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 18th June for failing to provide safe care to Harry Richford, who died seven days after his emergency delivery in November 2017 (source – Daily Telegraph – 19th 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 11th 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 6th 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 17th May and an extract reproduced below, shows PHSO was not on the radar of her enquiry.
“Thank you for your letter dated 11th 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.

Thanks for this analysis which furthers understanding.
Gosh it is stark how few of those 275 investigations received were actually upheld, even partially so. How does this encourage a complainant with genuine concerns to apply? So little has been resolved this way.
The low rate may alert complainants, licking their wounds because their case was not upheld, that they are certainly not alone.
One might have thought there would be more curiosity on the part of Shrw & Telford. As you say, ‘not on the radar’. Were it not for phso-thefacts, perhaps little would be spotted on anyone’s radar.
In the interests of improvement, good show for joining dots and posting!
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Thanks
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All very confusing. Chris Stephens is an SNP member. Scotland has its own Ombudsman yet the bill is being introduced to give powers to PHSO. Not due for second reading until January 2022. Will the bill fail because Michael Gove has no plans for Ombudsman reform.
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Interesting that you mention PHSO failure to identify systemic problems as just this week a proposal has been put to the HoC that PHSO are given the powers to investigate systemic problems at the DWP. What could possibly go wrong?
https://www.theyworkforyou.com/debates/?id=2021-06-21b.616.10&s=Parliamentary+and+Health+Service+Ombudsman
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What is the point of giving him these powers when he is shelving cases he is supposed to be currently investigating
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Exactly. And he has taken 4 years and counting to investigate the DWP over failure to notify 50s women over changes to pension age. They clearly don’t want or expect the ombudsman to speedily identify systemic problems.
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That’s a great piece of sleuthing and raises the question yet again – “What’s the point of the Ombudsman?” Everyone knows or should know that he fails to bring public bodies to account or uphold justice for complainants. But it turns out that he can’t identify systemic problems either. There has to be a full inquiry into the failures of the PHSO and the complaints system or else these problems will happen again and again and more Harry Richfords will die. Doesn’t anyone care?
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