Written evidence submitted by Dr Maureen Rickman (PAR 18)

The story presented here, about Joanna Deering, was published in ‘The ‘Peoples’ Ombudsman – How it Failed Us’ by the Patients Association, November 2014.

Written evidence submitted by Dr Maureen Rickman, relating to complaints made to the NHS, and then referred to the Parliamentary and Health Service Ombudsman, on behalf of my sister Joanna Deering who had serious mental health problems and who sadly committed suicide in October 2011.

1)     I am submitting evidence on the Parliamentary and Health Service Ombudsman (PHSO) because I don’t believe it offers quality of service or value for money.  I fully acknowledge the need for a public investigatory body to oversee the NHS, and step in when serious complaints have been inadequately addressed through the NHS complaints process, but I do not feel that the PHSO, in its current form, is adequate for that job. My experience of using the PHSO informs the evidence and the critical perspective presented here.

2)     Summary of main points:

• PHSO was not able to fully investigate all aspects of my complaints – I was told, resources are not available for this and, in complex complaints like mine, they can only focus on the most serious elements.
• PHSO’s investigation of the main events of my complaints meant that other important issues were not investigated at all.
• The PHSO, and NHS, are failing to address, and deal with, serious disciplinary issues that are uncovered during the course of investigations.
• PHSO was not able to investigate all NHS staff involved in my complaint - specifically, PHSO did not have jurisdiction to investigate the Responsible Clinician involved. 
• The limited jurisdiction of PHSO to investigate staff working for the NHS means that some staff are not actually scrutinised by a public investigatory body and made accountable when things go wrong. As a consequence, complainants are not actually able to access a fair and comprehensive complaints service through the PHSO.
• Recommendations made to the NHS, by the PHSO in their Final Reports, are not actually enforceable by PHSO.
• The absence of an enforcement strategy to implement PHSO Recommendations allows  the NHS to produce frivolous and quick fix  solutions  –as I found in the  NHS ‘Action Plan’ in response to my complaints which consisted of reminding staff to do their jobs properly!
• Because there is no binding obligation for the NHS to deliver real changes to working practices in response to PHSO Recommendations, the NHS is not actually improving its service at all, and PHSO is clearly party to that failure.
• Because PHSO lack the power to enforce the Recommendations it makes to the NHS, there is no incentive for PHSO to criticise the frivolous solutions proposed in NHS ‘Action Plans’ and, as a consequence, they are accepted by PHSO without question.
• Since the role between PHSO and complainant effectively concludes when the Final Report is issued, the complainant is denied the opportunity to object to the PHSO about the frivolous ‘Action Plans’ produced by the NHS. 

Context

3)     The detail here is drawn from my complaint to the NHS in July 2011.

4)     My sister had paranoid schizophrenia. In the months leading up to 23.05.11, when my sister was sectioned, her health was deteriorating and I was unable to get her the help she needed from the mental health team. My sister lived at home with our Mum who had severe arthritis, dementia, eating problems, and extensive personal care requirements. I was our Mum’s main carer.

5)     The mental health team didn’t communicate with Mum or I at all when Jo was under section, and they failed to tell us about leave. My sister arrived home unannounced, just two weeks after section, for extended leave – granted by the Responsible Clinician though a record of assessment made prior to her leave was not found by PHSO. When my sister arrived home she was still psychotic and this was very evident in her aggressive and abusive behaviour towards me.

6)     The CCO with my sister, failed to take appropriate action to deal with my sister’s psychotic and abusive behaviour towards me; the CCO dismissed my concerns about my sister’s state of mind, and she also failed to accurately document and record what happened that morning. Without any form of consultation with Mum or I, and irrespective of the fact that I was Mum’s carer, the CCO arrogantly announced her intention to get Social Services in to assess Mum’s care needs, and the intention that Mum would pay for the help she required. 

7)     My objection, that my sister’s paranoid aggression towards me made it impossible for me to provide care for our Mum was ignored by the CCO and the mental health team who installed my sister as  Mum’s carer instead.

8)     The mental health team not only dismissed Mum’s care arrangements without consultation with her, but they also jeopardised her safety by passing responsibility for her care over to my sister who was still psychotic.

9)     At the same time, the mental health team further jeopardised my sister’s health and well-being by placing her in a position of responsibility for the extensive care needs of our Mum – a role she repeatedly said she did not want -  and, in doing so, cruelly denied her the time, the space, the opportunity and the dignity to recuperate properly.

10) My sister committed suicide in October 2011.

11) The result of the NHS investigation into my complaint, was received the day my sister was taken into hospital after taking a massive overdose of Paracetamol; the NHS response was completely and utterly dismissive of all the concerns I raised.

