House of Commons Public Administration Select Committee WORK OF THE OMBUDSMAN
Written Evidence
List of written evidence
1. M B Wright (PHSO 1) 2. Alan Vaughan (PHSO 2) 3. C N Rock (PHSO 3) 4. Alison Pope (PHSO 4) 5. Helga Warzecha (PHSO 5) 6. Brenda Prentice (PHSO 6) 7. Alan Reid (PHSO 7) 8. Which? (PHSO 8) 9. Dee Speers (PHSO 9) 10. James Titcombe (PHSO 10) 11. Action Against Medical Accidents (AvMA) (PHSO 11) 12. Anonymous (PHSO 12) 13. Uncaged Campaigns (PHSO 13) 14. Parliamentary and Health Service Ombudsman (PHSO 14) 15. Patrick Cockrell (PHSO 15) 16. W Morris (PHSO 16) 17. D R Tweedie (PHSO 17) Written evidence submitted by M.B.Wright (PHSO 1)
1) Although we understand the PASC cannot look at individual cases, we have a long outstanding and legitimate grievance against the PHSO case which highlights very serious failings by various senior members of that organisation, and they have resisted all attempts to get them to explain and/or justify their unsustainable position. Given the role they nominally perform, their reluctance – indeed their determination –not to even try to substantiate their indefensible position is very worrying – and suspicious.
2) We have submitted full detailed information of this travesty – with photocopies of all salient documents – to the PHSO, yet they negligently and unprofessionally overlooked the undisputed facts and merely nodded through the unsustainable status quo, presumably believing they would never hear of it again. When we quite properly questioned their flawed decision – sending copies of various letters and emails confirming our position and drawing attention to the errors in their findings – they simply clammed up and refused to explain themselves.
3) We believe this is because they realised they had been caught out. They could hardly admit they had nodded it through without the inconvenience of bothering to read the file, yet they could not claim that they had read it either, for how could they conceivably have arrived at such an absurd conclusion, given the undisputed facts?
4) So, what to do? They did nothing! Nothing! No explanation! No retraction! No nothing! Knowing full well the monstrous injustice they were condoning, they all sat back and did nothing, ignoring our many pleas for justice, in the forlorn hope that we would eventually give up, and they would get away with it.
5) Notwithstanding Oral Evidence 29th November 2011 (Q45 to Q62 and particularly Q49) the PASC itself is also guilty of treating us with contempt. In that evidence the PASC clearly pours scorn on the PHSO’s stock get-out of recommending a judicial review – a wholly impractical course for individuals to take – yet this is the very same advice given to us by the PASC itself (PASC letter to me dated 14th June 2012). We are entitled to ask whether the PASC is any better than the PHSO!
6) It is impossible to fully describe the utter frustration and disappointment we feel for all the incompetent and unprofessional people involved in this scandal – at the very highest level at both the Parliamentary Ombudsman and Public Administration Select Committee. On the indisputable evidence of this case – and there is no reason to believe it is untypical - negligence is rife throughout both pitiful outfits. Is it right that we should be denied justice simply because we cannot afford to take it further? This was the gamble the useless Parliamentary Ombudsman made when caught out. Is this justice? No, it is not! Is the PASC just a waste of time, like the PHSO?
November 2012 Written evidence submitted by Alan Vaughan (PHSO 2)
I wish to bring to the committees notice my views of the failings of the Ombudsman.
The Ombudsman fails to serve and protect the General Public for the following reasons.
1. Refuses to undertake full investigations into complaints made by the General Public.
2. Refuses to undertake full investigations into complaints when requested to do so by an M.P. (Dr Julian Lewis) on behalf of one of his constituents.
3. Fails to get independent opinion on cases and only uses Doctors and other people with health service background therefore only having biased views on which to make her decisions.
4. Suggests that members of the public seek satisfaction to their complaint by seeking a Judicial Review this would only be available to people with very deep pockets. So therefore antagonistic.
Observation.
It appears that the Ombudsman's office is only interested in pushing around a few letters and not fully investigating legitimate complaints. Employing one or two consultants who are no doubt handsomely rewarded for what I would suggest are biased opinions as they neither fully investigate the complaint.
December 2012 Written evidence submitted by C N Rock (PHSO 3)
The main points I am making
1. Ombudsman is failing to deal with NHS complaints to satisfaction of complainant—too presumptuous of PHSO aims and purposes.
2. Patient or Complainant is left battered and reeling from inappropriate language and terms used by PHSO, especially in case rejections - especially where known facts are denied by PHSO without first gathering all relevant information.
3. NHS Complaints Procedures have in most cases already failed, even before case is made to Ombudsman. Even this is not followed-up.
4. I cannot understand why PHSO or NHS could not gain by finding out why my son died without receiving NHS best efforts for treatment – and to allow PHSO to be able to recommend appropriate action and changes to services.
5. An injustice was served by PHSO consideration not to investigate evidence or question anybody involved in the bad treatment and death of my adult son, but this simply was not appreciated under their terms. No amount of explanation would make up for that. There was a failure of management which needed addressing.
6. In seemed patently obvious to me that the Ombudsman’s advisors—and who, I understand, may not even be in Practice—were out of touch with procedures, NICE guidelines, and available interventions.
About me
7. My son died as a result of what to me was clear incompetence and negligence by NHS, and problems for which I tried to get attention, without success.
8. Trying to get reasonable answers on my son’s death has consumed my life for four years without real satisfactory outcome. The Ombudsman saw nothing amiss in services.
9. The event left his sister, myself and my wife permanently traumatised. No support was offered except by charitable organisations. Any approach to question the NHS was traumatic in itself. We have been scarred mentally, and have been unable to work normally, with loss of income and future outlook.
Factual information I would like the committee to be aware of
My Case:
10. My son took his own life after I had been trying to get attention for him for five years. He was ignored by the GP; was left-out by Mental Health services; was harassed by careless NHS behaviour, then ostracised because he was not able to understand his illness.
11. Neither the Trust involved or the GP were competent at investigating themselves—the GP was actually deceitful.
12. After the very unsatisfactory NHS responses, I approached the PHSO then under Ann Abraham, who rejected the case with inappropriate language; then on Appeal, responded with more unsound reasoning; and without interview or requesting further evidence of my claims.
13. I had to deal with 5 or 6 PHSO correspondent name changes over 9 months of waiting (this after 6 months NHS investigation delay). The final response made no sense and cut off seeing evidence.
NHS Complaints - Reasons given in defence:
14. The GP felt bound by Confidentiality not to communicate my son’s problems (my concerns expressed abundantly to GP) to Mental Health services for advice or peer specialist consultation.
15. The Psychiatrist felt bound by other rules to get my son Sectioned before any intervention such as Family Work could be offered or used to engage him in understanding his illness (even though the Trust had an established service available for this).
NHS Problems:
16. Patient Confidentiality was interpreted as “Can’t help”.
17. GP and Mental Health operatives both interpreted Patient Confidentiality to their own advantage, not the patient’s. They were oblivious to NICE Guidelines for dealing with family in cases such as this.
18. There is no Complaint Investigation Procedures for GPs (GP could not provide their own). I was refused being given any evidence that an investigation was actually carried out.
19. GP could not be trusted to investigate herself honestly. There were 5 years of neglect to investigate: GP only covered one month of action, in less than half an A4 page. GP lied, and misled subsequent interested parties including the Coroner. No evidence of contributory effects of prescribed drug use was submitted.
20. PCT(Contracting) would not get involved in GP Complaints (their stated policy).
21. No common complaint system for NHS. Fragmentation of NHS services – i.e. disjointed case research and disconnected responses in own interest – not patients. No sense of urgency for complaints (I made a complaint before my son died— pointless).
Recommendations that I would like the committee to consider including in its report
PHSO needs to be asked to:
22. Take an empathetic and broader view of cases to achieve what is being sought by complainant—not as interpreted by Ombudsman in order to reduce the PHSO’s workload (“no worthwhile outcome for whom”, exactly). What is the PHSO really for? Why are so many people (98%?) rejected (dissatisfied). Where do PHSO Customer Satisfaction statistics come from? (I was never consulted.)
23. Not to just deny what people are claiming as failures without asking them (clarifying) what is being said. For example, stating “we saw no evidence…” without asking to see it (PHSO stating that she saw no evidence is not evidence in itself—merely stating that they did not see it either literally, or figuratively). Could they not pick up the phone and ask the complainant?
24. Look seriously at how to approach the ‘Catalogue of Errors’ syndrome. Each potential or contributory error is taken up, reasoned, assessed and dismissed individually, when the outcome—in this case, our son’s death—is the result of error built on error in different contexts or NHS departments, over a long period. This oversight, combined with the internal boundaries of the NHS which prohibit proper investigation in the first instance, then results in NHS piecemeal management of problems, and contributory negligences being overlooked.
25. Make more use of serious and appropriately phrased recommendations (orders?) to GPs and Trusts to act forthwith with immediate reparations, and to make longer term plans to resolve procedural and educational problems. But the failures have to be ‘seen’ and understood first.
26. Failing the existence of a joined-up NHS investigation procedure, PHSO should act as intermediary in conflicting GP/HealthTrust claims and individual defences
27. Save the NHS money by not driving dissatisfied complainants to take legal action leading to compensation settlements and legal claim costs—which resolve nothing, ultimately.
28. Save the NHS money by recommending sacking, retirement, striking-off, restructuring, of offending workers and teams. For us, one death should be adequate indication of mismanagement needing serious attention, but no opportunity for this was even considered. And written—published—apologies should be the norm rather than the forced exception. The NHS took my son’s life and never apologised for the errors – yet paid a mean Settlement for their mistakes, after I took legal action.
29. Think about your impact on NHS victims, and the Economy.
Enduring Impressions
30. I listened online to Ann Abraham performing smoothly at the last annual Select Committee meeting. I was entirely unimpressed by her performance, her one- sided and patronising answers, the questioning that too easily accepted the contorted reasoning, and the high rejection rate of NHS complaints. Unbelievably the Ombudsman seemed satisfied that she had managed to hack down cases by around 98% to a mainly “satisfied” 356 cases. I am very aware of the cost of that figure not being 357, but not out of Ann Abraham’s budget.
31. I too was told there was “no worthwhile outcome”, so no investigation; then I had to take private legal action to a mediocre, mainly unsatisfactory, yet I think “worthwhile outcome”—but never got an apology.
32. I had the distinct impression that the Ombudsman was not trying to resolve (NHS) problems, but to cut the ‘cloth’ of massive dissatisfaction to the ‘need’ (or resources) of the Ombudsman. Everything could be explained away and all the monitoring and technical bits had been covered to look fine and stand up to questioning: just like the NHS.
33. But the Ombudsman process is unfit for purpose and is failing to seize opportunities to learn, and pull public services into line. This one death destroyed our world and also our view of justice as dealt out by a civil servant.
34. At the end of the day, there still is no NHS complaint system which stands up to fair scrutiny and follow-through: what hope for improvement?
December 2012
Written evidence submitted by Alison Pope (PHSO 4)
I found that the Ombudsman’s office failed completely in its objectives to identify maladministration and unremedied injustice and then to recommend actions to remedy this.
• The process of referring my complaint to them was a complete waste of my time and effort and that of my I.C.A.S. advocate. • The health authority clearly knew exactly how to play the system and the Ombudsman's office merely rubber stamped their position. • No credence was given to any information and evidence provided by myself. Instead, the Ombudsman’s office based their conclusions solely upon the paperwork provided to them by the health authority concerned. In every instance, the Trust’s records (or lack of them) carried more weight than my own contemporaneous notes. • The Ombudsman’s decision regarding my case was made prematurely, before all the relevant evidence requested by her office had been obtained. • Correspondence from the Ombudsman’s office is littered with inaccuracies as is the information supplied to them by the health authority. This was pointed out to the Ombudsman’s office repeatedly throughout the process. • Evidence that there were clear failures in the administrative process followed by the healthcare authority were ignored by the Ombudsman's office. • The Ombudsman's office also ignored the fact that the Trust was obstructive and in many instances contradicted itself during the complaints process.
December 2012
Written evidence submitted by Helga Warzecha (PHSO 5)
o The PHSO needs to get involved earlier in the complaints process.
o The PHSO needs to become not the last port of call for the complainant.
o Time frames for sending complaints to the PHSO need to be extended.
o NHS patients and their families need an independent complaints system that is easy to access.
o It would be advantageous both clinically and financially if a culture of honesty were to be fostered in the NHS, where mistakes are acknowledged both to the patients and their families and to the trusts where the mistakes have taken place. This way lessons can be learnt and implemented for the good of other patients. Tensions between practitioners, administration and complaints can be minimised. I believe the PHSO should be a lead in this.
1. The PHSO does not get involved early enough in the complaints system, especially in complicated and difficult complaints that cover several years and people with multi- morbidities.
2. The idea that local resolution has not been possible needs to be acknowledged earlier rather than later. There appear to be no clear guidelines as to when this has happened. In my case my MP considered this so, however the PHSO told me that the Trust should fully investigate. There is also a time frame in which a complaint can be brought before the PHSO; however a trust is quite capable of prevaricating and making it impossible for the complainant to go to the PHSO.
