Dear Parliamentary and Health Service Ombudsman,

Yesterday you published on your website a response to a letter from James Titcombe detailing the PHSO's heavily criticised involvement in the massive scandal surrounding the death of his son Joshua. Details of the Health Secretary's criticism of the PHSO can be found here:

http://www.telegraph.co.uk/health/health...

It is stated in your response that:

"Our role is to consider individual complaints. It is not to act as an early warning system".

In the document penned by Ann Abraham which was also published and which refers to how Mr Titcombe's complaint was handled it is stated:

"a decision should be deferred pending a conversation with CQC to find out what action they were taking, or might take, to address the broader issues about the standard of maternity services".

Please provide all information held confirming the date that the PHSO policy of considering wider issues changed to that of considering individual complaints only.

Yours faithfully,

J Roberts

foiofficer, 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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James Titcombe left an annotation ()

J Roberts makes a good point in relation to this response. Clearly, in the case of how the ombudsman responded to my complaint about Joshua's death, the principle of 'we consider individual complaints' became blurred. Plenty of evidence existed at the time showing that my individual complaint hadn't been answered properly (the Ombudsman's own investigation years later eventually upheld this). The logic for not investigating was based on the flawed premise that you can preempt the outcome of a proper investigation before such a process has been undertaken and a badly handled, muddled and non documented process looking at the wider systemic issues and making assumptions about how they would be addressed - exactly what Mick Martin's letter states is not the Ombudsman's role.

What ever way it's looked at; the Ombudsman's handling of Joshua's case was truly disgraceful. Not only this, but the complaint I made in relation to midwifery supervision (another complaint that was eventually upheld years later), was also rejected by Ann Abraham and only investigated following the threat of Judicial Review.

The external review that was triggered by my application for Judicial Review can be seen view here.

https://www.dropbox.com/s/8nb0wwaoj2y0su...

J Roberts left an annotation ()

James Titcombe,

Thank you for providing the link to the second review - it's a chilling read.

............................................................................................

Here is an news article from today's Daily Mail that others might like to read.

'More than 50 mother and baby deaths at scandal-hit hospital under investigation

'Investigators probing failings at a scandal-hit hospital are looking into the deaths of more than 50 mothers and babies.

'An inquiry into the NHS trust running Furness General Hospital in Cumbria was first ordered last year by ministers following fears over the deaths of at least eight mothers and babies.'

Read more: http://www.dailymail.co.uk/health/articl...
Follow us: @MailOnline on Twitter | DailyMail on Facebook

foiofficer, Parliamentary and Health Service Ombudsman

Dear J Roberts

 

Your information request – FDN 200715

 

I write in response to your Freedom of Information request dated 2
September 2014, in which you asked:

Please provide all information held confirming the date that the PHSO
policy of considering wider issues changed to that of considering
individual complaints only.

 

I confirm we do not hold recorded information as you have requested.
However, it may be helpful if I explain the role of the Parliamentary and
Health Service Ombudsman (PHSO) has always been to investigate complaints
that individuals have been treated unfairly or have received poor service
from government departments, other public organisations and the NHS in
England. Where we uphold complaints we will not only make recommendations
for remedy for the individual, but we will also take the learning from
individual complaints and look at broader issues to help the NHS in
England and other public bodies to understand service failures and make
improvements. This is most evident in the publication of reports about
specific themes like sepsis which we have seen arising in the individual
complaints that come to us.

 

You may be interested to read our recent published reports on sepsis and
on midwifery which have brought about agreement to changes to medical and
healthcare practice. For ease of reference, please click on the links
below:

 

·         Time to Act Severe Sepsis: rapid diagnosis and treatment saves
lives:
[1]www.ombudsman.org.uk/__data/assets/pdf_file/0004/22666/FINAL_Sepsis_Report_web.pdf

 

·         Midwifery supervision and regulation: recommendations for
change:
[2]www.ombudsman.org.uk/__data/assets/pdf_file/0003/23484/Midwifery-supervision-and-regulation_-recommendations-for-change.pdf

 

You may also wish to read our most recent Annual Report and Accounts which
provides an insight of the work we did in the reporting year 2013/14:
[3]www.ombudsman.org.uk/__data/assets/pdf_file/0010/26020/FINAL_PHSO_Annual_Report_and_Accounts_2013-14.pdf

 

I hope my response is of some assistance.

 

Yours sincerely

 

 

 

Sohifa Kadir

FOI/DP Officer

 

 

 

 

 

 

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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

References

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2. http://www.ombudsman.org.uk/__data/asset...
3. http://www.ombudsman.org.uk/__data/asset...

Jt Oakley left an annotation ()

The PHSO seem to be saying that if it receives 10 complaints about the same ward in the same hospital, it is not its business to act as an 'early warning system' , so the evidence that something is dramatically wrong can be safely overlooked.

J Roberts left an annotation ()

James Titcombe was interviewed for 'Learning from Life and Death' - a Radio 4 programme presented by Matthew Syed and rebroadcast on 17/1/18:

http://www.bbc.co.uk/programmes/b08wmpnl

It took him 400 letters and emails to get a satisfactory answer. Reference is made to 'self-justifcation after adverse events' and the 150 avaidable deaths every week in the NHS.

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