Personal Statement by Scott Morrish [CCF0079]
Summary 5 - 9
Context - It started with Sam 10 - 22
Understanding ‘how’ and ‘why’ 23 - 37
A combination of solutions 38 - 49
Conclusions 50 - 53
Last but not least. 54
P.S. The Ombudsman 55 - 62
Introduction
My name is Scott Morrish. I am responding to the Public Administration Select Committee’s (PASC) call for evidence on the issue of National Health Service (NHS) complaints and clinical failure. My contribution is limited to observations and thoughts from a patients perspective, sparked by the sudden and unexpected death of my bright and beautiful little boy - Sam - just two days before Christmas 2010.
I draw upon first-hand experience spanning 4 years, starting with the NHS’s instinctive responses to Sam’s death and our questions; working through its complaints systems; through the Parliamentary and Health Service Ombudsman (PHSO); to the PASC, and this inquiry.
Aware of my bias, and the fact that I may be wrong, I try to understand the nature of the problems we have experienced and possible solutions as objectivity and fairly as I can. I am grateful for the Patients Association’s unwavering support, witness to the PHSO’s handling of my complaint, and preparedness to speak out when necessary.
Everything here is written in the hope and expectation of reduced avoidable harm and - accepting that people make mistakes - conviction that whenever bad things happen, more compassionate and positive responses for patients and staff are necessary, achievable, and within reach.
Summary
The NHS is incomplete without expectations, strategies and systems for learning focused on reducing avoidable harm and increasing both patient safety and staff welfare. Without recourse to blame, we all need to move beyond a fatalistic acceptance that ‘bad things happen. This requires cultural change. Inquisitive, objective, learning-focused and expert-led investigations have a key role to play.
The power and ability to bring about the necessary changes rests with legislators and leaders. But the responsibility to bring about change also rests with patients and staff and depends upon evidence-based learning and insight derived from critical, analytical, divergent and creative thinking about the origins, nature and consequences of problems.
This requires partnership and a shared commitment to find, implement and evaluate solutions. The observations, memories, and knowledge exist, but are divided between patients and staff. Insight and clear thinking therefore, depend upon pooling that knowledge openly in order to allow a complete picture which can then be scrutinised in search of learning; and the hope of reduced harm; increased patient safety and staff welfare.
Accordingly, I wholeheartedly welcome this PASC inquiry and support Carl Macrae and Charles Vincent’s timely suggestion that the NHS needs a new clinical accident investigation body, as a significant and positive step towards a healthier NHS for everyone, everywhere, all of the time.
My hope from this inquiry is that it goes further, persuading the government, the DoH, legislators, regulators, and the many constituent parts of the NHS to tackle cultural problems that compromise patient safety and staff welfare by [1] Differentiating ‘the need for learning’ from ‘complaints handling’; [2] Separating ‘Investigations and learning’ from ‘regulation and accountability’; and to create [3] An independent, investigative, evidence-based learning system; [4] A smaller, simplified, ‘restorative’ complaints system; [5] A single, effective and ‘qualitatively' accountable ombudsman's service; [6] A regulatory framework that supports an open, inclusive, learning-focused, patient-centred culture, whilst protecting patients and staff from avoidable harm through a just implementation of accountability.
Context - It all started with Sam
On December 23rd 2010, my little boy Sam, died suddenly and unexpectedly. He had Flu, and although not in an at-risk group, died as a result of a secondary infection: sepsis. He had been seen and sent home on consecutive days by GPs; triaged by NHS Direct; and admitted to accident and emergency via our local out of hours service. He died in the High Dependency Unit of Torbay hospital aged 3 years, 8 months and 12 days old.
I expected NHS investigations to take place automatically, focused on the possibility of reducing ‘avoidable harm’ for others. Given the sudden and unexpected shock of Sam’s death - anything less was inconceivable. Disinterested in blame from the beginning, I have always sought a better understanding in the hope of rebuilding confidence in the NHS. I had to.
We were quickly led to believe that Sam’s death was unavoidable. Inevitably we had questions, and were repeatedly assured that thorough investigations were being undertaken. But month after month, no one proved able or willing to answer simple, relevant and reasonable questions. I started to wonder why? Whomever I asked, the reasons offered were always ‘the system’ or ‘the process’.
