As yet another NHS scandal hits the headlines. BBC Health Editor Hugh Pym asks;
Patient safety – will there be a big step forward?
BBC News 8.7.20
Hugh Pym has been around long enough to know that the latest scandal concerning vaginal mesh is unlikely to result in the cultural change needed to turn the defensive NHS into a service which admits and corrects mistakes as soon as they are brought to attention. He lists the recent catalogue of shame in his opening paragraph.
The list is a dismal and shameful one – Mid-Staffordshire, Morecambe Bay, the rogue surgeon Ian Paterson, maternity care at the Shrewsbury and Telford.
All those who monitor the health sector know that the 3D strategy is an automatic response when the NHS receives a patient complaint.
Deny – Delay – Defend
The NHS has been allowed to deflect valid complaints due to the compliance of the regulators, who receive due condemnation in the Baroness Cumberlege report.
They claim that the remits of HSIB and the Ombudsman are too narrow, and that only a limited number of complaints are followed up. It is a scathing indictment that, even after previous instances of patient mistreatment, and repeated calls for lines to be drawn and new safety regimes established, another review has found systemic faults.
The dangers of vaginal mesh, used to treat women with post-birth incontinence or pelvic organ prolapse, have been known about since at least 2017, when more than 800 women threatened to sue the NHS .
This report from woman&home gives a detailed account of the appalling suffering of those affected and their long fight to be heard.
Baroness Cumberlege’s mesh review was released today
A damning report published yesterday has stated that vaginal mesh concerns from women have been ‘dismissed’ by the medical profession for years. It states that too often, the worries over vaginal mesh – as well as the ill effects over other procedures and medicines – has been dismissed as ‘women’s problems’.
Review chair Baroness Julia Cumberlege said she was shocked by the “sheer scale” of suffering from women, and urged that the health care system must apologise to women for being so dismissive.
She said, “I have conducted many reviews and inquiries over the years, but I have never encountered anything like this. Much of this suffering was entirely avoidable, caused and compounded by failings in the health system itself.”
The voices of these women, suffering chronic pain and disability, were dismissed not just by the medical profession but by the Health Service Ombudsman. Once again it was not the Ombudsman who alerted the world to this scandal by investigating complaints and laying a report before parliament. The Ombudsman’s casework report 2019 does not include any investigations into vaginal mesh though it is inconceivable that no complaints were made to PHSO on this issue. A key word search on the PHSO website does not link to any information on this subject, and neither was any found on the Patients Association website apart from their ‘shock’ at reading the report. It was a fierce patient-led campaign which resulted in the independent medicines and medical devices review
The proposal of the Cumberlege review was to bring about a cultural change by the introduction of a Patient Safety Commissioner.
So what will a Patient Safety Commissioner mean?
The plan is to have an individual with “real standing” outside and independent of the system, accountable to the parliamentary Health and Social Care Select Committee.
The Commissioner would be expected to take up and investigate patient complaints where appropriate, and hold organisations to account – the review had stated that the failure of health authorities to respond to concerns was a recurrent theme.
It is interesting to note that a new Patient Safety Commissioner would have ‘real standing’ outside and independent of the system which rather begs the question as to the ‘standing’ of the current Health Service Ombudsman. Importantly, the Cumberlege review acknowledges that accountability can only be achieved by establishing a Patient Safety Commissioner who is a ‘legally empowered patient champion.’ Anyone who has taken their complaint to the Ombudsman would know that PHSO are not legally empowered and neither are they a patient champion. With a very low uphold rate (fewer than 20% of all complaints were assessed and less than 3% upheld via investigation in 2018/19) it is clear that the Ombudsman is part of the problem and not part of the solution.
A Patient Safety Commissioner would be a step in the right direction and PHSOtheFACTS, a citizen-led campaign group, have long claimed that NHS complaints should be handled by a dedicated body with both clinical and legal expertise. But the Ombudsman is also failing the public with regard to parliamentary complaints. It was not PHSO who revealed the shocking treatment of the Windrush generation at the hands of the Home Office, neither are they reporting on the continuing scandal of slow compensation payments. In 2018/19, 861 complaints were made about the Home Office to PHSO. They investigated 21 cases and partially upheld just 13 complaints.
Neither have PHSO protected the WASPI women, many of whom have been made destitute by changes to the pension age, poorly notified by the DWP. The Ombudsman decided to intervene on these cases in 2017 in order to speed up resolution but to date the six sample cases are still awaiting investigation outcomes. 1,553 complaints were made about the DWP in 2018/19, 30 cases were investigated and just 4 partially upheld.
With the Cumberlege Report it has been officially recognised that PHSO are not to be relied upon for patient safety. It should also be recognised that PHSO are not to be relied upon to uphold the rights of the citizen against government departments. It would appear that the Ombudsman has dubious ‘standing’ as an ‘independent’ body, it has no powers of legal enforcement and an extremely low uphold rate.
