We all like to put a positive gloss on things and none more so than a government Minister. Jeremy Hunt is working hard to put out the message that the NHS is improving under the watch of the Conservatives and despite facts and figures which suggest the opposite the media message is clear – the NHS is safe with us. When you have the media on-board it is easy to maintain this central narrative as you need to see both sides of the story to understand the truth behind the headlines. On the surface, this recent announcement looks like nothing but good news.
Hunt To Pledge Independent Investigations For Families Who Endure Stillbirth
But when you dig a little deeper you have to ask yourself why are these independent investigations not already commonplace? After all the Health Service Ombudsman has been in existence since 1993 with wide-ranging powers to investigate such instances. Interestingly, in all the articles citing this recent announcement, none of them mentions the work of the Ombudsman in this area or how the new Healthcare Safety Investigation Branch (HSIB) will carry out so many independent investigations when it is only funded for 30 investigations per year. None of them except this one by Bruce Newsome and published in Reaction on 28.11.17 – so read on to get the bigger picture before you make your mind up. health-secretary-still-doesnt-understand-risk-management/
Hospitals need to be accountable to someone other than themselves: here’s why
BY BRUCE NEWSOME / 28 NOVEMBER 2017
The Health Secretary says that the NHS must reduce maternity deaths and injuries by learning lessons, but yet again he’s saying something agreeable while avoiding accountability.
Year on year, the NHS is responsible for an unusually high rate of avoidable deaths compared to its peers. Its cost of malpractice also is high relative to peers: in fiscal year 2016-2017, the NHS paid more than £1.7 billion in damages and costs for clinical negligence, up from £1.5 billion in the previous year.
Why is Jeremy Hunt suddenly focused on learning lessons from maternity risks? He is perhaps belatedly compensating for unauthorized revelations in August that English maternity wards temporarily closed 382 times in 2016 – a record in recent years. The National Childbirth Trust previously reported that mothers in labour are being “treated like cattle” in NHS wards: half are left alone for hours without care or painkillers. The report’s authors – in consultation with the professional groups – chose to blame understaffing. Hunt’s new statement admits that staff numbers must increase. In immediate reaction to Hunt’s statement, journalists on BBC Radio 4’s Today Programme and a representative from the Royal College of Midwives blatantly colluded to discuss understaffing as the only issue.
What everybody involved agrees to avoid is structural accountability for malpractice. Hunt says all unexplained maternity cases should be investigated “independently” so that “lessons can be learned” without “blame,” but British healthcare is already subject to more than 70nominally “independent” investigative organizations (by Parliament’s own count), and the lessons are always the same, but never learnt.
Currently, hospitals investigate themselves; if patients are unhappy, they can raise a complaint to one of those “independent” organizations or start civil legal action. Increasingly, patients go straight to legal action, given the frustrations and biases of officially “independent” organizations – whose dominant incentives are to avoid work and to protect the government and/or the professions that they represent, resource them, and staff them. The other term used officially for these organizations is “arms-length” – that’s not the same as “independent,” but since neither term is legally defined, these terms are used unaccountably.
The self-interests can be appreciated from the fact that the Parliamentary Health Services Ombudsman (PHSO) – the ultimate “independent” body for any complainant – investigated less than 8% of complaints in peak year, or merely 2,199 complaints; NHS England alone received 175,000 complaints that year. In the most recent year, the number of complaints rose, but the PHSO’s rate fell below 5%. According to heart-breaking testimonials, the other 95% are treated by PHSO staff as time-wasters, liars, idiots, fantasists, egotists, and objects of ridicule.
This is not an undiscovered problem, it’s an officially ignored problem: the PHSO has been the top of the pile since 2009, the anti-PHSO pressure groups date from around then, Jeremy Hunt has been Health Secretary since 2012, I have been reporting the structural explanation for Britain’s high health risks since 2013, and the Public Administration Select Committee has complained since 2015 that the PHSO is practically unaccountable to Parliament.
Yet here we go again: Hunts promises more “independent” “lessons-learning.” Hunt says that the Healthcare Safety Investigations Branch (HSIB), which became effective in April, should investigate all cases of unexplained serious harm during maternity care, but it is resourced to investigate 30 cases per year, when about 1,000 babies per year unexpectedly die or are severely brain damaged in Britain during maternity.
Hunt says the HSIB is “independent,” but the HSIB is not independent: it is funded by the Department of Health and sits within a department called NHS Improvement.
