Written evidence from Colin N Rock (PHS 27)

 

Public Administration and Constitutional Affairs Committee

Parliamentary and Health Service Ombudsman Scrutiny 2019-20 inquiry

 

Written evidence - Parliamentary and Health Service Ombudsman Scrutiny 2019-20

The Public Administration and Constitutional Affairs Committee (PACAC) is responsible for scrutinising the work of the Parliamentary and Health Service Ombudsman (PHSO).   Thereby“where these reports highlight failures in the quality and standards of Civil Service administration, PACAC may use them to hold the government to account.”

 

Introduction and outline of experience

  1. I have previously offered evidence to this Committee, and have detected no benefit of outcome in serious matters of PHSO failure to provide Value as “The last point of appeal for complaints from people who have suffered great distress and loss”.
  2. I hope to illustrate why it is my firm conviction that the PHSO cannot be trusted to perform Government purpose in health related matters and which appeared to be beyond its aptitude. I believe has been demonstrated too often for public safeguard.
  3. Having sought resolution—and closure for me—over 11 years, in a complaint of NHS negligence and maladministration in events before my son’s suicide, the PHSO has continually defied accountability and transparency in Principles for Good Administration, Good Complaint Handling or of Remedy. I did not question that my son chose to take his life; I questioned the negligent care and provocation before that decision, and was at that time in live complaint to NHS Services (GP[i] and Mental Health Trust[ii]). In the event, both chose to deceive, rather than apologise, compensate, and learn.
  4. I ask that Committee members try to place themselves in the position of devastated complainant, whilst judging my evidence. It is not easy facing the ploys of NHS respondents, or the PHSO shenanigans, whilst in PTSD from injury or immediate family loss, let alone of a ‘child’ whom although adult, bore the brunt of careless threats, inappropriate care, or professionals that complained “they had difficulties”, yet never peer-referred, discussed, consulted, or involved patients carers under the local and NICE national policy of assistance.
  1. KPIs: I will not be drawn on statistics set and measured by the PHSO because I do not expect them to be an indication of actual benefit in showing PHSO Value. I have no confidence that KPIs reflect measure of quality of work carried out in line with Government aim or PHSO Principles. I am aware (anecdotally) that some cases never reach the PHSO, and I believe those choices are due to PHSO’s reputation of prejudice against complainants, with the potential for extended distress.
  2. The PHSO claims independence of State, but has yet to show independence of judgement, with strong indication bias against the complainant. Instead of focusing on PHSO measurements, it may be useful to take a holistic view of instance and evidence indicating maladministration permitting duplicity and actual harm under the banner of ‘Value and excellence in of Government work. Ineptitude has been seen as follows:
  1. It has been noted that in the matter of responding to FOI and SAR information requests, PHSO has been tardy, equivocal, and obtuse. Whilst (in FOIs) the PHSO had provided verbatim guidelines and policy, it has been the experience that these are transliterated in practice; sometimes excused opaquely as ‘discretion’; at other times varied without elucidation; and yet others as ‘fantasy’ to expect compliance (as for example during PHSO Customer Services complaint).
  2. In SAR, PHSO responses have been clearly lacking in content which explained given PHSO opinions, and at other times have proved PHSO duplicity and corrupt intent; delayed after response timeframe or simply ignored—as omitted in Behrens’ (2018) and previous PHSO’s responses (to 2016).
  3. The current PHSO has shown no interest. Serious points of complaint in the above have not been addressed. They were brought to PHSOs J Mellor and R Behrens’ attention—and to PACAC attention, repeatedlylatterly in April 2020 at https://committees.parliament.uk/writtenevidence/2545/pdf/
  4. Aside, it might be worth noting that where, even for partial uphold, derisory awards in matters of negligence of a level suggesting the need for serious disciplinary process, do not get that action recommended by PHSO, for Services benefit-[iv]. But I can understand that the PHSO might claim it’s not their problem i.e. Out of scope?
  5. Summing up my points, the Committee has been made aware of harm committed by the Office of PHSO, against UK law and prolonged even after notifications of such harm. I claim that previous evidence has been ignored, and the PHSO has shown no regard whatsoever to extended in-process harm caused to complainant. The PHSO has not once questioned this harm, but I can publish details if necessary. Complaints made to PHSO as early as 2013 were exacerbated, then manipulated to dismissal in 2017, after frequent tedious and harrowing requests between those dates, despite PHSO management promise, years since.
  1. I give this evidence as my final contribution to the PHSO Committee’s affairs, and it has been difficult for me to give in shorter form. More specific details appear in my last submission made earlier this year (2020, see above) which I urge members to read. It refers to the death of my son and NHS and PHSO combined attempts to cover up serious negligence leading up to my son’s death. However, as Appendix to this submission I attach details—as brief as I can make—of key points in timeline. My opinion on these matters is only where stated, and not where the PHSO wishes to exploit as fantasy.
  2. PHSOs Mellor and Behrens refused to elaborate on unsupported counter-claims, and it has since (by SAR) been revealed why I suspect this.
  1. In the matter the local Services Agreement (or MOU)—withheld from me for ten years—it was used speciously to permit BSMHFT CEO to admit to a Social Services legal failing, BUT strangely disregarded in its agreement on cross-service cooperation in service provision and complaint referral. The PHSO was patently dishonest in forgetting the implications here.