Even when a rogue doctor’s dishonesty is exposed sometimes nothing much happens.
‘Dr Ashhab retrospectively altered the medical records of Patient A from those recorded on 15 June 2016 and included information that was untrue.’
Click to access dr-issa-ashhab-24-sep-20.pdf
The patient died a few weeks after surgery. Dr Ashab only got a warning.
Has anyone complained to the PHSO about Dr Sudip Sarkar GMC ref. 3617342?
He served three years in jail and has now had his name erased from the medical register. He ‘grossly exaggerated’ his experience to get a job and put patients at risk as a result:
Click to access dr-sudip-sarker-19-feb-21.pdf
’26. Dr Sarker submitted that he had identified his previously undiagnosed dyslexia as the reason for his mistake at the interview and has identified reasonable adjustments that could be made to prevent any similar mistakes happening again.
Sickening. Why did I waste time with new-broom Behrens (PHSO) when the same rhetoric and derision was to come out of it. It’s just a game to them both in NHS/PHSO comfortable partnership. More harm and more lives lost. Dishonourable discharge the only way forward now imho. Complaint 2009 – 2020 Unresolved. Just a game while people get too weak, too traumatised or too old to keep playing. NHS/PHSO just renew themselves in the lying and cover-ups.
I hate to say this but if men had mesh implanted in their groins and suffered as these women did the procedure would have been stopped long ago. A patient safety Commissioner is just another one of these appointments to be seen to be doing something. A new Patient Safety strategy was produced last year and it has made no impact. Until the culture in the NHS changes nothing will make an impact.
Staff are bullied by Managers who run the NHS like the Mafia to protect themselves. They aren’t interested in patient safety which I knew from being a NHS whistleblower to protect patients from harm. Now as a patient I speak up if my health is at risk from poor standards and am labelled a vexatious complainant! I even have a letter detailing changes as result of speaking up which contradicts itself but still labels me as vexatious.
Standards in the NHS have never been so poor as they are now. Report after report all say the same things yet nothing changes. The Patients Association has gone soft on the PHSO it is a critical friend. No it isn’t a friend of the PHSO it should be the tiger making PHSO become more effective. All the trust pilot reviews of the PHSO aren’t wrong yet the PA say the dates they refer to might be outwith the review period. Err well the date the review is posted is a big clue.
The reality is that patient safety in the NHS is a farce. In 2015 after mid Staffs it was never again. How many Consultants who knew what was going on there spoke up or were held accountable? No it would be the nurses held to account and definitely not the Managers. This breed of NHS Manager has no conscience and their attitude is accept what we give you and don’t question even if the standards are poor and patients are at risk of harm or death. They move around like a virus infecting everywhere they go with a toxic culture not even held to account by the Fit and Proper Persons legislation. That legislation is under the domain of the CQC who are another quango failing at their role who ignore patient safety like the PHSO.
In times gone past Consultants would put Managers back in their boxes and collectively use their voice. Now it is a case of how high should they jump for NHS Managers because they are spineless and they too ignore patient safety. Expect more NHS scandals because nothing changes.
Sadly all true Caroline.
On the face of it, the Cumberlege report is a good one. It advocates creating a Commissioner for Patient Safety, but I fear it will become another opportunity missed regarding health service complaints. Page 201, point 8 of the report states:
“There is a tremendous number of opportunities to improve patient safety across a wide range of organisations. At the same time it is a crowded landscape that can stand in the way of timely responses.”
So far so good. However this well intentioned aim is negated at Page 206, point 25 where it states:
“Legislation will prevent the Commissioner from investigating individual cases as this would duplicate the work of the Parliamentary and Health Service Ombudsman.”
This would add another “quango’ to the crowded landscape. Better to do away with the Ombudsman and absorb the Health Safety Investigation Branch (HSIB) into the work of the Commissioner for Patient Safety and give the Commissioner power to investigate individual cases with right to intervene in any complaint at an early stage. This would reduce the ‘quango’s’ from three to one, giving the patient a single port of call and the establishment speedier knowledge of when patient safety is at risk. The public don’t deserve to wait, sometimes over 20 years, for the establishment to catch up. The next one coming up looks to be Shrewsbury and Telford NHS Trust maternity services – now subject to an enquiry and also a Police Investigation
It’s almost as if they don’t want the solutions to work isn’t it.
Seems to be another PR exercise to improve the look and reputation of a broken system which no-one has the guts to tackle or reform. Unlikely that yet another volunteer Ombudsman will have the nous for it either, in the current scheme – imho
My comment more concerns protecting patients from harm than the role of the PHSO.
Some readers might be interested in this recent appeal decision of the Court of Session (Inner House). The appellant was a dishonest midwife who put lives at risk. She was struck off and her appeal failed: a total of fifty-eight allegations proved, fifty of which amounted to misconduct:
 CSIH 40 XA 107/19
Prior to qualifying she was a military field medic for 16 years.