3. The complaints system within the NHS does not work because staff and trust administrators are always on the defensive to the point of dishonesty. PALS being part of the trust does not serve the complainants well as they too seem to be set on obfuscation and omission in their dealings with the complainant.
4. My daughter died 5th September 2011. She was a long term patient at Addenbrooke’s. She had been dialysing thrice weekly since September 2004. In February 2007 she asked for a heart scan as she was becoming very breathless, had put on a great deal of weight especially in her chest, her blood pressure was very low, and every time she went on the machine she would get the chills. She had open sores under her left breast. I was being told that she was not being compliant in her eating and drinking which was why she was so ill, there was an intimation that she would die if she did not start to comply. No doctor or dialysis nurse seemed to consider any other possibility why my daughter had all these symptoms. By this time I had bought her a wheelchair as she could not walk for more than a few steps. April 23rd I brought her to the hospital for the heart scan, she was barely conscious and I believed that she would die on me as I was driving her. She was not allowed to leave the hospital as a large mass was to be seen on the scan. After tests she was found to have a massive infection, she was taken to Papworth were she had open heart surgery. Despite telling us that her survival was not assured she lived another 4 years, with a damaged heart. If my daughter had not from somewhere within her had the wit to ask for that scan she would have died in 2007.
5. She was told that she would need valve replacements. This became obvious at the beginning of 2011. Also at the beginning of 2011 my daughter started to loses muscle mass, her breast shrank to nothing, her belly started increasing in size – so much so that several people asked her if she was pregnant. Both a cardiac consultant at Addenbrooke’s, as well as the Consultant surgeon at Papworth was aware of this. However it was not noted by any of the renal team, neither nurses or doctors or consultant. I have been told that the ascites was covert.
6. My daughter knew she was dying, we knew she was dying. The hospital I believe knew that she was dying but could not agree on how to talk to us. We spoke to the renal registrar the Thursday before Dani died in order to get an overview of her problems and to request that a different consultant be appointed. None of this conversation has been noted I have been told. My daughter did tell the registrar that she believed she was on the brink of multi organ failure – she was assured that this was not so and that once her infected ascites had been dealt with she would be able to have her heart valves replaced and would be able to go back onto the transplant list. She was also told not to worry about her gross malnutrition.
7. I am still trying to get a copy of the incident report from 2007. A few nurses said they were sorry that my daughter had been so ill, but there was no acknowledgment from anyone that there was a fault in care and observation that led to this massive infection. The reason that I wish to see this report is to find out if the systems have changed and that what happened to my daughter will not happen to anyone else.
8. I also wish to know why no one noticed how badly distended my daughters belly was in 2011, she was a thin young woman who wore very skimpy tight clothes – not difficult to miss a large swollen abdomen I would have thought.
9. My question is how could the same department make 2 similar series of mistakes?
10. And why when offered was the idea of an autopsy not taken up? Apart from everything else my daughter had a very rare syndrome Frasier syndrome and Addenbrooke’s is a research hospital. Exactly why she died we will never be sure, her heart failed, yes but why did she have ascites with listeria in it? The ascites was not typical, so again surely they would have wanted to know so that it could not happen to anyone else? There are still many questions, many of which I will never get answers to. At some point very soon I suspect that this will come the way of the PHSO but from all that I have heard it will not get me the answers nor will it change in any way the way that Addenbrooke’s deal with people with multi-morbidities.
I am sorry but much of what I have written about my daughter is written about elsewhere and at greater length.
December 2012
Written evidence submitted by Brenda Prentice (PHSO 6)
Thank you for the opportunity to submit my evidence to the PASC. This will not be an academic piece of work, I have no qualifications. I am just a mum who came to PHSO on many occasions in the hope of some justice for my son, he has since died. All I have is experience of using the service. I think that should be important and it should be listened to.
I understand no individual cases will be considered, I will use my case for illustrative purposes only. Please see attached.
My concerns in no particular order. • Accountability. When a 'review' of a decision is asked for by a complainant, what is reviewed is the way a decision is reached and not the decision itself. It should be obvious if a review is offered and responded to, then what is needed is a review of that decision.
1. Last year Ann Abraham told the committee that the Court Justice System is where accountability is tested. No one has won a Judicial Review, the PHSO have a 'get out of jail free' card, it's called 'discretion'. Ms Abraham also said anyone can take a JR to court, it is not expensive and there is no need for a solicitor. She also said that the PHSO always asks for costs. This path is not an option for ordinary people. Where is the accountability? I can see none.
2. If a NHS complaint procedure is seen as satisfying a 'Complaint Procedure' the complaint will be rejected, 98% of complaints are not dealt with. The fact that the NHS Complaints Procedure may have been incomplete or misleading, or even not be true is not taken into consideration. Where is the justice? • Perverse. The PHSO look for 'maladministration'. Their interpretation can be so huge that is defies common sense.
1. A Director of Public Health upheld a decision by a GP that someone with 5 major health problems, including no Pancreas, was not medically vulnerable. The outcome of this statement was that the person can 'sleep on the streets without detriment, the same as any other homeless person'.
2. Question. Where does someone who is homeless keep insulin in a fridge as directed? Where can prescribed morphine be kept in a secure place, as the law requires? There is no answer.
3. After a complaint was not upheld, a FIO request showed that the GP was investigated and 'took early retirement', he was an alcoholic. The Director of Public Health moved to another job! None of this was shared with the complainant. He was just left homeless with no help whatsoever. PHSO said it was a LGO complaint as it was a housing decision, housing said they took advice from Meds! Where is the justice?
• Fairness
1. Experience using a contracted organisation, (lCAS, paid for by Dept of Health) to bring a case to the PHSO. Their remit is to advise and support complainants to navigate through the system. A case is presented to PHSO by lCAS. The advisor is inexperienced and new to the job, There is no support, line management or peer review for the advisor.
She presents a 29 page report. After discussion with PHSO it is thought a shorter report is required so it is withdrawn. A 26 page report is sent to PHSO! Complainant told by ICAS advisor; 'no it's not too long it's what they (PHSO) want'. Nine complaints made, the only one upheld was already admitted to and apology made.
2. Complainants complaint to lCAS up held by lCAS and apologised for. BUT the poor presentation had no bearing on the fact that no complaint was ever looked at by the PHSO! Sight of contract between Dept of Health and lCAS revealed lCAS clearly didn't fulfil the terms of the contract, another complaint, not up held by D of H!!!
3. Some complaints can be 'considered' for a very long time. This may take a complaint over the 'time bar' for court proceedings. The number of complaints investigated is about 2%
4. PHSO have commissioned a 'Complaints Review' but I can't find the terms of reference.
• Advice. PHSO take medical advice from their advisors. The advice can be asked from someone in the wrong discipline. Therefore the advice maybe somewhere near what it should be, but not near enough for a sensible decision. Quotations from guidelines can be quoted but not in its entirety, it then becomes misleading.
1. Complaints are not listened to there is no consultation as to the right discipline to be approached for advice.
2. I have contacted Sir Jon Shortridge, Brian Landers, Mei Sim Lai. On PHSO committee. None have come back to me. The word sinecure comes to mind.
• Conclusion
PASC have responsibility for PHSO. It seems to me there are two ways forward.
1. Give the Ombudsman better guidance on what is expected of such a service with emphases on justice for members of the public who only have this path to use. We know there is much dissatisfaction by looking at 'Whatdotheyknow' a FOI website and Ombudsman Watch. This is just a tip of the iceberg as most people are too worn by their experience to make further enquiries.
If this is the best that can be provided as a service to the public, then save the £34 million per year and put it to better use. Restore cuts to the Legal Aid budget and allow some (which is better than none) proper accountability by way of initiating proceedings with no reference to PHSO. PHSO with no accountability is a waste of public funds.
November 2012
Written evidence submitted by Alan Reid (PHSO 7)
The service provided by the Ombudsman and her team
Summary
• The Ombudsman comes across as a body so preoccupied with demonstrating its transparency that procedures and alternative scenarios must be explained in detail, and precisely adhered to. Transparency can be taken too far when it is so prescriptive. • Introducing a stage where a complainant is telephoned for no obvious reason can lead to the impression that an attempt is being made to get the complaint dropped. • The Ombudsman needs to look at its data protection policies, notably the passing of details to a market research organisation apparently without conditions and without prior permission (complainants must opt-out instead of opting in). • The requirement to submit an admissible complaint via an MP simply extends the procedure (for how long will depend on the MP’s priorities), and leads to unnecessary complications. • In any case, the Ombudsman must make clear that it is not necessary to pass through the (current) constituency MP and, in the case of complainants outside the UK, make clear that it is not necessary to pass through the chairman of the PASC if the complainant knows another MP who would be willing to act. • In the case of my complaint against the UK Border Force, it should be explained why the complaint has been switched to the UK Border Agency, meaning that an executive agency is responding to my complaint against a Home Office operational command.
1. This submission recounts experience of the handling by the Ombudsman of a complaint against the UK Border Force. After over three months since sending in my admissible complaint, the Ombudsman has yet to arrive at a decision on whether to undertake an investigation. I was sufficiently disconcerted at the internal procedures that I recently wrote a letter of complaint to the Deputy Ombudsman (as required). After receiving an acknowledgment chit in which I am described as “Complainant/aggrieved: REID ”, the reply from an Assessment Manager recognised to differing degrees the pertinence of points now made in this submission. The reply is marked ‘In confidence’. Apart from the mention of the name of the complaint handler who confusingly called me in advance of my receiving the letter that this handler would be calling me (paragraph 11), I see nothing confidential in the content. Therefore, in the interests of transparency (notably for paragraph 13), and bearing in mind that the Ombudsman is an officer of Parliament, I have drawn upon that reply in this submission. I believe that complaints concerning the level of service by the Ombudsman (i.e. not the decisions) should be handled by some kind of independent adjudicator and not by an Assessment Manager communicating in confidence.
2. As a British national without a constituency MP (because I have been out of the UK for too long and not because I am a prisoner), I enquired by e-mail what to do if the final reply from the UK Border Force was not satisfactory. A Customer Services Officer advised that “…you will need to ask a MP to pass on your complaint to us… Bernard Jenkin MP, Chair of the Parliamentary Administration Select Committee, will pass on complaints from people living outside the UK who do not have constituency MPs.” This form of wording is confused. Firstly it indicates that one can go though any MP, but then implies that one must go through the constituency MP. Secondly, in the case of complainants living outside the UK, the wording implies that they can only go through Mr Jenkin. In my case, I would have preferred to have gone through one of a number of MPs whom I know personally.
3. When the time came to ask the Ombudsman for Mr Jenkin’s contact details, the response of 17 August 2012 was quite a long e-mail telling me how to complete the complaints form and how to compose my letter to Mr Jenkin, then explaining what Mr Jenkin would do, and then what the Ombudsman might do under various scenarios. My as yet un-submitted complaint to Mr Jenkin was given a number and even a deadline for receipt by the Ombudsman. I really did not understand why my simple request for an address needed such a complicated answer.
4. I posted my completed complaints form, with my covering explanation and attachments of some ten pages, on 27 August 2012 to Mr Jenkin. One month passed before I knew that my complaint had arrived either with Mr Jenkin or the Ombudsman. On 28 September 2012, I received an e-mail from a Customer Services Officer, who said that my complaint was received on 17 August 2012, which could not be correct. Until that point, I had to assume that Mr Jenkin, possibly aided by his committee staff, had dealt with my completed form expeditiously, so that there was no reason for him to acknowledge receipt, on the premise that the Ombudsman’s service would acknowledge receipt soon after. In fact, I learned from the Assessment Manager that the Ombudsman received my complaint on 17 September 2012.
5. The Customer Services Officer’s e-mail of 28 September 2012 opened with a reference to “having completed our initial checks”, and then went into some detail on what the Ombudsman’s service might or might not do in the future. The next stage would be a “closer look”, and in the stage after that my complaint would be passed to “the person who will deal with your case”. This person’s job description is then given, including possible contact with Border Force, and contact with me “to arrange a time to discuss your complaint”. The next stage would be “once we have looked at all the information, we will decide whether we can help you” and five scenarios are set out for resolving my complaint without a formal investigation.
6. The first scenario was whether Border Force were “still considering your complaint” , so it seems that the initial check did not even extend to examining the form signed by myself and then by Mr Jenkin. Under question 2, I had of course ticked that I had completed the UK Border Force formal complaints procedure. After all these ins and outs, I am finally told that ‘if we feel we need to look in more detail at your complaint we may decide to do a formal investigation’. With this fuzzy wording, the Ombudsman service becomes less than transparent about when it would do a formal investigation.
7. I received the ‘discussion’ phone call at lunchtime on 16 October 2012. I pointed out that I did not have my papers in front of me (and remember it had been nearly two months since I had last looked at them), but I accepted to proceed, simply because I thought my submission was perfectly clear, and I could not see what there was to discuss. My interlocutor said she wanted to be sure that she well understood my complaint. I thought it was perfectly clear that I was complaining that I would be illegally prevented by the UK Border Force at Brussels Midi and at St Pancras International from entering my country unless, in addition to my British passport, I produced my train ticket for stamping and checking.