PHSO casework performance, including performance against KPIs

  1. As stated it’s my understanding that KPIs are set and measured by PHSO and in that consequence I hold no trust, based on previous conduct and evidence. It is my firm belief that work reported as completed to PACAC is not correct—indeed, fallacious. I will only suggest that KPIs are set and construed to create a favourable picture of PHSO work.
  2. Performance: In its declared role the PHSO has shown not the slightest respect or appreciation that, despite rejected warnings and complaints, having your son die following five years of sparse and negligent care—is no reason or indication of “distress and loss”; a prime failing throughout handling, and brought home by the dismissive response of Behrens (2018), and which supremely illustrated my point: this defies credibility.
  3. Harm: It appears to me that a PHSO base-assumption over twelve years has been NHS synonymous with infallibility; Complainant synonymous with fabricator… and easy lone target.  
  1. My complaint remained open as an intensified ‘injury’ up to January 2016 when, after another spurious[vii] investigation (as Historic Complaint, 2015-2016), the complaint was closed: but only after being ‘adjusted’, under pressure, to favour NHS parties (harm #4). Marked as ‘closed’, but its terms were never justified or explained as required under PHSO Policy (harm #5). It would remain open until mid-2018 (harm #6). Again, PHSO Principles were neglected.

 

Staff management and training

  1. Evidence illustrates that good management has been very severely in want. Serious gaps in staff training and oversight of work, show a pervasive and arrogant culture of indifference to complainant evidence, from first contact. Combine this with caseworker deficiencies in understanding case material, demonstrated by careless opinion and inexpert rationale, with nil regard for complainant situation or disability, and a recipe for failure is born: but perfect for NHS patronage.
  2. As ‘independent’ service the PHSO is entirely driven by customer demand and contact. The dismissive nature of staff—in my experience—is endemic, from management to front line: the PHSO has shown zero responsibility for the command it carries in this respect.
  1. The process is flawed in my opinion and familiarity. This benefits no-one except ‘defendant’ services; pleased to direct incapacitated complainants to death-by-fatigue, whilst defendant parties continually renew themselves (see endnotes). I hold that the entire process leads to severe prejudice against the consumer—the complainant.
  2. Endemic also is the permitted practice for PHSO to be ‘creative’ in assumptions and interpretations of data; showing a prejudicial ‘selectivity’ in complainant and defendant opinion—whether professional or punditcommissioned by caseworkers. The PHSO freely oversteps their amateur status, where crucially unbiased analysis and presentation of fact is required.
  3. There was never any indication during my painfully protracted case that training was given, or any skill was indicated, in the line of independent investigation. Details I give illustrate an extreme ineptness of staff in this field: the failure to follow-through lines of inquiry or substantiation of fact traceable to secure source. The potential and possibility of error and injustice do not appear to be—and were not—appreciated. I believe this was exacerbated by PHSO agenda based on weak ‘triage’ of details given—potentially—under duress or under an injured or disabled stance. This was made obvious under PHSO messrs Abrahams and Mellor. Current PHSO R Behrens was expected to show a new leadership. This failed to materialise, in my opinion.
  4. Of my several FOIs placed on the matter of training, PHSO responses have shown glaring omissions which gave need to question the behaviour which triggered the request. I will give details of breaches of required codes of conduct and courtesy, and failures to consider Equality and Disability, over the entire period of my case being open.
  5. Whatever the response (in Disability, diminished resource, failure of NHS duty of communication, then failure of PHSO transparency), my evidence claims the existence of PHSO discrimination and harassment due to the misguided interpretation of such and the neglect of such provision in training.
  6. Neither PHSO management nor training prepares workers to be adequate or fit for purpose, or comply with intent of the law, in my opinion.

