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 | ARENA | BLIND SPOT |
Not known to others | FACADE | UNKNOWN |
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:
“We refuse to know what we do not like to know”

Reblogged this on disabledpartylitigantlegaljourney.
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In relation to the comment above “[Behrens] thinks it is enough for allegations to be dismissed as false and irrelevant by trying to address the criticism as if made by questionable people. Therefore he attacks the critics, because he’s unable to attack the criticism.”
This has been the picture with the last 3 Ombudsmen, but not quite as distinct and obvious as with Mr Behrens, who has been made aware in person of several cases of actual harm committed on complainants.
I have made applications under FOI to the PHSO with no clear response except for on enquiring on PHSO service complaint procedure (NB there is none).
“To clarify and confirm, the PHSO does not consider itself to have abused any complainants. ”
and yet this, despite PHSO being notified “…you may wish to note that despite many previous FOI questions on these matters including direct approaches, the PHSO has yet to show advance or initiative. It is unlikely that I personally shall ever recover from such abuse.”
The PHSO takes not an iota of interest nor further enquiry of these matters.
I offered in example “[the] PHSO’s use of unsubstantiated or covert NHS ‘evidence’; PHSO refusal to quote sources of accusation; acute bias in [their] lay or ‘amateur’ interpretation; imposition of unrealistic deadlines or [an] ‘agenda’ to close complaints with nil regard to due diligence [which] all add to the harm and damage to complainant, resulting in [substantial harm to said complainant]”
A response on similar complaints had met with a quote from the PHSO viz. “…there remained a small group of vocal and challenging critics who were unlikely to ever be supportive….”; which I find derisive and dismissive… closed minds… tunnel vision… jobsworths.
I personally never set out to “support” the PHSO (as gaslit here) except in improving its service by highlighting material errors and fallacious and unsupported assumptions. I have always been available to respond to enquiry or give advice gleaned from traumatic experience, or from Professionals of status and esteem. The PHSO has never set store in either esteem or qualified rationale because that would undermine their very tools of complainant attack, here seen used freely, again.
I also asked for PHSO policy on mental abuse of complainants [as illustrated and as rejected by PHSO]. The PHSO “has no policy [which would assist my FOI enquiry]”.
My complaints had been offered to the PHSO at several times and at unappreciated effort considering my disability. The PHSO has rejected, disparaged, closed without response, or never shown interest; all under their only statement (i.e. ‘the policy’?):
“Your request appears to be regarding situations where you believe complainants have been harmed by PHSO “abuse”. To clarify and confirm, the PHSO does not consider itself to have abused any complainants.” Nota Bene – the PHSO’s mocking parenthesis of “abuse”.
I find this sort of PHSO response sickening to me and all those who have been harmed, of course, but a blatant breach of UK (and EU) laws and Acts passed for the protection of all consumers of any service, Government funded or not. The PHSO chooses to dismiss the effects on its victims, illegal or otherwise.
Despite the laughably optimistic “vision” of being the “exemplary public services Ombudsman…” (according to Behrens), the PHSO is saying in repeated requests for transparency “we don’t care [about disability; trauma; harm; accuracy; professionalism”, and Government PACAC* year-on-year ignores escalated complaints of zero accountability in the PHSO’s duty to handle complaints and complainants with due respect to the complainant and to the law.
The PHSO forgets (or ignores) the fact that many of those ‘challenging’ critics have relevant training and experience far above any mocking PHSO caseworker or green customer services agent is ever likely to have, receive or be offered. My particular experience would extend that surmise to those of upper PHSO rank also.
My FOI requests can be found here:
https://www.whatdotheyknow.com/user/c_rock/requests.
My previous evidence to PACAC can be found here:
https://committees.parliament.uk/writtenevidence/13783/html/
Others of the same year here:
https://committees.parliament.uk/work/609/parliamentary-and-health-service-ombudsman-scrutiny-201920/publications/written-evidence/
* PACAC “…is responsible for scrutinising the work of the Parliamentary and Health Service Ombudsman… ” but only though the PHSO’s own reports of success and promises.. ” patently, due to the sheer volume of powerful but ignored user-feedback presented to PACAC, year after year from the rapidly-growing ” … vocal and challenging critics…”. A challenge the PHSO dismisses at great cost to failing Government Services and potentially £billions to taxpayers in running other negligent public services.
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CR. You have captured all that is wrong with PHSO in your response to my article. Thank you. Last week, PHSO laid a report before Parliament regarding problems with MRI and X ray imaging. This week he has put out a report regarding DWP and pensions plus his annual report. Funny how these things materialise just before Parliament goes into recess for the summer isn’t it?
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As the old sign says, ‘when will they ever learn’ oh no they will never learn… honesty, truth and all the other things normal people consider right and proper. Such sad people…. so over paid but they may Reap the whirlwind yet….
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Hey there Della
This is what you were referring to ref blogs way back.
Not sure how to work those. But it’s the 27th tomorrow Joy Morrisseys time up, so will press ahead at the printers and get 3,000 postcard sized cards and they will be commercially delivered within the Beaconsfield Constituency through the front doors of domestic and business properties as it’s become clear our businesses were being turned over too.
But that’s mostly circumstantial evidence but strong, the domestic side evidence solid. https://unwantedcounciltax.com/
I have asked and can only hope folk start moving it out to their contacts and so on from there, but I will be making contact with council tax groups up north so see how it goes? Have someone to move it on Twitter, several on Facebook as everyone seems to be on that but not me.
Freedom Day they say on Monday, a couple of weeks and back into lockdown possibly, glad I’m retired and no mortgage!
Stay well and kind regards Della 😘
Nigel
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” for four years, Mr. Behrens has never put the specifics in writing”.
Mr Behrens suffers what in the study of argumentation and logic, is referred to as ” ad hominem attacks”. He thinks it is enough for allegations to be dismissed as false and irrelevant by trying to address the criticism as if made by questionable people. Therefore he attacks the critics, because he’s unable to attack the criticism.
One would assume that someone who is leading an “important” organization such as the PSHO, would be able to do a lot better than that. Therefore he disappoints on multiple levels.
Sorry about your tribulations.
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Spot on. He is unable to refute the facts.
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Do you guys know of any investigation where maladministration has been admitted, compensated for by the DWP
And then been ignored and re-investigated by the Independent Case Examiner concluding no evidence even though
In the next comment identified the DWP have destroyed records in line with their data retention policy?
Further to this point I.C.E decide because the DWP decision maker had not recorded the reasons for her decision then
the ICE examiner can conclude no evidence found of the maladministration?
I would love to get some feedback if anyone else has been subject to this type of irregular ICE investigation which goes
Against the guidance in redress for maladministration 2012.
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Sounds familiar. They stick together to deny justice
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Jobs worth jobs never own up, deny and stick to it.
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