April the 1st 2011, struggling, but trying, I wrote: “As you will be aware, we want our 'part of the picture' leading up to Sams death, to be seen and understood. We have not been asked for this, so we do not understand how the NHS thinks it will ever see the 'whole picture’? Accordingly we wonder how lessons are learnt, if there are any, and how systems and health care will improve?” The response, sincere, and meant kindly, was revealing“I am truly sorry you are finding the NHS so difficult and frustrating and wish there was more I could do to help. Sadly there don't seem to be any guidelines for us to refer to.”
This created new problems. I had expected the NHS to share a need, albeit for different reasons, to understand ‘what’ had happened, ‘how’ and ‘why’. The persistent inability to answer simple questions, or to ask us any, suggested that it didn’t. I don't believe the NHS was intentionally heartless or cruel, although at times it felt like it was both. Individuals were sympathetic but seemed to feel powerless. As a result, collectively, the health service’s response proved inept.
Resorting to a formal complaint felt like an admission of failure, but the alternatives were worse: the press, the courts, or doing nothing. We needed openness and honesty. We expected learning. We were never interested in blame. The press was unthinkable. Courts don’t lead to learning. Doing nothing was not an option. After 15 months and two failed multiagency investigations, with a very heavy heart, supported by the Patients Association, I formally complained to the PHSO.
At different times after Sam died, almost everyone urged me not to complain. Some were aware of the impact it could have. Others assumed my questions were an expression of grief. Most were convinced that asking questions and raising concerns would make absolutely no difference: they had already given up on the complaints system.
A friend, who happens to be a GP, explained that even from within the NHS it was very difficult to get anything changed by raising concerns. There was a universal, despairing and fatalistic acceptance that culturally the NHS was either indifferent or impotent, and that it was too big and too complicated to change. Having watched Sam die, I could not, and did not, agree.
With time I learnt that the ombudsman's service is not dissimilar to the rest of the complaints system: same finger-prints, same DNA. Unless intimately involved in a complaint, their ineffectiveness is unknowable. After another 15 months, having hit another brick wall, I spoke to the Sunday Times, and another 11 months later, to the Daily Telegraph.
Eventually, 3.5 years after Sam’s shocking and unexpected death, the PHSO published its report stating that Sam’s death was in fact avoidable. They upheld our complaints about each of the 5 NHS agencies involved, for which we remain grateful. They also apologised for the length of time they had taken and, perhaps for the first time, acknowledged methodological weaknesses. The Secretary of State for Health’s unprecedented criticism of the PHSO mentioned their failure to apologise for the mistakes they made during the investigation. As expressed at the time, I thought the ombudsman had “failed everybody: parliament, patients and all NHS staff. What the PHSO should have been doing, alongside investigating why Sam died, was to probe why the NHS failed to investigate Sam’s death in the year that followed.”
The PHSO’s focus on arriving at a ‘robust adjudication’ based on comparing ‘what is documented to have happened’ with ‘what should have happened’ without regard to ‘how’ or ‘why’ deprives every one of an opportunity to learn, reduce avoidable harm, or to move forward. Whilst judgements can lead to stark headlines, they are no substitute for learning.
Learning is now influencing change in some areas, most notably with regard to sepsis, for which we are incredibly grateful. But why was there no attempt to understand how or why local investigations were able and allowed to fail? And what about the competence, effectiveness and qualitative accountability of the PHSO itself? It was this question that led me to the PASC.
Perhaps my instinctive need to understand how and why Sam died simply fell beyond the collective capability, interests or intentions of the current NHS culture and its complaints systems. In order to try to encourage learning I have persisted in asking simple questions because I continue to believe that change is necessary, possible, and in everybody’s interests.
Understanding ‘how’ and ‘why’ investigations and complaints go wrong?
The NHS’s responses to untoward clinical incidents are inconsistent at best. Currently there is no systematic, reliable and effective approach to investigating or learning from clinical failure or untoward clinical incidents, much less a patient-centred, open, unbiased and accountable one. As a result there is no certainty of meaningful or effective investigations, let alone learning.
Patients who ask questions can be perceived as a threat, especially if those questions might draw attention to the NHS’s own part in clinical failure or untoward clinical incidents. This can even happen when, as in my case, the motivation was purely a need for understanding, and an awareness (on my part) of the possibility of learning. I was grieving, but consistently articulating no interest in blame.
The NHS’s instinctive and, in human terms, rational response to perceived threat is to retreat and defend itself, its employees, and organisations - giving rise to a bunker-mentality that allows the protection of reputations to take precedence over the best interests of patients or staff.
