Mr Behren's apology re report on Averil Hart's death

D. Moore made this Freedom of Information request to Parliamentary and Health Service Ombudsman

This request has been closed to new correspondence from the public body. Contact us if you think it ought be re-opened.

The request was refused by Parliamentary and Health Service Ombudsman.

Dear Parliamentary and Health Service Ombudsman,

The Ombudsman comes in for some criticism in this harrowing story concerning Averil Hart, a young anorexic woman who died:

http://www.dailymail.co.uk/health/articl...

Averil's father "criticised the ombudsman for taking three and a half years to produce the report and for relying on the word of clinicians rather than actual medical records.'

The Ombudsman, Mr Behrens, apologised for the delay in producing the report.

1. On what date did you first receive a complaint about the death of Miss Hart?

2. On what date did your investigation into her death begin?

3. On what date did you conclude your investigation into her death?

4. On what date was the complainant notified of the outcome of your investigation?

5. Please send me a copy of any information compiled by PHSO staff to inform Mr Behren's:

a. of the circumstances surrounding the delay; and
b. how he might respond publicly to it.

Specifically, check his email account using the search terms 'Averil Hart' and 'apology' for emails sent to or received from PHSO staff. Please provide me with copies of these emails and any attachments.

6. If PHSO engaged lawyers to deal with the complaint please state:

the date they were first contacted;
the name of the legal practice; and
the total amount paid to them/due in respect of dealing with the case.

Yours faithfully,

D Moore

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


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InformationRights, Parliamentary and Health Service Ombudsman

Dear D Moore,

 

Request for information under the Freedom of Information Act 2000

 

Further to your email dated 8^th December, in which you request the
disclosure of information under the provisions of the above Act, we are
now in a position to respond.

 

The Ombudsman comes in for some criticism in this harrowing story
concerning Averil Hart, a young anorexic woman who died:

[1]http://www.dailymail.co.uk/health/articl...

Averil's father "criticised the ombudsman for taking three and a half
years to produce the report and for relying on the word of clinicians
rather than actual medical records.'

The Ombudsman, Mr Behrens, apologised for the delay in producing the
report.

1. On what date did you first receive a complaint about the death of Miss
Hart?

2.  On what date did your investigation into her death begin?

3.  On what date did you conclude your investigation into her death?

4.  On what date was the complainant notified of the outcome of your
investigation?

5.  Please send me a copy of any information compiled by PHSO staff to
inform Mr Behren's:

a.  of the circumstances surrounding the delay; and
b.  how he might respond publicly to it. 

Specifically, check his email account using the search terms 'Averil Hart'
and 'apology'  for emails sent to or received from PHSO staff.  Please
provide me with copies of these emails and any attachments.

6.  If PHSO engaged lawyers to deal with the complaint  please state:

the date they were first contacted;
the name of the legal practice; and
the total amount paid to them/due in respect of dealing with the case.

We refer you to our published report Ignoring the alarms: How NHS eating
disorder services are failing patients:
[2]https://www.ombudsman.org.uk/sites/defau....

 

Any information held by the PHSO beyond what has been published in the
report is exempt from release under Section 44 of the Freedom of
Information Act. Section 44 of the Act states that information does not
have to be disclosed under the Act if another Act of Parliament states
that the information requested cannot be disclosed. Section 15 Health
Service Commissioners Act prevents us from releasing to you the
information that you have requested. Section 11(2) of this Act states that
the Ombudsman’s investigations must be carried out in private. Section
15(1) (a) of the Act provides that information obtained by the
Commissioner or his officers in the course of or for the purposes of an
investigation shall not be disclosed except for the purposes of the
investigation and any report to be made in respect of it.

 

Please see the recent ICO decision notice on our application of section 44
of the Freedom of Information Act
[3]https://ico.org.uk/media/action-weve-tak...
. This recognises our duty to investigate in private which is vital to our
independence as an Ombudsman Service.     

 

If you believe we have made an error in the way we have processed your
information request, it is open to you to request an internal review.  You
can do this by writing to us by post or by email to
[4][Parliamentary and Health Service Ombudsman request email]. 

 

You will need to specify what the nature of the issue is and we can
consider the matter further. Beyond that, it is open to you to complain to
the Information Commissioner’s Office ([5]www.ico.org.uk).