8. To explain, the UK Border Force officer at Brussels Midi said that he was asking for my ticket under the Immigration Act 1971, Schedule 2, thereby in my view obliging me to produce my ticket in addition to my British passport. The UK Border Force official at St Pancras International said that he was asking for my ticket as a customs check (i.e. under the Customs and Excise Management Act 1979) to know where I was coming from. In my view this was an abuse of power to conduct a customs check on all intra-EU passengers in this way. In reply to my subsequent written complaint, the UK Border Force finally said that the requirement to produce my ticket to the Border Force officials was under Schedule 4 of the Channel Tunnel Act (!).
9. My interlocutor then asked how I was inconvenienced, which rather astonished me, with the implication that not being able to enter my country, unless I submitted to what I consider was an illegal request from UK Border Force, would just be an ‘inconvenience’. My interlocutor then asked why it was such a problem for me to produce my ticket, and I told her that her questioning was beginning to make me angry. This was because I had gone though all the procedures – asking the officers at Brussels Midi and St Pancras for their complaints procedure, submitting an official complaint to UK Border Force, assembling a dossier for Mr Bernard Jenkin for forwarding to the Ombudsman – yet here was an employee who was apparently not concerned with the Ombudsman’s principles for public bodies, including complying with the law and having regard to rights.
10. In my view, this telephone call was unnecessary, but apparently it had to be done, because that is the procedure which must be followed. The result was a one-sided line of questioning with my interlocutor effectively dismissing my written argumentation that none of the three legal bases cited by the UK Border Force for requiring a ticket to be produced were valid, having regard to the European Convention on Human Rights (“No-one shall be deprived of the right to enter the territory of the State of which he is a national”), EC Directive 2004/38 and UK Immigration rules. I concluded that there was no purpose in further discussion, and I wanted the Ombudsman to get on with a formal investigation. In reply to my letter of complaint, I have been assured by the Assessment Manager that the Ombudsman service is acting objectively.
11. On 17 October 2012, the day after the telephone call, I received a letter of 15 October 2012 from a Business Support Officer. The letter informed me that “your case has now been assigned to….……….. for a more detailed further assessment and that assessment will form the basis for our decision on whether or not to undertake an investigation of your complaint”. The conjunction of the letter of 15 October, received on 17 October, and the telephone call of 16 October was rather confusing since, even if I lived in the UK, in all probability I would not have read the letter before the telephone call.
12. I would make two remarks on data protection. Firstly, I am told that that e-mails from the Ombudsman may have details removed, including mention of the UK Border Force. Naturally, I do not want to have any details removed, and I am not going to remove details from any e-mails of mine. In any case, I am not sufficiently aware of UK data protection legislation to know what details I ought to remove from my e-mails, and anyway I do not understand the logic. A letter can be intercepted in all sorts of intentional and unintentional ways e.g. in shared accommodation, by a family member, or because the letter was put in the wrong letter box, or wrong pigeon hole in the office. Be that as it may, I have asked for correspondence to be conducted by post. On the other hand, the Ombudsman freely passes complainants’ contact details to an external research company unless complainants write to opt-out. I certainly do not want my telephone number passed to a research company in the UK. My understanding of the law is that i) complainants should have to opt-in rather having to opt-out of personal data being passed to a third party and ii) complainants should be told of the conditions under which their data are being given to the research company. In response to my letter of complaint, I have been told that my details had not yet been communicated to the research company. I recognise that these are peripheral points, but they are further examples of the way the Ombudsman bamboozles complainants with procedures.
13. The Ombudsman’s letter of 17 October 2012 was headed “Your complaint about the UK Border Agency and the UK Border Force”. As a UK national, I do not require a visa to enter the United Kingdom, and so I asked in my letter of complaint why the Ombudsman had brought in the UK Border Agency. I was told that any complaints regarding UK Border Force are still considered by the UK Border Agency. Ordinarily, this arrangement might be none of my business, nor that of the Ombudsman, but I find it distinctly odd on two counts. Firstly, my original complaint to the UK Border Force was replied to by the UK Border Force and not by the UK Border Agency, and the Ombudsman’s e-mail of 28 September 2012 said they “may talk to UK Border Force”, so why the switch now? Secondly, the two bodies are not equivalents. The UK Border Force is a Home Office “operational command”, which to me essentially means a police force under the Home Secretary, yet complaints against this force are being handled by a directly-managed executive agency.
December 2012
Written evidence submitted by Which (PHSO 8)
Direct access to the Parliamentary Ombudsman
1. Which? welcomes the opportunity to submit written evidence to the Committee’s enquiry into the PHSO. We would like to raise one issue with the Committee which relates only to the Parliamentary Ombudsman’s work –enabling direct access to her service and removing the MP filter.
2. Which? is an independent, not-for-profit consumer organisation with around 1 million subscribers and, as such, is the largest consumer organisation in Europe. Which? is independent of Government and industry, and is funded through the sale of Which? consumer magazines, online services and books. Our advice and information services, including our Which? Legal Service and Money Helpline, assist consumers, including signposting them to appropriate redress mechanisms including the Parliamentary Ombudsman.
3. In August 2011, the Ombudsman consulted on removing the MP filter so that complainants would have direct access. In November 2011, the Ombudsman reported her findings that the vast majority of respondents supported this move. Like Which?, they supported a dual track system allowing complainants the option of either making a complaint through a MP or directly.
4. At that time, the Ombudsman said she would conduct a joint survey of MPs with this Committee, the PASC. At the same time, the Law Commission’s report ‘Public Services Ombudsmen’ recommended a number of changes to modernise the legislation governing public sector ombudsmen in England and Wales, including reform of the MP filter.
5. Which? agrees with the Ombudsman that the Government could remove the MP filter and allow direct access to the Parliamentary Ombudsman either through an amendment to the legislation that governs the Ombudsman’s Office, or do so as part of the wider strategic review recommended by the Law Commission. However, over one year later, it is disappointing to note this small but important change has not yet happened and it is not clear when it will happen.
6. Why does Which? support direct access to the Parliamentary Ombudsman?
Our views were laid out in our response to the Parliamentary Ombudsman’s consultation and, put simply, it is about consumer empowerment. The Which? mission statement is highly relevant; it states that 'Which? exists to make individuals as powerful as the organisations they have to deal with in their daily lives', in other words through empowering consumers. It is our view that requiring complainants to refer any complaint via a MP completely undermines genuine consumer (or citizen) empowerment.
We believe a MP filter goes against the grain of what the Government itself would like to see; in April 2011 the Cabinet Office and BIS produced a report 'Better Choices, Better Deals' which was all about how people can help themselves. The then Consumer Affairs Minister concluded "We want to see confident, empowered consumers able to make the right choices for themselves and be able to resolve problems when things go wrong".
We can see no reason at all why a person should not be able to directly access the Ombudsman if that is the route they wish to take for whatever reason they might have. For instance, it might be that they are willing and able (in other words, empowered already) to pursue their complaint themselves; it might be that they do not want to involve their MP for a particular reason or do not have confidence in their MP to support their complaint; or it might be that their complaint in some way involves their MP. Our support for removing the MP filter is however predicated on access to the Ombudsman only being possible once a complainant has exhausted the relevant 'in house' complaints process.
However, though we support direct access, we do also favour retaining a link to the MP. We therefore favour the dual track approach as some people, possibly a majority, will prefer to use their MP to help champion their case. That route should not be closed off.
We have one additional point to make which relates to retaining the link to the MP. This can be important for a different reason than giving the MP the role of filter. As long as any data protection concerns can be met and the complainant agrees, we would support the local MP being informed that one of their constituents had a 'live' complaint before the Ombudsman including key information about that complaint. We think this could be helpful to the MP to know so that they are aware of alleged failures by Government Departments and their delegated agencies, and can, when appropriate, take this up through parliamentary devices such as parliamentary questions, adjournment debates and EDMs. It may also be of importance to the MP even if they are not involved in the complainant's specific case as the complaint may in fact be a systemic problem rather than just an individual isolated case.
7. We urge the Committee to work with the Ombudsman to ensure that direct access to her service is implemented as soon as practicable.
December 2012
Written evidence submitted by Dee Speers (PHSO 9)
Summary: • I realise you don’t investigate individual complaints and I am using this information as an example of how serious complaints are often dealt with, Therefore, I am not expecting anyone specific to deal with it: • In August 2005, my 29 yr old son died whilst detained under Section 2 of the MHA “for own safety” in Duty of Care of West London Mental Health Trust. • There was no police involvement, no weapon was secured (or ever seen) and WLMHT failed to submit key documents for Inquest hearing. • Trust CEO and senior management team left posts and Board also stepped down. • WLMHT is a Trust with “secure status” (as they also manage Broadmoor Hospital and Feltham Young Offenders Institution) hence “line of sight by Secretary of State for Health
History of Complaint!
1) This case was upheld by the Healthcare Commission under the three tier complaints system. It was escalated to PHSO and the then PHSO Ann Abraham took the case with her to 2 tier complaints system. 2) The case was left in “reconsideration” for over 6 months then refused again, despite the PHSO case managers opinion in 2010 that there was still an “un- remedied injustice”.
3) To quote further from PHSO External Reviewer Para 4 “There is no doubt that the Trust failed in its Duty of Care to Richard and the follow up to his death was badly handled. That has left a deeply grieving mother convinced that justice has not been done to the memory of her son and sceptical as to whether lessons have really been learned.” 4) Most worrying aspect is lack of honesty shown to PHSO office by SHA Investigation Manager who stated that I had agreed and was happy with the Terms of Reference for the SUI Investigation (which incidentally was offered almost 6 years after my sons death) 5) Not only did I not agree Terms of Reference and was deeply unhappy with them, but I only allowed the SUI to commence if my family’s feelings were noted on Terms of Reference page. This was done and can be evidenced! 6) On 16 March 2010 I received a letter from then PHSO Ann Abrahams detailing why she wasn’t offering an investigation. and I quote “let me try and explain why our decision was not, as I fear you believe, an attempt to sweep the issues under the carpet. Rather it was because we considered that follow up action by the Care Quality Commission,(CQC) with its broader remit is a faster and better way to assure that lessons are learned than could be achieved through a further investigation on our part.” Please be aware there was no investigation into my sons death at all by CQC and the only comment made by CQC was referring to the Patient Safety Investigation we secured via the Healthcare Commission (who completed it before it closed its remit) the final Report was published by CQC. http://iapdeathsincustody.independent.gov.uk/news/cqc-publishes-report-into- west-london-mental-health-trust/. I have subsequently used information from that investigation to inform various public inquiries and ‘listening exercises’.
7) Most of this has occurred in the transitional period between Ann Abraham and current PHSO Dame Julie Mellor. 8) Re Dame Mellor’s handling on this case. There have been endless reviews, external reviews and clearly an acceptance of misinformation from WLMH Trust and Strategic Health Authority NHS London. The fundamental failures of admittance that my son was failed and lack of notes appears to have been glossed over with usual “soothing words” of how I have achieved much so far in my sons name. But of course nobody can tell me what this is! 9) Clearly the inpatient death of a 29 yr old man, detained by the State’s agents “for his own safety” and he was not kept safe does not appear to warrant further investigation!
10) Letter dated 28th March 2012 confirms Dame Julie’s non- acceptance of the Health Select Committees recommendation for a “complete role overhaul”. This recommendation came from the “Complaints and Litigation Inquiry” which also found ”NHS Complaints system is not working” http://www.parliament.uk/business/committees/committees-a-z/commons- select/health-committee/news/11-06-28-clreoprt-substantive-/ and to quote the findings ” The Health Committee has found that the role of the Health Service Ombudsman needs a complete overhaul if it is to provide an effective appeals process for the complaints system”. It appears from the letter I have been sent that the PHSO states “So there is no “overhaul” taking place as a result of the Health Committees Inquiry. Having said that, I am very keen to develop the Ombudsman’s office. Therefore., I have commissioned a review of the longer term plans of this office. We aim to produce a plan at the end of 2012. This plan should outline how we achieve more impact for more people, whilst recognising that we do not have the remit of regulators and inspectorates such as the CQC.
10a) My comment here is clearly the PHSO process is NOT an effective appeals process for NHS complaints. …therefore “NOT FIT FOR PURPOSE” And as Parliament found “NHS Complaints system not working and role of PHSO In need of a “complete overhaul” that has effectively left us, the paying public, with no working complaints system or appeals system for well over a year! I believe the data on number of complaints investigated by PHSO is not impressive either. I believe less than 2% are actually investigated and PHSO process costs in excess of £30m per annum. What for?
11)Dame Mellor also said in her letter to me “To help make my plans to achieve more impact for more people, I am sure that I would benefit from hearing directly from you about your experience of NHS Complaint handling and any ideas you have about how my office can improve. This could be either by us meeting or having a phone conversation.