Feeling embattled, apparently crippled by fear, and preoccupied with itself, the NHS can loose sight of patients - allowing them to be marginalised; driving an ever-deeper wedge between patients and staff; generating frustration, anger and yet-more-fear; all of which can be intensified by adversarial complaints systems. It keeps defence unions, lawyers and litigation authorities busy. For the rest of us it is painful, and costly. It tests character to the limit.
In the meantime patients and staff can find themselves isolated, in a no-mans land, their concerns ignored, whilst everyone cedes responsibility to ‘processes’ and ‘systems’ without taking responsibility for either. When no one feels responsible, everyone feels powerless. Actions taken, decisions made and conclusions drawn, if inept, create more frustration, fear and sometimes irreconcilable differences. It also leads eventually to the despairing and fatalistic acceptance of avoidable harm; the notion that there is no need or point in investigation: there is no expectation of learning. It gives rise to a universal feeling of powerlessness where patients do not think it is worth the phenomenal risks involved in raising concerns, because staff seem (and feel) powerless to help; complaints handlers only find fault in systems, processes and services; and no one is deemed responsible for anything. When responsibility is ceded to large and complex processes and systems but no one takes responsibility for them: no one is accountable. This is not a figment of complainants imaginations.
The consequences are profound, insidious and pervasive to the point where they undermine the NHS by alienating patients from staff, and staff from each other, all the time eroding trust and respect in all directions. The same alienation and erosion of trust and respect occurs between commissioners and providers, and between both with their regulators. Nothing is learnt. Nothing changes.
It takes time, effort and determination, to understand all of this, but as the picture becomes more complete, it is no longer a mystery, or even a surprise that people we know to be kind, caring and good, can do or say apparently senseless things which, unintentionally, can cause additional suffering. The only way I can understand such paradoxical behaviour is in terms of culture, which can be paraphrased along the lines of “Blame the system. It is not our fault. It is the way we do things around here.”
From a patients perspective it seems as if those with authority over these processes instinctively back-the-system and each other, secure in the knowledge that the complaints system can often act with impunity. They can also hide behind its ridiculous and inexcusable complexity, knowing that of the few who will actually complain, most will give up sooner or later, either ground-down, or giving up; often hurt; and always feeling powerless in the hands of a system that is opaque, unaccountable, defiantly stacked against them and protected by ‘defence’ unions and litigation authorities. It can feel like a conspiracy against patients that dare to ask questions or hope to spare others from their own harrowing experiences. And all of this from a publicly funded national health care system: who does the NHS exist for?
In an instinctively defensive culture where risk and uncertainty are ever-present, which clearly they are in medicine, and with so much fear of blame, judgement and recriminations, it is wholly unrealistic and unfair to blindly assume that, when things go wrong and harm occurs, staff will be, or feel, able to impartially and objectively articulate - with unflinching openness and honesty - their own errors, or those of their colleagues. I don’t know many people, anywhere, in any walk of life, that would find that easy, or instinctive. Yet of course that is precisely what the NHS needs to improve both patient safety and staff welfare. It is not easy: it requires courage: but it is essential.
The absence of a 'system for learning’ can force patients into the often dysfunctional and ram-shackle world of complaints systems which in turn, can cause yet more harm. The need for a complaint in such circumstances is, in itself, symptomatic of problems. The burden of learning should not fall upon the shoulders of patients, or depend upon them for impetus, especially at times when most in need of support and least able to cope: their energy will be needed elsewhere. Learning should take place irrespective of whether there is a complaint or not.
Current complaints systems (including the ombudsman) fail to recognise, understand or take account of the dynamics of culture, its influence on behaviour, or even the extraordinary range of biases that affect us all. As a result complaints systems, rather than helping or healing can be divisive; counterproductive; add complexity; increase confusion; miss the point; and actually cause harm.
Every-time the complaints system fails - it fails everyone - patients and staff alike, making learning less and less likely. At the same time defensive responses and denial become more likely, as does a diffusion of responsibility, a division of ‘us’ (staff) from ‘them’ (patients), and an apparent determination not to deal with the real problem. In fact the complaint, and the complainant can (ironically) be perceived by the NHS, to be the problem.
I don't think all of these failings are the fault of the complaints system. Often, as alluded to in the call for evidence to this inquiry, a complaint is simply the ‘wrong place to start’. I’d also suggest that the complaints system itself is the ‘wrong tool to use’. To compound problems, it is often in the wrong hands and is sometimes being used ‘for the wrong reasons’. But in the absence of a system for learning, for patients, the complaints system is the only tool available: there are no other mechanisms.
