Written evidence from Brian Cooper (PHS 22)
Public Administration and Constitutional Affairs Committee
Parliamentary and Health Service Ombudsman Scrutiny 2019-20 inquiry
The PHSO closed my case in September 2020, it did not uphold any of the concerns I made whatsoever, it provided no feed back to the organisations concerned and made no recommendations for improvement in care or treatment.
I make the following submission to The Public Administration and Constitutional Affairs Committee (PACAC) regarding the Call for evidence - Parliamentary and Health Service Ombudsman Scrutiny 2019-20.
Closing date: Friday 30th October 2020
Date of this submission: Thursday 29th October 2020
Re: PHSO case regarding the death of Mrs. Evelyn Cooper – Died 3rd April 2015 aged 83.
This submission is made by her son Brian Cooper.
I have no objection to any of the information in this submission being made public.
It should be the duty of organisations such as NHS complaints and the PHSO to uphold and promote high standards of care.
The facts in this case show no learning on critical care has taken place and it is my opinion that future patients will suffer as a result.
The PHS Ombudsman is supposed to be impartial and neutral. The evidence I have contradicts these values.
My evidence relates to the following subject areas:
• Value for Money – They wasted my time and their effort and therefore wasted public money investigating undisputed events.
• Impact on other organisations. - NHS England, Hospital Trust, GP Practice – No feedback - positive or negative was given – no learning or any attempt to raise the standard of care provided.
• The time taken for the PHSO to respond to correspondence – Takes months to provide information and requires a response in days.
This is quite a complicated case and my knowledge of the issues has evolved over the 5 years since my mother died.
All I ever wanted to know was how my mother became so seriously ill, it was said at the inquest and in the subsequent NHS Complaint Investigation that it was two prescription drugs that caused the problem. My mother had been on these drugs for years and the 2 drugs in question have been in the top 20 most prescribed drugs in the UK for years.
I made the point to the PHSO that it was the gradual worsening with age of her congenital heart defect that was the cause and there was no monitoring or treatment given for this condition.
The PHSO refused to investigate my claim and upheld the view that is was the drugs that caused the critically low electrolyte levels.
Those involved have not fulfilled their Duty of Candour and this includes the PHSO, NHS England Complaints, and some of the medical professionals involved.
For a long time I was side tracked, an old fashioned term would be “lead down the garden path”.
There has been a very concerted effort not refer to the real issue, nobody tells lies they just don't make reference to the real problem and avoid anything that can remotely point to the truth.
The PHSO avoids addressing the key issues and as such avoids areas of contention. Misdirection is commonly used to great effect to deflect attention away from crucial evidence.
My real concern is that other patients with the same medical condition as my mother will fail to get the treatment they need. My mother was 83 but what happened to her could happen to those much younger.
In the 5 years since my mother’s death and given the time taken by the NHS Investigation. then the PHSO investigation it is not inconceivable that patients have already suffered through lack of proper treatment.
The PHSO has not provided feedback to those involved in her emergency treatment, this is why it is entirely possible that the medical professionals involved could make the same mistakes again.
In fact the opposite is true, those involved can only think they have done excellent work which is endorsed and upheld by the Ombudsman. I find this thought chilling.
For the sake of clarity I will list the 3 main issues I have with the PHSO investigation.
My mother was admitted as an emergency on the 28th March 2015 for intravenous replacement of 3 main electrolytes.
My mother died on the 3rd April 2015, 2 days after a 5 day stay in hospital
I made a complaint to NHS England in January 2016 about the 20 days my mother suffered unnecessarily as a result of the incorrect diagnosis made on the 8th April 2015 at the same ED department for the same condition as she was admitted for on the 28th March 2015.
My final complaint to the PHSO has very little to do with my complaint to NHS England but the PHSO insist on constantly referring to the NHS investigation findings, this is a complete waste of time, the issues I raise were not covered in the NHS report that I received in December 2016.
My mother was born in 1932 with a heart defect now called mitral valve regurgitation (MVR).
From an early age she was told she had a hole in the heart.
In those days this malfunction of the heart could be confirmed by a stethoscope, these days ultrasound and ECG are used to get a much more accurate understanding of the function of the heart.
When I mention heart monitoring in this statement it means ultrasound and ECG.
My mother’s heart problem was not serious and it did not prevent her from living a normal life until she was in her 70’s, she died when she was 83.
The main visible sign of this heart defect in my mother was a high respiratory rate (over 20 per min) as a result very mild exercise such as walking from the lounge to the kitchen for example.
It is worth noting that for patients with MVR there is a danger of fluid building up on the lungs (oedema) due to this repeated high respiratory rate.
Diuretics are generally used to counteract this fluid build up on the lungs although surgery to improve heart function can also be done and this can help reduce the patient’s respiratory rate during normal day to day activities.
My mother had a procedure to widen an artery leading to the heart when she was in her 70’s.
My mother had her diuretic, prescribed for high blood pressure and taken for 17 years, removed as part of the treatment for low electrolytes (there is a drug conflict between the diuretic and Alfacalcidol (synthetic Vitamin D which greatly facilitates calcium absorption) which was prescribed for the first time as a recurring prescription while in hospital
The point I did not know until 2019 was that patients with MVR are at risk of heart failure due to infective endocarditis especially when they have bacterial inflammation.
Infective endocarditis happens as a result of the heart’s regurgitation of blood, if bacteria are present in the blood then the heart can get overwhelmed with a mass of bacteria building up in the heart.
The solution to prevent this occurring is the use of antibiotics particularly at the first signs of any bacterial inflammation, inflammation which is indicated by a high CRP (c-reactive protein) reading.
This drug can be used as an empirical treatment to guard against life threatening consequences of endocarditis.