Value for Money

  1. This is hard to be objective with in monetary terms, but I do have comment. I am concerned that the end-to-end Value, and cost of failure are yet to be thoroughly taken into account by PACAC.
  2. It is my opinion that, due to previous contrived responses and incidents, the PHSO cannot be trusted to carry out true estimate, and the consideration of PHSO self-set and self-measured KPIs will have very little value in this exercise. May I recommend that independent research be carried out into the full cost of PHSO failure including knock-on costs yet unmeasured?
  3. Cost of harm caused by PHSO on complainants as made aware to PHSOs Mellor and Behrens and, apparently, still of zero appreciation. For the entirety of my complaint whist in effect still open and unresolved (2009-2018), the PHSO had no complaint procedure and in fact refused complaints numerous times despite known distress being caused, even where complainant has broken down during a call.[viii].
  4. Cost of overlooking or dismissing NHS negligence and effect on the case including potentially, cases of similar or identical failure pattern. The PHSO showed itself incapable and in denial of patterns of failure, or cause and effect failure (chain of events). This may be due to the lay nature of its caseworkers and their overall management. Several FOI requests of my own confirmed the PHSO had no training intrinsic to investigative practice.
  5. Cost of parallel actions brought about by PHSO denial and procrastination. In respect of PHSO rejection in 2010 (failure not admitted until 2015) frustration prompted seeking private legal claim. This was NOT in lieu of NHS complaints procedure having the opportunity to learn from the negligence seen. In the event, NHS provider BSMHFT denied all claims, as if nothing to learn.
  1. It is my opinion that many injuries even avoidable deaths are sustained due to the PHSO being keen to show “no crusading for complainants, yet collaborating with Services well versed and resourced in the complaint contest ‘game’.
  1. In summing up Value – it cannot be judged without considering the entire impact of PHSO work and actions. I have given instance of shameful PHSO behaviour: bullying, derision, mocking, damaging ‘throwaway’ comments, ridicule of my ‘expectations’, denials of evidence given in good faith, of patient/complainant harm; yet perfunctory acceptance of ‘professional’ statements, often given as assumptions, as reassessments of historic matters, as recollections, or of critical matters not recorded or supported by captured, secured, released, medical records.

 

Impact on other organisations.

  1. Claiming Independence the PHSO must surely disclaim all impact on other organisations, apart from where negligence and abuse continues to be a theme of failure in such organisation, or where PHSO findings are properly evidenced, relevant and sound—always assuming that a body deems corrections to be within budget.
  2. Also as an ‘independent body the only impact on other organisations that the PHSO could pretend to claim, would be as a model of its Principles: can it be impartial, trusted and useful to Government purpose? Without that, it would have no value or need claim impact.
  1. I know that the perception of the PHSO was respect by NHS bodies that I had the misfortune to be enmeshed with, and I was told they took outcomes seriously.
  1. Other bodies: On reporting GP negligence to the GMC however, I was astonished that such Professional Body would delay action until complaint had been judged by the [lay] PHSO. In reliability, I would not consider this a desirable impact for UK health interests.

 

PHSO’s provision of reasonable adjustments to service users.

  1. In the entire lifetime of my case being open (2009 – 2018) the PHSO failed to offer, take regard, observe or assess any requirement under UK law in this matter. Of several FOIs placed on this topic, the PHSO had no policy, instruction or guidance having any effect on staff in its responsibility.
  2. FOIs also showed training in the matter was absent. PHSO contact since (2019-2020) has indicated it still lacking, unfortunately. Experiences exampled here should illustrate the difficulties this has presented over that time, and the harms caused without recognition or investigation—despite numerous complaints.
  3. During my entire experience the PHSO has failed—in fact refused—to operate any ‘adjustment’ or even complaint management system, or shown any compunction to do so. According to several FOIs on this matter, various responses were:
  1. In the matter of PHSO conduct there are, ostensibly, “guidelines available”—but still open to arbitrary interpretation and no respect in actual practice.

 

Time taken for the PHSO to respond to correspondence, including Subject Access Requests and Freedom of Information requests.