The complaints system’s primary concern is with managing complaints, and complainants. Even if working well, (as I assume it must somewhere), the complaints system is not designed to learn. It is narrowly focused on the substance of the complaint itself, which is of course, limited in terms of scope and detail by the knowledge and understanding of the complainant. When ‘focus’ becomes too narrow it can become blinkered, and coincidentally allow an extraordinary range of problems to be ignored. Unchecked this can constitute wilful blindness, which given its insidious and pervasive properties can lead to a systemic problem: a ‘cultural blindness’.
In the absence of an inclusive, inquisitive, evidence-based learning system, there is a cavalier reliance upon assumptions and assurances, even when evidence - if looked at - calls both into question. The validity of evidence seems to depend upon who offers the evidence. Medical records are deemed to be ‘good evidence’, but first-hand accounts from complainants are routinely deemed ‘not good enough’. Coroners can take information from the NHS at face value, meaning that in some cases they constitute little more than a ‘rubber stamp’. Likewise Child Death Reviews and the Child Death Overview Process (DfE) are entirely reliant upon the efficacy of the NHS’s own ability to investigate sudden and unexpected deaths. Their processes are also unaccountable, opaque, lacking check-or-balances and of unknown effectiveness. Their existence unhelpfully creates an impression of exhaustive investigation and of competence, which can be thoroughly misleading, and in the context of this inquiry, dangerous.
A combination of solutions - to help everyone help each other.
Patients and staff desperately need an NHS that understands and acknowledges that failing to learn from clinical failure or untoward clinical incidents increases the probability of harm. We all need an NHS that investigates harm in the ‘expectation of learning’; that has a ‘strategy for learning’; that identifies problems; that looks for solutions; and that evaluates progress; understand that it is an iterative and on-going patient-centred process; and that sometimes it may be necessary to start all over again.
The NHS does not need any more guidelines, pledges, or tick-box action-plans, to be filed, unread, gathering dust on overflowing shelves. We need different priorities, a different focus, different responses and a different mindset - a different culture.
Learn to avoid harm. In the event of clinical failure or untoward clinical incidents the objective should be, [1] to understand ‘how’ and ‘why’ it happened without the need to complain. Once the ‘whats,’ ‘hows’ and ‘whys’ have been established, [2] relevant expert opinion, critical analysis, and divergent thinking should all be applied. The objective should be to identify whether anything can be learnt to help reduce the likelihood of similar untoward clinical incidents recurring. [3] Take relevant and meaningful steps to reduce avoidable harm and monitor them for effectiveness whilst prepared to start over.
Take fear and blame out of the equation. Openness, inclusiveness and impartiality are prerequisites of trust and respect. Focusing on ‘learning’ and ‘problem-solving’ rather than ‘judgement’ and ‘blame’ will help. Consistently challenge the fatalistic notion that nothing can change. Understand that culture is simply ‘the way we do things around here’. Accept that ‘the way we do things around here’ will change anyway - so lets actively choose to shape and refine it in the shared interests of patient safety and staff welfare: don’t leave it to chance, or let eyes or mind close to problems or harm.
Culture. A positive, inclusive, compassionate can-do culture based on trust and respect of (and between) patients and staff has to be aimed for, nurtured and protected. Like any thing of fundamental importance - we cannot afford to leave it to chance. Culture is tested most when things have gone wrong. Priorities, principles and values are revealed through actions, choices and decisions that either help, or harm patients and staff. Each element of a health care system needs to be designed, and steered by regulation, to pull together in the right direction. To be resilient, such a culture needs to recognise that complaints may be alarm bells, and that patients safety and staff welfare would be better served by a different kind of complaints system that strives to identify, understand and solve problems, rather than finding ways to ignore, hide or appease them. It is not enough to describe what went wrong. We all need to know ‘how’ and ‘why’ bad things happen in search of insight and learning that can lead to solutions and therefore make a reduction of avoidable harm possible.
Inclusive, independent, investigations. People who have the misfortune to suffer untoward clinical incidents should be encouraged, if they so wish, to engage in the process of establishing the facts about ‘what’ happened. The option of inclusion, in-place of deliberate exclusion, would represent a positive and profound cultural shift. Some people will not want to engage; some will feel unable to; some may want to engage more, or less, than others and it should not matter. People should be free to choose, and that choice should be an integral part of the NHS’s response to any untoward clinical incident. Imagine if I had felt free to choose not to become immersed in the minute details of everything that happened as Sam died because my questions were answered; investigations had led to learning; and there was evidence that harm may be avoided for others. That is not a fantasy: it is the reality we need to strive for.