Hunt’s new statement on maternity risks went on: “We have to change a blame culture into a learning culture.” In fact, we don’t have a blame culture, because none of those “independent” organizations blames individuals. So far as they ever reach judgements, these are to the effect that “mistakes were made,” but no person is held accountable. Focusing on culture is convenient because a culture is the attribute of a group, but is no person’s fault. The HSIB was set up explicitly to avoid “blame” in favour of “learning lessons” from a few exemplary cases – but this is contradictory, since selective and blame-less investigations cannot learn all the lessons.
More importantly, a system without blame is an unaccountable system, and unaccountable systems are riskier systems. Unless the persons who are the sources of health risks are accountable for health risks, health risks will continue to move in the wrong direction.
Accountability should start with the government. If the Department of Health were to be made responsible for investigating the hundreds of thousands of complaints made against British health and social care per year, and were to be made accountable to Parliamentary committees for reducing health risks, our health risks would soon improve. Britons are dying for accountability.
Bruce Newsome, Ph.D.
Evidence-based knowledge and practical skills
“No assumption too sacrosanct”
Brenda. Many thanks advice re Mr. Sprakes at Bridge Mc Farland. Grimslby is a bit far from where I live in Surrey and I am looking to a locally based solicitor through avma in Croydon .
Given that we all seem to be banging out heads on a brick wall against a system set up by naïve politicians who wrongly assume that staff in the NHS will not cover up for mistakes, can I suggest we set up a team to bring a class action against NHS England who are supposed to govern and regulate the trusts covering up for their own mistakes . It is patently obvious from the diversity of comments over many years that PHSO is not fit for purpose and never will be.
Hi John, you are so right. I wouldn’t have sued if I had been told the truth. We all make mistakes, that’s being human. It’s how you deal with them that matters. I once heard an MP say, ‘it’s those complainants they need to learn how to forgive’. I said, ‘as no one has done anything wrong over my son’s avoidable death, there is nothing to forgive!’
All I wanted was to know why? What lessons have been learnt so it doesn’t happen to others….No hope there.
So if we the complainants don’t agree with PHSO. it’s us that’s wrong because PHSO can’t make mistakes. If the process is right the answer must be!
Life is cheap, especially if you have long term illness…Who cares…? Not PHSO or Mr Hunt it seems. If they did, things would have changed by now. They know what’s wrong, but no change.
You could try Mr Sprakes at Bridge McFarland Grimsby.
You are so right Brenda “to err is human but to cover up is still a choice”
Right again “Life is cheap, especially if you have long term illness…Who cares…? Not PHSO or Mr Hunt it seems. If they did, things would have changed by now”.The process is SKEWED!
I can only say TG for PHSO Pressure group (which Della coordinates so well) the group has been my rock,.Not only losing my 29 yr old son(in hospital) wasn’t bad enough, the lack of official support was terrible.This group has supported me through very tough times and I may have sunk without a trace without them. Our fighting spirit comes from injustice suffered, and whilst we have no issues with good staff we will always shine a light in bad ones.I personally wonder why my complaint is now deemed ‘historic’ ,,,,,,could it be part of the delaying tactics used by phso office ( Because I certainly helped all could)or maybe the delay was down to 50+ case workers who accessed my file,(were they training?) that’s after an ‘Unremedied injustice’ flag on my file was removed by ? ( 1 Year later am STILL waiting for answers) Yes I am angry, my son is dead& its almost Christmas again) and I still dont know what happened to him.I don’t expect a magic wand but I do expect Truth and for public servants just show some professional and personal integrity. My son was my baby once and I cared for him……..how are you going to fix this?
Can you learn any lessons?
Thank you Bruce Newsom for telling it as it is and not just how it could be. We could certainly use a few more like that.
Brenda, sadly your experience is common with most if not all complaints sent to the PHSO. in 2015 I had a joint complaint against an NHS Trust and County Council Social services investigated and the person investigating failed to consider evidence. and claimed there was not fault on either party.
I was also informed by the PHSO after the first nine months of delay that if I took legal proceedings they would cease their investigation.
Now I have another problem with two incompetent G.P.s and am not going to bother with PHSO as it is clearly a waste of time. The only way to get justice is through the courts which is why there are so many solicitors looking for no win no fee costs.to line their pockets . It is merry go round of negligence and incompetence caused by NHS staff and doctors failing to tell the truth when they make mistakes. !
