The Public CONfidence Trick

PHSO are once again in transition. The recent loss of both the Ombudsman, Dame Julie Mellor and the Deputy Ombudsman Mick Martin under a cloud of collusion has left the reputation of the Ombudsman’s office somewhat dented to say the least.

Public confidence is essential to public services.


No matter what chaos is happening on the ground the public must remain confident that the organisation is working for the common good. Rule number one in Sir Humphries Rule Book.

Rob Behrens took up the role of Ombudsman in April 2017 and is in charge of the new strategy to be launched in 2018 and last until another new strategy is introduced. His first priority has been to listen to critics, learn lessons and with improvements in place, restore public confidence in the Ombudsman service.

Fortunately, for PHSO most of the public are ignorant of their existence. They rarely manage to score above 20% on public awareness surveys. Equally, there is very little media coverage of the Ombudsman’s work apart from that released by their own media team. A media team who appear to be on something of a campaign to restore public confidence despite the fact that the hard work of making the service fit for purpose has yet to be done.  There are mixed messages here. In August Mr Behrens informed Shaun Lintern from the Health Service Journal that standards had not been adequate and substantial reform was required to make PHSO an exemplar service. It was, in his own words, ‘a big job but the transformation has begun.’ mr-behrens-makes-promises-of-change-for-the-future-but-what-about-the-past/

But just a month later and the media team are publishing letters in local papers such as the one below from The St Ives Times and Echo (27.9.17) encouraging people to make a complaint to the Ombudsman, despite the fact that just a month earlier Mr Behrens had stated that, ‘critically, we have not yet found a way of relating to complainants so that we understand their cases and that relationship is key to a good outcome for the process whether or not we find for them’

THE NHS provides excellent care to thousands of people day in, day out. We all have an understanding of the pressures the NHS faces, but this should not stop people from speaking up when things go wrong.

Data published last week by NHS Digital revealed that there were 208,400 complaints about the NHS in 2016-17. However, all too often, patients and their families are not fully aware of their rights. The NHS Constitution states that everyone has the right to complain, to have their complaint about NHS services acknowledged within three working days, and to have the matter properly investigated.

It is important that patients are also aware that if they are dissatisfied with the way in which their complaint is handled, they have the right to bring their complaint to us the Parliamentary and Health Service Ombudsman (PHSO)  for an independent and impartial view.

Where the PHSO upholds complaints, we recommend that the NHS puts things right by offering an appropriate remedy. This might be an apology, a financial remedy, the creation of action plans to ensure mistakes are not repeated, the introduction of additional staff training, or changes to policies and procedures. Throughout our work, we see a wide variation in the quality of NHS complaint handling so it is imperative that people know their rights and are not afraid to complain when mistakes are made.

ROB BEHRENS Parliamentary and Health Service Ombudsman

You may indeed have the right to complain to the Parliamentary and Health Service Ombudsman but you do not have the right to an investigation. That is up to the Ombudsman’s discretion.  In 2016-17 about 25% of the complaints made were assessed, only 13% made it to investigation and a tiny 4.7% achieved any type of uphold.  For 95% of the people submitting a complaint, it was nothing but a frustrating, waste of time.

It would appear that PHSO are focusing on restoring public confidence when they should be focusing on restoring a service fit for purpose.  In the  2017-18 Business Plan

there is a success criterion to consistently achieve 95% positive or neutral media coverage.  

By default, the media coverage will be positive when we all have something good to say, but it would appear that PHSO aims to meet the criteria without necessarily achieving the success.

PHSO regularly release positive statements on Facebook demonstrating the values of their organisation. Comments are then made by members of the public and in my experience, these comments tend to be negative. In fact, I have never read a positive one yet.  On recent postings, I’ve noticed that it is possible to see the number of comments made but for some reason, the comments themselves will not open. Mmmmm – very curious.  The same is true for PHSO posts to twitter. The comments are hidden from public view.  Why would this be?

Meeting the media target requires close monitoring of social media but it shouldn’t include censorship.

The PHSO media campaign is, however, in full swing and this month Mr Behrens has launched Radio Ombudsman in order to engage the public in dialogue. Guests will be invited where PHSO decide they are ‘informed or interesting’ and questions are selected from Twitter. Where is the locus of control in this arrangement? Firmly in the hands of Mr Behrens who chooses both the guests and the questions. I listened to the first podcast which was an interview between Mr Behrens and  Scott Morrish a previous complainant.

To open, Mr Behrens stated that the Ombudsman is ‘independent’ and ‘impartial’ yet there is no evidence to support this view but that of the Ombudsman himself. The Patients Association, phso-thefacts and submissions to PACAC repeatedly cite bias towards the public body under investigation.  But no doubt Mr Behrens would disagree with that.  He disagreed on a number of points made by Mr Morrish but did not substantiate the reasons why. Is this a genuine attempt to listen and learn or just a masterclass in PR spin?

Disagreement without good reason is just denial.

On August 13th Bruce Newsome posted a raw and undoubtedly negative account of the way PHSO fail to manage risk on the Conservative Home website. 

Mr Newsome is a lecturer in International Relations at the University of California, Berkeley and an expert in risk management. His aim was to draw attention to the lack of accountability for the work of PHSO and as previously articulated on this site, without accountability you get impunity.