  1. I have highlighted some FOI and SAR references throughout my submission.
  2. The matter has always been a bone of contention and I believe the Committee has been made aware of it via other sources. Even the simplest response requested was typically delayed until the last ‘statutory’ day.
  3. Other tactics have been to give simplistic or irrelevant response to extend the timeline or, as I have experienced, to deliberately confuse the issue (change the question) or give other defensive or unhelpful deviation
  4. SARs were particularly subject to delay especially if likely to be contentious in argument in content or on source of PHSO ‘evidence used in giving opinion.
  1. In final comment I should highlight attitude so destructive in typical PHSO response, indicating an institutional ‘conditioning’ against complainant. It was after my effort conquering trepidations [x] in meeting the new PHSO personally in London (Oct 2017) and the promise of fresh practice in a ‘personal review’.
  1. I would like to assure PACAC and PHSO that I have taken considerable time and effort over years to verify and document specifics, and ‘expectations’ of the NHSparticularly resonant at this time of COVID-19 NHS expectations. This has involved consultation with: a leading GP expert witness; two specialist medical-legal assessors; several trusted health professionals within BSMHFT; a leading QC; the bodies of NHSE, GMC and NICE; and, perhaps most revealingly, anecdotal feedback (all informants of which will remain unidentified in any exposure) from mental health sufferers and carers having to face crisis alone under BSMHFT indifference and ‘coal-face rules’ citing lack of support and other deficiencies [against NHS Trust Policies and Guidelines]. Giving further account appears pointless whilst PHSO assessment of value and competence is at cursory and broad level and with potential conflicts of interest in representation.
  1. Under stricter command or inducement I would be able to release copious NHS and PHSO communications and documents including names and unadulterated transcripts for assessment, should my case ever be considered for scrupulous, independent and transparent investigation, which I believe is currently beyond PHSO ability.

 

Appx. 1. Summary of Events, follows Endnotes (below)


 

[i]Endnotes

Bernays and Whitehouse GP Practice, Solihull, B90 3DT (implicated in complaint but not notified at that time due to unclear or undefined boundaries in PCT, Social Services, BSMHT and GP responsibilities). Now managed as Solihull Healthcare Partnership.

[ii] Birmingham and Solihull Mental Health Trust BSMHT, Birmingham Office B1 3RB and Lyndon Resource Centre B92 8PW (complaints refused by both centres only weeks before son’s death). The body gained approval as Foundation Trust BSMHFT, in 2009, shortly after the flawed investigation of my son’s death.

[iii] With regard to continual renewal of PHSO and defendant highly resourced capability in contest e.g. varying interpretations of policy and practice; varying assumptions and the introduction of amateur discretions; the resource and volume of ‘defendant’ ‘PHSO Liaison’ posts and departments (as at BSMHFT), and the frustrating renewals and replacements of communicants involved. This ‘replenishment’ targets the singlehanded complainant; surely tenacious, but potentially traumatised, to become progressively disabled and harmed by PHSO intransigence and opacity.

[iv] As I understand NHS working, NHS contractors sign-up to agree to documented procedures and professionals under oath of promise to do their best for patient outcome. But the PHSO holds amateur opinion to the contrary by mocking patient expectations as they did in my case. It’s by professionals ignoring their terms, people are harmed or put to avoidable suffering. It is hardly a Resolution that PHSO in scorning these requirements dismiss my research which shows otherwise. I have endured continuation of harm in this respect.

[v] CEO J Short BSMHFT covertly admitted in 2016 that careers had not been involved by the Trust (nor offered carer assessment—see note below), in over 5 years of need. That was 13 years late and 8 years after my son’s ‘death by disengagement’ of Services (and yet in ~2012 at my son’s Inquest, associated psychiatrist on the case admitted he or his team—it was not clarified—had a problem with engaging reluctant patients. This was not a Trust-wide problem however, and there had been policy and training in place for precisely that situation. It was confirmed to me (from BSMHFT records) that persons on his team had had that training. NHS admissions and actions since futile legal Claim proved my point: someone had lied and was still obviously lying, and the PHSO let it pass.

[vi] Harm #1 being regarded as the lack of candour and comprehensive failure of any NHS party to operate The NHS Complaints Procedure, with commensurate delay total of ~12 months. Both parties were later to misadvise the PHSO in repudiation of this delay, each claiming the fault as mine, but neither following contractual rules nor local health area cross-service Written Agreement or, indeed, personal promises (by BSMHFT [named] directors, Dec.2008). Again there was a lie, or PHSO was deliberately misled or induced to ignore through compromise.