 

 

Yours sincerely

 

 

Freedom Of Information/Data Protection Team

Parliamentary and Health Service Ombudsman

W: [6]www.ombudsman.org.uk

 

 

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4. mailto:[Parliamentary and Health Service Ombudsman request email]
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D. Moore left an annotation ()

More information can be found here:

http://www.averilhart.com/

J Roberts left an annotation ()

The PHSO has described its handling of Mr Hart's complaint in the following terms ('Memorandum to the Public Administration and Constitutional Affairs Committee by the Parliamentary and Health Service Ombudsman' – ref. HOS 22 published on 5 May 2020):

“In 2019, we carried out a review of PHSO’s handling of a complaint made by Mr Nic Hart following the tragic death of his daughter Averil. This review was carried out so that we could learn from failings in our investigatory process and account for that learning publicly.

The review found failings ranging from the length of time it took to conclude the case, to failings in the way PHSO communicated with Mr Hart. We have apologised unreservedly for the difficulties and stress these caused Mr Hart and his family at an already distressing time when they were grieving for their loved one.”

It specifies tardiness and communication problems only.

Mr Hart (HOS 33 page 4) has presented detailed evidence to PACAC:

“It was clear right from the start that this PHSO review was not going to be either independent or impartial, being controlled and edited by the Chief Executive.

Although this PHSO review claims to have involved Averil’s family, we did not take part in the process. The PHSO refused to visit us, they refused to pay for any travel to their offices, and they effectively cut us out of the process. This was typical of the unfair way that the PHSO deals with families and patients. (Please do not believe for one moment, page 5 of the PHSO review, section 4.4, this is typical PHSO spin).

To add insult to injury, the PHSO published the report before we were able to see it and did not give us the Egress access code to read the report until some time after publication. We were finally given a copy of the report by a journalist from the British Health Service Journal, who asked for a comment on the PHSO’s investigation into Averil’s death.”

On page 20 he wrote:

“The worst meeting with the PHSO was at the Royal Society of Medicine, where we had suggested a meeting to include Katherine Murphy (then head of the patient’s association). The current Ombudsman agreed to meet Averil’s family there, but then at the last minute, insisted that I pay for the hire of the room myself. The Ombudsman was in a foul mood at the prospect of leaving his Millbank offices. He treated us all with total disdain and contempt throughout the meeting, insisting that the PHSO would publish the final report into Averil’s death, even though as we pointed out, there were still numerous errors in the report. An arrogance which I still find astounding.”

Parliamentary and Health Service Ombudsman Scrutiny:

https://committees.parliament.uk/work/69...

J Roberts left an annotation ()

In a comment left on 'Trustpilot'* dated 4 November 2019, Mr Hart detailed the difficulties he experienced with the PHSO:

https://www.trustpilot.com/review/www.om...

* Trustpilot includes over 100 reviews of the PHSO. 96% of the reviews fall into the 'bad' category.

J Roberts left an annotation ()

At today's PACAC annual PHSO scrutiny hearing Rob Behrens was questioned on the PHSO's handling of this case. He was asked why the investigation was led by a senior PHSO person and not someone independent. Mr Behrens conceded:

'PHSO got this case badly wrong.'

J Roberts left an annotation ()

The Char of PACAC, William Wragg, said that he would be writing to the Ombudsman about certain matters because of limited time (PHSO Scrutiny hearing 18 May 2020). His letter has now been published.

A fair portion of his questions concern the Ombudsman's handling of Mr Hart's complaint e.g. his case being passed to ill-informed caseworkers, caseworkers failing to communicate appropriately, personal information being misused and evidence not being properly weighed. He has also asked for details of the actions proposed by the Ombudsman to remedy failings found by the review.

https://committees.parliament.uk/publica...

J Roberts left an annotation ()

Mr Behren's response to PACAC - further training for casework staff is 'under development':

'10. Mr Hart explained to us that the PHSO failed to assure him that evidence he submitted was given the proper weight. How do the PHSO’s caseworkers seek to assure complainants that their evidence has been given proper weight? (For example, is all evidence the complainant submitted commented on, to actively demonstrate it has been considered?)'

'In decision letters and investigation reports,we set out the evidence we relied on when explaining the decision we have made. On 7 May this year, we published guidance for complainants explaining the approach we take when considering and assessing evidence. Further training for casework staff about how to effectively balance evidence and explain our decisions is also under development as part of our commitment to continuous improvement.'

https://committees.parliament.uk/publica...