11a) Then with incredible lack of tact, I have to say, PHSO continued: “I should make clear that I am not suggesting that we discuss the details of your complaint about Richard’s care. That is not because I do not care but because I have nothing to add to what I and Ms Abraham have already written to you. I would not want you to think that if we have a conversation I will be in a position to answer any further questions about what happened to Richard or how the NHS had responded, the lessons it has learnt.. I realise in saying this I am imposing restrictions on any conversation we might have. You might not be prepared to accept such restrictions . If that is the case then we should not talk, I must be absolutely clear to you because the last thing I want to do is raise your expectations that I will be able to give you answers which I simply do not have. What about listening and learning?
11b)I wrote back on 14th April accepting the offer of a meeting (for the other families I may be able to help, I was willing to try and not discuss my sons case. ) I also asked various process and system questions based on my need for answers. I was amazed when on 2nd May 2012 Dame Mellor wrote and stated “In my letter of 28th March I hoped I had made it clear that the purpose of any discussion we might have was not to discuss the details of your complaint about Richard’s care. Rather, I explained that I wanted to talk to you about your experience of NHS complaint handling and any ideas you have about how my office could improve on its current approach” .
11c) I was staggered to think that I should not be able to question systems and processes as per my democratic right and I said this in my letter dated 25th May I am also horrified to think that as PHSO, Dame Mellor is not prepared to listen to my complaint…as lessons have clearly not being learned! I suppose I am left wondering how I could possibly comment on my experience of NHS Complaints and not mention my son….his tragic death is fundamental to the whole experience.
12) I felt I was being “closed down” and thankfully this was corrected by PHSO on 25 July 2012 .I still feel confused by the PHSO unwillingness to learn any more from our family, all of whom were willing to meet with her. It was in this letter that I heard that Baroness Fritchie had been commissioned to undertake a review on complaints and I was informed my complaint was going to be included in Baroness Fritchie’s review.
13) Meanwhile I and another campaigner James Titcombe, whose complaint re his baby sons death was also going for the complaints review, wrote to Dame Mellor and asked if we could agree Terms of Reference for Baroness Fritchie’s Review. We were told the Terms of Reference were on the website but we couldn’t access them! Subsequently we had an offer to take part in the review but we felt we needed to agree Terms of Reference…we never did get the opportunity and last communication from PHSO office stated Baroness Fritchie’s Review had almost been completed.
14) In conclusion I feel there is a serious discrepancy between expectation and actual remit. If PHSO is an appeals process for NHS complaints then should difference between PHSO regulators and inspectorates remits be made clearer?
Also if Health Select Committee found need to recommend “complete overhaul of role of PHSO, why didn’t Public Administration Select Committee find this during their scrutiny meeting just three weeks earlier?
I have also asked the above before on previous occasions and have not had an acknowledgement.
I attach again for your consideration my idea for a possible effective complaints process: I have presented this #1-6 to the Health Select Committee when I gave evidence and have heard no more . I believe complaints system need to be independent of NHS.
I now believe SMART(er) #7 must be employed across all services for a less fragmented approach. …see below:
Possible solution to ineffective NHS Complaints service
1. All complaints on avoidable deaths, across all services , MUST be ‘truly’ independently investigated.
2.Building on Advocacy experience, Independent Complaints Advocacy Service (ICAS) could oversee the complaints process….if totally independent of DH & NHS
3.Funding would come from a ‘complaints pool’ funded by all Trusts.
4 Trusts who failed to resolve the complaint at local level aka “local resolution” must pay substantially more into the pool. This would have the added benefit of saving money (as we would no longer need the ineffective PHSO process. ) Local resolution would mean not escalating complaints to the PHSO.
5. In fact the £32m odd that the PHSO service currently costs the tax payer annually, may not be needed as the PHSO service only investigates less than 1.5% of complaints, has never investigated a reconsidered complaint, despite keeping it in ‘reconsideration’ for up to a year.
6. All investigation reports must be aligned to show where service failures have not adhered to National Service Framework, local and national policy and NICE guidance.
7. Ideally across all services, SMART(er) targets replace random fundamentally flawed ones: • Specific (what is it?) • Measurable (what is needed?) • Achievable (Can this be done?) • Realistic (What is the learning from this?) • Timebound (By when, what timeframe?) Only then (Evaluate and Review) for continuous improvement.
December 2012
Written evidence submitted by James Titcombe (PHSO 10)
Summary
I first became involved with the Parliamentary and Health Service Ombudsman (PHSO) in early 2009, following the preventable death of my son due to failures in his care at Furness General Hospital (FGH) in November 2008.
I understand that the PASC is unable to examine the individual circumstances of our case, but I wish to draw your attention to some specific issues which should be considered as evidence relating to the general administration, operation and functioning of the PHSO in the context of the committee hearing.
Part 1 -The process followed by the Ombudsman prior to refusing to investigate Joshua's case and the refusal of the PHSO to properly deal with my subsequent complaints in relation to this. Serious discrepancies between statements made by the Ombudsman's office and the clear documentary evidence available regarding what actually happened. I will set out why I believe that the Ombudsman's own complaints handling process falls seriously short of the standards and values it promotes for NHS bodies.
Part 2 - The lack of transparency or clear terms of reference in relation to the Baroness Fritchie review. I was initially told by Dame Julie that she was commissioning a 'piece of work' specifically to learn lessons from the handling of our case. I will explain why I have concerns about the process and objectivity of this work and that I have been refused the opportunity to meet with Baroness Fritchie, or indeed the opportunity to submit evidence for consideration as part of this work.
Part 3 - The separate complaint I made in relation to the North West Strategic Health Authority (NWSHA). This complaint was initially refused for investigation and subsequently this decision was upheld by the review. Subsequent to this however, I started legal proceedings against the PHSO and wrote a 'letter before claim'. This resulted in the Ombudsman re-reviewing their decision. The second review concluded that the reasons given for refusing to investigate 'did not stand up to scrutiny'. The complaint is now being formally investigated along with three other similar complaints about the NWSHA in respect of perinatal and maternal deaths at Furness General Hospital (FGH). My submission will explain why I am concerned that this experience may indicate more widespread failures of practice within the PHSO decision making process that remain hidden, with potentially very serious implications. I will set out my submission as concisely as possible, referring to other documents for more detailed information.
References
I have included the following documents for reference with this submission:
A. ‘Ombudsman dishonesty.pdf’ – Extracts of letters and emails from the PHSO relating to conversations between Cynthia Bower and Ann Abraham that appear to contradict.
B. ‘UHMBT Failure – The role of the CQC and Ombudsman.pdf’ – Detailed evidence and commentary in support of this submission.
C. ‘Letter from Dame Julie 22 June 2012.pdf’
D. ‘Dame Julie 9th Nov 2012.pdf’
E. ‘Ombudsman Second External Review – April 2012.pdf’
Part 1. - The PHSO involvement in my complaint about my son's death.
1. I wrote to the PHSO in early 2009, requesting an investigation into the circumstances of my son's death, due to failures in his care at Furness General Hospital (FGH) in November 2008.
2. After a protracted period of 'consideration', the PHSO wrote to me in February 2010 confirming that they would not be carrying out an investigation into my son's death. The following two primary reasons were given.
3. "As you know, despite thorough searches, the records for the first 24 hours of Joshua’s life are still missing. The staff involved had been interviewed on more than one occasion. It is unlikely that they would now change their accounts of the events and for this reason, in the absence of records, a further investigation is not likely to reach a firm finding of what took place and why".
4. " One of our concerns has been to make sure that the CQC was fully aware of the issues arising from Joshua’s death and was actively overseeing the work of the Trust on its action plan. The CQC does indeed have the Trust closely under review and is looking to see positive outcomes from the action plan before its concerns will be reduced."
5. The turn of events following the PHSO decision not to investigate Joshua's case is now a matter of public record and has been extensively reported in the national media, most recently in the Panorama film 'How safe is your hospital' broadcast on 3rd December 2012. In summary, just two months after the PHSO decided not to investigate Joshua's case, the Care Quality Commission (CQC) registered Morecambe Bay Health Trust 'without conditions'. Subsequent reports state that 'significant risks' to mothers and babies at FGH continued into late 2011, when eventually, following an inquest into Joshua's death, the Coroner issued a rule 43 letter and Monitor and CQC took drastic actions. See.
http://www.independent.co.uk/news/uk/home-news/watchdog-waited-two-years-to- act-over-failing-maternity-units-7985986.html
6. Following this very sad turn of events at FGH maternity unit, I have sought to understand more regarding the regulatory failures that led to such serious risks being unaddressed for so long. In early 2012, I made DPA subject access requests to CQC, Monitor, Morecambe Bay Trust and the PHSO for all information relating to Joshua's case.
7. Over the last few months, I have carefully reviewed the information provided and this has led to very serious concerns which I have attempted to raise appropriately with the bodies involved. The most serious issues include the following.
8. Information from the PHSO which demonstrates the depth of concern of senior PHSO officers prior to the refusal to investigation Joshua's case. These include the following statements made within the PHSO case files.
9.‘We already have a significant amount of information to suggest that the Trust did not follow the usual procedures following Joshua’s death and that they did not achieve a clear view of what had happened as a result’ – Kathryn Hudson (Deputy Ombudsman).
10.‘I am concerned that this case may be demonstrative of a service failing with the Trust’. – (PHSO caseworker)
11. ‘Given the Trust’s apparent failure to handle Mr Titcombe’s complaint in a satisfactory manner, he has not been provided with a reasonable response to his concerns about events surrounding his son’s death.’- (PHSO caseworker)
12. Information obtained from the Trust which raises serious concerns that inappropriate collaboration took place between Tony Halsall, the former Chief Executive of Morecambe Bay and CQC. This includes an email dated 2nd June 2009, in which Tony Halsall writes to Eddie Kane (the former Chair of the Trust) as follows.
‘If I’m correct then the CQC can cover off the Ombudsman in their response if they are prepared to have that conversation with them which they didn’t indicate they were not’.
13. The above email led to me having concerns that the CQC may have influenced the Ombudsman inappropriately to bring about a decision not to investigate my son's death. I raised this directly with the Ombudsman but I was reassured that this was not the case.
14. However, when I subsequently obtained information from the PHSO in response to my subject access request, clear evidence was obtained suggesting that indeed such inappropriate conversations took place at the highest levels of both the CQC and the PHSO. This evidence included the following.
15. A memo from Kathryn Hudson to Ann Abraham dated 10th September 2009 (attached), which stated 'In your conversation with Cynthia Bower shortly before your leave, the suggestion arose that if we could assure Mr and Mrs Titcombe that as a result of their experience CQC are now taking robust action to ensure improvements in the quality of maternity services in the Trust, you might decide not to investigate'.
16. Given that no documented record of any conversation between Cynthia Bower and Ann Abraham existed in the case records, and given the significance of the conversation which the memo from Kathryn Hudson clearly demonstrates took place, I sought an explanation from the PHSO about the matter.
17. On 17th August 2012, the Ombudsman's office wrote to me as follows.
'We have told you that the conversation was brief and merely served as a way to establish a contact for Kathryn Hudson. There is no record of the conversation other than in Kathryn Hudson’s minute and so we cannot provide any further details about it. Again, I appreciate you think that the conversation must have been more detailed and significant than described, but it was not.'
18. However, contrary to this assertion, once I received the information requested under the DPA from the CQC, yet more records referring to a detailed conversation between Cynthia Bower and Ann Abraham relating to Joshua's case emerged. These included the following.
19. An email from Kathryn Hudson to Amanda Sherlock (CQC) dated 4th September 2009, which states the following.
'My understanding from Ann was that she had discussed this very sad case with Cynthia in order to consider the best way of handling it. We have not yet made a decision on whether to accept it for investigation and are aware of your interest and that of Monitor. I had thought that Cynthia had suggested there might be a better way to deal with the issues involved through other assessments of the quality of the Trust and the future of midwifery services in the North west'.
20. It should be noted that this email correspondence was not released to me by the PHSO, as I believe it should have been under my DPA subject access request.
21. I have included copies of the original documents relating to the above with this submission. Please refer to reference document A.
22. From reviewing the clear evidence available, it is hard to conclude any other than that Cynthia Bower and Ann Abraham met and discussed the circumstances of my son's death in detail.
23. The emphasise of these discussions, from the records available, shows that Cynthia Bower had suggested that the PHSO would not investigate Joshua's case.
24. This is consistent with the opinion of the Chief Executive of Morecambe Bay, expressed in his email to the Trust's Chair on 2nd June 2009 (see paragraph 12).
25. I have detailed these concerns to the PHSO and have repeatedly asked for a second external review of the circumstances leading up the decision taken by Ann Abraham in February 2010, not to investigate Joshua's case.
26. All requests have been refused and the position of the PHSO remains that the conversation between Cynthia Bower and Ann Abraham was merely to 'establish a contact for Kathryn Hudson'.
27. The PHSO have subsequently emailed me confirming that they will not respond to my detailed letters about this issue and are refusing to discuss the concerns with me further.
28. I am concerned that the facts outlined above demonstrate that the PHSO does not operate openly and transparently and does not take responsibility or accountability for the actions it takes.
29. The response to my complaints to the PHSO relating to these issues does not appear to be consistent with the principles of good complaint handling which the PHSO advocates that NHS bodies themselves should adopt.