Taxpayers have the right to see Value for Money demonstrated- PHSO audit fails to evidence any.
Taxpayers expect the establishment to comply with, and uphold the law. In 1998 the UK parliament implemented the Data Protection Act. In 2017 PHSO is still evidenced as ignoring this law. Another branch of the establishment ( Information Commission) allows this illegal operation to continue with impunity. No public body can demonstrate VfM when its operates illegally- why does no one care who has any power to make a difference? Only the victims of this institutionalised abuse have no power but they care deeply. The Hillsborough case identifies that eventually the victims achieve justice after 28 years. Way to go yet but truth will out! Denials of knowledge will not provide any defence. TJ
After saying my son’s death was avoidable PHSO did nothing, so I sued the Trusts involved for negligence. Two bodies ‘in focus’ settled out of court. So how could there have been nothing wrong PHSO?
It was then made public that I had received £50,000 compensation when I received no compensation! I didn’t ask for any, just my costs.
How arrogant and corrupt is that? I should have sued for that but I didn’t. ‘They’ just can’t learn lessons it seems. Now what is my next step in my battle for ‘them’ to learn…..so it doesn’t happen to other families?
The first time I took a complaint to PHSO, it was told by authority, the complaint is out of time and PHSO agreed, even though it wasn’t, so PHSO didn’t investigate. Staff at the Trust were then heard saying, PHSO found no case to answer! How arrogant and corrupt is that?
It is heart breaking for us as a family to lose our lovely son, grandson, brother, uncle, but who cares, not authorities or the PHSO. Just so long as they can get away with no accountability, that’s all that matters. He was just 38 years old. Such a waste and no lessons learnt.
Oh, and I think my son’s life was just as important as anyone else’s, including babies Mr Hunt!
You cannot fool all of the people all of the time and indefintely. Throwing away people’s lives and livlehood is corruption at gutter level. Times are changing though….
“Jeremy Hunt is working hard to put out the message that the NHS is improving under the watch of the Conservatives and despite facts and figures which suggest the opposite the media message is clear – the NHS is safe with us”
This sounds hauntingly familiar. Now who does that remind me of. Oh yes, PHSO. Dishonest statistics, false assurances and still a sinking ship.
We all know why “lessons are never learned”. Because there is no real regulation worth a damn and no real consequences to NHS Trusts. If a CEO needs to go, they will just move them sideways quietly.
Bruce Newsome is absolutely right. Yes, there has to be blame where blame is due. All the time NHS staff are allowed to practice negligence, corruption and cover-up, this culture will continue. So if you are going to blame the culture you have no choice but to default to blaming the individuals. It’s a ridiculous and tragic state of affairs. It’s also absolutely unacceptable.
Bravo Della and Bravo Bruce.
“CORRUPT BY DESIGN”
Brian Newsome delivers a super straight-no-nonsense report here.
The timing of his guest blog is relevant to victims who will be watching The Public Administration and Constitutional Affairs Committee engage in a pantomime display of fake “good” news from the Parliamentary Ombudsman. This yearly seasonal performance is in a fortnight’s time on the 12th December 2017; thereby ensuring that there is little media coverage of the Panto?
Mr Newsom writes, “Accountability should start with the government”. His Blog confirms what Della Reynolds has outlined since 2014. The PHSO-the-facts report; “Corrupt by Design”. can be viewed here;
It is said that corruption starts at the top and trickles down;
the law behind the Ombudsman is CORRUPT BY DESIGN & those MPs, Law Commission, Ministry Of Justice, HMCTS staff and the Civil Service seem to be in on this legalised Misconduct In Public Office against the British Public.
Excellent guest blog by Bruce Newsome.
Jeremy Hunt is a career politician, and must feel like the man pushing a pea up a hill. you cnanont blame him for all the ills of the biggest organisation in the UK What he is overseeing is a group people within the NHS whose sole purpose is to preserve the status quo. and to cover up for each other when mistakes are made. They are all insured against public liability so do not care about the £1.7 billion paid out in compensation by their insurers.
I am currently dealing with four GPs who have never heard of the NHS complaints procedure even though it was passed into law by Parliament in 2009 . I would not waste my time with the PHSO and these G.P.s are all very upset because I am taking them to court as well as reporting them to the GMC.
The “medicolegal” doctors within the “Medical Defence Union” are now going to try to defend the GPs misconduct . It is all a bit like the mafia looking after its own.