First published by Romy Cerratti January 24th 2022

  A German doctor saved my life when I was just over a year old. A joyous first family Christmas in Germany ended in me catching an infection from my cousin, sepsis and ICU. The doctor gave my fragile young body the best possible chance and I owe him much. Sadly many of my subsequent encounters with doctors and nurses have been the opposite and it is these that have left their mark. I was assaulted by an NHS doctor when I was 14 and desperately unwell with a complex mental illness. However it’s never been as ‘straightforward’ as dealing with the one horrific incident. Many months of bullying and threats preceded that assault. In the years that followed I went through unnecessary incarceration in inpatient units and damaging treatment therein, intimidation, lies, misdiagnosis, catching life threatening hospital infections and plain old incompetence. I have more often survived despite and not because of medical ‘care’ and have added PTSD to an already complex set of mental and physical health conditions. It is a great source of pain to me that I now approach all medical professionals with distrust, even fear.

   However the prevailing British view of ‘our NHS heroes’ and ‘our amazing NHS’ could not be further from mine. The reverence of many Brits for their healers knows no bounds and most won’t tolerate criticism of their modern day saints. This even extends to when their health or the health of a loved one has been mishandled and damaged, sometimes even when the result is death. Just recently I read a newspaper report of the tragic cancellation of vital scans, due to NHS Covid policy, for a 15 yr old boy with a brain tumour. It struck me that the mother did not blame the NHS for this or even the doctors for missing the clear symptoms of a brain tumour earlier on. Heartbreakingly this poor lady almost blamed herself for not being ‘pushy’ enough! My mother encounters this regularly in the course of her job as a vicar looking after 8 rural parishes. Even when an avoidable death has occurred, people are reluctant to complain about their medical treatment. ‘I’m sure they did there best,’ or ‘it’s a problem of the management and resources not the doctors and nurses’ are the predictable responses. Such pervasive NHS worship can also scare would be complainents and whistleblowers into silence. I am often contacted privately on social media by those who want to tell me their story of medical mistreatment. Telling me is ‘safe’ because they know I will accept and empathise rather than judge or dismiss their NHS heresy. It is a heartbreaking privilege. Recently a Twitter follower shared both her story of doctors covering up the failings in her treatment and a link to the ‘Oliver McGowan Mandatory Training in Learning Disability and Autism video’. Oliver’s brave mother eloquently tells the heartbreaking story of the catelogue of errors and mistreatment that lead to her son’s death. It somewhat shocked me that even in a case where there was clear blame to be ascribed to individual physicians, she said ‘It’s not about pointing fingers, it’s not about blame.’ But is it?

   It’s actually quite rare for people to make an official complaint against the NHS, even if they do feel wronged in some way. The intrepid who do embark on the official complaints process find their path beset with obstacles that can feel designed to make you give up.

‘Scandalous and shameful. If you’re looking for an outcome and you’re emotionally stressed, don’t waste your time with these corrupt individuals.’

This is a Trust Pilot review of the Parliamentary and Health service Ombudsman, (PHSO), the final and highest arbitrator of complaints against the NHS and its employees. It is indicative of pretty much every single review. Undeniably people who have had bad experiences are more likely to leave online feedback. However this near universal unbridled fury and distress, summed up in one review as ‘The PHSO is a vehicle for injustice,’ suggests a fundamental problem.