30. It is very serious because further preventable deaths took place following the refusal of PHSO to investigate the death of Joshua.
31. It is arguable therefore that lives would have been saved had PHSO acted in accordance with the concerns expressed within their organisation that appear to have been overruled.
32. I have recently met with David Behan, the Chief Executive of the CQC, whom I reviewed this evidence with in person. Mr Behan expressed great concern and sympathy regarding the evidence provided and has subsequently confirmed he has widened the remit of an ongoing investigation into CQC’s involvement in Morecambe Bay to include these issues.
33. This demonstrates that other organisations are taking the issues seriously yet the approach from the PHSO could not be more different.
Part 2. - The review being carried out by Baroness Fritchie
34. Following correspondence between myself and Stephen Dorrell MP relating to the circumstances described in this submission, Dame Julie wrote to me on 22nd June 2012.
35. I have provided this correspondence as part of this submission. Please refer to reference document C.
36. In this letter, Dame Julie accepted that the circumstances surrounding Joshua's case were ‘unsatisfactory’; particularly that the interventions at the Trust were undertook as a result of the Coroner's inquest some years later, rather than through a PHSO investigation.
37. This letter stated 'I am commissioning an external piece of work that will consider the lessons learned from our handling of your complaint'.
38. However, the letter went on to state that Dame Julie would not allow an external review of the decision not to investigate Joshua's case and described the decision made as 'reasonable'.
39. I was unhappy that from this letter, it appeared that the proposed piece of work would hold the fact that the decision taken in relation to Joshua's case was 'reasonable' as a pre determined conclusion. I felt that the terms of reference for the review were unclear and I raised these concerns with the PHSO and stated that I did not want to be associated with the piece of work unless the terms of reference were made clear. I expressed that such a review could only be meaningful if the conclusions and recommendations were made following an independent review of the evidence, not before.
40. In the subsequent months, I continued along with another complainant (Dee Speers), to seek to clarify the terms of reference of the review. During this time, the terms of reference seem to have evolved from the description of the proposed piece of work outlined to me in Dame Julie's letter of 22nd June, to now involving a review of '100 cases' concerning cases of potentially avoidable death in the NHS. Please refer to reference document D.
41. Furthermore, my requests to meet with Baroness Fritchie to go over the concerns expressed in this submission, have been refused. I have not been permitted to submit evidence for consideration of the review and I understand that no one involved in the review has been invited to submit evidence for consideration.
42. It is therefore not possible in my view to regard the Baroness Fritchie investigation commissioned by Dame Julie as being a valid piece of work with the genuine intention of considering 'the lessons learned’ from the Ombudsman’s handling of our case; rather I see the review as being a way for the PHSO to appear proactive in light of likely criticism from Robert Francis and in light of the previous failure of the Ombudsman to implement the clear recommendations of the Health Select Committee report made by Stephen Dorrell MP last year.
43. I am concerned that the external work being carried out by Baroness Fritchie appears to have been carefully designed to ensure that the detailed evidence available in relation to our case is not available and therefore cannot properly be considered as part of an open and objective review.
Part 3. - My complaint to the PHSO in relation to the North West Strategic Health Authority (NWSHA).
44. Please refer to the document 'Ombudsman Second External Review - April 2012', reference document E.
45. This document details the circumstances relating to my complaint about the NWSHA in relation to my son's death in a very clear, accurate and concise way. I will therefore not repeat this detail in the main body of this submission but refer the committee to this document for the background information.
46. Subsequent to the second external review by , the PHSO reconsidered my complaint and have since opened a full investigation of my concerns which is being carried out in conjunction with similar complaints made by three other families relating to infant and maternal deaths at FGH.
47. In summary, my complaint relating to the NWSHA was dismissed by the Ombudsman and their first review supported this decision.
48. However, following the start of legal proceedings against the Ombudsman, a decision was made to have a second external review.
49. This second external review was highly critical of the initial decision made and concluded that the reasons given for not investigating 'did not stand up to scrutiny'.
50. It is my opinion that these circumstances raise very serious questions about the objectivity of the PHSO decision process and the objectivity of the PHSO review process.
51. I am concerned that other decisions made in relation to other cases may also fail to 'stand up to scrutiny'.
52. I am concerned that the first external review, which was carried out with full access to exactly the same information as that made available to , reached such different conclusions regarding the decision made.
53. I am concerned that the circumstances exposed by this review, may be demonstrative of more widespread process failures in the PHSO decision making process that remain hidden because of the rarity of the sort of scrutiny carried out by and that this has very serious implications.
54. I believe there is an urgent requirement to introduce sample audits of PHSO decisions and reviews to ensure such process failures are not more widespread.
54. I therefore have no confidence in PHSO and feel that their failings warrant further, proper, independent investigation. My family's attempts to discover the truth about my son's preventable death have been hindered and obstructed by PHSO, making it more difficult for us to move on and come to terms with our loss.
55. I believe that the current framework and operation of the PHSO allows avoidable deaths in the NHS to go without proper investigation. I feel that this represents a fundamental flaw in the current NHS two tier complaints system that must be urgently addressed if situations like Morecambe Bay are to be avoided in the future
December 2012 Written evidence submitted by Action Against Medical Accidents (AvMA) (PHSO 11)
Summary of Issues Covered
• Introduction • Capacity of the Health Service Ombudsman to investigate complaints not resolved at the local level • Inappropriate refusals to investigate • The Ombudsman’s relationship with Regulators • Transparency and Accountability of the Ombudsman • Appendix with examples of correspondence re legal action decisions
1. Introduction
Action against Medical Accidents (AvMA) is the specialist charity working for patient safety and justice. AvMA provides free independent specialist advice to over 3,000 members of the public each year who have been affected by a medical accident. The vast majority of our ‘clients’ have been affected by medical accidents in the NHS in England, and our advice to these invariably includes advice about the NHS complaints procedure including the role of the Ombudsman, as well as other rights and routes to raise concerns or seek redress. We have a specialist team of medico-legal advisers. We have significant experience of supporting complainants bringing a complaint to the Ombudsman spanning 30 years.
We have the greatest respect and admiration of the Ombudsman as an institution and enjoy a good relationship with the Ombudsman and many of her staff. Are comments in this submission are designed to be helpful in generating discussion as to how the Ombudsman Service could be improved so as to benefit complainants, patient safety and the NHS. We consider ourselves a ‘critical friend’ of the Ombudsman – the best kind of friend a public body can have.
2. Capacity of the Ombudsman to investigate unresolved complaints
We remain deeply concerned about the consequences of the move to a two stage NHS complaints procedure and removal of the right of complainants to seek an Independent Review of their complaint which previously was available from the Healthcare Commission. We fear that as a result of limited capacity at the Ombudsman’s office, many complainants are unable to challenge responses from NHS bodies by referring to an independent body. In 2007-2008 the Healthcare Commission carried out 7,827 independent reviews. In 2011-2012 the Ombudsman carried out just 328 NHS cases were investigated by the Ombudsman. In 2007- 2008 the Ombudsman investigated over 100 NHS cases when complainants still had access to an Independent Review from the Healthcare Commission, so only around 200 extra cases are being investigated now. Notwithstanding the fact that the Ombudsman is now ‘taking a closer look’ at a number of complaints and where possible seeking a remedy without having to conduct a full investigation (a pragmatic approach which we applaud), this still leaves a ‘black hole’ in which many dissatisfied complainants are left. There is no evidence to suggest that the NHS Complaints Procedure itself is operating significantly better than before and leaving complainants satisfied. Whilst those that are helped by the Ombudsman are very appreciative, there are many complainants who are left without any formal independent investigation and holding NHS bodies to account, which the old Independent Review could provide. However well intended, informal help from the Ombudsman is no substitute for a formal independent investigation in many of these cases. We believe the Ombudsman requires more of the resources which had previously made available to the Healthcare Commission for Independent Reviews, so that more investigations can be conducted and also agree with the Health Select Committee recommendation (6th Report, Complaints and Litigation, 2011):
“50. Many people see the role of the Ombudsman as a general appeals process for the complaints system, but the remit under the Health Service Commissioners Act is much narrower than that. The Committee is of the view that a complainant whose complaint is rejected by the service provider should be able to seek independent review. The legal and operational framework of the Ombudsman's office should be reviewed to make it effective for this wider purpose.”
3. Inappropriate refusals to investigate
We remain concerned that some complaints to the Ombudsman which really should be taken on for investigation are being inappropriately turned down. There is inevitably a pressure on the Ombudsman to operate a high threshold to accepting complaints for investigation due to the capacity issues referred to above. However there are two reasons for rejecting complaints for investigation which we think are most commonly misused: the fact that a complainant may be taking legal action (or even just considering taking legal action) over an issue related to the complaint; and subjective decisions made as to whether a ‘worthwhile outcome’ is perceived to be obtainable from an investigation.
We have seen a number of cases where we feel the complainant has been unreasonably denied an investigation by the Ombudsman on the basis that they are making a clinical negligence claim for damages or even that they are simply considering doing so. In 2009 the Department of Health changed the Complaints Regulations so that taking or considering legal action should not get in the way of a complaint being investigated. However, the Ombudsman’s regulations are separate and the Ombudsman is not allowed to investigate if the complainant has or had “a remedy by way of proceedings in any court of law” (HSC Act 1993 s 4). Unfortunately, some of the Ombudsman’s staff have been interpreting this as meaning that the Ombudsman can not investigate cases if the complainant has commenced or intends to commence legal action for a clinical negligence action related to incidents which form part of the subject matter of their ‘complaint’. See the Appendix for examples of correspondence confirming this interpretation.
This approach is completely out of keeping with the new approach in the NHS Complaints Procedure, of which the Ombudsman is the crucial last remaining independent stage. We believe it is grossly unfair, damaging to public confidence in the Ombudsman, and that it is based on a misinterpretation or misapplication of the Ombudsman’s regulations. The remedy which a complainant is seeking from the Ombudsman is rarely if ever primarily compensation. Although this is one of the remedies that the Ombudsman can recommend includes some form financial compensation, this is not intended as a substitute for damages which might be awarded by a court. Complaints to the Ombudsman invariably seek accountability of the body complained about ; explanations and apologies; establishing the truth and actions to put root causes of the problem right. A clinical negligence claim on the other hand can only deliver compensation and none of the other remedies which are the main concern of the complainant.
We have raised this issue with the Ombudsman but recent feedback suggests that wrong advice is still being given by Ombudsman staff on this matter. The Ombudsman’s complaint form still asks the question whether legal action is being taken or considered, which is gives the impression this would stand against a complaint being investigated. The only circumstance in which we can imagine it being legitimate for the Ombudsman to refuse to investigate due to a clinical negligence claim, is if the only outcome the complainant is seeking from the Ombudsman is compensation for the damages sustained. There should be an explicit statement from the Ombudsman to this effect and written guidance and training provided to staff about this.
With regard to the refusal to investigate on the basis of “no worthwhile outcome” we would go further than the Health Select Committee (6th Report, Complaints and Litigation, 2011):
“49. The terminology "no worthwhile outcome" which arises from the Health Service Commissioners Act is being used in communication with complainants. Several have told us that their complaints were rejected because "no worthwhile outcome" could be achieved. The Committee recommends that the Ombudsman urgently reviews the use of this terminology in correspondence as it appears significantly to undermine public confidence in the complaints handling process.”
This is not just a matter of communication. We have seen very disappointing uses of this reason for not investigating a complaint. Within reason, it should be a matter for the complainant as to whether the potential outcome is ‘worthwhile’ and the Ombudsman should restrict her considerations as to whether there is still a case to answer. An individual taking on an NHS body can be a ‘David and Goliath’ struggle. Complainants can be faced with a wall of denial and only have the Ombudsman left to rely upon. Having it confirmed that you were right and making an NHS body face up to that is extremely important to individual complainants but also to public confidence in and accountability of public bodies like the NHS.
4. The Ombudsman’s relationship with regulators
The removal of the Independent Review stage form the national NHS regulator (the Healthcare Commission as was) means that it is imperative that the Ombudsman relays information to the regulator (now the Care Quality Commission) as quickly as possible where there are potential patient safety or serious governance issues. There needs to be absolute clarity about how and when this should happen and there should be openness with the complainant about this in individual cases.
5. Transparency and Accountability
We believe that public confidence in the Ombudsman could be enhanced if there were greater transparency about the way in which she operates and also some clearer forms of accountability or independent input into and review of her processes. The bottom line is that we should be able to expect at least as much from the Ombudsman on these issues as we and she would expect of an NHS body. However, whilst her independence is vital, the Ombudsman is sometimes perceived by our clients as a ‘law unto herself’. We have given one example in (4) above of where absolute transparency with a complainant should be guaranteed. We would refer you to the submission of one of our clients, Mr James Titcombe, for an example of how this is not necessarily the case.
At the moment there is no form of appeal about a decision by the Ombudsman not to investigate a complaint or over a response to a complaint. The only way to hold the Ombudsman to account is through a judicial review. However, a judicial review is very expensive indeed and realistically way beyond the means of an ordinary man or woman. We have heard examples of where having refused to investigate a complaint even after reviewing the initial decision, when faced with a threatened judicial review, the decision being reversed. These cases are not made public and there is no feedback on how the original faulty decision came about and what lessons have been learnt to improve decisions in the future.