[vii] Spurious due to (a) bizarre claims and statements made (as given elsewhere), causing (b) distinct harm to me, and with (c) PHSO utter refusal to explain lay opinion, then (d) delivered to an agenda coinciding with memories of the desolate period of our son’s avoidable death, against my request, and (e), the ‘Resolution’ was claimed statistically as

Endnotes

 

‘Part Upheld’, despite the Upheld not being my complaint of the negligence affecting my son, but a PHSO invention of little concern.

[viii] A written complaint in 2013 was held open (despite [named] senior management pledge to investigate) for four years, before being accepted for investigation in 2017. In this instance the PHSO created the points of investigation, rejected my clarification (becoming suddenly incommunicado) and made no reference to instances of complaints (accumulating and becoming more intense since 2009). The PHSO has lied about this.

[ix] 

To remind PACAC; I took legal action after the PHSO’s first dismissal with abusive prejudgment (2010). Several legally-considered claims relevant to NHS negligence were put to NHS, but each was denied. The NHS body BSMHFT however offered settlement simultaneously and before Court Proceedings. Settlement of that action was advised despite its meagre value considering implications in negative costs liable to me, but engineered into NHS scheme in rebuttal. The NHS Complaint process was not complete however and I had right to fair independent consideration as expected, for the learning it might achieve for other’s benefit. It transpired not to be the independent system ‘as promised’… and there was no learning. I believe that others died for comparable reasons: NHS provocation, disengagement and isolation of the patient.

[x] Trepidations related to harms suffered through PHSO toxic behaviour and contact; the increasing efforts to obtain sense and understanding, or of any explanation as to why PHSO Principles were continually breached; having to relate traumas over and over again to deaf ears with set ‘agendas’; derision; opacity; broken PHSO undertakings etc. Harms including extension of original PTSD; panic attacks variously as social isolation, claustrophobia, agoraphobia; breakdown of trust in any professional or controlling body or organisation; delayed then postponement of major surgery; sleep deprivation, body function disability, heart rate, palpitations, mental disability, mental focus, concentration, visual disturbances and, related to all these, the effect in restricting normal life in previous skills and interests, restriction of travel and normal enjoyment of life. In response Behrens continues to deride these impositions as “they’re just not happy” with “their decision”. I’m sorry but this appears to be criminal disregard.

[xi] Duty of Professionals: I quote from GMC website:

The primary duty of all doctors is for the care and safety of patients. Whatever their role, doctors must do the following.

  1. > “Engage with colleagues [including non-Professional] to maintain and improve the safety and quality of patient care”.

 

 

Endnotes

 

  1. > “Demonstrate effective team working and leadership”.
  1. > “Promote a working environment free from unfair discrimination, bullying and harassment, bearing in mind that colleagues and patients come from diverse backgrounds”.
 
  1. > “Contribute to teaching and training doctors and other healthcare professionals, including by acting as a positive role model.
  1. > “Use resources efficiently for the benefit of patients and the public.

 

It should not be necessary for me to draw attention to the points that the PHSO disregarded all of these factors and complaints; also evaded by R Behrens in personal (“trusted partner”) review (2018).

 

 

Appendix 1

Summary of events

Appx. to evidence to PACAC Committee October 2020 regarding PHSO activities against core purpose and Principles, and based on complaints regarding witnessed negligent care leading up to my son’s death avoidable, I claim, by thoughtful application of locally implemented NHS practice. Approach to PHSO in 2009 under A. Abrahams was soon after responsibility for NHS complaints was adopted. My claim was failure of NHS and co-operatively engaged social workers (unaware to me at the time), to give satisfactory account before and after my son’s suicide; avoidable if NHS procedures had been recognised and employed.

