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.



Patients Association slams PHSO as not fit for purpose.


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

Patients Association Press Release

 18 November 2014  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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