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.

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


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 deliver an Ombudsman service fit for the 21st Century?

PHSO Pressure Group at cabinet office

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

On 7th October the PHSO Pressure Group attended a stakeholders meeting held at the Cabinet Office to discuss complaint handling and the role of the Ombudsman. We were invited by the Rt. Hon. Oliver Letwin and present at that meeting was Robert Gordon CB and his team.  Mr. Gordon has had a distinguished career in the Scottish Office where, among other things, he helped to set up the devolved Scottish Parliament.

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

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

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

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

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

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

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

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

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

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

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

You can see the full summary presented by the PHSO Pressure Group to Mr. Letwin and Mr. Gordon here:

Can James Titcombe force PHSO to face their own failures – for all our sakes?

James Titcombe                                                                        Sent via email 8th July 2014

Dame Julie

The Parliamentary and Health Service Ombudsman,

MilbankTower, Millbank,  London SW1P 4QP

Our meeting on Friday 4th July 2014 

Dear Dame Julie,

Thank you for meeting  with me on 4th July, which I attended with support from David Behan.During this meeting, you agreed that you would undertake a review and respond to the  concerns I have raised about your organisation and the decision not to investigate  Joshua’ s death following my referral in 2009.

It was agreed during  the meeting that it would be helpful if I wrote to you to summarise a clear list of the key questions which I would to review and respond to.These are as follows.

1)      The process and basis  for refusing to investigate Joshua’s death 

At the time of Ann Abraham’s decision, the Coroner had refused an inquest and therefore my family and I had nowhere else to turn to ensure that my son’s death was  properly investigated.

Could you set out  for me and my family, the reasons why PHSO decided not to investigate Joshua’s death when I  referred my complaint in 2009?

I  would like this response to consider and acknowledge that the case advisor (Harriet Clover) assigned to review Joshua’s case had recommended that the case should proceed to an investigation. Her reasons included recognition that the trust had failed to investigate  Joshua’s case adequately, that my family and I had not received an adequate response to our questions about the events that led to Joshua’s death and a concern that the failures were systemic in nature.These are important points to emphasise as previous responses to my concerns have not acknowledged this.

2)      Interactions between Ann Abraham and Cynthia Bower 

The decision not to investigate was made after at  least two  meetings between Ann Abraham  and Cynthia Bower.  Kathryn Hudson gave evidence to the Grant Thornton investigation relating to a conversation she had with Ann Abraham relating to one of these meetings. Kathryn Hudson’s evidence(confirmed by other documents), referred to a ‘meeting’  in  which Joshua’s case was discussed whereby a ‘suggestion’ was made that PHSO ‘might not investigate’ if CQC would take ‘robust’ action. Despite this, when I asked for an explanation, I was told in writing by PHSO that such a conversation did not take place.This letter was written when Kathryn Hudson was still working at PHSO.  During our meeting on Friday 4th July, you informed me that Kathryn Hudson was involved in the preparation of this letter.

  1. Can you clarify what conversations took place between Ann Abraham and Cynthia Bower in relation to Joshua’s case, including what was discussed during these conversations and the accuracy of the information previously provided to me about this matter by your office.
  2. Can you please provide clarification surrounding the handwritten note referred to in the Grant Thornton report which Ann Abraham made prior to her meeting with Cynthia Bower on 12th August 2012, in which it is clear  that she intended to discuss Joshua’s case?
  3. Can you please clarify why this note was  not disclosed to me when I made my initial DPA request and whether or not you believe it should have been provided to me either at the time, or subsequently when your organisation became aware of the note at the time it was provided to Grant Thornton.
  4. This note has still not been disclosed to me,  please can you now provide it.
  5. Do you accept that  the evidence given by Kathryn Hudson and Ann Abraham to Grant Thornton regarding  the nature of the conversation between Cynthia Bower and Ann Abraham conflicts and can you please explain this.

3)      PHSO’s understanding regarding what actions CQCwould take 

One of the main reasons Ann Abraham gave for declining to investigate Joshua’s case was the role of CQC.  As you know, the case advisor had recognised that the issues surrounding Joshua’s death had not been properly investigated and was concerned that the issues involved were systemic.