Within two days of publication, Conservative Home received a complaint from PHSO regarding the accuracy of the article. No doubt PHSO would have been delighted for the piece to be removed or amended to their satisfaction.  Fortunately, Mr Newsome did neither. But this is all very worrying.

When you achieve your media target by controlling the media coverage you have clearly missed the point.

My advice to Mr Behrens would be to get on and deliver a customer focused Ombudsman service, hold authorities to account and make sure that learning is acted upon. Let the positive media coverage follow all by itself and be a true measure of his success. I would be delighted to publish a good news story on phso-thefacts, I just don’t have one yet.






PHSO offers to train NHS staff to improve complaint handling.

  On 22 August, Shaun Lintern from HSJ released two interviews from Rob Behrens, the new Health Service Ombudsman.  You can read the first one here

Mr Behrens talks in the first interview about the failings of PHSO and the need to invest in training in order to ‘professionalise’ the staff. In the second, reported in full below, he says much the same about NHS managers and complaint teams. In a move away from previous Ombudsman responses, which preferred finger wagging to intervention, Behrens offers to extend training to NHS staff to improve complaint handling at the first-tier level. Improvements here would clearly save time, money and great distress for all parties as complaints stretch out over years without resolution. The only question is, given that neither the PHSO nor the NHS presently has the expertise, who is going to carry out the training?  Just a thought.                     Della Reynolds


blind mice

NHS managers think admitting mistakes is wrong, says PHSO

By Shaun Lintern22 August 2017

Senior leaders in the NHS have believed owning up to mistakes was not the right thing to do for too long, the new health service ombudsman has told HSJ.

Rob Behrens, the new head of the Parliamentary and Health Service Ombudsman, warned that the NHS was still too defensive about mistakes and that it failed to invest in proper complaint handling.

In a bid to show that the PHSO was willing to help the NHS, Mr Behrens said it would offer training to NHS staff next year on how to better handle complaints. He also promised no “negative press releases” but instead there would be constructive criticism and sharing good practice.

Mr Behrens said: “We have a very defensive NHS culture. We have complaints handlers in the NHS who don’t have the skills or the authority or seniority to do their job to the best of their ability, and we have an absence of flexible resolution techniques to deal with issues. These things will need to change.

“This is a big issue and I don’t have easy answers but I think one of the problems for the NHS has been a senior management view that to own up to a mistake is not a good thing to do. I don’t think the real world is like that.

“No one is saying the NHS is not a prized national asset; no one is saying that professionals don’t make mistakes, and I think with greater confidence and with a more supportive collegiate environment it is possible to create a culture in which you can deal with complaints in a less defensive way.”

He said trusts needed to understand that the PHSO was “not gunning for them” but wanted to provide redress for people unfairly treated. He added: “It is not about trying to rubbish organisations. We need to talk to people to explain that and to encourage them to take a more transparent view of these things.”

Mr Behrens said neither the NHS nor the PHSO used mediation and early resolution actions to deal with complaints, which he wanted to see introduced.

He added: “In order to contribute to the development of complaints handling in the NHS, through our strategic plan, which will come out in March 2018, for the next three years we will offer a limited capacity to complaint handlers in the NHS to uplift their skills and to demonstrate good practice to them so they can use it in their own organisations.

“It’s not nailed down yet. There’s a lot to discuss because we can’t do it on our own. What we want to do is to provide a limited amount of that training so that other people could copy it and use it themselves. I think we have the knowledge, commitment and skills to kickstart something important and that’s what I want to put on the table.”

Mr Behrens accepted that in the past the PHSO had not offered as much practical advice and examples of good practice as it could.

He said: “You won’t see any negative press releases from me. You will find me to be endlessly constructive in the context that there are examples of maladministration and poor service that have to be addressed, and I know that from talking to and looking at cases personally where things have happened that should not have happened. We won’t shy away from that but we will balance that with examples of good practice so that people can understand and take pride in things when they go well.”







Mr Behrens makes promises of change for the future – but what about the past?

A refreshing statement here from Mr Behrens, new Parliamentary and Health Service Ombudsman, courtesy of Shaun Lintern HSJ. There is an acceptance that standards have not been adequate and substantial reform is required to provide an ‘exemplar’ Ombudsman service. So far so good. But missing from this account is how Mr Behrens plans to address the damage done by years of poor performance and rectify matters for those with badly handled but now ‘historic’ cases.  Listening and learning is a start but it’s not enough. Action Mr Behrens, action is required to put right the damage caused by the now accepted poor investigation processes. We watch and we wait.

Regulator chief promises new

‘rigour and consistency’

By Shaun Lintern

22 August 2017

The new head of the Parliamentary and Health Service Ombudsman has admitted the regulator still struggles to relate to complaining patients and families, but has pledged to bring “rigour and consistency” to its work.

Rob Behrens took over the ombudsman role in April after Dame Julie Mellor and her deputy Mick Martin were forced to resign. Their departures followed revelations by HSJ that Mr Martin had helped to cover up the sexual harassment of an NHS director and Dame Julie took no action when she was warned about his behaviour.

Whistleblowers at the PHSO had also raised concerns over the management style and “toxic” culture at the ombudsman, which is the final arbiter of complaints against NHS organisations.

Mr Behrens told HSJ the regulator’s recent history had damaged staff morale and led to a loss of confidence and defensiveness, which he was determined to tackle.

He promised to invest in staff training to “professionalise” the handling of complaints and in recent months had personally overseen complex and lengthy complaints, which he accepted took too long to close.