Events

  1. My son Nick became unwell while at Gloucester University in his third term. He received no attention there. He had a breakdown, and had to end his course. Back at home, he had symptoms of a mental illness but would not seek help.
  2. After a year of no improvement his GP was made aware but would take no action nor advise how we should proceed. This was presage to five years of NHS contact difficulties—that is, getting the right attention when it was needed. It would continue up to Nick’s suicide 5 years later.
  3. It was difficult to get any attention over this time. GPs obstructed access to services who then, by ignoring Nick’s wishes—and our input as carers—contributed to Nick’s recognised ideas of services’ persecution, and dismissed complaints.
  4. We had to bypass the GP ‘NHS gatekeeper’ to get anywhere. Nick’s first assessment by senior professionals (NHS mental health providers BSMHFT) was organised, low key, and considered. However when Nick’s case was handed over to their mental health resource team (MHT) things began to go wrong, and Nick’s health deteriorated markedly.
  5. The MHT did not follow the senior professional’s recommendations for gentle approach. MHT attendances were threatening to him and appeared haphazard in manner. Nick related he’d felt threatened, but reporting of this was obstructed by administration staff (later found to be under unclear instruction). Meetings were not documented. Carers (we, as his parents) were not involved.
  6. As crucial communicants, the MHT never identified us as carers nor as having advantageous contribution or involvement – for example to keep in touch or be involved in a care programme. Nick was left unmonitored and unsupported for many months. The MHT said he was happy and employed. He was neither, during those months medically unsupported; and there was no feedback channel for NHS to be informed of this later claim.
  7. We were keen to be involved in Nick’s care and potential care progress. His health declined and there were no communication arrangements. GPs would not respond to complaints, and trying to contact the mental health or social services was made difficult by delays, and lack of contact or responsible person. A fair assumption is that the MHT could have advised on handling his illness day-to-day and help with recognisable difficulties. They did not.
  8. We were never advised that the NHS Trust had—over 8 years previously—devised, funded and implemented procedures for exactly their situation [difficulty in engaging with patients].
  9. Years later at my son’s Inquest, the BSMHFT MHT representative told Court that [they] had a problem with patients who were ‘reluctant to engage’. This ‘reluctance’ was typical symptom appreciated nationally by NHS. In Nick’s case it was never tackled locally for over five years of involvement.
  10. I requested our MP’s assistance due to NHS distance from care. Only three weeks before Nick’s death—at a requested urgent MHT meeting—they were warned of Nick’s worrying deterioration and possible consequence (and the meeting was delayed 5 weeks by Services disorder).
  11. A written complaint was refused with apathy by the MHT, and then by BSMHFT administration; apparently because the trust did not recognise input from carers as a valid request. The stalled complaint was ‘live’ and unprocessed at the time of Nick’s death.
  12. When to Trust got around to looking at the complaint it was a different picture. We were in trauma and devastated. The Trusts agreed to process complaints and advise and cooperate with GPs involved. There was an understanding that the Trust would carry this out, bearing in mind that we had no knowledge of NHS structure in complaints or actual procedures.
  13. The Trust reneged on this. Complaint responses were delayed, insincere, specious and inadequate in their dismissal of 5 years scant interest or care. The GP was not advised of the complaints and implication to investigate under NHS procedures.
  14. This caused a 6 month delayed [second] application to the PHSO, who in their own time gave the speculative dismissal “[Nick’s avoidable death] was not worthwhile an investigation”. The harm of this statement was felt throughout the grieving family.
  15. This led to legal consultation and further delay of Nick’s Inquest.
  16. In response to Coroner’s questions, one of the MHT professionals involved gave opinion that he considered the Trust procedures [to implement NICE guidelines for patient best outcome] were not appropriate and unlikely to have been of benefit: i.e. an assumption and patent admission of failure on MHT’s part. The same witness told Court he also had a problem with patient engagement in care.
  17. It was very clear after the Inquest that legal claims would be justified and appropriate.
  18. Claims were placed on BSMHFT but were denied, against professional medico-legal assessment. Despite denying all charges NHS volunteered legal settlement.
  19. The PHSO was approached again in consideration of clear evidence and to permit NHS complaints system to be followed through.
  20. The PHSO’s discharge of these failures was that I expected too much. In particular they dismissed NICE (clinical best practice) as just “guidelines” and, I was derided for expecting other documented procedures to be followed.
  21. In Nick’s five-year abortive care process involving scarce and threatening interventions; followed by his sudden death; our harrowing experience hearing insubstantial argument and unsupported assertions given in litigation, investigation, and vastly protracted PHSO process, critical NHS claims were just not substantiated by contemporary medical record. No considerations, care plans or ‘decisions’ on courses of action had been recorded by GP or Mental Health Trust, as required by NHS process and contract.
  22. Recently, research revealed that NHS conjecture, statements and defences were based on ‘private notes’ of those involved i.e. not Trust-controlled medical records. Despite several attempts to obtain clarity in PHSO opinions, by request of caseworkers, then by SAR, records were delayed or withheld (against SAR).
  23. GP medical records were sparse and erroneous. As with other Services, vagueness and ambiguity afforded later denials and speculative claims. There appeared to be unjustified bias by PHSO to accept false claims and an incapacity to carry out required scrutiny.
  24. The situation of prejudice and defendant ‘collaboration’ appeared, and still appears, to be pervasive at PHSO.