A dedicated investigative branch of the DoH, if trusted, competent, effective, respected and accountable for the quality of its investigations, findings and recommendations, would make understanding what went wrong possible very quickly. It would also therefore, make rapid learning possible, which is essential if hoping to avoid the same things happening to anyone else. As a result it seems reasonable to anticipate both a reduction in the instances of harm and a reduction in the need for complaints. The NHS will become safer faster. There would be less need for barriers, division and tension ‘within and between NHS organisations’ and also between ‘patients and staff’.
Investigations should not and must not imply fault, blame, or judgement. That is why they need to be both independent and expert-led in order to engender trust, respect and confidence from everyone: patients, staff, regulators and legislators. Focusing on the most serious incidents would [1] liberate NHS staff involved in untoward clinical incidents by relieving them of the extraordinary burden of responsibility to run the most serious investigations, whilst [2] simultaneously liberating patients by relieving them of the burden of responsibility to fight for learning through complaints systems. It would also [3] reduce the need for ‘whistle-blowers’.
I think it is the single most powerful and positive step that could be taken to radically (and rapidly) improve the NHS in a huge number of areas (especially in conjunction with an overhauled complaints system, and an effective ombudsman). Qualitative accountability, as with everything, would be essential regarding effectiveness in the key areas of [a] investigation; [b] learning; [c] developing effective local ‘learning expertise’; [d] the dissemination of learning; and some measure of oversight of necessary improvements. I think this has to be through the Secretary of State for Health.
A learning-focused ‘restorative’ complaints system. If the learning system is effective, numbers of complaints should fall, but we will still need a functional, effective and accountable complaints system. The complaints system should be smaller and simpler. It should be clearly defined and understood as a mechanism for [1] addressing concerns and resolving disputes restoratively and without recourse to blame; [2] striving for learning where possible within those disputes; and [3] sharing that learning across the relevant parts of the NHS as appropriate. Complaints are not, and cannot be, substitutes for either investigations or accountability.
A ‘learning focused’ ombudsman. When the complaints system fails, as it will from time to time, we will still need a functional, effective and accountable ombudsman. PASC’s role here cannot be overlooked. Regulators need regulation too: there is no point in an ombudsman if uncertain of the quality of their work or their effectiveness. The ombudsman needs to be trustworthy and respected from all perspectives in terms of expertise, competence, capability, impartiality, and most importantly of all, for the quality of its investigations, findings and recommendations. Its effectiveness should be demonstrable. Anything less is of questionable value and risks doing more harm than good. Independence is important, but not at the expense of transparency and qualitative accountability. It should rarely be needed, but by the time a complainant has got as far as the ombudsman there is a very real need to get it right, preferably first time, and preferably quickly. That said, ‘haste’ should never be allowed to compromise ‘effectiveness’.
Supportive regulation. The detail of regulation is (thankfully) beyond my experience, but none of us can escape its consequences: amongst other things - it helps shape culture. Accordingly regulation has a vital role to play, but quantity of regulation cannot nurture an open culture whilst everyone feels powerless and / or fears blame and recriminations. Heavy handed regulation is unlikely to win hearts or mind; banish fear; or encourage openness, honesty, trust, respect and a sense of shared interests. Good regulation needs to explicitly and effectively encourage, support and protect the culture that we want. In that context all regulation, however complex, should be tested and evaluated in simple terms of patient safety and staff welfare, whilst ever-wary of unintended consequences.
Conclusions
When bad things happen - as they will - patients and staff need open-minded, inclusive, and inquisitive investigations as well as expectations, strategies and systems for learning.
The current culture, fearing blame, judgement, and damaged reputations leads to a bunker mentality. Defensiveness, self justification and biases are all natural responses to fear. Ceding responsibility to unaccountable ‘processes’ and ‘systems’ disenfranchises everyone and leaves no one accountable. In turn this alienates patients and disenfranchises them too. A universal feeling of powerlessness combined with a fatalistic acceptance of ‘avoidable’ harm condemns others to ‘avoidable’ harm too, because it closes eyes and minds to the possibility of learning through investigation. Failing to learn from adverse outcomes simultaneously jeopardises patient safety and staff welfare. To compound these problems, the NHS is undermined by its current complaints systems. Additionally, the NHS should not be dependant upon complainants (or whistleblowers) to identify problems and provide the impetus for change.
