisations with an interest in complaints handling.



Can a leopard change its spots?

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

sally sykes

Sally Sykes – PHSO

The Action against Medical Accidents Conference:

NHS Complaints – Putting Recommendations into Action.

24th March 2015, Manchester Piccadilly.

 Attended for PHSO the Facts by Jill Mizen and Elizabeth Gould



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

And as for the leopard and its spots?

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

Pressure Group members attend NHS Complaints Conference.

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

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

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

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

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

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

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

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

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

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

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

On that note you may wish to listen to David Drew speaking on Radio 4’s Midweek about his horrendous nightmare following his decision to blow the whistle regarding concerns for patient safety at Walsall Manor Hospital, where he worked as Head of the Paediatric department If you want to cut to the chase his part starts at 11.41. He speaks of the culture of closed groups and once more makes the point that the perpetrators are the very same people who investigate the complaint.  This is unacceptable. You can get his book, ‘Little stories of life and death’ here:

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

head up bum Link to slideshows from the day:




Can Oliver Letwin redeem himself as the Complainers’ Champion?

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

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

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

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

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

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