Clearly there needs to be a final port of call, however we believe that it should be possible to build in more independent input and transparency into the Ombudsman’s work. This would be more fitting for a 21st century Ombudsman service and more in tune with the move towards more transparency and accountability in all our public bodies.
Amongst the ideas we would like to out on the table are:
‐ A more formalised process for reviewing decisions not to investigate complaints internally, with independent specialist advice being made available to complainants to support them in seeking a review ‐ Public reporting of complaints made to the Ombudsman about the Ombudsman and reviews of decisions not to investigate ‐ involvement of at least one independent scrutineer in reviewing complaints and reviews of decisions ‐ Independent audit of a sample Ombudsman decisions and investigations with report back to the Ombudsman and made public ‐ An annual independent report on the performance of the Ombudsman service
December 2012
Anonymous submission (PHSO 12)
Short Summary
1. The Parliamentary and Health Service Ombudsman (PHSO) needs to review its staff training in children’s safeguarding roles, the engagement of staff in children’s safeguarding and governance arrangements, and its procedures for handling cases involving children’s safeguarding.
Statement
2. A letter dated 20th February 2012 provided the PHSO’s response to a complaint about my GP. A letter dated 18th April 2012 requested a review of the case but this was rejected by the PHSO. The PHSO explained that in considering cases it looks at treatment of a patient and not the accuracy of a diagnosis. The rejection of my complaint against my GP by the PHSO does not bear scrutiny. An advocate from the Independent Complaints Advocacy Service gave the impression that while my case was valid, he was unsurprised at the verdict. I had the impression that the PHSO’s staff while publicly rejecting my complaint appreciated the injustice of the decision. In March 2012, following an inspection Ofsted reported that children’s safeguarding in was inadequate and NHS Trusts were criticised.
Expertise of GPs
3. In 2003, my GP was confronted with making specific allegations of mental health problems against me. had just read a lot of information on the side effects of Parkinsonian medicines. Her allegations were very light on observational evidence but she used a lot of emotion to emphasis her case. At the same time, I was describing a lot of observations of which I thought might be some form of unhealthy sexual behaviour. My GP thought that side effects of Parkinsonian medicines in me were suspects. In 2004, I reported concerns regarding behaviour towards , and in 2007 I reported further concerns that might indicate serious abuse. From 2003 until 2009, my GP did not give serious consideration to the possibility that my concerns were founded in reality.
4. I doubt whether my GP has any expertise in sexual addictions and therefore she was unable to say reliably whether my observations described a sexual addictive problem. Neither do I think it likely that my GP is an expert in child abuse in families. She had to trust who can easily be shown to be a highly practised liar with regards to these matters. I wonder whether the PHSO’s clinical adviser, an experienced GP, has expert knowledge of sexual addictions or abuse which transcends generations in families. I would speculate that the Ofsted’s criticisms of NHS Trusts in apply to both my GP and the PHSO’s clinical adviser.
My GP’s treatment has been unreasonable
5. I largely held the same concerns regarding behaviour from 2003 to 2007, although for short periods because of circumstances, pressure and denial I would passively accept that I was mentally ill. Consistently since 2007 I have held the same concerns. If my GP says I was mentally ill in 2007 then I have been mentally ill ever since. My GP has failed me. If I am mentally ill then I have not been treated. If I am not mentally ill then my GP has failed to act on my concerns.
6. At least since the autumn 2009, I believe that my GP realises that I have no psychiatric or mental problems and she has made grave mistakes. She was unable to provide sensible explanations to questions or points raised during two local meetings.
Drug induced mental side effects
7. The PHSO says it was reasonable for the my GP’s Practice to offer to write a statement saying I had no history of “mental illness” and that my symptoms were thought to be as a direct result of drug induced side effects. Since no doctor has been able to list my psychiatric or mental symptoms I doubt whether the PHSO could state my symptoms. The constant accusations of mental or psychiatric problems without proper explanation are abusive.
8. This statement contradicts the opinion of my current Consultant Neurologist who said I was either mentally ill or not, but not mentally ill due to Parkinsonian medicine. In May 2004, I described with present my observations to a Consultant Psychiatrist who said that the assertion that was suffering some form of sexual problem was not unreasonable. In 2007, told me that she suffered “obsessive sexual thoughts”. In 2007, a second psychiatrist said my children and me should be given safe haven from the influences of . I wonder what documents were supplied to the PHSO by my GP’s Surgery.
9. In September 2007 after a month under the care of third Consultant Psychiatrist, he shook my hand and told me that “he just didn’t know” presumably referring to my mental health. In October 2007, he told me I had no psychiatric or mental conditions which needed referring to the DVLA. At a meeting in December 2008, I described to this Consultant Psychiatrist how unprofessional my then Neurologist had been. The Consultant Psychiatrist became and remained flustered saying “you won’t get them to admit that they’re wrong”. For the first time in 16 months having never referred to any concerns regarding my mental health he then said he thought I had possibly been delusional. My GP is aware that the Consultant Psychiatrist’s opinion belatedly changed.
Consequences
10. The only rational conclusion that can be drawn from the concerns regarding is that a thorough investigation is needed. The findings of the PHSO make this less likely. In the meantime the adverse effects of this debacle on health and well being will continue and probably worsen. Others, including Council, will continue to be affected. I would roughly estimate that this debacle has so far cost the tax payer £50,000. My trust and respect for the authorities is evaporating.
Conclusions
11. Quite rightly both my GP and the PHSO’s clinical adviser considered the possibility that the side effects of Parkinsonian medicines might explain my concerns regarding behaviour. Both have acted unreasonably in failing to consider the possibility that my concerns were founded in reality. Probably neither has the expertise to form a reliable opinion and neither has sought additional expert advice. Since my concerns suggest child abuse neither has acted in the interest of my children.
12. I fail to understand when the diagnosis that I am mentally ill due to Parkinsonian medicines has been so discredited how it is possible that my GP’s treatment can be found by the PHSO to be reasonable. I wonder whether my GP was selective in supplying records. I wonder whether a full investigation by the PHSO would have improved the chances of a fair outcome. The PHSO has not acted in the interests of children.
December 2012
Written evidence submitted by Uncaged Campaigns (PHSO 13) Ombudsman failure to adequately investigate evidence of Home Office maladministration In April 2003, Uncaged published over a thousand pages of confidential documents contained in two leaks from Imutran Ltd (spring 2000) and the Home Office (October 2002), together with the report based on those documents1. Uncaged had argued that the documents revealed breaches of legislation and inaccurate public statements on the part of Imutran, and official misconduct on the part of the Home Office in its implementation of animal research regulations. Therefore, Uncaged submitted, the public interest in revealing such wrongdoing outweighed the claims for commercial confidentiality. Legal aid had been awarded following a decision by the Legal Services Commission’s Public Interest Advisory Panel (PIAP) that the case raised particularly significant matters of public interest, and that the Defendants’ had a good chance of success in the case insofar as the documents demonstrated Home Office misconduct. At this point in proceedings, Imutran and Novartis offered to settle out-of-court and a new Court Order was agreed on 31 March 2003 authorising publication of over a thousand pages of documents listed by Uncaged as demonstrating the key public interest elements of the case.
While the outcome of the legal proceedings appears to confirm the evidence of Home Office misconduct, the Government continued to refuse to establish an independent inquiry. Following the submission of memoranda by Uncaged and the Home Office, in 2004 the Home Affairs Select Committee declined to launch their own inquiry, citing their existing workload, the complexity of the case and the time elapsed since the research programme. In December 2006, following a three year investigation hampered by staff absences2 and, as explained below, an apparent difficulty in understanding the regulatory system, the Parliamentary and Health Service Ombudsman (PHSO) laid before Parliament a final report3 that dismissed Uncaged’s complaint of maladministration in respect of the Home Office’s regulation of Imutran’s research (PHSO, 2006).
1 www.xenodiaries.org 2 The PHSO’s draft decision letter dated 4 May 2005 stated: ‘[T]he investigation of the complaint has been interrupted on more than one occasion by illness, which has meant that the case has had to be considered by several different officers, which has led to significant delays’ (paragraph 2). 3 http://www.ombudsman.org.uk/__data/assets/pdf_file/0007/3877/Home-Office-regulation-of-animal- experimentation.pdf
Uncaged’s complaint had explained that where procedures were allowed to continue until the point where the animals were found dead, instead of the animals being killed at or before the specified endpoint, then the endpoint and its corresponding moderate severity limit categorisation had been breached. In response, the Ombudsman stated: In considering the explanations given by the Home Office, the Ombudsman's staff have noted that death, in itself, does not appear to constitute a breach of the moderate severity limit within 'The Guidance on the Operation of the Animals (Scientific Procedures) Act 1986'. This view is supported by the 'Report of the cost-benefit working group of the APC’ which considered 'The weight assigned to "death of an animal" in itself (i.e. in absence of suffering)'. Within that heading they weighed various arguments put forward on whether a humane death (that is one without suffering) should be included in the cost/benefit assessment. A number of indirect 'harms' were put forward, which could be caused by the death of an animal, and that might be considered within the cost/benefit assessment. The report observed, however, that 'whilst these potential harms are important and should be considered within the cost-benefit assessment, they are not relevant to the question of whether death in itself is a harm'. (paragraph 13)
However, the Ombudsman’s reasoning fundamentally misconstrued the complaint and the role of endpoints in limiting suffering. Uncaged’s complaint was not based on the argument that 'death, in itself… constitute[s] a breach of the moderate severity limit’. Instead, the complaint was based on the fact that animals were allowed to suffer up until the point of death, i.e. that death was the de facto endpoint in some instances. Uncaged did not assert that ‘death in itself’ counted as harm in this regulatory context. On the contrary, we argued that the animals should have been killed earlier in the procedure in order to comply with the moderate severity limit. In reviewing their decision, the Ombudsman dismissed these submissions from Uncaged, falsely claiming that they did not add to previous complaint submissions.
Concerns about the adequacy of the PHSO investigation were intensified by subsequent comments by the-then Ombudsman Ann Abraham to the Public Administration Select Committee in February 2011: We might [investigate], if there was a wider public interest. I am trying to think of an example that would help you, and most of the examples I can think of are where the wider public interest is in the possibility of the Ombudsman saying there was not maladministration. One of the cases we looked at some years ago was a complaint, again referred by many MPs and many complainants, about the regulation of the animal experimentation industry, and concerns that the regulation was not being carried out properly. There was a lot of outrage, a lot of concern, and a lot of distress about all this, and some very unhappy people. We did a very thorough investigation and we were satisfied that
actually everything was being done reasonably, in accordance with the requirements of the regulatory regime. We produced a public report to say that. Now actually the wider public interest was in the Government Department concerned being able to say "The Ombudsman has looked at this, and this is being done properly." So there are lots of circumstances in which we would say that it is worth us doing this.4
However, given the basic error at the heart of the Ombudsman’s exoneration of the Home Office and their repeated refusal to take Uncaged’s submissions seriously, these comments raises questions regarding at what point in the investigation did the Ombudsman decide there was a public interest in maintaining confidence in public institutions (regardless, it appears, of whether they actually deserved that confidence)? Relevant to this concern is the Ombudsman’s position on the issue of severity limit breaches in their draft decision letter issued on 4 May 2005, which differs markedly from their final report:
7. When considering complaints concerning decisions that are reliant on professional judgements, The Ombudsman would not normally seek to substitute her judgment for that of relevant expert. You will appreciate that there are many such decisions within this case, and this confines our legitimate interest to the overall process governing this area.
…
13. Whilst there would appear to be an element of subjectivity involved in the assessment of severity decisions about what severity limit to apply to the various procedures were a matter for the Inspectorate’s professional judgement and expertise. I do not see any basis upon which this Office could seek to question their assessment of the position (paragraph 7). In the light of that, and as I can see no evidence of administrative fault by the Home Office in their handling of this matter, I can see no grounds for the Ombudsman’s further intervention in the matter.
It is hard to reconcile the PHSO’s original decision to sidestep the issue of severity limits because it were deemed to be beyond their competency, with the subsequent assertion that they ‘did a very thorough investigation’ and were able to legitimately claim ‘The Ombudsman has looked at this and this is being done properly’. When considered in conjunction with the Ombudsman’s misrepresentation of the difference between the harm caused by ‘death-in–itself’ compared with ‘death–as-an-endpoint’ in the final report, it is hard to avoid the conclusion that the Ombudsman’s motivation for exonerating the Home Office had little to do with the facts of the case.
December 2012
4 http://www.publications.parliament.uk/pa/cm201011/cmselect/cmpubadm/781/11020902.htm accessed on 29 November 2011.
Written evidence submitted by Parliamentary and Health Service Ombudsman (PHSO 14)
INTRODUCTION
1. We welcome the opportunity to give evidence to the Public Administration Select Committee before the session on 18 December 2012 on our 2011-12 Annual Report, Moving forward, and also on other matters since Dame Julie Mellor was appointed in January 2012.
