By David Czarnetzki
“As we know, there are known knowns: there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns – the ones we don’t know we don’t know”
These words, spoken by U.S Secretary of Defense Donald Rumsfeld in 2002, attracted some ridicule at the time but they are actually based on a model of the Johari Window shown below:
Known to PHSO
|Not known to PHSO|
Known to others
Not known to others
So, I hear you ask, how does this relate to the Parliamentary and Health Service Ombudsman?
On 7th July 2021, the Ombudsman Mr. Behrens, laid a report before Parliament entitled “Unlocking Solutions in Imaging: working together to learn from failings in the NHS”.
The report is a synopsis of 25 complaints ‘investigated’ by the Ombudsman since 2013 and closed by 2018. This was of particular interest to me as failure to accurately interpret an MRI scan led to my prolonged pain being exacerbated and delay in treatment. I have also become aware of at least two other members of PHSOtheFacts who, to some degree, have been affected by this particular issue.
What then has Mr. Behrens report put into the ARENA?
In half of the 25 cases, guidelines of the Royal College of Radiologists were not followed, there were failures to act on important unexpected findings and failures to learn from mistakes.
In one third of the cases, the Ombudsman identified delays to reporting or reviewing images .
Additional information, arising from the report and now in the ARENA includes:
Failures to implement recommendations of previous work by HSIB and CQC in 2018 and a report by Mike Richards for NHS England in 2020
The details of four case studies leading to PHSO recommending payments of £10,000, £2,500, £950 and an apology.
Well, so far so good but it is important to reflect on what the report does not contain, in other words – the FAÇADE
What were his findings in all 25 cases and could some of them have been expected rather than unexpected? Surely this should be reported to eliminate bias and provide a balanced view.
Whilst he made recommendations for payments, were these payments actually made by the Trusts involved and did he follow up on this?
If the investigations were completed in 2018, why has it taken until July 2021 to selectively report his findings. The issue of Covid did not materialise until January 2020.
I will never know whether my case was one of the 25 case studies, probably for four reasons:
- It took from June 2015 (when the PHSO final report was issued) until April 2018 for PHSO to recognise and admit their initial investigation into my case was flawed.
- PHSO made a compensation payment to me including a sum for its own failings. Perhaps not a good look for PHSO to make this fact public.
- Like every other member of PHSOtheFacts, I am now ‘persona non grata’ as far as the Ombudsman is concerned for what he describes as making serious and unsubstantiated allegations against the organisation, despite the fact that, for four years, Mr. Behrens has never put the specifics in writing. So much for openness and transparency.
- It is clear the Ombudsman does not see himself as being directly answerable to complainants but only to PACAC for scrutiny of his annual report.
In addition to laying the report before parliament, Mr. Behrens has also sent letters to Jeremy Hunt, Chair of Health Select Committee, William Wragg, Chair of PACAC and Nadine Dorries, Health Minister responsible for patient safety. Rest assured I intend to do the same to provide some balance.
Is this a good job done by PHSO or is it just a regurgitation of the work of others with a few PHSO selected cases thrown in? The document adds little weight to the issue and even less to the debate.
In summary, I have to highlight the Ombudsman’s BLIND SPOT. It is his continuous refusal to engage with members of the public just because of association with PHSOtheFacts. See PHSOthetruestory – the PHSO e mail in the blog “Who do you think you are kidding Mr.Behrens?” To this end, if Donald Rumsfeld’s words were spoken by Mr Behrens today, the final additional sentence would probably need to be: