When will the performance of PHSO be externally examined as part of a healthcare failure inquiry?

When one door closes another door closes

A blog by David Czarnetzki

East Kent Hospitals University NHS Foundation Trust entered a guilty plea at Folkstone Magistrates Court on Friday 18^th June for failing to provide safe care to Harry Richford, who died seven days after his emergency delivery in November 2017 (source – Daily Telegraph  – 19^th June 2021).

The Trust was fined £733,000.

One baby and one tragic death, but no doubt ‘lessons will be learned’.

The question I continue to ask is whether there is any evidence of the Ombudsman playing a significant part in helping the learning of lessons. In recent months, my  FOI enquiries of PHSO and correspondence with Donna Ockenden, Chair of the enquiry into Maternity Services at Shrewsbury and Telford NHS Trust provide some illumination. I reproduce my letter of 11^th March 2021 sent to Donna Ockenden.   

“Dear Ms. Ockenden

Role of the Parliamentary and Health Service Ombudsman (PHSO) into maternity related complaints at Shrewsbury and Telford Hospitals NHS Trust

Thank you for your letter of 6^th January. I note you have not explored the role of PHSO in relation to maternity complaints and do not hold information relating to this. I have, as you suggested, made freedom of information requests to PHSO. I attach the e mail thread which has passed between PHSO Freedom of Information Officer and myself in recent weeks. You will see from, the e mails, how haphazard PHSO information systems are. The e mail exchanges evidence the following:

Pieces of information relating to Shrewsbury and Telford NHS Trust have been supplied by PHSO in various tables. To ease understanding, I have consolidated these in the table below: 

Year*	Total Investigations Received	Investigations Upheld	Investigations Partly Upheld	Maternity Investigations Completed	Maternity Investigations Upheld	Maternity Investigations Partly Upheld
2013-14	47	0	2	0	0	0
2014-15	43	2	5	1	1	0
2015-16	28	2	7	1	0	0
2016-17	23	1	0	0	0	0
2017-18	35	0	4	2	0	2
2018-19	46	0	0	0	0	0
2019-20	53	0	3	0	0	0
Totals	275	5	21	4	1	2

The PHSO response to my FOI requests makes it difficult to compare ‘like with like’. For example they are able to identify total investigations received in relation to areas of Trust activities as a whole, but cannot supply the total investigations received relating to maternity issues. Also, PHSO cannot supply the number of complaints they received and then rejected for investigation either as a whole or for maternity in particular.

Notwithstanding the inadequacies of their information systems, the consolidated table makes disturbing reading regarding the lack of effective impact PHSO had over the years on maternity issues at the Trust that are the subject of your investigation. PHSO has completed just 4 maternity investigations regarding the Trust in 7 years.

In my view, this equates poorly with the total of 1862 cases you have looked into. I accept you have gone back further in time.

May I respectfully ask that you briefly re-visit this important aspect of NHS complaints and investigations by issuing a short questionnaire to those victims (post 2013) you have been in contact with to include the following:

• Did they make an initial complaint to the Trust
• Did the Trust investigate
• Were they satisfied with the Trust Investigation
• Did they progress the complaint to PHSO
• Was any complaint to PHSO rejected for investigation

Your interim report released in December 2020 has been widely applauded and your final report has yet to be issued.  Development of these issues presents you with a unique opportunity to reflect on the role of PHSO involvement (or the lack of it) in the failures you have so clearly uncovered at Shrewsbury and Telford so far.

I am sharing this letter with members of our support group, PHSOthefacts and other interested parties. The internet site PHSOthetruestory will give you wider understanding of the concerns of PHSO victims as will examining the public evidence submitted to the Public Administration and Constitutional Affairs Committee (PACAC) in advance of their PHSO scrutiny hearing held in November 2020.

Yours sincerely

David Czarnetzki.”

The response from Donna Ockenden, dated 17^th May and an extract reproduced below, shows PHSO was not on the radar of her enquiry.

“Thank you for your letter dated 11^th March and the information and analysis you have provided. It is interesting to see the apparently very low number of maternity investigations at SaTH undertaken by the PHSO.

However, I am advised that the operation of the PHSO scheme for patient complaints does not fall within the terms of the review’s remit. I wish you well in your efforts to secure improvements to the PHSO scheme”.

Well, at least there was some recognition the PHSO scheme needs improving but with the Ockenden review covering 1862 cases and PHSO conducting just 4 investigations since 2013 there is a serious mismatch in ‘the system’. 

Rather than create a robust system of complaint investigations, the establishment prefer nearly three quarters of a million pounds to be paid from the public purse for health to a different part of the public purse.

No doubt millions more will go when the legal cases at Shrewsbury and Telford are eventually resolved, but hopefully appropriate compensation will be forthcoming for those who have been adversely affected. 

In the meantime, Governors at PHSO maintain their golden silence about the backlog of 2600 cases awaiting allocation to an investigator and Michael Gove has no plans for Ombudsman reform before and including up to 2023-24.