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Learning from mistakes: An open and honest review of failings in handling a serious complaint

Today, the Parliamentary and Health Service Ombudsman (PHSO) has published an important review. It looks at the way PHSO handled a serious complaint from the father of a young woman who tragically died in December 2012, following very serious failures in her care by a number of different organisations. 

The report is a frank account of how PHSO got several things wrong in the way it dealt with the complaint and the considerable impact this had on the family.


'Reflecting on my own experience' by James Titcombe, Patient Safety Campaigner and member of PHSO Expert Advisory Panel.

"Reading the report, I couldn’t help but reflect on my own experience of the NHS complaints system following the avoidable death of my baby son Joshua in 2008. 
Like so many other families I’ve met over the years, our experience was of an NHS that acted to conceal the full truth about what happened. As a result, there was little learning or change. The impact this had on our family was to make coming to terms with what happened so much more difficult.
In the months and years after Joshua’s death we were left feeling badly failed by both the local response to what happened and by how other organisations responded, including PHSO.
In recent years the NHS has recognised the need to improve its systems and processes for responding to and learning from patient harm. But it is fair to say that change has felt slow."

A candid account of what went wrong
When the local response to serious failures in care does not address all of the issues, it is crucial that patients and families have somewhere to go where their concerns can be independently assessed and investigated. This is even more vital when patients and families feel that the truth has been suppressed and lessons not learned.
In the most serious of cases, families going through the NHS complaints system may already have been through protracted local investigations and complaint responses. 
By the time they reach out to PHSO, their trust in the system may well be badly eroded. This means the way the Ombudsman reviews concerns, obtains expert advice, weighs up evidence, listens to and engages with the complainant, and explains decisions is crucially important.  
Today’s report is a candid account of how PHSO got a number of these aspects significantly wrong, and the consequences this had on the family involved.
As is too often the case, it is only because of the extraordinary efforts of the complainant to persevere through a sometimes very challenging and complex complaints process that serious failures were eventually identified.
This is true not only of the care provided but also of the local responses to what happened.
If we want a safer and kinder healthcare system, it’s crucial that a number of things change. 


Read the full report here

Source: Parliamentary and Health Service Ombudsman (PHSO) 9th January 2020

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NHS Complaints Summit 2020
Monday 12 Oct 2020
West One De Vere, London