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Learning from mistakes: An open and honest review of failings in handling a serious complaint

Patient Safety Campaigner and member of PHSO Expert Advisory Panel

Today, the Parliamentary and Health Service Ombudsman (PHSO) has published an important review. It looks at the way PHSO handled a serious complaint from the father of a young woman who tragically died in December 2012, following very serious failures in her care by a number of different organisations. 

The report is a frank account of how PHSO got several things wrong in the way it dealt with the complaint and the considerable impact this had on the family.

Reflecting on my own experience

Reading the report, I couldn’t help but reflect on my own experience of the NHS complaints system following the avoidable death of my baby son Joshua in 2008. 

Like so many other families I’ve met over the years, our experience was of an NHS that acted to conceal the full truth about what happened. As a result, there was little learning or change. The impact this had on our family was to make coming to terms with what happened so much more difficult.

In the months and years after Joshua’s death we were left feeling badly failed by both the local response to what happened and by how other organisations responded, including PHSO. 

In recent years the NHS has recognised the need to improve its systems and processes for responding to and learning from patient harm. But it is fair to say that change has felt slow. 

A candid account of what went wrong

When the local response to serious failures in care does not address all of the issues, it is crucial that patients and families have somewhere to go where their concerns can be independently assessed and investigated. This is even more vital when patients and families feel that the truth has been suppressed and lessons not learned.

In the most serious of cases, families going through the NHS complaints system may already have been through protracted local investigations and complaint responses. 

By the time they reach out to PHSO, their trust in the system may well be badly eroded. This means the way the Ombudsman reviews concerns, obtains expert advice, weighs up evidence, listens to and engages with the complainant, and explains decisions is crucially important.  

Today’s report is a candid account of how PHSO got a number of these aspects significantly wrong, and the consequences this had on the family involved.

As is too often the case, it is only because of the extraordinary efforts of the complainant to persevere through a sometimes very challenging and complex complaints process that serious failures were eventually identified.

This is true not only of the care provided but also of the local responses to what happened.
If we want a safer and kinder healthcare system, it’s crucial that a number of things change. 

Firstly, the way in which serious failures in care are investigated locally needs improving. National work is currently underway towards this, including the development of a national patient safety syllabus and the Learning from Deaths programme. 

Unless we make sure that local investigations are carried out by professionals who have suitable experience, skills and independence, and who listen to and engage with patients and families throughout, the system will remain set up to fail.

It is also crucial that when local processes fall short, the Ombudsman can provide an effective and compassionate service, and carry out an objective review and investigation.  

Taking action to put things right

Today’s report details several changes that have been made by PHSO in recent years. These measures include:

  • new processes to ensure consistent allocation of caseworkers
  • a new casework management system
  • a training and accreditation framework for caseworkers
  • improved data governance 
  • communications training for staff 
  • updated policies and guidance on how evidence from organisations and complainants should be equally considered. 

I am pleased to learn that the Ombudsman is currently piloting a new approach that gives complainants the opportunity to see clinical advice and have a meaningful discussion about it with their caseworker. 

This feels like an important initiative as patients and families are often experts in their own cases. They ought to have the opportunity to read, understand and share their insights on clinical advice and how it is used. 

The report published by the Ombudsman will no doubt make uncomfortable reading. I am sure it will resonate with other people who have been through the NHS complaint system following serious failures. 

However, it’s crucial that organisations are able to reflect candidly when they get things wrong and this review is a welcome example of that.

Building on the learning

In the year ahead, it’s vital the Ombudsman builds on the learning from this review. Changes must be embedded to make sure that other people who turn to the Ombudsman service have a different experience. 

I hope that 2020 will also see further changes across the healthcare system to make sure families affected by serious failures are properly supported through high quality investigation processes from the outset. 

Open and honest responses and early identification of actions are needed to make care safer for the future. The considerable impact on families, future patients and also healthcare professionals is simply too great not to make this an urgent priority. 


Download the Report of a review into PHSO’s handling of Mr Nic Hart’s case from August 2014 to December 2017 (PDF 7.57KB).