Mr Behrens said: “We still take too long to close cases… and critically, we have not yet found a way of relating to complainants so that we understand their cases and that relationship is key to a good outcome for the process whether or not we find for them.

“The experience of the PHSO is variable; there have been bad experiences but there have also been some excellent experiences and we have to bring a rigour and consistency to what we do to make sure where we act well that is replicated, and where we don’t act so well we address that very quickly, as we ask other bodies to do.”

Mr Behrens, who previously led the Office of the Independent Adjudicator for higher education complaints and was complaints commissioner at the Bar Standards Board, said he was confident the PHSO could be turned around.

He said: “Change had not been handled well in the organisation and this has had an impact on staff morale and one of my earliest challenges has been to talk to everyone in the organisation, to listen to their experience and to take a view about what the way forward is, given the history of the organisation. Some of that history has created a loss of confidence and a defensiveness, which we are addressing and need to turn around.

“I know from the staff surveys what the staff have thought about the leadership of the organisation. [Chief executive] Amanda Campbell and I constitute a new leadership team but this is not something that can be done by two people at the top of an organisation; it has got to be worked through, although the leaders have to set the tone for it. On the basis of what I have seen the executive team has got integrity, skill and a determination to transform this organisation. As long as they show that – and the people who work for them show that – we can move forward.

“I am confident, together with colleagues, we have what it takes to move forward and address the need for this organisation to be an exemplar of ombudsman services not only in the UK but around the world.”

Mr Behrens said in November that the PHSO would hold the first of two annual public meetings bringing together complainants, stakeholders and staff “to discuss the progress of PHSO in a public way. We have never done that before.”

There will also be £300,000 invested in training PHSO staff to help improve complaints handling, despite the ombudsman facing £24m in budget cuts over the next four years.

He said: “We have to professionalise what we do in terms of our investigative process. Amanda and I are jointly united in agreeing that there will be investment at the front end of our organisation, a big training and development programme for all staff, particularly case handlers, to reassure ourselves that we have in place a skilled team to deal with complaints.

“If we don’t do that properly, how can we have moral authority with the bodies in our jurisdiction when we are encouraging them to improve their complaint handling process?”

He added: “This is a great national institution that needs investment and needs to return to the DNA of its ombudsman roots. This is not a fairy tale; this is a big job but the transformation has begun.”


Grenfell fire shows the world what lack of accountability looks like.

Open letter to James O’Brien LBC


Dear James,

I heard your frustration and absolute disbelief as you asked the question about what systems exist to hold Kensington and Chelsea council to account following their decision to close a meeting regarding the Grenfell fire because the media were in attendance.  You articulated the commonly held belief that as public servants there must be means by which they are accountable and asked members of the public to phone in with suggestions.  Unable to contact you at the time I have written this open letter to put you in the picture.  The simple truth is there are no effective mechanisms by which any public servant can be held to account.

I heard you read out The Nolan Principles of public life, of which number four is indeed ‘accountability’ but when did you last hear of a public servant being held to account for a breach of the Nolan Principles?  Never, they are not worth the paper they are printed on.  In order to hold anyone to account you must have an independent body with the authority to investigate and the powers to apply sanctions.  That body does not exist. 

I noticed that no-one suggested going to the Ombudsman as a solution.  The Local Government Ombudsman (LGO) handle complaints about local council provision and the Parliamentary and Health Service Ombudsman (PHSO) handle complaints about all government departments and the NHS.  These bodies are free to use and supposedly provide an unbiased arbitration service to protect the public from the abuse of power.  Except, they don’t.

In 2015/16 LGO received 19,702 complaints from the public.  They investigated 4,464 cases (22.6%) and upheld 2,260 cases (11.4%).  Many of the upheld cases will be for minor issues – not full uphold.  Is it worth taking the trouble to make a complaint to LGO when nearly 90% result in no uphold?

PHSO are even worse.  In 2015/16 PHSO received 29,046 complaints, investigated 3,938 (13.5%) and upheld 1,543 (5.3%)  Just a 5% chance of uphold for all your time and effort.

Most people discover this unpalatable truth after suffering a traumatic injustice.  They turn to the authorities for protection and remedy only to suffer further abuse as those in authority manipulate the facts and collude together to avoid accountability.  Many have described using the Ombudsman as more traumatic than the original event.  It engenders a feeling of helplessness which can trigger post-traumatic stress disorders. Imagine thousands of ‘Hillsborough’ victims all fighting their own lonely battle for year after year with no worthwhile outcome.

The Ombudsman has no powers of compliance so must ‘reach agreement’ with the public body under investigation when applying sanctions.  The Ombudsman does not follow up on any recommended action plans so even when the case is upheld no-body knows whether any improvements have been made.  The Ombudsman only has the funds to investigate a fraction of the cases presented (13.5% for PHSO and 22.6% for LGO) and bends over backwards to avoid uphold.  Clear breaches in guidelines are passed off as ‘shortfalls’ rather than ‘maladministration’ keeping uphold rates down. It is a farce James – it would be laughable if the complainants were not vulnerable individuals already reeling from injustice.

The media have continually failed to show any interest in this national scandal but perhaps now that we can all see how easily the wheels fall off in the Grenfell Tower case more questions will be asked and the ineffective and biased Ombudsman should come under the glare of publicity as a complicit organisation which protects the guilty at taxpayer expense.