  1. Please can you explain why no letters or any other kind of documentation exist which confirm what action CQC had agreed to take prior to Ann Abraham’s refusal to investigate Joshua’s case?
  2. Given that the evidence clearly shows that PHSO were  aware of systemic concerns at the maternity unit at FGH and the ‘need for a wider investigation into the quality  of maternity services at the trust’ was acknowledged by Ann Abraham, please can you advise what steps were taken by the PHSO to ensure appropriate action would be taken by CQC before declining to investigate Joshua’s case?
  3. Please can you advise if you believe that the  steps taken to communicate  the concerns and the reasons for not investigating  Joshua’s case were sufficiently communicated to CQC at the time the decision not to investigate was made?
  4. Evidence provided by senior CQC staff (confirmed in the Grant Thornton report), suggests that CQC staff apparently interpreted Ann Abraham’s decision not to investigate  Joshua’s death as a ‘reassurance ’that things were‘ ok’.  Please can you clarify how you believe this misunderstanding happened and what lessons have been learned from these circumstances?
  5. Do you accept that had the Ombudsman investigated Joshua’s death properly at the time, the  course of events at Furness General Hospital (FGH) may well have been different and that problems at the maternity unit at FGH could have been exposed and addressed sooner?
  6. Do you acknowledge that as a consequence  of Ann Abraham’s decision not  to investigate Joshua’s death, my  family and I have had to fight a prolonged and arduous battle to establish the truth about why my son died? Can you please clarify whether or  not you feel the decision not to investigate was reasonable given that thec ase advisor had accepted that my family and I had not received an adequate response to our questions about Joshua death?
  7. During our meeting, Is hared with you an email written by  CQC staff on 20th August 2009,  in which it was stated  ‘I have heard by a roundabout route that the Ombudsman aren’t investigating [Joshua’s case]’.Are you able to  provide any explanation regarding  this memo and how CQC may have been given an impression that PHSO would not be investigating  Joshua’s case at this time (a number of months before my family and I were  informed of the provisional decision).

4)      Internal  Review Process 

Following the rejection of my complaint in relation to the North West Strategy  Health (NWSHA), I appealed the decision and the review supported Ann Abraham’s decision not to investigate.Following this, I started a Judicial Review process which triggered a second external review which was highly critical of the decision stating it was‘flawed’.    The eventual investigation carried out led to national recommendations for change. PHSO have apologised for  this decision but what  steps have been taken to strengthen the internal review process to ensure that ‘flawed’ decisions are no  treviewed as  being satisfactory in the  future? Can you summarise any  learning PHSO have taken from these circumstances?

5)      My letter to Ann Abraham of 26th August 2010

I have attached  a letter I sent to Ann Abraham  of 26th  August 2010. On page 3 of this letter, I set out what I believe the consequences of the  decision  not to investigate Joshua death were, for the ‘NHS and other families in the future’.The first item listed states:

“Uncertainty as to whether or not all possible lessons from Joshua’s death have been taken locally,this means an increased risk to mothers and babies in the local area”. 

Do you now accept that this was indeed a consequence of the decision made not to  investigate Joshua death and  that risks to other mothers and babies at the maternity unit  at  FGH were only subsequently identified following an inquest and subsequent regulatory action more than a year later?

These concerns summarise the  issues and questions I feel that I have been asking you to respond to since  July  2013.  However, I have recently received a  large number  of documents from your organisation under the Data Protection Act(DPA) and would like to raise some additional concerns as follows.

6)      Pre-occupation with reputation 

  1. The initial assessment form following my referral of Joshua’s case to your organisation includes a risk assessment  which described the case as ‘high risk’ due to the potential for ‘media interest’. Do you agree that is it wrong to risk assess cases about potentially avoidable deaths in this way and that any risk assessment should be about risks to service users, not risk to your own reputation?
  2. Within recent documentation provided to me under DPA, I  have come across another risk assessment which states ‘medium risk’and describes my unhappiness with the decision not  to investigate Joshua’s case and concern from the Health Select Committee about the decision.The risk assessment summarises the risks as ‘a risk to our reputation’ and a ‘risk of litigation’.The‘mitigation plan’ involves ensuring correspondence from myself is passed through the Ombudsman legal services. Please can you clarify these circumstances and  explain if this type of risk  assessment will continue to be carried out in the future?
  3. Can you comment on the decision to refer all my correspondence to your legal team and clarify why this was done?

7)      Ability of PHSO to properly investigate cases of potentially avoidable death 

When we met,  MickMartin articulated that the methodology currently used to investigate cases of preventable deaths in health care by PHSO was not  ‘fit  for purpose’. Has this statement been made publicly and are you able to provide an action plan and time frame for when you hope these issues will be turned around?


I passionately believe that any organisation committed to genuine change must first get some  key basic principles firmly  in place.The most important of which is being absolutely open, honest and transparent when things go wrong, or when significant change is needed. It is now my hope that  you will  ensure that the serious issues I have raised relating to the way the Ombudsman responded to my family  following Joshua’s death, are properly reviewed and that I will receive a full, open and honest response.

For the sake on my family,including my wife, parents,in-laws and my children (who will one day  see kto understand what  happened to their brother) I hope that your response to these issues will bring us some closure and reassurance that all necessary lessons from our experience have been taken by  PHSO  to ensure other families in future do not go through what  we have had to.

Yours sincerely,

James Titcombe

CcJeremy Hunt

David Behan

Bill Kirkup