Ann Abraham deliberately lied to me

Dear Parliamentary and Health Service Ombudsman,

After being turned down for an investigation by the PHSO in 2009
regarding the death of my daughter, I had requested Freedom of
Information regarding the assessment process. However, on
re-reading this information earlier this year, I had realised that
the PHSO IPA, a Dr N J R Evans, had not had access to the Recovery
Unit notes wherein lied vital information which would support my
case.

However, in March 2010, after a 3 day Inquest, the Coroner issued a
Rule 43 against South Essex Partnership Foundation MHT (Whose Chief
Executive/Executive Nurse was for a long period of time not on the
NMC register and thus the lack of accountability to the NMC for
patients at this Trust. During this period of lapse of registration
he was employed by the HCC as an expert regarding the investigation
into West London MHT and was also made NHS Leader of the year in
2009!)

So, as a root cause analysis Serious Untoward Incident
investigation was not carried out despite this being Trust policy,
I did not know why or how these failings occurred and asked the
PHSO to take another look at my complaint earlier this year. As I
already had a Coroner's rule 43 applied against the Trust, I
thought this would be plain sailing. I eventually got a letter from
Ann Abraham herself who said that the original assessment by the
PHSO was "robust" but that "new" evidence regarding the Coroner's
findings would result in a "fresh" assessment.

However, I wondered how they could have found the original
assessment "robust", especially if it was reviewed without vital
information so I requested another Freedom of Information regarding
this assessment.

After receiving the Freedom of Investigation response, I was
shocked and felt violated to discover that Ann Abraham had
deliberately lied to me. The evidence of the Coroner was not "new",
it was used by Dr N J R Evans when they had reviewed my case again.
So Guess what? Dr N J R Evans did not agree with the verdict, that
the Trust had acted "reasonably" and commented that the Coroner was
not "medically qualified" Dr N J R Evans review of the verdict
contains several errors of fact and shows poor abstraction skills
from the case notes. Is it not common sense that a Coroner's rule
43 would imply that something seriously had gone wrong? Whilst Dr N
J R Evans did acknowledge that there might be other evidence,
really?, does this example suggest that there is something
seriously wrong in how the PHSO IPA's assess cases? Is this why in
2009/10, out of 867 complaints regarding mental heath services,only
11 investigations concluded, only upholding 3 complaints. Are
mental health services in the country so perfect that out of this
number of complaints, only 3 were upheld?

Dr N J R Evans appears to be the only Psychiatrist on the PHSO IPA
list. When you consider the saying that if a patient sees 3
different Psychiatrists, they will each come up with a different
diagnosis. Is the PHSO relying on a restricted number of IPAs, who
appear to excellent at gatekeeping/obstructing access to
investigations, to the detriment of complainants? Then surely this
methodology needs to be reviewed?

The following is an extract from my Freedom of Information request.

"In the light of the reputational risk here for the Office, in that
we are disagreeing, to some extent, with the Coroner's comments, I
also obtained legal advice. That advice recommends that we
undertake a fresh assessment of the case. The legal advice suggests
that we need to have compelling evidence to support a departure
from the Coroner's findings and that it is not sufficient for us to
come to a different conclusion merely because it is amongst a range
of reasonable conclusions we could reach. The advice says that we
need to consider whether there is any compelling evidence to depart
from the Coroner's findings of fact, rather then considering
whether the Coroner's findings call into question the IPA's advice
and our original decision. The advice also reiterates the IPA's
point that we do not know what other evidence may have been
presented at the Inquest".

"Having taken account of the legal advice I believe the best way to
mitigate the risk to the Office's reputation is to undertake a
fresh assessment on the basis that the Coroner's findings
constitute new evidence that was not available during the original
assessment (comment, BUT AVAILABLE FOR THE COMPLAINT REVIEW).
Whilst I have no reason to question Dr Evans' advice in this case,
in order to ensure that our decision is as robust as possible I
would suggest that a different IPA/EPA be asked to give advice for
the fresh assessment. It seems to me that this would further
mitigate the risk to our reputation"

I am not willing to be exploited in this way and have asked that
the complaint not be upheld and formalised with the reasoning of Dr
N J R Evans. I have lost complete and utter faith in this
organisation

If I, with a Coroner's rule 43 cannot get an investigation fairly
with what is robust evidence and implications of serious service
failings,then what chance does anyone else?

My request is can I have a copy of the PHSO policies and procedures
regarding the use of Indepedent Professional Advisors?

Yours faithfully,

L Cowling