Della Reynolds










Mr Behrens, our new Ombudsman, wants to hear from you.

Rob_Behrens   It would appear that Mr Behrens who took up his appointment as new PHSO Ombudsman at the beginning of April is ready to hear from ‘service users’ as he starts (yet another) programme of reform.

In all of this, we need to keep listening to people who use our service and be flexible, but not unprincipled, in response. I know that this is exactly what Amanda Campbell, our Chief Executive, and the Executive Team are working towards.

Keep your eye on the ‘unprincipled’ part of this response.  It could well be the loophole through which PHSO will escape any obligation to deal with poorly handling historic cases.  For instance,  would it be ‘unprincipled’ to reopen a case against an authority where they have previously closed it without uphold?  Would it be ‘unprincipled’ to hold to account individuals who may not have been at the organisation when your complaint was handled 3, 4, 5 years ago?  Would it be ‘unprincipled’ to cause distress to public sector employees who have already been told they have not acted with maladministration or hold to account PHSO workers who have now left the organisation?

We must give Mr Behrens the benefit of the doubt – for now.

You can read his full statement here  and do let him know exactly what you think of PHSO – after all, he is looking forward to hearing from you.

Towards the end of May I’ll be taking part in a Twitter Q&A through the @PHSOmbudsman Twitter account. If you have any particular questions or topics you’d like to us to focus on, please email them

If you have any questions regarding an individual complaint please email

I look forward to hearing from you.

Welcome Mr. Behrens – here is your starter for 10 question

Q.  Why do so many people make complaints to the Parliamentary and Health Service Ombudsman when there is no merit to their complaint?

It’s odd isn’t it, we British are not a nation of whingers.  If someone treads on our toes we are the ones to say sorry.   Yet for some inexplicable reason, nearly 30,000 of us make mainly spurious complaints to the Ombudsman.  If the uphold rates are to be believed we are a nation of vexatious fools.

In 2014/15  PHSO received 6,920 parliamentary complaints.  Of these, just 885 (12.7%) were investigated and a mere 323 (4.6%) upheld to some degree.  95% of the people who complained did so without just cause.

In 2015/16 PHSO received 6,323 parliamentary complaints.  Of these, just 649 (10.2%) were investigated and a minuscule 279 (4.4%) upheld to some degree.  Once again over 95% of the people who took the time and trouble to pursue a complaint over many months or years did so for no good reason.  Just time wasters with nothing better to do than write letters and moan.

This chart shows that for the last three years, despite the ‘more impact for more people’ initiative there has never been more than a 30% chance that PHSO would be able to positively resolve your complaint and in 2015/16 that fell to just 21%.  (See blue figures, final row – Put right by PHSO in total)


And having been told that their case has no merit, why is it that so many ask for a review of this decision? These crazy fools have been caught out in their malicious mud-slinging, yet still they go back for more.   In 2015/16 a total of 1,969 people requested a review which is 24.2% of the 8,125 complaints assessed.  Don’t these people know when the game is up?  percentage_of_review_requests_FOI

So here is the big question Mr. Behrens, is it that year on year the British public make false claims and simply waste public money on vengeful complaints.  Or is it that PHSO act with bias towards the public bodies, skewing the data in their favour?

Let’s look at the evidence:

The Patients Association, who work with hundreds of people who have made health service complaints to the Ombudsman have used true stories to demonstrate that the Ombudsman is both inept and actively biased.  The strength of this view has triggered three reports on this subject which you can read here;  PHSO-The-Peoples-Ombudsman-How-it-Failed-us  (2014)  PHSO-Labyrinth-of-Bureaucracy (2015) and PHSO-Follow-up-report (2016).  This latest report lists as the two top issues that PHSO;

  • does not investigate complaints fairly – evidence is ignored;
  • is biased in favour of the organisation they are supposed to be investigating;

So, Mr. Behrens, if you are looking for bias what form would it take?

1. Failure to investigate valid complaints. 

PHSO regularly find any excuse to put the complainant back to the original body complained about (unless they are trying to meet their 4,000 cases investigated target by the end of the financial year of course).  There must be oodles of evidence for this in those stored PHSO case files.  Just take a look at this data regarding complaints made about the Information Commissioners Office (ICO).  Complaints about ICO from 2007  If you look at 2016, the last data recorded, you will see that 98 complaints were made about ICO in that year, only 6 (6%) have been investigated and to date no upholds.  Don’t look and you don’t find. 

2. Timing complaints out. 

Ombudsman legislation states that the complainant must approach the Ombudsman within twelve months of first knowledge that something was wrong.  That is an arbitrary date which should be changed to 12 months from final closedown of initial complaint.  Although the complainant may give a date that they were first aware it has been known for the Ombudsman to disagree and consider a different date to be the most likely and use that to invalidate the complaint.   PHSO also give advice to public bodies on using ‘time out’ procedures as you can see here.

3.  Failing to take account of any evidence which does not fit the chosen narrative.

There are many examples of this which is no doubt why ignoring evidence was top to the Patients Association list.  Here are a few to start you off.

  • ..we cannot question “discretionary” decisions made without maladministration. The fact that your adviser has a different opinion on the available evidence does not in itself mean that there was fault in the decision-making process.

PHSO ignored written evidence from GP’s, health records, hospital records and solicitors’ letters, which all disputed their findings.