Patient safety and staff welfare would both benefit from a ‘restorative’ rather than ‘adversarial’ complaints system - more befitting of a service committed to care and compassion. When complaints arise, from patients or staff, they should be responded to as if alarm bells. Insight and learning from patients and staff should be treasured and celebrated: they are the gold dust.
When responding to clinical failure or untoward clinical incidents, the best-interests of staff and patients are inseparable. If patients and staff of the NHS choose to establish better ways of responding to clinical failure and untoward clinical incidents, there will be more learning, less harm, less complaints, and a new culture will emerge. The power to bring about change depends upon us all - patients, staff, leaders, regulators and legislators - making and remaking positive choices. Every one of us has that power. And every choice is an opportunity to use it. This is how cultures work.
And last, but by no means least…
Susanna and I have also experienced the very best-of-the NHS from the same front-line organisations that we turned to for Sam - both before and after Sam’s death. We remain grateful to the individuals that tried to help Sam; to those who continue to provide us with health care; to everyone working to raise awareness of sepsis; and to everyone striving for improved patient safety and staff welfare. I apologise for anything that is unfair, unkind, or unclear.
P.S. Thoughts about the ombudsman
I recognise that the PHSO is currently in a difficult place. There is talk of change but in the absence of evidence, all assurances need to be tested. Qualitative accountability of the ombudsman's service, and of the NHS complaints systems is essential and achievable. Evidence of effectiveness is the single most important metric. In the absence of relevant and meaningful metrics, qualitative accountability is not possible, and effectiveness is left to chance. Neither parliament, the DoH nor the NHS can afford to continue to allow matters of such great importance to be unaccountable, or left to chance.
It is a mistake to think of their process in terms of ‘investigations’. It is an arms-length, paper-based complaints handling processes. Based on past performance, talk of investigations, investigators, and investigations managers simply adds to the confusion. It all sounds great - but sets everyone up for disappointment.
The PHSO is not reliably capable of investigating complex complaints, or sufficiently assessing / analysing medical evidence relating to clinical incidents. Their methodology has been fundamentally flawed, and they have also been lacking expertise and core skills - for example the ability to conduct interviews. As a result it has been failing complainants and complainees.
Central to their problems, their focus historically has been confined by the inherent limitations of a complaints process, and its preoccupation with judgements based on what happened, without any regard or interest in ‘how’ or ‘why’. In the absence of a (separate) system for learning, it has been expected to achieve more than it can. Why? Because there is nowhere else to go. The PHSO is not designed to ‘learn’ through investigation: it is designed to ‘judge’ based on review of available (NHS) information, eyes closed to the weaknesses of such an approach.
The PHSO is ‘qualitatively unaccountable’ and it’s effectiveness is unknown. This can only be revealed through insight into (at least some) individual cases. The quality or effectiveness of a PHSO investigation cannot be determined by reading their reports or by seeking assurances from the PHSO - again highlighting the inescapable fact that regulators also need effective regulators.
Beyond an ability to manage complaints and investigations, relevant and meaningful metrics are needed to gauge the ability and effectiveness of the ombudsman [1] to derive learning and insight that can [2] improve outcomes for future patients and staff. Neither the quantity of complaints rejected or investigations upheld tell anyone anything about quality or effectiveness. Beware of an ombudsman that has the capacity to ‘manage complaints, and complainants’, whilst failing to undertake ‘genuine investigations’.
In fairness - I have ended up feeling sorry for the Ombudsman and anyone employed to handle complaints. Expectations and need outstrip their capacity, competence or capability. Whatever the original intentions were - the system cannot currently deliver the learning that is desperately needed by patients and staff. The complaints system should not be expected to mask or compensate for the lack of investigative capability in the NHS, or for its shortcomings in terms of accountability or effective regulation. Yet this is the current situation and the harm it causes is painfully real; often undocumented and therefore overlooked. It is the polar opposite of anyone’s needs from a health care system.
We need a different kind of ombudsman service, focused on investigation, understanding and learning in the best interests of patients and staff, complainants and complainees, patient safety and staff welfare. To these ends the PHSO needs a different approach, focus and methodology, mindful that everything it does or says shapes the culture of health care. To help any of us, including themselves, they need to help all of us.
9 February 2015