2. This memorandum covers our casework performance, the learning we have taken to inform our new Strategy 2013-18 and management of the organisation including our finance and people.
CASEWORK PERFORMANCE
3. The details of our casework performance for the business year 2011/12 are set out in full in our Annual Report.
4. Following on from previous comments both from this Committee and the Health Committee we presented our statistics in a way that we hope explains more clearly all the work that we do, including how we resolve complaints without the need for a formal investigation.
5. In 2011/12 we did a detailed assessment of 4,732 enquiries. We found that there was no case to answer in 3,552 cases. For 759 cases we put things right quickly without the need for a formal investigation and in 421 cases we decided that a formal investigation would deliver the best outcome.
6. As in previous years, we received a very high percentage of complaints (74%) from people who either had come to us before they received a final response at the local level or approached us without an MP referral (for our Parliamentary jurisdiction). In those 15,589 cases we helped people to make their complaint either to the appropriate organisation or to us.
7. We have provided our figures for the past three years below, in this new format, to facilitate a comparison.
Casework 2009/10 2010/11 2011/12 Enquiries received 23,667 23,422 23,846 Enquiries resolved 24,240 23,667 23,889 Advice provided on the right organisation to 3,318 3,340 3,298 complain to Help with making a complaint to an organisation 16,273 15,591 15,859 within our jurisdiction or to us Cases that received a closer look 4,649 4,736 4,732 Closer look – we found there was no case to answer 3,900 3,728 3,552 Closer look - we put things right quickly without the need for a formal investigation 393 605 759 Closer look - we accepted the case for formal investigation 356 403 421 Investigations concluded 322 419 410 Fully upheld 47% 61% 60% Partly upheld 25% 17% 20% Not upheld 28% 22% 20%
8. We are very proud that in 2011-12, we met five of the six customer service standards that we set ourselves. We fell short of one of our standards – concluding 79% of investigations within 12 months against a standard of 90%. The three main factors contributing to this were:
• Growing resistance from organisations to our recommendations for remedy at the point we have completed our investigation and issue a draft report. This can lead to a delay in the issuing of our final report and formal closure of the case; • We focused on clearing older cases during 2011/12; and • Some investigations are more complicated than others, for example an investigation about Cafcass’ complaints process took less than 3 months whilst an investigation about the care and treatment of someone with learning disabilities who tragically died took over 15 months.
9. Our mid-year performance figures for 2012/13 show that we are currently meeting six out of six of our customer service standards. Sustaining that performance until the end of the year will be challenging, partly due to the issues highlighted above, but we will continue to work hard to provide the best possible service for our customers.
10. Our performance against our service standards for the past three years is shown below.
Service Standards 2009/10 2010/11 2011/12 Mid-year 2012/13 Acknowledge 100% of email enquiries within 1 working day 100% 100% 100% 100% Acknowledge 100% of written enquiries within 2 working days 100% 100% 100% 100% Close 90% of enquiries within 40 working days 78%* 91% 91% 91% Conclude 90% of investigations within 12 months 65%** 88% 79% 91% Acknowledge 95% of complaints about us within 5 working days 96% 96% 96% 98% Resolve 90% of complaints about us within 16 weeks 93% 99% 99% 97%
Note: *Target was 80% in 2009/10, **Target was 55% in 2009/10
11. Acceptance of our recommendations remains high, as does compliance with those recommendations (100%). Compliance in line with our target date (generally 4 weeks for an apology or payment and 3 months for an action plan) is improving but needs to improve further.
Compliance 2010/11 2011/12 Mid-year 2012/13 Acceptance of our recommendations 100% 100% 99% Compliance by target date 35% 51% 60%
Customer satisfaction
12. We undertake customer satisfaction surveys on a quarterly basis and publish a summary of those results on our website. The latest summary will be published in December. The overall satisfaction level in 2011/12 was 82%, compared to 88% in 2010/11. Results from those surveys show that a customer’s view of whether they have ‘won’ their case significantly affects their satisfaction levels with the service we have provided. The Financial Ombudsman Service’s (FOS) satisfaction survey reveals a similar result. In 2011/12 the average satisfaction rate with the service PHSO and FOS provided for those who feel they have ‘won’ is over 80%, whereas it is around 50% for those who feel they have ‘lost’.
Investigations PHSO PHSO PHSO Financial 2009/10 2010/11 2011/12 Ombudsman Service 2011/12 Upheld 90% satisfaction 94% 88% 89% satisfaction Not Upheld 67% satisfaction 63% 50% 52% satisfaction
Published reports
13. During 2011-12 the previous Ombudsman laid nine reports before Parliament about our casework. These were discussed with the Committee at her final appearance in November 2011, before her retirement.
14. By the time of the Ombudsman’s appearance on 18 December 2012 we will have laid four more reports before Parliament about our casework.
Joint report with LGO about section 117 aftercare (October 2012) 15. Section 117 of the Mental Health Act provides for patients who have been compulsorily detained under the Act to receive free aftercare. The complaint related to the standard of mental health care provided by Avon and Wiltshire Mental Health Partnership NHS Trust and Wiltshire Council to the complainant’s late mother, in particular that the mother had to fund her own care in a residential care home.
16. This joint investigation by the Health Service Ombudsman and the Local Government Ombudsman did not uphold the complaint. While the complainant’s mother was found to have had severe and enduring mental illness over many years, her period of residence in a care home, in the last years of her life, could not be linked to aftercare arising from compulsory detention in hospital some 15 years earlier. Her general deterioration could not be attributed definitely to her mental health problems, so it could not be concluded that the care home fees should have been met from public funds.
A false economy (October 2012) 17. The Planning Inspectorate’s decision to close its ex gratia payment scheme in March 2011 as part of its plans to reduce spending, forced people to escalate their complaints to the Ombudsman to seek compensation.
18. The Planning Inspectorate’s decision not to compensate individuals who were left out of pocket because of the Inspectorate’s own mistakes was unfair, unjust and a false economy. As a result of the Ombudsman’s investigations, the complainants received individual payments to put right the financial impact of the Planning Inspectorate’s failures as well as additional compensation in recognition of the inconvenience they had experienced. We made clear in our report that the most cost effective way to resolve complaints is to do so properly, and as early as possible.
19. Our report cautioned government organisations against refusing to pay compensation when their mistakes have left individual members of the public footing the bill, and concluded that individuals must not bear the cost of government errors.
Listening & Learning 2011/12 (November 2012) 20. In November 2012 we published our third annual review of NHS complaint handling in England. We found a significant rise in the number of complaints where the NHS had failed to provide an adequate remedy or proper apology when things had gone wrong. The report concluded that the NHS still too often fails to communicate effectively with
patients and families. We highlighted the importance of the NHS Commissioning Board working to embed good complaint handling across the new NHS landscape and providing guidance on good practice.
Responsive & Accountable 2011/12 (December 2012) 21. In December 2012 we published our second report on the complaint handling of central government. The report highlights that people still find it too hard to complain, and often do not because they feel it will take too long, that they may get a worse service if they complain and that complaining won’t make a difference. When people do make a complaint, our research shows that 36% feel they’ve not been listened to or kept up to date and 46% feel they’ve not been taken seriously. The report acknowledges that everyone makes mistakes, but, highlights that too many basic mistakes are not being handled properly and are then escalated to us. It concludes that in a time of budget constraints, failing to resolve complaints at an early stage costs the public purse more in the long run.
22. In last year’s report Ann Abraham highlighted inconsistent and haphazard complaint handling across government. We are pleased to say that the government has started to take action to address our concerns through work on a set of high level standards that will be applied across government, and in formalising a Cross-Government Complaint Handling Forum through which best practice can be shared. We are also pleased to note that the Head of the Civil Service, Sir Bob Kerslake, has agreed to explore the possibility of feeding information about Government Departments’ performance on complaint handling into the reporting and appraisal arrangements for Permanent Secretaries.
OUR STRATEGY 2013-18
23. Our new strategy, published in December 2012, sets out how we will work over the next five years to deliver more impact for more people.
24. The strategy has been developed after taking views from the public, Parliament, advice and advocacy groups, some of the most complained about bodies in our jurisdiction, regulators, and professional bodies.
25. This process has revealed a clear unmet need among the public for: • simpler, clearer information about how to complain; • a better, more efficient complaints system; and • the public to have more confidence that complaints will make a difference.
26. This reflects PASC’s 2008 report that highlighted the confusing array of methods for complaining to government. These findings were backed up by our own 2011 report, Responsive and Accountable, which described the cross-government complaints system as inconsistent, haphazard and unaccountable.
27. To address this will require action from the leadership of the civil service and from all organisations within our jurisdiction.
28. We can also contribute to achieving this. To help meet this need, our strategy sets out how we will:
• Make it easier for people to find and use our service; • Help more people by investigating more complaints and provide an excellent service for our customers; • Work with others to use what we learn from complaints to help them make public services better; and • Lead the way to make the complaints system better.
29. In order to achieve our strategic aim of delivering more impact for more people we believe the legislative framework governing our activities needs modernisation. We believe we should be able to conduct investigations on our own initiative and the public should have direct access to all of our services.
30. We also want to build our relationship with Parliament by sharing more learning from complaints and supporting them in holding Government and public services to account.
ORGANISATION
Financial resources
31. We met all of our funding and financial targets in 2011/12 and are on track to meeting them in the current year and delivering our financial strategy and remaining within our flat-cash Parliamentary funding settlement.
32. Our performance over the past three years is shown below.
Parliamentary Funding & Internal 2009/10 2010/11 2011/12 Mid-year Financial Targets 2012/13 HM Treasury Target Net Resource DEL within Budget Met Met Met Meeting Net Capital DEL within Budget Met Met Met Meeting AME within Budget - - Met Meeting Total Net Resource within Budget - - Met Meeting Total Net Capital within Budget - - Met Meeting Net Cash Requirement Met Met Met Meeting
Internal Targets: Resource Budget underspend <£500k Not Met Not Met Met Meeting Capital Budget underspend <£100k Not Met Not Met Met Meeting Net Cash Requirement Met Met Met Meeting Payment target Met Met Met Meeting Resource Budgets within 2% Not Met Not Met Met Meeting Resource Budgets by Month within 2% Not Met Not Met Met Meeting Income Recovery Not Met Not Met Met Meeting
Note: Internal targets in 2009/10 and 2010/11 were not met as a consequence of changes in capital investment (leading to less capital spending and commensurately lower resource depreciation).
People
33. We have provided information below on our staff turnover, sickness absence, workforce diversity and staff engagement over the past three years for comparison.
PHSO staff turnover
2009/10 2010/11 2011/12 Mid-year 2012/13 All Staff 11.8% 9.0% 9.4% 11.1%
PHSO staff sickness
Target 2009/10 2010/11 2011/12 Mid-year 2012/13 Fewer than 6 days per 5.0 days 6.1 days 5.3 days 5.9 days year/FTE
Workforce Diversity
Workforce measure 2009/10 2010/11 2011/12 Benchmark
BAME London 15.6% 18.8% 17.8% 19% BAME Manchester 2.0% 5.2% 5.6% 6% Disabled London 7.4% 7.9% 9% 4.7% Disabled Manchester 3.4% 4.2% 10%
Staff Engagement Index Score
Indicator Staff survey Staff survey Interim Employee 2009 2011 Engagement Survey 2012 Engagement Index N/A 73% 69% Score (new)* Engagement Index 79% 80% N/A Score (old)*
*The Employee Engagement Index uses questions which measure the extent to which employees want to “Say”; “Stay” and “Strive”. The average positive score from the selected questions is used to calculate the overall Engagement Index score. The table shows two indices – this is because in 2011 we decided to use a more ‘challenging’ set of questions for a ‘new’ Engagement Index Score. For reasons of continuity and comparability we used both the ‘old’ and ‘new’ Score in the 2011 survey. In the latest Interim Survey in 2012 we only used the ‘new’ score. This means that we can compare the 2009 and 2011 ‘old’ scores and the 2011 and 2012 ‘new’ scores. But we cannot make comparisons between the ‘old’ and ‘new’ scores over the years.
Strategic Plan 2013-18
34. We are in the process of developing our strategic plan that will enable us to deliver our strategy. We are confident that any activities arising from our new strategy will be affordable within our current resources as we have used continuous improvement and investment funding provided for within our Baseline.
35. By spring 2013 our strategic plan will be agreed and the business planning to deliver the first year underway. We would be happy to update the Committee in more detail then.
36. To support the Ombudsman in her executive reponsibilities, she has appointed a Chief Operating Officer, Helen Hughes, who took up post on 3 September 2012. Helen Hughes will be directly accountable to the Ombudsman for ensuring effective management of the organisation.
37. Since Dame Julie Mellor’s appointment, we have been reviewing the governance arrangements that were established by the previous Ombudsman. These were fully appropriate in meeting the needs of her office and her responsibilities as set out in our Statement of Responsbilities. We are now looking to strengthen these arrangements and
bring them more into line with current corporate governance expectations in the wider public sector and beyond.
38. The office is therefore in a period of transition, with an organisational review under way, including a review of our senior management structure, to underpin our refreshed strategy and the change in priorities and process that entails.