12) I complained about that NHS investigation, particularly about:

• The fact that a large proportion of the detail and evidence used in the response was erroneous, including personal information about my sister that had been drawn from her mental health records.
• The utterly inadequate nature of the complaints process which was grotesquely biased and utterly lacking impartiality, objectivity and integrity.
• An investigative complaints procedure that clearly worked most efficiently for NHS staff - to protect and shield them from complainants like me.
• The use of an investigative method that was akin to Chinese Whispers and concluded predictably with distortion of evidence and information.
• The fact that the CCO involved with my sister’s leave had clearly lied when questioned about what happened, and had failed to reveal, and also document and record, my sister’s state of mind and aggression towards me.
• I also complained about the CCO’s defamatory remarks about me and the way these were used in the NHS response to simultaneously intimidate and demonise me.

13) In January 2013, I compiled a further complaint response to three official NHS Reports issued to the Coroner prior to the Inquest in October 2012, into my sister’s death. This complaint addressed the following concerns:

• The shocking quality of the information used in these Reports, including personal information about my sister, rendered them appallingly inaccurate and unrepresentative.
• The same discrepancies, omissions, errors and falsehoods that structured the NHS reply to my first complaint, also informed the NHS Reports to the Coroner.
• The Reports misled the Coroner in regard to the circumstances of Jo’s home leave, and events leading to her suicide.
• The Reports revealed the mental health team had poor insight and understanding of my sister.
• The Reports indicated the failure of staff to perform an adequate risk assessment of my sister.
• The information used in the Reports indicated that the mental health team had:

• Failed to record and document information properly
• Failed to use and share information appropriately
• Failed to conduct effective communications

• The Consultant Psychiatrist's Report failed to inform the Coroner of the fact that my sister had been feeling ‘very depressed lately’ when he last saw her, and that he had also failed to act on that knowledge.

• The Reports revealed many false claims – such as the CCO involved in my sister’s leave who claimed that she had meetings with my brother when, in fact, she had not, and she claimed appointments too with my daughter when, in fact, she had never even met my daughter!! There was also the claim that my sister received extensive care prior to being sectioned when in fact I could only identify two actual points of contact with the mental health Team  - one initiated by my sister, and a second that was initiated by my call for help when my sister was physically abusive towards me .
• Prior to the findings of the Coroner’s Inquest, the NHS Critical Incident Review Report commended the conduct of all staff involved with my sister, and particularly the CCO involved in my sister’s leave and whose rude and unprofessional behaviour was central to my original complaint (it turned out that the author of this Report was good friends with the CCO involved).
• I criticised the self-congratulatory tone of the Critical Incident Review Report, which was deeply offensive, especially in light of the care and service failings that I identified.
• Lastly, as the three NHS Reports were based on evidence that was not factually accurate or reliable, the three Reports were therefore not fit for the purpose of informing the Coroner about my sister and events leading to her suicide.

14) The NHS failed to formally investigate this last complaint and failed to provide a written response to address the concerns I raised. My experience of two NHS investigations into my original complaint, and the failure to investigate the second, has left me in no doubt that the NHS complaints process I encountered was utterly biased and corrupt.

15) When PHSO took up my complaints in January 2014, I was relieved to think that my complaints would be investigated properly. Due to a backlog of complaints, it was five months before PHSO started their investigation.  

16) However, when PHSO commenced their investigation, I was told they would not be able to cover all aspects of my complaint as the resources were not available for this. Amongst other things, this meant the long term lack of care received by my sister prior to section in 2011, and the lack of support from a designated CCO, and the shocking state of official medical records concerning my sister, were not investigated.

17) It wasn’t long before PHSO’s legal team also advised that PHSO did not have jurisdiction to investigate or interview the Responsible Clinician who had granted leave to my sister, or the consequences of his actions.  The inability of the PHSO to investigate the Responsible Clinician undermined the coherence of my complaint, and transformed the PHSO investigation into a series of detached parts, whereby poor care received by my sister during and after section in 2011 was separated from the Responsible Clinician’s decision to grant leave which instigated the shocking situation that followed.

18) It is grossly iniquitous that Responsible Clinicians are beyond the legal remit of PHSO, the public body tasked with investigating the NHS when things go wrong. In fact, Responsible Clinicians simultaneously work within and beyond the NHS and are protected from issues of accountability and transparency by the cobwebs of the antiquated legislation of the Mental Health Act 1983, defended by the investigative jurisdictions placed on PHSO, and shielded further from investigation by ‘team decisions’ that dilute culpability, and the inordinate lengths of time complainants are kept within the NHS complaints process. As the actions and decisions made by Responsible Clinicians clearly impact on the vulnerable NHS patients they treat/ assess, they absolutely ought to be accessible to PHSO for investigation.

19) PHSO did in fact ask CQC to investigate the Responsible Clinician but CQC refused because my complaint had ‘timed out’ due to the length of time it had been with the NHS. More recently, CQC added that it does not investigate individual Doctors / practitioners anyway.

20) Faced with this dilemma, I reported the Responsible Clinician (and the Consultant Psychiatrist) to the GMC. However, I conclude from their decision to take ‘no further action’ against the Responsible Clinician, that the GMC sanctions the practice of sending vulnerable, psychotic individuals home to take responsibility for the care of frail and vulnerable 89 year old ladies with severe arthritis, dementia, eating problems, and extensive personal care requirements –and all this, of course, without prior warning or consultation with the family.  I wonder if the GMC would come to the same conclusion about this callous brand of so-called Care in the Community if it was their sister, and their mother, being treated in this barbaric manner by a so-called Responsible Clinician.

