Can PHSO rise to the challenge of IPSIS?

phsothefacts Pressure Group made this Freedom of Information request to Parliamentary and Health Service Ombudsman

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phsothefacts Pressure Group

Dear Parliamentary and Health Service Ombudsman,

In April 2016 the Independent Patient Safety Investigation Service (IPSIS) is due to come into operation. This body will give support and guidance to NHS organisations on investigations into serious patient safety incidents and be in a position to carry out some investigations itself.
https://www.gov.uk/government/consultati...

In your recent #mythbusting series you state that;

"It is not our responsibility to deliver changes and improvements in public services; our role is to make final decisions on complaints that have not been resolved by the NHS in England, UK government departments and some UK public organisations."
http://www.ombudsman.org.uk/about-us/myt...

Q1. Are there any plans to take a more pro-active role and offer advice on how to improve first-tier investigations or is phso's role simply to report to the media the dire state of complaint handling by public bodies?

IPSIS will focus on root cause analysis investigations to identify what went wrong and why. A full understanding of the complex causes of incidents will enable service providers to prevent similar incidents occurring in the future and improve patient safety.

In a response to the PASC inquiry regarding IPSIS, Dame Julie Mellor stated that;

66. In her oral evidence to us Dame Julie acknowledged a need for change: “we need to
address things like the “why” question, training all our staff who do our most serious
investigations in root-cause analysis and human factors science.”180

Q2. Given that a significant number of serious investigations will still fall within the remit of phso can you give details of how many staff have been trained in root-cause analysis and human factors science, plus how many staff you expect to be fully trained by April 2016?

IPSIS will be the second body with direct responsibility for investigating individual complaints. The only other body with that remit is phso. There will be limits on the resources available to IPSIS and it is unlikely that they will be able to review historic cases.

Historic cases, which did not receive full investigation in the first instance can highlight systemic weakness in the system which continue to put patients at risk. Recently phso have accepted that they do not have the ability to investigate historic cases such as that of Elizabeth Dixon. https://www.dropbox.com/s/023tlep7mkg9kr...

Q3. Once your staff are fully trained in root-cause analysis, are there any plans to offer investigations to complainants who continue to wait for answers to historic complaints which have not been resolved due to delay, denial and defensiveness?

Yours faithfully,

Della Reynolds

phsothefacts Pressure Group

foiofficer@ombudsman.org.uk, Parliamentary and Health Service Ombudsman


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D. Speers left an annotation ()

I guess on evidence now finally in press (Sunday Times Sept 6th) Can PHSO afford not to rise to the IPSIS challenge?

phsothefacts Pressure Group

Dear Parliamentary and Health Service Ombudsman,

For some reason you decided to reply to this request with a personal email. As I am aware that this subject is of great public interest I have copied your response below:

Dear Ms Reynolds

Your information request: FDN-233414

Thank you for your email of 5 September 2015 in which you requested information regarding PHSO’s role in first-tier investigations, staff training in root-cause analysis and human factors science and plans to offer investigations to certain complainants. I have responded to each of your queries below.

Q 1. Are there any plans to take a more pro-active role and offer advice on how to improve first-tier investigations or is PHSO's role simply to report to the media the dire state of complaint handling by public bodies?

One of our aims is to lead the way to make the complaints system better. In relation to our health jurisdiction, we have been working with patients and service users to define what would make complaining about the NHS or social care a positive experience for people. The outcome of this work, 'My expectations for raising concerns and complaints', is available here: http://www.ombudsman.org.uk/__data/asset...

More generally, we have published the Principles of Good Administration which are broad statements of what we believe bodies within the Ombudsman’s jurisdiction should be doing to deliver good administration and good customer service. These Principles are available here: http://www.ombudsman.org.uk/__data/asset...

In addition, the Principles of Good Complaint Handling are intended to help public bodies to deliver first-class complaint handling to their customers. These Principles are available here: http://www.ombudsman.org.uk/__data/asset...

Q 2. Given that a significant number of serious investigations will still fall within the remit of PHSO can you give details of how many staff have been trained in root-cause analysis and human factors science, plus how many staff you expect to be fully trained by April 2016?

The first human factors training we did was on 1 October 2013. This was an introductory/overview session attended by 16 people.