The hearing that determined that she be struck off lasted 16 days, spread over a period of 7 months.
For anyone interested, the Nursing and Midwifery Council publish the most recent three months of hearing outcomes:
Thank you. Another excellent blog -and another opportunity to reflect on the extent of the powers and commitment of our Health Ombudsman by means of another scandal finally exposed.
NHS England, in order address concerns over the use of mesh , wrote in their interim report way back in 2015, ‘There is evidence that complications, when they do arise, can be very severe and life-altering.’ The report pointed out that ‘there is a lack of comprehensive data on complications, due to issues relating to data coding and incomplete data recording’. Professor Keith Willett, NHS England wrote (2015) that, he became involved in this work ‘because I recognised the system needed to do something to deal with a set of issues that have remained unresolved for too long.’
Click to access mesh-wg-interim-rep.pdf
Over all those years up to the present, the PHSO, according to Baroness Cumberlege, failed to find a solution. Kath Sansom, founder of Sling the Mesh campaign, wrote of the Cumberlege review, (https://www.bbc.co.uk/news/health-53307593) that it was ‘hard hitting and recognises the total failure in patient safety, regulation and oversight in the UK.’
I have yet to find any PHSO statement regarding Baroness Cumberlege’s report on the Ombudsman website or on Twitter. However, on July the 9th, the PHSO tweeted about their forthcoming podcast with the Catalan Ombudsman. The subject of their conversation is, ‘How valuable is #Peer Review for Ombudsman organisations?’
Rather than pick his own peer reviewers for his publicised PHSO podcasts, I wonder if Mr Behrens might be persuaded to be more imaginative, more embracing and consider inviting those wrestling on the home front on behalf of the patient – say Kath Sansom, Baroness Cumberlege, or the co-ordinator of the support group PHSO-thefacts.
PHSO failed to find a solution to patient harm – scandal after scandal. PHSO have repeatedly failed the public. Time for a full review.
Add the Shrewsbury Telford maternity cases – same pattern of a few prominent cases – then many more realising they could speak out… Just back from that area – visiting family..
How many times does the PHSO have to be called out for incompetence and negligent investigation. While it continues to harm complainants for wanting candour and to put things right, the PHSO continues to denigrate, bully and harm them – sometimes for years on end – just so NHS negligence and avoidable deaths can be let off with hardly a rebuke. Is is my view that whoever leads this rabble of an organisation should be dishonourably dismissed without ‘consideration’ – much the same as complainants are and have been for the last 3 Ombudspersons. I have heard of complaints needing medical assistance for themselves as a result of PHSO biased and unprofessional responses, even lying with no substantial justification or hard evidence.
I agree. It’s impossible to have confidence in a body that colludes with & condones unsafe, unlawful & unethical NHS practice. I wish it were different. Like many other people we gave the PHSO the benefit of the doubt but we were appalled by the (at best) unprofessional report they produced into our complaint in 2019. Yes, in 2020 they acknowledged fault existed in their 2017-2019 investigation, but the PHSO proposal to reinvestigate our complaint falls far short of an appropriate remedy for the personal injustice we suffered because of PHSO maladministration. We wanted the report quashed but our reasonable request was refused. So now, more public money is to be expended on a new investigation which we have no confidence in & the original flawed, unsafe, & defamatory report still stands. There really are no words & we can never be returned to the position we were in before the PHSO became involved.
You do have the wonder how much longer can the group PHSO the True Story be ignored? It has be bringing stories of injustice to PHSO for many years and yet, it/we are still ignored. Mr Behrens won’t even speak to our group! Critical friend’s who tell the truth, they don’t like!
Reading the account of Margaret Whalley’s review, pg 84 of ‘What’s the Point of the Ombudsman’ it reminded me of the Ombudsman review of my son’s case. PHSO admitted it was an avoidable death, but did nothing about it. Why should they, he was just one of about 150 avoidable deaths in the NHS a week.
How could there possibly have been a review of my son’s case, the Ombudsman destroy files after one year…. But there was! I still wondered what they ‘reviewed’ with no files….anyway, they found nothing wrong of course. What else should we expect? Justice???? No, just defend the indefensible.
Members of the public; learn from our mistakes, don’t go anywhere near the Ombudsman, it’s bad for your mental health.
Excellent analysis of the sorry state of affairs regarding patient safety. Despite decades of scandals, reports and recommendations, nothing has changed. Now, after years of the Ombudsman explaining to people that he wasn’t a ‘people’s champion’, it turns out that what is required to improve patient safety is indeed a ‘people’s champion’. Only not the Ombudsman, but another body to add to the many already created. Will this make a difference? Will it ever be created? I expect the report is already gathering a film of dust, despite all the shock that has been expressed. If the Ombudsman, defined as an official charged with representing the interests of the public, cannot actually do this and requires a Patient Safety Commissioner to do the work that he is incapable of doing, then indeed ‘What’s the point of the Ombudsman?’. Read the book!