  • You have stated a number of points disagreeing with our decision on the dosage of rotigotine and Madopar, including disagreement with our adviser’s opinions. We have noted the guidance you have referred to in relation to these aspects, both the recommended dosage of the rotigotine patches and the Parkinson’s UK document. We acknowledge your view. However our advisers are very experienced physicians and we have no reason to question their clinical view, both in relation to the dosage of the Rotigotine patch and the Madopar. We are satisfied that our advisers were aware of and referred to all the relevant guidance and standards that apply to the issues we looked at. Therefore we will not comment any further on this and our decision remains unchanged.

Their advisers are so experienced that their clinical views cannot be questioned, despite the fact that neither of them are experts in Parkinson’s disease, merely consultant physicians. Again the last couple of sentences seem to be boilerplate. The PHSO don’t have to prove to me that they have considered the guidance, just satisfy themselves (so they claim)

  • The first PHSO investigation finalised on 23 July 2013, investigating officer XXXX, didn’t use the statement from a Judge, stating that the court deemed that my husband lacked capacity (23 December 2011), the CMHT deemed my husband fit, well and in sound mind and body with full capacity and discharged him from their care as fit and well on 22 December 2011. He was in court with me on 23 December the day after the Trust declared him well on every front, sat in a wheelchair, with second-degree burns to his feet, looking as though he was going to lose his foot, emaciated and completely bonkers, the court ushers mentioned he was quite delusional. This wasn’t used in the report. 


  • But In respect of complaints I made at draft findings stage in relation to the PHSO not taking the following into consideration:
    • NICE Guidelines
    • NHS Constitution
    • Mental Capacity Act
    • Human Rights Act
    • The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 in handling the complaints

    The PHSO responded by saying:

     ‘You say that we have failed to consider a number of guidelines, standards, legal requirements and Human Rights breaches when investigating our complaint.  It is for us to decide which standards are most relevant when investigating complaints.  That is what we did.’


4.  Finding no link between maladministration and harm. 

This requires some crystal ball gazing but evidently, PHSO are expert at predicting that the harm would have been caused in any event or that it cannot be proved that the action caused the harm even when the balance of probabilities is overwhelming.

  • ‘we are unable to explain why you were fine before the smear test and were in pain later.  We recognise that this will be frustrating for you.  We asked our advisor if there was any further explanation she could add and she reiterated that the speculum examination will not have been the cause of your persistent pain.  It would be inappropriate for us to try to offer you an explanation as this would be speculation’.

  • The first report found that, ‘The medical care fell so far short of the applicable standards at to amount to service failures’, and ‘The nursing care fell so far short of the applicable standards as to amount to service failures’.  That part was upheld, but it was stated that even if my husband had of received the correct diagnosis, which was changed from the diagnosis he ended up with back to the correct diagnosis after the investigation, that we would never know if the outcome would have been different. This was based on ‘probability’, and the report stated that the injustice we suffered was that we would never know if things would have been any different.
  • 28 – “we consider we cannot prove that the long term problems you have reported were caused by clinical failings from the Trust(in part because your operation records were lost)”.

5.  Putting things right. 

You may have presented conclusive evidence of appalling practice yet if the public body inform the Ombudsman that they have since ‘put things right’ there will be no uphold recorded in your case.  It needs to be noted here that PHSO have no remit to check that appropriate actions have been taken and neither do CQC follow up the supposed action plans.

  • You disagree with our findings on the care provided to your mother with regards to her pressure sore. As our report explains, there is evidence in the medical records that podus boots were used. We are unable to say which particular type was used as there are many but the evidence shows podus boot was used. We found that the foot drop could have been prevented with regular observation and physiotherapy. However, the Trust have already taken steps to put things right by updating their guidance for relieving pressure sores, and the type of boots offered, which is in line with the new guidance in 2014; this was after your mother’s time in hospital. As the Trust have already taken steps to put things right, we will not be asking the Trust to take any further action on this and our decision remains the same.

6.  Illogical and unsubstantiated conclusions

As the investigation process is largely carried out ‘in secret’ it will not be until you receive the draft report that you will find that PHSO have (mis)used the evidence to draw illogical and unsubstantiated conclusions which deny uphold.

  • You have said that your mother had not eaten anything and had very little fluids for more than 36 hours prior to the discharge. You said she should not have been discharged in this condition. Our advisers have reviewed all of the relevant information in relation to the discharge and we do not consider that she was unreasonably discharged. We can appreciate that she deteriorated further in the discharge lounge and she was readmitted. However our advisers have taken the overall clinical picture into account and your mother not eating and limited drinking was in line with how unwell she really was. lt would not be expected for her to be eating or drinking, given how unwell she was. Our decision has not changed on this aspect.

So it seems she was so unwell it was OK to discharge her!!?  The Trust actually acknowledged the discharge was inappropriate and apologised and arranged for a review of discharge procedures but this was ignored by the PHSO in their desire not to uphold the complaint.

  • the PHSO agreed that it wasn’t necessary to write on the discharge summary that my husband had been given a CT scan of the brain that showed brain damage, the PHSO agree with the Trust that the diagnosing of old brain damage (husband was in a coma for nearly three days), was a ‘fairly common mistake made by general radiologists to make, the PHSO agreed that it was acceptable that if thinking the brain damage was old it was feasible that no neurological input was necessary, even though my husband was admitted with GCS8 coma.