The PHSO steadfastly refused to appoint a heart and lung specialist to investigate the factual evidence I presented.
This is an example of how the PHSO avoids any possibility of producing compromising evidence.
In the last set of blood tests carried out 2 days before she left hospital, CRP was 80 which is 8 times the normal accepted maximum of 10.
The facts reveal the Trust did not monitor or provide treatment for infective endocarditis.
The misdirection by those investigating has been to ignore the heart issue and focus on the process in replacing the electrolytes. I have never disputed that the electrolytes were correctly replaced.
As previously mentioned In 2019 the PHSO steadfastly refused to investigate my concerns related to endocarditis and resolutely refused to appoint a heart and lung specialist.
The investigators appointed in November 2019 were an Endocrinologist, a GP and a Nurse.
The reasons the PHSO gave for not appointing a heart specialist were:
An endocrinologist was quite capable of answering any heart related questions.
There was no specific mention of of endocarditis in the agreed scope of March 2019 as shown below.
It is true I did not specifically mention endocarditis but I only became aware of this after the scope was agreed.
The point I make here is that there is no provision for updating the scope at a later date as a result of additional evidence.
In my view the PHSO are very inflexible and intransigent and not welcoming to new crucial evidence, especially late in the investigation process.
The GP did work for the Trust part time in the ED department, so perhaps there is a conflict as to patient confidentiality.
It is my view that those involved, including the GP, were not aware of my mother’s congenital heart condition and that is why there was no treatment.
Of course as an endocrinologist if you are not aware that the patient has MVR at the time of replacing the electrolytes then you are unlikely to treat endocarditis no matter how good your knowledge of matters related to heart defects are.
The question is; Did her GP know of my mother’s heart defect? I think not.
Given that the PHSO now knows about the MVR and endocarditis and that it was not mentioned in the NHS Complaint Investigation, should the PHSO inform the NHS England Complaints, the Trust and the GP Practice?
Should a GP know about infective endocarditis in patients with MVR and should the PHSO make sure they are fully aware of the condition and treatment, especially as this point was not raised at the inquest or in the NHS Investigation.
I can understand medical professionals not incriminating themselves but the issue here is about honest reporting by the PHSO.
The PHSO appears to me to be very good at looking one way while walking the other, I did say this to them but this was ignored.
Did I mention that there is a Duty of Candour placed on all concerned but the PHSO made no comment.
It is a tribute to my mother that when she had critically low electrolytes for at least 20 days combined with bacterial inflammation and MVR she kept going.
This issue is related to issue 1 (GP worked part time in ED department)
The PHSO has resolutely failed to agree to my request to investigate the GP Practice for not monitoring my mothers MVR in the year prior to her death and also at her consultation with the GP at the surgery 2 weeks before she died.
Incredibly and unbelievably, in the provisional report the PHSO GP investigator stated that such heart conditions are monitored by Practice staff on a yearly basis and any issues are fed back to the GP for action.
On reading this statement by the PHSO GP Investigator I said (wrote) to the PHSO and stated the GP Practice had not carried out any monitoring of my mother’s heart condition in the year (2014/ 2015) and prior to her death.
I was already aware as a result of my own subject access requests that there was no evidence as far as I could see that any monitoring of MVR was undertaken by the Practice staff.
I wanted the PHSO to check this, they steadfastly refused saying they did not think checking the 2014 patient records was relevant. With this kind of inane logic dealing with the PHSO is a waste of time.
The GP was not invited to give evidence at the inquest even though he had a consultation with her 2 weeks previously and I did not learn the GP worked in the Trust ED department until 2018.
The PHSO are aware of these facts.
Issue 3 – The curious case of the missing vitamin D blood test.
I had said to the PHSO that I suspected that some blood test results were deleted and one was altered.
The PHSO dismissed this out of hand saying there was no evidence of this.
I asked the PHSO to ask the Trust pathology department if they produce PTH and Vitamin D3 blood test results at the same time.
The PHSO resolutely refused to do this saying there was no reason to do this.
In the ward notes the consultant endocrinologist had specifically asked for PTH and vitamin D blood test results.
There is much talk about vitamin D at the moment so in the interests of clarity, this is my understanding.
Vitamin D is a parathyroid (PTH) hormone and is fat soluble.
I understand the body stores excess vitamin D in fat deposits in the summer and releases it when sunshine is low in the winter.
It is important to note that the body can’t process dietary calcium or supplements for that matter when vitamin D is low. The lower vitamin D gets the more the body has to pull calcium from the bones as it can’t get it from food. The body needs calcium to function properly.
My mother was critically low on calcium hence my interest her vitamin D level.
The parathyroid hormone(PTH) and vitamin D3 are tested together, in fact I understand you can’t do one without doing the other.
My mothers PTH reading was available, and was absolutely normal, right in the middle of the lower and upper range limits.
I understand when calcium is critically low it is unheard of for PTH to be normal.
This is why I wanted the PHSO to ask the Trust pathology department to confirm they provide PTH and vitamin D readings at the same time.
As reason suggests if the answer is yes then there would have to be an explanation why the vitamin D test result was missing.
I also stated to the PHSO that to prescribe Alfacalcidol without first testing vitamin D is reckless.
I am unimpressed with the PHSO, they have wasted my time by not investigating properly.
They have wasted money in investigating what was not disputed and what was covered in the NHS report.
By not investigating properly they have put patient lives at risk and not informed NHS England, the Trust and the GP Practice how improvements can and should be made.
An analogy I would use to describe the PHSO is:
It is like betting on a carthorse to win the Grand National, it will finish but not before walking around the hurdles.
It is my view the government has lost a lot of money by investing in the PHSO.