  In 2016, after a scandal provoked a change of Ombudsman , chief executive at the Patients Association, Katherine Murphy said patients had ‘been failed by the PHSO for too long.’ However, the statistics, as well as patient feedback, suggest nothing has improved. In 2018/19 it was found that the PHSO upheld just 2.4% of all the complaints submitted. (It must be added that if resolution without investigation is taken into account this figure rises to 20% but also that ‘resolution’ is most often no more than a simple apology). This is a decline from the already paltry 3% in 2016/17 and even further from 4.7% 2015/16. The Ombudsman is theoretically held to account and monitored through the submission of annual reports to the Public Administration and Constitutional Affairs Committee, (PACAC), a parliamentary committee made up of cross-party members. However PACAC can’t review individual complainants cases and the Ombudsman’s verdicts can’t be challenged. Therefore the Ombudsman is not accountable in any meaningful sense. The only recourse available to a complainant is Judicial Review, a path that precious few citizens have the means to make use of. One rare example of a successful High Court challenge in the High Court was brought by two GPs in 2018. In the ‘Miller & Anor V Health Service Commissioner for England’,  the judgement criticised all aspects of the investigation process including failure to consider all the evidence and an inadequate review process. Importantly it also highlighted the ‘lottery’ of the ‘clinical advisor’ selected for each case. When the PHSO investigates and scrutinises a case it uses but a single clinical advisor whose words are Holy Writ. Therefore one person’s opinion is basically all that matters and it is an NHS doctor reviewing one of their fellows. The NHS arguably acts as its own judge and jury.

 ‘It doesn’t matter what I say or what evidence I present you will simply stick to your narrative that bears no relation to the truth. I am powerless.’

This time these are my own words, taken from my response to the PHSO’s final report on one of my two complaints I submitted in late 2018. I had already gone through a long mentally draining process to get to this stage of utter despair. That involved having to first complain to the hospital and the NHS Trusts, several labyrinthine forms and some rather interrogatory face to face meetings. This smorgasbord was completed by a random, intimidating phone call from someone at the relevant NHS Trust trying to dissuade me from taking things further. Both complaints centred around the absence of psychiatric assessment, misdiagnosis and serious negligence in both psychiatric and physical healthcare. The consequences of the way I was treated have been profound and I am living with the terrible consequences daily. But those wounds were actually deepened by the complaints process I had hoped would bring some healing closure and justice. The fact that my records were lost, my complaints muddled up resulting in huge delay and my caseworker frequently went AWOL almost feels inconsequential to me now in the light of the whole process being a whitewash. The first question asked of the PSHO’s clinical adviser assigned to my case was: 

‘Is there any evidence that Ms Cerratti should have been assessed by a psychiatrist during her admission/time as an inpatient?’

The Ombudsman actually questioned whether it is essential for someone with severe psychiatric problems to be assessed by a psychiatrist whilst in hospital. This gives a fair impression of the whole tortuous coverup of an ‘investigation’. I was left staring at a page of my medical records, on which was written a few notes of my medical history, dictated to a nurse by my mother, but on which the PHSO insisted was recorded a psychiatric assessment. One by one family members stared at the same page and we all started to wonder whether we’d fallen ‘through the looking glass’. Indeed my whole encounter with the PHSO had the bewildering feel of being in a shape shifting bonkers Wonderland. 

‘“When I use a word,” Humpty Dumpty said in rather a scornful tone, “it means just what I choose it to mean — neither more nor less.”’

They were in control and could weave whatever bizarre fiction they chose irrespective of what most would understand to be reality.

   I have nothing but admiration for the amazing Mrs McGowan, the architect of the much needed Oliver McGowan Mandatory Training in Learning Disability and Autism programme. She has achieved more regarding NHS reform than I am ever likely to. I also respect her emphasis on improving the education of NHS staff. However improved training, although vital, can not alone solve the problem of NHS malpractice. In order to stop the rot we must get rid of rotten apples and that very much involves both blame and pointing the finger. It must involve holding individual medics to account, even criminally, and certainly striking off the worst offenders. In Oliver’s tragic case no amount of extra training could have prevented the arrogant disregard of his medical notes and ignoring his family’s and indeed his own wishes. In my friend’s NHS story, it was not ‘lack of training’ that made doctors falsify her medical notes to conceal their bad practice. In my own case there was an invisible psychiatric assessment, disregard of my previous trauma and the unwillingness to believe me or even listen to me, none of which was down to a lack of training.

   The medical abuse I have suffered hasn’t just left me with a distrust of medics, it’s given me a deep rooted distrust of life. Ironically the process I hoped would help ease that, the NHS complaints process, actually reinforced it. I can only speak out to encourage other victims to do likewise and in the hope that our suffering will be acknowledged and provoke reform of the NHS, it’s culture and its complaints process.