In late 2014 and early 2015 human factors training was delivered to all complex health investigators and a couple of additional staff. Specifically, we trained 14 people on 26 and 27 November 2014, 13 people on 9 and 10 December 2014 and 17 people on 8 and9 January 2015. The training company was Consequence UK. The trainer then came back to do some further work with complex investigators.

There is no further human factors training planned at this stage. As such, we do not hold information regarding how many staff will be trained by April 2016.

Q 3. Once your staff are fully trained in root-cause analysis, are there any plans to offer investigations to complainants who continue to wait for answers to historic complaints which have not been resolved due to delay, denial and defensiveness?

At this stage, there are no plans to offer such investigations. As such, we do not hold information of the description specified in your request. Under the legislation which governs the Ombudsman’s work, we cannot investigate unless complaints are put to us in a timely fashion, subject to a discretion to accept cases "out of time" if we think it reasonable to do so, or there are special circumstances which make it proper to do so (see section 6(3) of the Parliamentary Commissioner Act 1967 and sections 9(4)-(4B) of the Health Service Commissioners Act 1993).

If you have any further queries, or would like to ask for a review of my decision you can write to me at [email address].

Philippa Curran

Legal Assistant

Parliamentary and Health Service Ombudsman

E: [email address]

W: www.ombudsman.org.uk

foiofficer@ombudsman.org.uk, Parliamentary and Health Service Ombudsman


Thank you for your e-mail to the Parliamentary and Health Service Ombudsman. This return e-mail shows that we have received your correspondence.

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All email communications with PHSO pass through the Government Secure Intranet, and may be automatically logged, monitored and/or recorded for legal purposes.
The MessageLabs Anti Virus Service is the first managed service to achieve the CSIA Claims Tested Mark (CCTM Certificate Number 2006/04/0007), the UK Government quality mark initiative for information security products and services. For more information about this please visit www.cctmark.gov.uk

phsothefacts Pressure Group

Dear Parliamentary and Health Service Ombudsman,

It is clear from your response that those cases going to PHSO for full investigation and remedy will be very much the poor relation to those investigated by IPSIS.

IPSIS will be able to give direct feedback on poor clinical practice and poor investigation processes. In comparison PHSO provide general guidelines in the form of 'My expectations' and the 'Principles of Good Complaint Handling'. Yet you state that your intention is to 'lead the way' on improving complaint handling.

By January 2015 you had trained approximately 60 people in human factors and (although not stated) root cause analysis. The purpose of this training would be to provide PHSO case workers with the skills to determine the root cause(s) of the incident and feedback specific guidance to the NHS Trusts in order to prevent future occurrence. Yet in June 2015, Mick Martin suggested that such action was outside of the remit of PHSO.

http://www.ombudsman.org.uk/about-us/our...

There is a lot of confusion about our role, so to be clear:

we investigate cases so that we can make decisions on complaints, not to make up for poor investigations at local organisation level;
we press public organisations to learn from and improve their ways of working, we can't make that happen;
we work hard to obtain a remedy for people when they have experienced injustice, we don't favour them when we are investigating their case or advocate for them, and
we provide invaluable insight on things that keep going wrong, we don't provide solutions.

You don't provide solutions. What would be the purpose of root cause analysis if if were not to provide solutions? It would seem that PHSO are wearing two hats here. If you are only able to look at administrative failure and are unable to ensure that improvements are delivered, you need to be clear to the public from the outset and make this clear to PACAC at the annual scrutiny meeting.

You skirt around my final question with the suggestion that you are unaware of such historic cases. A great many complaints are put to you in a 'timely fashion' but your lack of expertise has prevented you from undertaking full investigations. I cited in my original letter the case of Elizabeth Dixon and the failure of PHSO to investigate this case (quite recently) as part of an historic review. You will be aware that Jeremy Hunt has felt the need to intervene in this matter stating that this case had been 'passed around the system for far too long'. He has called upon Mike Durkin, NHS England Patient Safety Director to conduct an investigation, nearly 15 years after the incident occurred. It would appear from your response that you are not prepared to close this 'regulatory gap' in fact your are not even aware of it. https://www.dropbox.com/s/023tlep7mkg9kr...

This response says to me that complainants will get nothing more than an arms length, desk investigation of administration processes when they bring their complaint to PHSO; which will be a very poor second to the direct intervention of IPSIS.

