PHSO actions and investigative standards excluded from patient safety review
I am grateful to Private Eye magazine for alerting the public to a review being conducted by Dr. Penny Dash, who is Chair of North West London Integrated Care Systems, and I was eager to find out how we, as members of the public, could assist her in her work. I wrote the letter below to Dr. Dash.
10th January 2025
Dear Dr. Dash,
It is reported in this week’s edition of Private Eye that, following your report on the failings of the Care Quality Commission, you have been asked to review patient safety across health and social care more widely.
The report indicates you will be looking at Healthwatch UK, the National Guardian’s Office, the Patient Safety Commissioner, NHS Resolution and the CQC.
I would be grateful if you could confirm whether your remit extends to, and includes, the Parliamentary and Health Service Ombudsman (PHSO), the Local Government and Social Care Ombudsman and the Health Safety Investigation Branch (HSIB) amongst others.
You may or may not be aware that the Public Administration and Constitutional Affairs Committee (PACAC), chaired by Simon Hoare MP, has opened an inquiry into public bodies. Full details can be found on the PACAC website and the closing date for submissions is 7th February 2025. I have already forwarded my evidence, which awaits publication, to the Committee.
Along with many others, I have been a long-time campaigner for reform of the system regarding complaints about the NHS whether arising internally from whistleblowers or externally from patients. I have been a regular contributor to the website ‘PHSO the true story’ and also follow the experiences of others in a group focused on keeping the NHS honest.
There will be many who stand ready to assist you in the task, hence the reason for introducing myself and I ask for your response as to which organisations involved in the complaints process you will be looking into.
Private Eye indicates they are expanding their interest in the issues in their next publication on 24th January. I look forward to your speedy response. I would also be grateful for a contact address for your inquiry if it is not the North West London ICB.
Yours sincerely
David Czarnetzki
The email below is the reply received on 24th January
SENT ON BEHALF OF DR PENNY DASH
Dear David Czarnetzki
Thank you for your recent correspondence of 10 January 2025.
I have been asked to carry out a second review looking at patient safety across the health and care landscape in England, within the context of wider regulation and improvement of quality of care. The terms of reference were published on 15 October 2024 and can be found at the following link:
Review of patient safety across the health and care landscape: terms of reference – GOV.UK
The main focus of the review is the Care Quality Commission, National Guardian’s Office, Healthwatch England and Local Healthwatch network, Health Services Safety Investigation Body, Patient Safety Commissioner and NHS Resolution. Where these organisations have functions related to both health and social care, both will be in scope.
The review will also include speaking to other organisations involved in safety and wider quality (including the parliamentary health service ombudsman) but they are not the focus of this review.
Regards
Dr Penny Dash
The full terms of reference are reproduced below. Followers of PHSO The True Story may well share my concerns at the limited scope of the terms of reference in that it will not:
- examine the six named organisations in detail or
- include an examination of the role of either the Parliamentary and Health Service Ombudsman or the Local Government and Social Care Ombudsman
INQUIRY TERMS OF REFERENCE
October 2024
Applies to England
Introduction
Quality is a critical issue for health and care services.
Using the definition from Lord Darzi in High quality care for all, quality needs to be seen as having 3 distinct, but closely interlinking components, namely:
- safety
- effectiveness
- user experience
The focus of this review will be safety, but it is important to recognise the links between these 3 domains, as safety does not stand alone.
This review will:
- map the broad range of organisations that impact on quality (and therefore have links to safety), but will not examine them in detail
- focus on 6 key organisations overseen by the Department of Health and Social Care, which have a significant impact on safety
Background
The Secretary of State for Health and Social Care has been clear about his commitment to improving quality of care, including safety. Through learning from user experiences and challenging poor culture and practice where it occurs, the Secretary of State intends to restore public confidence in our health and care system.
The landscape of bodies that impact on safety has changed significantly since the late 1990s. Recent commentary, for example in the final report of the Infected Blood Inquiry, highlights that the way the landscape has developed means multiple organisations are involved in related activities.
This may have limited, rather than supported, national system leadership in relation to patient safety and created an unquantified overhead on provider organisations.
