toxic cocktailIn August 2013, Dame Julie Mellor, the Ombudsman identified a ‘toxic cocktail’ of complaint handling within the NHS.  In a typical media spun, finger wagging exercise, Dame Julie pinpointed the reasons why so many people felt dissatisfied when they made complaints to NHS staff.

The toxic cocktail can be neatly summed up as

‘delay, deny, defend’

and she should know, as her own organisation, PHSO are the absolute experts.   Let me give you some examples.


PHSO deal internally with all complaints made about their own staff.  Most of these complaints are just dismissed as complaints about the decision and the ones that aren’t are just put on hold.  Forget all about their policy of objective investigation by another member of staff not involved with the original case.  It just doesn’t happen, in fact, nothing happens.   Hence this request for information regarding a formal complaint made against legal advisor Anne Harding over a year ago who has since retired from PHSO and no doubt taken all those pesky complaint letters with her.


PHSO regularly deny receiving evidence and deny the content of any evidence that doesn’t fit their chosen narrative.  They also deny access to transparency of their process, which is aptly demonstrated by the regular sidestepping of FOI requests on whatdotheyknow ably abetted by Steve Brown, Head of Risk and Assurance who can be relied upon to agree with all their decisions.   One complainant simply requested the name of the reviewer who dealt with her case and was told;

“I am sorry I am unable to provide you the name of the external reviewer who reviewed your complaint. This is because it constitutes their personal data and we do not have their consent to provide you with the details, as such the information is exempt under the section 40(2) of the Freedom of Information Act 2000 (third party personal data). The information would also be exempt under section 7(4) of the Data Protection Act 1998 if we considered your request under subject access.

Open, transparent, customer focussed.   Delete as appropriate.



PHSO can be relied upon to defend every decision.  According to their Annual Report 2013/14 they found error only 0.2% of the time.  Maintaining a high accuracy rate of 99.8% is however fairly easy when you internally review every decision yourself.  Except of course when there is a public inquiry.  In March 2015 the Kirkup Inquiry reported findings from the Morecambe Bay maternity scandal which found that mothers and babies had died unnecessarily due to poor maternity care; including the son of James Titcombe.  James had previously pushed (via judicial review proceedings) PHSO to investigate his personal case and although largely upheld, PHSO could find no evidence of collusion between the midwives prior to the inquest.  Therefore this aspect of the complaint was not upheld by the Ombudsman.  This was the final report, the final outcome and it vindicated the midwives concerned.

 Until the Kirkup Inquiry reversed that decision.

“Concerns were raised after the Kirkup inquiry’s conclusions contradicted a PHSO investigation last year on the question of whether Morecambe Bay midwives colluded over evidence to an inquest. The Kirkup inquiry said there was “clear evidence of distortion of the truth” by midwives, describing how they were given a crib sheet of “model answers” before the inquest into the death of Joshua Titcombe, who died as a result of failings at Morecambe Bay in October 2008. This came a year after ombudsman Dame Julie Mellor said she found no proof that the midwives colluded over evidence. She said she saw no evidence of “professional wrongdoing” by midwives ahead of the inquest taking place.”

Yet the Ombudsman still stands by this flawed report and has refused all requests from Mr. Titcombe to amend the final version; an action James describes as ‘disgraceful’.

But this is what you can do when you have total discretion to act as you like and cannot be held to account by the law or by parliament.  If you are concerned about this state of affairs and wish to share your views with the government then please respond to the Cabinet Office public consultation on reform of the Ombudsman landscape before 16th June 2015.  We now have a chance to make a difference and end this impunity once and for all.

Also, check out the PHSO Pressure Group aims for reform here on  and join the Pressure Group  – together we will be heard.