December 2012
Written evidence submitted by Patrick Cockrell (PHSO 15)
I refer to your Public Administration Select Committee announcement dated 16 November 2012, which you sent to me.
My evidence is with regard to the PHSO’s handling of my request for a Statutory Investigation into the ‘failure of the public consultation process’ recently carried out by the EA
This relates directly and solely to a formal complaint I had made against the EA, namely that of the ‘Failure of Public Consultation Process’ as regards the proposal to construct & operate a large incinerator plant in the Loughborough/Shepshed conurbation of eighty- five thousand inhabitant.
SUMMARY
My complaint against the PHSO’s handling of my complaint against the EA is several- fold but can be summarized as:
- Slavish adherence to Departmental process whereby if a member of the public raises concerns about the way their original complaint (about an outside organization) has been handled/reviewed by a PHSO staff member and senior management agree with these concerns i.e. it was not deemed to be a sound decision to reject the request for a statutory investigation, then it must be passed over to the Review Team to consider this ‘internal’ complaint; and, if you argue that the subsequent decision made by that member of the Review Team is also incorrect and again senior management agree with these concerns then yet again it is passed to yet another member of the Review Team …..and so on it goes (in my case there were three attempts by the PHSO before they sent me their final letter). This process may be satisfactory in some cases but has its problems for the member of the public concerned because the rules appear to dictate that you can only make complaints/challenges about specific issues raised by the last reviewer and not about previous issues raised with earlier reviewers or new issues. This results in a frustrating and disjointed form of communication
- Following the PHSO’s third review they sent their final letter stating that they would not accept any further correspondence. I again failed to agree with their summary as it failed to see the wider-picture i.e. that a formal investigation was in the Public Interest
- Selective quotations from my correspondenc
- Failing to assign staff with a sufficient logical intellect
- Tendency to apply strict legal interpretations where normal common sense should prevail.
1. Background: It is important to understand that eight days after the end of the public consultation period I informed the EA that a large amount (over 30%) of the information in key tables in their public consultation document, that the decision making process relies upon, was wrong,
The EA include these key tables in order to demonstrate to the public and other statutory authorities that their Statutory Limits of airborne pollutants have not been exceeded. However, upon studying these tables I came to the conclusion that the data in these tables was incorrect and it was illogical for the EA to state that these Limits had not been exceeded as it was impossible to deduce this from the data presented and therefore the public had been misinformed and consequently the consultation process was flawed and not fit for purpose.
In view of the large number of errors I requested of the EA that they should correct these errors and publish them to inform the public and Statutory Authorities, and allow these parties a two week consultation period to consider the revised data and thereby allow them to make an informed decision rather than one based on the published incorrect data.
The EA conceded that there were a number of errors in these tables but they were not prepared to concede to my request for this two week public consultation. (CRUCIALLY, THE EA WERE FULLY AWARE THAT THE PUBLIC HAD NOT BEEN PROPERLY CONSULTED WELL BEFORE THE EA REACHED THEIR FINAL DETERMINATION).
2. Consequently, I made a Formal Complaint to the EA and they confirmed that they would not change their stance After receiving the full support of my local conservative MP Nicky Morgan (Loughborough) and completing the PHSO standard complaint form it was signed by my MP and submitted via her office so that the facts could be established and a Statutory Investigation be undertaken.
3. For reasons I explain below I have lost faith in the PHSO and in the public consultation process and am outraged that the EA’s errors have led to inaccurate information being provided to the public upon which they totally relied to make an informed decision as to the correctness of EA’s proposal to grant an environmental permit. Public consultation is a fundamental part of the democratic process and this also has been sorely damaged by the EA’s actions.
4. The cavalier attitude by the EA is exemplified by their response to one of the questions put to them by the PHSO: Question 1. – How did these errors come to be in the Draft? (Public Consultation document). EA (Quote) answer – Unfortunately, Tables 5.2.1 and 5.2.2 in the draft decision document included errors. The errors occurred as the tables were copied directly from Biffa’s permit application. The incorrect data was not found by our internal checks as we relied on the raw data. We accept there were errors of our own making in Table 5.5.1 of the final decision document. We are not able to say how they occurred, just that they did and were not identified. There is no technical explanation for the incorrect data.
5. This incinerator project resulted in at least 650 people and organizations objecting to this proposal and I feel sure that many more had attempted to read and understand this complex and highly technical draft consultation document but probably gave up in frustration baffled by the Tables (5.2.1, 5.2.2 and 5.5.1) resulting from the errors.
The PHSO has stated to me that they follow this process in order to learn lessons from each review.
May I request of you to ask the Parliamentary and Health Service Ombudsman what lessons they have learned in a complaint case whereby it is factually demonstrable that the EA failed in their statutory duty i.e. to carry out meaningful public consultation, and yet the PHSO deems it not sufficiently proved as to justify a formal investigation into this matter.
December 2012
Written evidence submitted by W Morris (PHSO 16)
1. How long a time does Ombudsman consider as effective and useful from original incident to resolution by PHSO? • a year, two? • To be relevant and make impact? (My experience is going into its 6th year and no lessons will be learned or implemented after this length of time.) • Does PHSO actually make any difference to NHS care and conduct? • Any stats on implemented improvements because of PHSO across NHS? not individual trusts.
2. How many cases is the Ombudsman aware of, still with PHSO that exceed the time limit she suggests? • What has caused the delays within PHSO – mine is into 3rd year of PHSO. (the Trust delayed for a year but PHSO takes no robust stance to get Trust responding in time frames.) • Would “guilty as charged if they prevaricate and delay” focus the Trusts minds? • Phso could apply common sense (eg complaint of rusty stained bedrails - No properly run Trust has these so PHSO censures Trust.) Currently PHSO accepts assurance that a Trust has removed them as the answer! No interest how they came to be used etc.
3. Does PHSO now use a process to verify source data to eradicate the problems her predecessor seemed unaware of? • Without such a process is PHSO being misled and being naïve? • Is its credibility not undermined when Trusts know they can cheat and get away with it? (Trust knew it would get away with sending an edited file and did so. Only a lengthy FOIR by complainant, to both the Trust and PHSO exposed the docs that PHSO had not been sent.) (The internal PHSO Review process failed to note the problem, only intervention by the O. herself has raised the possibility of a re investigation. She was alerted by Dr John Pugh MP on behalf of the complainant.) • Can PHSO afford to give Trusts the message that cheating is OK? • Is justice served for complainants without robust source verification? ( remedy -same papers sent to both sides at start and subsequently.) (False data on a Protection Order against me was sent by the Trust and PHSO believed I was a lying, abuser of my Mother while it investigated.. Nov 2012 PHSo is aware the data supplied was false Doc supplied and its views distorted. Defamation by Trust and PHSO with no redress!) • More PHSO budget wasted on review and reinvestigating because no source data is checked as complete and true? • How does PHSO deal with cases when it has been proven to have used false data and have an unsound report? • Is there a clear, quick process once evidence is provided? ( No open process exists – subjective, committee approach, taking 3 weeks to date. Papers attached) • How can internal investigation of self, be sustainable?
4. How does the Ombudsman monitor to ensure that its processes are put into practice? Eg “standards relied upon in a report are provided to the complainant before or with the report” A. Abrahams Nov 2011 to PASC. (My case report Sept 2011 relied on Nursing standards which have still not arrived.) • Should PHSO staff be searching the internet to find something upon which they claim ”to have relied” and cannot produce to validate the statement to PASC last year? Attached docs. (The standard of Nursing was abysmal but was deemed “ an acceptable standard” without any benchmark.) • Is it not inequitable and unfair/biased that the complainant must prove with evidence everything, whilst a Trust and PHSO herself does not operate under the same constraints of evidence based verification? ( not a level playing field for complainants)
5. Does the Ombudsman have processes in use to cross reference/check any summaries upon which it relies for case assessments and decision making? No. • Monitoring in place? • Identify any failing if exists? (Assessors make a summary. They are junior and inexperienced. Any error at this stage prevents further PHSO involvement. It is subjective, interpretative process rather than being objective.) (Even Final reports rely heavily on this level of input record. Many errors can creep into a short summary and over time become a distortion of any facts. – Chinese whispers) (Docs sent for Review from FOIR postdate the summaries. PHSO ignores docs, despite clear evidence of wrongdoing in the Trust. PHSO system for review and summary is not fit for purpose.)
6. How does Ombudsman deal with Staff conduct complaints? • If no Review is granted, how are conduct complaint investigated? (as they are tied together in PHSO process.) • If a review looks at conduct it. • What process ensures the conduct matters are logged as separate? • Should there be long delays? can be years after the incident and papers have been lost/weeded. • Is this good business practice? • How can a complainant be sure that a conduct issue with a review team member/manager, will be dealt with when the same review team deal with these? (Mine went missing involving the Head of review. Coincidence? Transparency? Accountability?) (No complaint papers were provided in the FOIR but should have been present. PHSO said it was a complete set.)
7, How does Ombudsman ensure that all complaint letters and information are logged on receipt and actioned? ( My experience is of screening by staff, especially if the subject is a conduct complaint for them or their Team.Manager.) (Only by MP intervention did Ombudsman become aware that her own office staff were ‘diverting letters’, making subjective decisions whose effect was to send the letter to the subject of the complaint, with a grave risk of loss.) Some sifting is essential but what checks and counterbalances are in place to prevent misuse of public office?
I have found Dame Mellor more willing to become aware of how PHSO runs.
My experience suggests that the culture continues where PHSO is always right. When PHSO repeatedly get it wrong, that is not vexatious to the complainant? But should the complainant be determined and tenacious then he/she is readily labelled as vexatious and PHSo should follow its own protocol on issuing a warning first! Its own contribution to vexation and repeated error is ignored! Unfair practices.
Processes are cumbersome and open to misuse. The incontrovertible evidence of false source data was sent July 2012 for review, and was ignored.
Dame Mellor promised in Oct 2012, that if I could demonstrate with evidence that the PHSO report Sept 2011, had been unsound and was not itself evidence based, then I could have a reinvestigation. Letter Attached.
The incontrovertible evidence was sent July 2012 for review, and was ignored by the Reviewer and Team Manager who took receipt of it in July. Dame Mellor received it again 14 Nov 2012 and still has made no decision.
I trust that PASC will find the information useful In its meeting with the Ombudsman on Dec18th 2012.
December 2012 Written evidence submitted by D R Tweedie (PHSO 17)
Please consider my letter of 9-10-12 as an introduction.
My concern is with the poor quality of service provided by the HSO (Health Service Ombudsman).
Twice in the last 10 years I have brought serious issues forward for consideration by the HSO. Each involved long communications with the HSO and Hospital Trusts. On each occasion the HSO failed to investigate.
Most recently (2008/9) I was given a C.T. (with contrast medium) which involved: 1) A radiation dose 3 times the one I was told I would receive (400 Chest X-ray equivalents – 1250 CXR’s) 2) The procedure was not performed by a doctor 3) I was not informed of the need for the procedure at the consultation 4) To cover the omission in (3), a ‘fake’ letter was written by the Trust and a ‘file’ copy sent with my file to the HSO. I did not receive a copy. The HSO then sent this letter as part of my file to a reviewing doctor, which was when I first learned of its existence. 5) The Trust sent a misleading letter to me at the wrong address (I did not find out about until later). It did not arrive. It was included in the file to the HSO. The Trust gave the impression that a consultant had performed the procedure, which was untrue (cf point 2). 6) On the two days following the procedure I had 2 strokes/TIAs needing a week’s hospitalisation, which I believe was caused by the I.V. contrast medium used in the C.T. scan.
I believe the above gave ample evidence to instigate a full investigation.
Previously in 2001/4, I made a complaint about the quality of the treatment my mother received prior to her death. a) I felt that she had not received good quality care but on a specific day it was worse than normal, (a Sunday). I made a complaint to the hospital Trust and they gave the names of two doctors who had treated my mother. I raised this issue with the GMC and both doctors denied any involvement with my mother’s treatment. (Indeed, one claimed to be out of the country on the relevant day.) b) My mother was an 80 year old type 2 diabetic with renal problems and heart failure. She was put on Metformin (which is contra-indicated). Within 3 days she was in a coma and died 2 days later. c) When I made enquiries about the authorising doctor for the drug (Metformin), the Trust said that they could not identify the doctor from the drug sheet, (an unreadable bleep number followed by a squiggle).
It seems that the ‘Liverpool pathway’ was doing lively business in 2001. Indeed it seems my mother was helped along it.
I feel that any one of the above a), b) or c) should have been cause for investigation. Again, the HSO did not investigate.
The HS O is the last resort of any complainant against the Health Service. It should have more rigorous standards than have been demonstrated to me.
A willingness to ‘turn a blind eye’ to errors and omissions is no recommendation for the post of HSO.
Quis custodiet ipsos custodes. Certainly not the HSO.
Addendum to the letter
Having seen Mr Cameron answering questions from the Chairs of the Select Committees, I was most disappointed to note that he wishes to put the Judicial Review service even further beyond the means of the average citizen. I believe this is a retrograde move. It makes holding the HSO to account even more difficult.
December 2012