Purpose
The primary task of this review is to assess whether the current range and combination of organisations delivers effective leadership, listening, learning (including investigations and their recommendations) and regulation to the health and care systems in relation to patient and user safety (and to what extent they focus on the other domains of quality).
Based on this assessment, the review should make recommendations on whether greater value could be achieved through a different approach or delivery model.
The review will set out the wider landscape of quality, looking at health and social care. The mapping work will provide context for the review of the specific organisations named below. This work will also be used to more widely inform the 10-year health plan.
Scope
The main focus of the review will be on the following organisations:
- Care Quality Commission (CQC) – including the Maternity and Newborn Safety Investigations programme
- National Guardian’s Office (NGO) – NGO is hosted by CQC and its work on staff experience should inform improvements in patient safety
- Healthwatch England (HWE) and the Local Healthwatch (LHW) network – HWE is also hosted by CQC. Its work, alongside LHW, on patient experience should inform improvements in safety
- Health Services Safety Investigation Body
- Patient Safety Commissioner
- NHS Resolution (patient safety-related learning functions only, not clinical negligence functions)
Where these organisations have functions related to health and social care, both will be in scope.
The review will also work closely with NHS England and the Parliamentary and Health Service Ombudsman, as well as the Local Government and Social Care Ombudsman, where this is relevant, to support recommendations related to the named organisations.
Approach
The wider quality landscape
In relation to the wider quality (including safety) landscape, the review will map the overall current landscape of bodies that:
- undertake regulatory or non-regulatory activity with respect to quality (including safety)
- set standards in respect of quality (including safety)
- handle quality (including safety) issues as part of their workload
The review will also:
- consider the breadth of bodies currently collecting ‘people’s experience’ feedback, and how this could be more effectively channelled and used as a basis for assessment and improvement
- make recommendations for further work based on the mapping of the wider landscape
Named organisations
Focusing on the named organisations, the review will:
- make recommendations on the ownership, execution and accountability of key functions, with the objective of ensuring responsibilities are clear and distinct across organisations and are transparent to service users and service providers
- make recommendations on how to maximise the collective benefit of the organisations and propose different delivery models if greater benefits could be achieved
- make recommendations on whether there are key functions across the 6 organisations that are duplicated or are missing
- make recommendations on the rationalisation of data collection and improvements in data sharing and measurement
- ensure there are mechanisms for clear system-wide priority-setting to help ensure recommendations deliver the greatest impact
- make recommendations on how to ensure that people’s experiences and staff voice – including but not limited to data on complaints – are effectively used to make improvements in safety
- set out legislative inconsistencies and overlaps – for example, ensuring enforcement powers are consistent with the mission to rebuild the health and care system
I find it extraordinary that yet another review is taking place without a clear avenue for input by those most affected – the patients. The Secretary of State for Health has limited the terms of reference to bodies coming directly under his control. Unfortunately, this does not include either of the two Ombudsmen who will have the opportunity to exert their influence without challenge from the public.
In addition to this review by Dr. Dash, and as I averred in my letter to her, the Public Administration and Constitutional Affairs Committee (PACAC) has also instigated an inquiry into public bodies and invited evidence. The closing date for submissions is 7th February 2025. Mine was submitted and acknowledged on 30th December. The subject matter will form a future article for PHSO The True Story and will focus on whether the Ombudsman is indeed ‘independent of government’ once PACAC has made a decision regarding its publication.
phsothetruestory 
Patient Safety ?
Once upon a time, in an NHS hospital, a very old man ( 98) set off to the loo. Waiting and waiting for his return, I expressed concern to the ward manager.
Why was I so concerned ?
Wondering how he would find his way back, I said.
Why ? Real question – why on earth was she asking?
Because he was blind.
Response ?
Why was I claiming that he was blind ? ( and had dementia)
Part of a very long story, still claiming – like his actual NHS records, that the patient was blind, hearing impaired, had dementia, awol for a very long time. Retrieved at last, none of the rest has ever been resolved
Even longer ago, on a sunny February day, a six year old was kicked to the ground and violently assaulted by a mental health patient from a city hospital. Welcome to the NHS investigatory process…
At least the legal process was straightforward enough, child injured and hospitalised, assailant arrested, found unfit to plead, criminal injuries awarded. child missed a lot of school.