Yours faithfully,

Della Reynolds.

phsothefacts Pressure Group

foiofficer@ombudsman.org.uk, Parliamentary and Health Service Ombudsman


Thank you for your e-mail to the Parliamentary and Health Service Ombudsman. This return e-mail shows that we have received your correspondence.

show quoted sections

All email communications with PHSO pass through the Government Secure Intranet, and may be automatically logged, monitored and/or recorded for legal purposes.
The MessageLabs Anti Virus Service is the first managed service to achieve the CSIA Claims Tested Mark (CCTM Certificate Number 2006/04/0007), the UK Government quality mark initiative for information security products and services. For more information about this please visit www.cctmark.gov.uk

D. Speers left an annotation ()

Your initial reply stated "The first human factors training we did was on 1 October 2013. This
was an introductory/overview session attended by 16 people." so should I assume nothing was in place re RCA prior to this? APPALLING!

Fiona Watts left an annotation ()

Well done Della.

Well done for putting the moral spotlight on how staff at both the PHSO and the ICO both "skirt around the issues" in a blatant and evasive fashion.

I have this Public Office Ethics Test;
I reply to their corrupt-style-reports with 'Do you stand by this report in respect of all of the principles of The Data Protection Act 1998" The usual response is silence .... and then someone else gets in touch a few weeks later.

Same cycle of evasiveness - same farce. Well done you for scrutinizing how Dame Julie Mellor and the rest of the PHSO staff just keep contradicting themselves in the public domain.

They do this in the knowledge that there is NOBODY who has the interest in challenging them.

Fingers crossed for 5th October 2015.

Will there be a staff member at a police station out there that is willing to uphold the oath they took when they were sworn in as a police constable?

Onwards and forwards

D. Speers left an annotation ()

Hear Hear Fiona....and thank you Della

For info: IPSIS panel members with MH experience on Advisory Panel are Service User Alison Cameron (no relation!) and Deborah Coles, Director from INQUEST.

Both identified by NHS England Patient Safety Team.

foiofficer, Parliamentary and Health Service Ombudsman

Dear Ms Reynolds

Thank you for your comments.

I can confirm that in line with the Freedom of Information Act 2000, we have provided you with the information we hold and have confirmed to you where we do not hold information.
We have nothing to add to the explanations previously provided to you.

However, if you are unhappy with how we have processed your information request please let us know and we will carry out an internal review.

Yours sincerely

FOI/DP Officer

show quoted sections

All email communications with PHSO pass through the Government Secure Intranet, and may be automatically logged, monitored and/or recorded for legal purposes.
The MessageLabs Anti Virus Service is the first managed service to achieve the CSIA Claims Tested Mark (CCTM Certificate Number 2006/04/0007), the UK Government quality mark initiative for information security products and services. For more information about this please visit www.cctmark.gov.uk

phsothefacts Pressure Group

Dear foiofficer,

Don't worry about an internal review. The answer to my question 'Can PHSO rise to the challenge of IPSIS' is clearly NO.

Yours sincerely,

Della Reynolds.

phsothefacts Pressure Group

foiofficer@ombudsman.org.uk, Parliamentary and Health Service Ombudsman


Thank you for your e-mail to the Parliamentary and Health Service Ombudsman. This return e-mail shows that we have received your correspondence.

show quoted sections

All email communications with PHSO pass through the Government Secure Intranet, and may be automatically logged, monitored and/or recorded for legal purposes.
The MessageLabs Anti Virus Service is the first managed service to achieve the CSIA Claims Tested Mark (CCTM Certificate Number 2006/04/0007), the UK Government quality mark initiative for information security products and services. For more information about this please visit www.cctmark.gov.uk

Jt Oakley left an annotation ()

Under the legislation which governs the Ombudsman’s
work, we cannot investigate unless complaints are put to us in a
timely fashion, subject to a discretion to accept cases'

So any Trust that 'plays' a complainant be witholding files - until the complainat is 'out of time' -is likely to get off scott free.

Medical files can take YEARS to winkle out if the NHS.

It's a witholding strategy for being ticked off for poor paperwork - instead of negligence. And it works.

It's not unknown for the NHS to hand missing paperwork over to complaints on the eve of an inquest to avoid in-depth investigation.

https://mydaftlife.wordpress.com

This puts bereaved parents at a disadvantage - as their is no public funding for legal help at inquests for family.

.....There's plenty of legal assistance for negligent NHS trusts and employees though.

Shame the PHSO for supporting negligent lawyered-up Trusts- by looking the their way- and failing to collect all the evidence.