J Roberts left an annotation ()

PACAC - Second Report of Session 2019–21

'The handling of Nic Hart’s complaint

21. The PHSO published a review of its handling of Nic Hart’s complaint on the death of his daughter Averil Hart. The review was led by “a manager in PHSO’s senior leadership team. This manager was not employed by PHSO at any point during PHSO’s handling of Mr Hart’s complaint.” The review accepts a number of failures in the PHSO’s handling of Mr Hart’s complaint, including:

• The time taken to close the case — the case took nearly three years and four months to conclude.

• The resourcing of the case—there was not a clear and consistent plan in place to resource the investigation.

• Communication with the complainant — five caseworkers worked on the case at different times, which meant that Mr Hart had to build new relationships and re-tell his story to multiple caseworkers.

• Appointment of an external investigator — an external investigator was appointed, but their role and responsibilities were not clearly communicated to Mr Hart, leading to confusion.

• Decision-making — several changes were made to the PHSO’s approach to the investigation, causing confusion to Mr Hart about what the PHSO was doing and why.

• Use of evidence — the PHSO failed to explain to Mr Hart how his evidence was used or to assure him it was given proper weighting.

22. As a result of these errors, the PHSO has sincerely apologised to Mr Hart.24 In evidence to us Mr Hart described the impact these failings had on him, which were not insignificant.

23. As the PHSO’s report into Nic Hart’s case acknowledges, there were multiple failures in the PHSO’s handling of Nic Hart’s complaint and the Committee finds these failures extremely concerning. The report vividly demonstrates the scale of the serious problems that the PHSO was struggling with when Rob Behrens took up his post.

24. In an annex to a follow-up letter sent after the oral evidence session, the PHSO set out the actions they had taken since Mr Hart’s complaint to improve processes and prevent a similar case from reoccurring.

25. The Committee supports the improvements that the PHSO has implemented to prevent similar failures as that encountered by Nic Hart. In particular, it will revisit the PHSO’s changes to how it commissions and uses clinical advice in future scrutiny sessions, as this is particularly important considering that NHS cases take up the majority of the PHSO’s caseload. The PHSO must learn the lessons from Mr Hart’s case and ensure that these mistakes are not repeated.'

https://committees.parliament.uk/publica...

J Roberts left an annotation ()

Dr Bruce Newsome writes:

'According to heart-breaking testimonials, most complainants are treated by PHSO staff as time-wasters, liars, idiots, fantasists, egotists, and objects of ridicule. The victims have nowhere else to go. Parliament’s Select Committee on Public Administration has complained since 2015 that the PHSO is unaccountable to Parliament except through annual reports. The PHSO’s only practical accountability is to the executive, which controls its funding and appoints its person, but every executive has said that the PHSO is “independent.” Its own solution to criticism is to demand more powers.'

https://thecritic.co.uk/democracys-accou...

J Roberts left an annotation ()

Dr Bruce Newsome's criticism is as sharp as any surgeon's scalpel in his latest article on the PHSO entitled 'Healthcare Needs an Ombudsman':

https://thecritic.co.uk/healthcare-needs...

'Your final champion is supposed to be the Parliamentary & Health Services Ombudsman (PHSO), but this is mistermed in so many ways. It is unaccountable to Parliament, except to submit annual reports. It is unaccountable to the Prime Minister’s Office, except through long-term funding cycles and appointments. It can choose for itself which complaints to investigate or reject. No parliamentary committee or politician can overrule it.'

The experiences of complainants that he recounts echo the misery and frustration experienced by Mr Hart.

J Roberts left an annotation ()

Dr Bruce Newsome shoots to bits PHSO figures in his latest hard-hitting article entitled: 'letting another quango mislead parliament?'

https://thecritic.co.uk/why-is-the-gover...

'The PHSO investigated 30.6 percent fewer cases in 2019-2020 compared to the preceding year, even though enquiries fell by 7.4 percent. Yet, the PHSO misreported 13 percent more enquiries, as recently as August this year.'

'The PHSO refused to quantify the reduction of demand in the final six months. The PHSO’s communications with me on these issues were confusing. Its first excuse was that the person responsible for that part of the report separated from the PHSO. Another excuse was that the National Audit Office hadn’t asked for clarification or correction of that part of the report. In the end, it went back to its claim that because its metrics changed in November 2019 it could not be expected to quantify the subsequent fall in demand .'