7.  Ignoring comments made by the complainant on the draft report. 

Once you have the draft report you have the chance to correct any errors.  However, all too often PHSO will simply ignore any comments you make at this stage and plough straight onto the final report which is identical to the first despite pages of comments from the complainant.

  • The report which was sent to you on 8 March 2016 was our draft report with our provisional findings. This was explained in the covering letter that came with the report. We offer both the complainant and the Trust an opportunity to comment before we reach our final decision. As you have not provided any new information and the majority of your comments are reiterating your original complaint, our decision has not changed. Therefore, our final decision and final report has now been issued.

More boilerplate. They give the complainant a chance to provide comments on the draft report before ignoring them completely.

  • We are sorry to hear that you feel ‘the report leans heavily towards favouring the hospital’s account of events and does not give any credibility to my personal testimony.’ I can reassure you that we have carefully considered all the available evidence, including what you told us, in order to reach an independent and impartial view on your complaint.

8.  Sharing report with the public body before sharing with the complainant. 

When PHSO propose to uphold a complaint against a public body they will usually share the draft report with the body under investigation first and ask for feedback.  This can lead to a second ‘draft’ report being prepared and the complainant will have no idea that a ‘secret’ report has already been shared and commented on.  This favouritism is most probably caused by the fact that the Ombudsman has no powers of coercion so has to ‘negotiate’ an outcome that the public body is prepared to accept. ombudsman-to-public-bodies-please-do-as-i-say-pretty-please-ill-be-your-friend/

  • You are concerned that we shared a copy of our first draft report with xxxx without sending it to you. When we propose to partly or fully uphold a complaint, we often send it to the organisation concerned to let them comment on the shortcomings we have identified. On occasion, we change our decision in light of comments made by the organisation and/or because they might have sent new information which made our provisional decision wrong. With regard to your complaint, xxxx’s response caused us to reconsider our decision. I appreciate that you might disagree with this process, but we could not ignore xxxx’s response which caused us to reflect on and change our findings. I can see that we kept you updated while we discussed our provisional findings with xxxx and that we gave you the same opportunity to respond to our findings when we shared the updated draft report with you.”


These snippets of evidence, coupled with those contained in the reports presented by the Patients Association should give you, Mr. Behrens, cause for concern.  Apart from anything else, the uphold figures for PHSO, particularly regarding parliamentary complaints (less than 5% uphold) are reminiscent of the voting return for a corrupt despot who has total control to manipulate the figures at will.

 Time for a change?









A report from the genesis of HSIB. Patient centred at heart?

by Richard von Abendorff and Vanessa Wood
 Report and reflections from a meeting with Keith Conradi and Jane Rintoul (seconded from Department of Health to HSIB) comments invited

KC and JR said are dedicated to going beyond consultation for consultation’s sake and genuinely want to engage with patients and families in the pursuit of their sole agenda which is to bring about learning from events. They are in the process of considering the range of aspects of their organisation structure and methodology, not least the criteria for selecting the 30 cases a year for investigation from those that are submitted by any stakeholders via the upcoming website, and this includes families. They are charged with the task of remaining independent and will establish an advisory board to ensure that this is the case. They are also charged with the enormous task of acting as an exemplar and positively influencing the quality of investigations conducted by other NHS bodies. They feel that currently, the best way to do this is to conduct exemplary high-quality investigations themselves which are noted for their integrity.
They aim to organically test their methodology within a range of settings to ensure that it is fit for purpose across the NHS and will be initiating such investigations on initial cases after their launch in April. KC gave an impression of a real desire to get this right, bringing independent and fresh investigatory knowledge and indeed integrity from the air traffic investigation sector.

We urge everyone to contribute to the blog to feedback on these ideas and what more they believe needs to be done to give HSIB the best chance to actually address the serious pressures they will face in the restricted context they have been placed.

We urge HSIB to respond explicitly, transparently and fully to these issues as soon as possible to ensure serious failings that many of us have endured, some of which underpin the comments here, can be a force for learning and real change starting with HSIB.
Fuller notes of discussion and points raised:
The author (RvA) was invited to meet KC and JR and went together with Vanessa Wood (who has been on a similar, very recent journey to the author via the Hospital Complaint &  Harm Investigation system and PHSO). The purpose was to communicate the essence of their personal stories, the essence of the blogs demands and feedback to it from others and to gain information as to what HSIB was doing. We wanted a recording, to allow fuller notes, but KC felt he could speak more freely and openly at this stage without the use of that facility. These notes are what result and hopefully will stimulate more debate on this blog.  Please leave your comments below. 
Brief update:

The big message was there was to be an HSIB website launch (an initial version) with lots of information and referrals would be accepted from the end of March. There had been consultation with ‘the big stakeholders’ and unnamed whistleblowers and patients. It later emerged about 10 investigators have been appointed. When we inquired if a patient family advocate was on the panel JR confirmed it was Martin Bromiley. We did clearly express the view that the lack of transparency to date on any of these processes and ‘the usual’ top down appointees by the ‘great and good’ gave no reassurance that a new way of doing things, a new open culture was being modelled by HSIB .
Blog and feedback to the process:

JR was very clear they found my previous blog useful and wanted to hear as much as possible about feedback from patients, families and whistleblowers to it. We urge everyone who read it and contributed by email, twitter or other to do it via the blog as only some key points were passed on as some will see below. Some people are making very serious contributions via websites and twitter e.g. Whistleblower Dr Minh Alexander and Alexander’s Excavations
RvA said that a number of prominent complainant and whistleblower campaigners had been forthright about how they were very sceptical about the whole HSIB project, its progress to date and its potential, given:

1) the lack of any historical review of cases to date so no lessons were learned from past scandalous treatment of patients, families and whistleblowers which meant a number of people could not take part or offer support. As one person said ’we can’t just draw a line in the sand’.
RvA suggested this could be, in fact, must be, made part of the scope of the HSIB who at a very minimum should:
·        comment on the Experts Groups demand for an independent commission (as in the case of KC’s comments of safe space extension beyond HSIB-which he had strongly publically opposed),
·        offer to advise or contribute to this, as it would be HSIB who would need to hear and integrate lessons learnt from this into their  and ultimately others processes
·         Related to this in opening comments RvA has stressed how families should be seen as they were, not only as traumatised victims, complainants, but also experts by experience (of patient needs, care provided and failings in systems) and as  advocates of patients (sometimes in a legal capacity) and crucially as key  witnesses to events. KC said how shocked he was how families evidence was so often ignored compared to how eye witness evidence was used in air accident investigation,  even if the meaning and emotional context to testimony meant it had to be more deeply probed. VM commented how this contrasted with the treatment of health bodies’ evidence, like the legally crafted statements of medical staff and medical notes, not ‘objective’ records of facts, and sometimes ‘doctored’ which were accepted. 
2) Some feedback to the blog urged that enough information has already been submitted to the Expert Group over  18 months ago and needed full consideration by HSIB involving leading campaigners  e.g. based on the Bristol Histopathological Inquiry and  Bristol Paediatric Cardiological  Services risk summit.
3) Concern was also expressed about some ‘national stakeholders’ involvement when they have financial/contractual relations with key bodies that need reform. RvA and VW also expressed their varied personal experiences of bodies like Health Watch, CQC and CCG’s and leading charities in their capacity to respond adequately to major concerns raised by families about services.
4) Some feedback, in essence, suggested it was the corruption of systems and processes and political pressures and not mere incompetence or lack of resources that led to poor investigations. RvA suggests there are many serious pressures and understandable concerns of patients and whistleblowers and this reiterated the need for close scrutiny of how investigations are currently done and why they fail.  Fearless exposition may mean challenging conclusions and actions need to be taken. Learning is the core issue for HSIB
Human factors and learning:

KC confirmed that Human factors experts are involved because Human factors analysis are so very important at all levels in the system and while the AAIB use of human factors was only very recent they have really realised the value of it in an investigation.
The reason for the investigations is to improve learning- not to do it or act on behalf of staff or families. They will say ‘let’s have a look at these systems’
As they only have a budget for 30 cases, they tried to develop criteria and this has been to think about how these cases can be identified. Drawing on nationwide data systems as they don’t have any data themselves as starting from scratch. They are looking for people to point them in the right direction- they want to open doors to take info in. Criteria include looking at how serious in terms of a nationwide problem any event is and whether there is public confidence in the way it’s being investigated at the moment. They are charged with not doing historical investigations They will make their main focus those which occurred after April as a trigger.
They are looking to use their investigations to set an exemplar- they need to do investigations first to get experience, then check their model is working i.e. does it fit all processes and contexts e.g. mental health and community as well as hospital? They will be refining processes over a period of time, then they can look at how an investigation should be done and we urged the need to relate this to how and why they are done so badly for so many by trusts, PHSO and even NHS appointed Inquiries like in Bristol
In AAIB lawyers tended to circle (from both industry and family) after the report came out- the AAIb didn’t mention names- just lessons learnt without mentioning specifics- you can’t stop operators operating and things will be happening in parallel investigations too, such as inquests.
Who is consulted depends on the evidence and the incident. Need to talk to many including families,  staff and also at times to people who set the regulations- these will be evidence led investigations.
As HSIB has consistently said they will be a learning body it was also suggested by RvA they as a body and participants should be more explicit in spelling out the learning and follow-up actions. Both KC and JR, with very different backgrounds were still to make in their journey setting up HSIB. It may provide vital insights for all other bodies wanting to improve their investigation- for- real- learning capacity. Self reflective learning once again sorely missing in current defensive systems.
 Advisory board, patient input and consultation:
Board to be set up and appointment process to be published soon- terms of reference in the directions from Hunt are to monitor and check independence. Research of outcomes will also be commissioned they are aware. Being under NHS Improvement for pay and rations they know needs to change and are pressing for greater independence. They want representation from the major players on the advisory board which will be small.
Regarding patient advocates they were aware of the patient public voice group at the NHSI patients safety and want to use that group as a sounding board- JR to run workshops with that group. JR said their appointment had been quite ‘open’. As a recently appointed  PPV himself RvA fedback that while a very useful group of people he did not see its appointment as ‘open’ as JR implied, and as RvA  argued in the blog  care had to be taken to ensure Board appointees and appointment process was much more transparent and open as many campaigners were extremely concerned about the fact that all these bodies and reviews were conducted by those appointed by DoH, NHS England and the ‘safe hands’ they usually work with . Real independent candid and challenging clout was required on any board. An unasked question was what appeal and complaint processes were there and whether PHSO would have a role?!
The recent controversy over the Just Culture task Force referred to in the blog was quoted as an example of a way not to proceed. There was also discussion about the dangers of the usual full-time patient advocates who circulated in the system. The website will have info on the advisory committee investigators biographies etc. when going live.
Stakeholder involvement- how they can continue to be fed into the process themselves. Jane is going to devise some carefully crafted questions as a start which will be put out to us to answer on things they want to elicit views on. RvA emphasised that other key and independent stakeholders like leading family campaigners (e.g. those supporting Bristol families) and independent named whistleblowers (e.g. Dr Alexander) should and must be consulted now. The old adage of fair full consultation at an early stage must not only be done but be seen to be done. The lack of evidence of this was very concerning to us.
But there was explicit recognition for the need for whistleblowers in the process but no further discussion on this.
Consultation- who with and what does it look like?
RvA was reassured that in contrast to the poorly received expert group family consultation the same company would not be used this time.  The learning process is on-going.
 Selecting cases – JR is mindful of managing expectations of patients and families as well as all other referrers as they are aware they will have many making referrals.
Road testing methodology- they want to take it and test protocols and will not necessarily pick the first ones. They want to go into all kinds of settings e.g. community, primary care, mental health etc and see if the methodology works.
They invited us to help test the website That will be the route for referral. Jane has been looking at referral vehicles such as PHSO and the forms used. They are developing the forms at the moment. They beg patience while they refine the process.
There will be Patient and family support throughout the investigation process. RVA asked if this would extend to Board level to ensure feedback and support. KC said all the families and next of kin will get a chance to feedback on the report before the publication and right at the start they will meet with families to explain the process and their involvement. KC himself will need technical aspects of the reports explained to him as non-medical so that he can assure himself the report and findings are robust and also thinks families might want this explanation too. He also thinks in complex cases a face to face meeting would be warranted with families or patient. It will important to explain what their part is and how it is different to everyone else that might be involved  i.e. coroner etc.
RvA was relieved that families could make referrals to HSIB direct.
Feedback to HSIB:
·         the National reporting system essentially totally relies on hospital incident reports, with the inevitable and empirically proven limitations of this
·         how patient reports even when accompanied by excellent witness evidence, protocols  breached, coroners reports, or expert reports are so often totally ignored and the current system of reporting complaints, PHSO and the NRLS portal are not adequate to the task (although a NHS Improvement project may be working on the latter soon)
·         if not taken on by HSIB it should as a triage function to try and offer referral of cases to other bodies(RVA recounted that the only reason he was perhaps at the table of HSIB is that his commissioned expert report of a drug risk was only finally taken seriously by a safety committee of the Royal College of Anaesthetists) approached on his own initiative without help or advice fron any recognised body.  Clear safety issues need more avenues for reporting and consideration-HSIB will only take on a minute fraction.
Influence and wider change:
As to how to influence investigations in other NHS bodies local and national, by doing a great job themselves that will make the most impact. HSIB come with no agenda but to bring about learning from events KC repeatedly said this as his key message. He said he is not medical or NHS so comes without that baggage which is an advantage.
Furthermore, HSIB can only make recommendations, not able ensure that they are implemented.  They can’t be on bodies such as NICE as they need to be independent of them but they would observe various bodies( e.g. the safe anaesthesia liaison group of the Royal college of anaesthetists). They needed to work smartly- think smartly- trying to be as clever as they can to maximise the impact of their findings and recommendations. VM said psychologists can help with this- asked what type of psychologists they had- they said one involved in change management and another – then Keith said we can tap into the specialisms of stakeholders re particular issues. RVA suggested like PPV sometimes are asked via the safety response panel asked to consult other bodies, e.g. patient facing organisations and their members who were experts by experience.
Scope and types of cases:

RvA pushed one personal point how the scope of HSIB should be extended further at this stage even if most cases taken on would be ‘new’.  HSIB had to grasp fully the nature of the current investigation system they were trying to intervene in. Given 99.9 % of families unhappy with complaints, most harm related, would go through the PHSO system, with a new Ombudsman Rob Behrens abut to come in post and draft legislation being discussed surely it was suggested HSIB should devote some resources to examining how the current system worked and why it didn’t for too many. VW and RvA experiences were a testament that well evidenced and externally expertly validated major harm events could be shrugged off with totally inadequate by PHSO investigations.

For balance RvA also added that NHS appointed investigations could show the same massive failing as demonstrated in Bristol last year when in contrast it was PHSO in this case able to show how many serious failings were demonstrated in the tragic death of Sean Turner, covered by Shaun Lintern in HSJ, overturning a NHS England appointed review process.
Based on their own experience, RvA and VW also pushed for one group of patients they believe need to be part of a prioritised group for investigation.  Namely, more complex and multiple morbid hard to assess/treat cases which quickly became ‘palliative cases’ and died, (not treated in hospices or specialist geriatric settings) but whose last days were managed in acute hospital  settings, complex and complicated issues around capacity and consent, lifesaving  versus palliative interventions including concerns about use of opiates, and the role of specialists in acute settings.
Another focus of work suggested by RvA for HSIB was the still remaining poor investigation of never events and other failings raised in national safety alerts, exemplified by the recent nasogastric tube safety alert which had to be targeted at governance and Board level. Incidents like this and how to investigate and learn from them need to be a focus. A recent editorial of BMJ Safety by Trbovich urged for system changes and not simply safety alerts. This would seem a clear example. 
Please feel free to leave your comments.  All will be responded to.