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Reported in the Sun Newspaper Saturday 25th January 2025. Opiod Probe Rise. Regarding the independent police investigation into Gosport War Memorial Hospital Hants. Allegations include gross negligence,manslaughter.Directorate is reviewing the records of more than 750 patients and has taken 1,200 witness statements.
As to similar cases all over the country which have become exhausted due to stonewalling by managers of numerous organisations and have never been resolved deserve to have the same service across the board.
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Hi Della, What sort of submissions are invited to be sent to the Patient Safety Review?Why is the PHSO being excluded?Are they agreeing PHSO are not fit for purpose? As you know I have the evidence of just how not fit for purpose the PHSO not being impartial, and really supporting The NHS who are prepared to cover up any incident that will not hold them in a good light. The part uphold given by the PHSO for the death of my mother in 2016 and the most awful cover up still has a live Avon and Somerset police niche number.However hard I try to pursue it through the Police it gets ignored, I have an email from Clare Moody Police Commissioner to ‘let her know’ if I have no results. New evidence has come about that a ‘consultant’ involved in the case had ‘recently moved from Bristol to our local Trust shortly before my mother’s death and had been named in a previous inquest. The coroners assistant would not share the outcome with me but would share it with the police if they ‘enquired’ The whole silo of events leading to my mother’s case cover up heavily involved the CQC.Who were they were ‘silenced’ by? IMO by The Department of Health. The Health secretary? at the time. There could be ‘dangerous’ medics still working within the Trust who have got off Scott free protected by other unscrupulous colleagues, who can use an anonymity clause to get out of admitting they cannot be named as witnesses because it will damage their mental and physical health. These people then go on to rise in the ranks of their profession (my case in question) to Professor and draw eye watering salaries of £340 thousand pounds from the public purse, flitting in and out of positions in different Trusts, managing to avoid any scrutiny. How do they sleep at night? Very well I should imagine. This all being helped by The Ombudsman, who allowed his unqualified and unknowledgeable staff to have the wool pulled over their eyes by Trust Complaint Management to omit questions from their scope, and as it seems the regulator the CQC too. The Trusts do not abide by PHSO recommendations, leading to further grief and harms down the line, culminating in my husbands death 2021 where again they have repeated their ‘cover up’ style to escape any scrutiny. The Trust had 5 years to improve, they behave even worse. Where is the justice? What organisation can be trusted to help the patient? Will this new review be of any use? Is there anyone of them there who understands the workings of the NHS, Dept Health, the absolute power abuses? Just who can we trust? Can I ask PHSO the true story to support me in making a submission, because frankly, I am exhausted with the whole awful affair.
Sue Forsey
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Yes Sue we will help you contact us at phso-thefacts@outlook.com
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‘The NHS never apologises’ a quote from my MP when seeking her help over an issue concerning my late husband and myself. Patient safety cannot improve while the NHS and , in my case Social Services, stonewall so effectively.
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The NHS are expert at stonewalling and gaslighting
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This is ludicrous,get the historic cases available, where it all went wrong, where all the organisations where involved including the PHSO.The long suffering complainants can point you to the way foreward which is scrap the lot, save the public purse and stop hiding behind each other’s skirts.
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It’s makes you wonder if they actually want to get to the truth doesn’t it.
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Thank you for posting Della. Interesting that the reference to Lord Darzi “High quality care for all” relates to a report he wrote for Gordon Brown which was published in June 2008 – yes nearly 17 years ago. I find it interesting that the collapse of Lehman Brothers in the USA took place in September that year, just three months after the report was published thus creating a financial crisis. The Labour Government of the day found itself out of office in May 2010.
Patients and whistleblowers need a single investigative body that is able to provide a speedy response to issues AS THEY ARISE. The present system of giving NHS bodies the option of marking their own homework first is no longer tenable. That is why the six bodies under review, together with PHSO and LGSCO must be scrapped.
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They know it doesn’t work. It never has. There is always a hidden agenda to these patient safety reviews. Perhaps the private healthcare companies want to limit future scrutiny.
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