21) I am still awaiting the results of a GMC investigation into the conduct of the Consultant Psychiatrist who, apparently, left the country before the PHSO could interview him – though PHSO neglected to tell me this.

22) It took nearly a year, but the diminished PHSO investigation and Final Report identified:

• Service failure, relating to the way my sister’s leave was handled
• Service failure, relating to the Consultant Psychiatrists failure to act on knowledge of my sister’s depression.
• Maladministration, relating to inadequacies in the Critical Incident Review Report, and the Consultant Psychiatrist’s Report which failed to reveal my sister’s condition to the Coroner.

23) I am thankful PHSO was able to affirm these failings to me – but there’s a whole lot more that should also have been investigated.  I had also naively assumed that the findings of the PHSO, and the Recommendations made by PHSO to the NHS, would somehow serve to improve the quality of care and services provided for people like my sister, with serious mental health problems. But, I was wrong.

24) In fact, I was immensely disappointed to learn that the ‘Action Plan,’ devised by the NHS to address the Recommendations made by PHSO in the Final Report, consisted of a series of reminders to staff  - to  implement the procedures and regulations they ought to have been following anyway.

25) It’s not only utterly shocking that NHS staff are having to be reminded to carry out their jobs in a professional manner, but even more shocking that the only measures put forward to address the PHSO’s Recommendations are a series of reminders!!!!

26) And even more contemptuous, and treacherous, is the PHSO’s blithe acceptance and sanction of the scandalous NHS ‘Action Plan’ that consists of a series of reminders to staff!!

27) I really do find it extraordinary that a life has been lost, and two NHS investigations into my complaints yielded nothing, a PHSO investigation identified two counts of service failure and one count of maladministration, and the only outcome of all that is an inane NHS Action Plan that consists of a reminder for staff to do their jobs properly.  

28) The fact that NHS staff have failed to follow regulations and guidance, and are actually in breach of contract, is blatantly ignored by the NHS, and the PHSO. At the very least, the persons involved should be formally disciplined. But the NHS has done nothing to address the question of discipline and PHSO, who I hoped would address this complacency, actually seems to facilitate it. As discipline, and staff attitudes and behaviour, were so prominent in the Francis Inquiry it is surely imperative that PHSO addresses disciplinary problems.

29) A service that uses expert opinion to identify NHS staff and service failings for the sole purpose of arriving at ‘final decisions’  is not a commendable service and it is not value for money. What is the point of PHSO actively acquiring insight into the failings of the NHS, and its staff, if that knowledge is not going to be used to actively improve the NHS and its staff?   The public, and complainants, deserve much more and if the PHSO is going to continue in its role as a public investigatory body, then the service needs to improve quite significantly.  

30) Recommendations -

      PHSO needs to be granted the authority / jurisdiction to investigate all NHS staff, including Responsible Clinicians.

      If  PHSO’s Recommendations to the NHS  are to improve the NHS, then PHSO needs the authority to demand that practical ‘Action Plans’ are created by the NHS to meet those Recommendations.

      In order to ensure the PHSO’s recommendations to the NHS are carried out, PHSO needs to be granted the authority to enforce Recommendations and impose penalties for failings.

      PHSO needs to use its authority to address and deal with practice and disciplinary issues discovered in the course of investigations into complaints against the NHS, and should be actively directing these to relevant bodies/organisations.

      The PHSO, CQC, and GMC need to act responsibly and equitably to address NHS failings. The defensive culture currently exercised needs to change – for the sake of the NHS, and the people it serves.

      The role of the PHSO needs to evolve so that public money provides a functional service that serves the people by using knowledge and insights of the failings of the NHS to improve NHS services.

      PHSO needs to provide a professional service and carry out comprehensive investigations, covering all aspects of complaints. Skimming the surface is not good enough.

      PHSO staff need to be fully trained to carry out rigorous investigations, using different forms of evidence, and a range of analytical and investigative methods, to arrive at equitable outcomes - including the recognition that the lack of evidence found, is sometimes evidence of the problem complained about. 

      During the PHSO investigation, I was struck by the fact that professional records and opinions were repeatedly given greater intrinsic value than my records of events. As a complainant, I want to be taken seriously and, in the course of investigations, PHSO needs to actively exercise impartiality by according the same weight and value to the verbal and written testimony of complainants as they do to the verbal and written testimonies of so-called medical professionals/experts. Indeed, the professionals are not always reliable or truthful.

      Similarly, whilst PHSO interviewed NHS staff involved in my complaints, it failed to interview individuals and family who could have provided evidence to support my contention about my sister’s health when leave was granted. 

      Finally, the PHSO needs to be made fully and publically accountable for the service it provides.

December 2016