1st AUGUST 2018

Another TWO years. After a request by many people similarly treated by the PHSO, R. Behrens (3rd PHSO in post since first approached) took away (Oct 2017) a huge bundle of his so-called “Historic Cases” to review (these had been previously ignored by previous incumbents A Abrahams and J Mellor). This took another six months to come back on, with mixed but so-predictable results. No listening and no change. My complaint was closed with no evidence of a Review of it, or the many Service Complaints (including abuse of the complaint by PHSO staff), that had accrued over more than five years, with still no resolution. An expressed view by R Behrens that the PHSO was ‘confident in its staff’ was of course meaningless and pointless, with no appreciation of the time and energy that had failed to resolve anything in nine year to that date. There was no recognition of the harm that had been caused by the PHSO let alone the harm done to my son by NHS disjointed, rare and intimidating approaches. Oddly it was the PHSO who decided not to investigate the inflicted trauma and subsequent isolating effect of those instances on my son. Unresolved.

Only recently did I discover for myself that the NHS Trust had supported lies given to boost their previous unsupported statements, when I asked the PHSO for all the ‘evidential’ documentation. The PHSO dragged their feet in supplying these (this IS usual), but this time the evidence was even more shocking than the last DPA request. It proved without doubt that the Trust was prepared to lie and then, on the basis of a ‘barter’ agree to a closure of the complaint on their terms, with no cross-referral to me. I use the word barter because again, extraordinarily, the “Impartial” PHSO were demanded to drop some very relevant findings of negligence, in exchange for the more minimal agreement by the NHS Trust to accept the failing of a Social Services legal responsibility, viz. ‘Carer Assessment’.

So they could argue a way out either way, I noted. But of course the Trust never identified any Carers and did not invite help or feedback our son’s care, as per NICE clinical recommendations, NICE Guidelines and NHS Policies (or common sense). That was the real failing – but the NHS Trust could not bring themselves to admit it; they were now too entrenched in misinformation. No Blame. No Acceptance. At a cost of blatant lying to the PHSO and, potentially misinformation to HM Coroner during my son’s Inquest (yet to be investigated). I was there and saw the furtive tension during questioning; and relief when the questioning was stopped.

I have of course tried to point this out but the PHSO are refusing to respond to any emails or calls. ‘Customer Service’ have been instructed not to engage. This is how the PHSO handle fairness, openness, transparency and Equality. It’s the Policies or ‘caveats’ they don’t want complainants to be aware of; is my opinion. If it was a non-government service like your Utility provider, say, it would be serious Corruption of public interest. You’d want to change provider. Unfortunately the PHSO holds a ‘monopoly’ on complaints and how they are dealt with via Judicial Review, including on their own corrupt service.

I now sit on the corruption and lies that have taken almost 10 years to reveal and ten years of missed life. The result is a deep depression and medication to control the after effects: for just asking why my vulnerable son was mistreated, and why the PHSO sinks to use any defence that preserves their negligence and inflicts new abuse on a PTSD complainant, and WHY the PHSO continues to avoid the slightest transparency. I expect the answer will be more lies, so why bother?

29th JANUARY 2016

I received a letter from the GP Practice with a cheque, and an apology prompted by the PHSO’s communication to them. An apology for what -in total- exactly? It doesn’t say. Is this cheque ‘compensation’ for inconvenience? How was its value arrived at? I wasn’t asked that’s for certain. This negligence cost me my son and then 7 years of ageing getting nowhere that can be regarded as closure.  A life on hold, and now a cheque for £250. Is this the PHSO’s value of my trouble – is this a game show? Sometimes in a sick dream I believe it is.

BWMP letter 220116R

I’ll reply to this and return the cheque, which somehow became modified from the £750 recommended by PHSO -was this another joke?- still a paltry sum considering the damage done to my family, and continuing negligence seen in failing to carry out NHS complaint procedure.

Link to my letter is BWMPresponse1R


23rd JANUARY 2016.  Waiting 7 years for a proper investigation? I’m still not sure I’ve had it, but had a new ‘Final’ report – which I have still not not read. Judging by the covering letter (see below) the PHSO appears to have gone back on my previous expectations of a fairer coverage, by moving the goalposts again. He will not be investigating parts of my complaint about NHS services, and has not responded to my complaint about the PHSO. The PHSO ‘back burner’ must be a total log jam of complaints they have no intention of addressing. I’ll be updating this blog with some of the issues the PHSO dare not address.

Last week I responded to the covering letter, having to use the general email, because Mr Gwyn Richards (caseworker) had deleted his email address we had been using (is this a new tactic?).

“Health Services Ombudsman (PHSO)
Millbank, London.

Good Morning Mr Gwyn Richards

In relation to the death of my son Nicholas Rock on 9/11/2008 involving negligence and incompetence at Birmingham and Solihull Mental Health Trust, Bernays and Whitehouse Medical Centre Shirley, and Social Services Solihull; also in relation to the incompetent and deceitful investigation requested thereafter.

I have received your report and have first read only your covering letter: and I see you have misaligned remarks I made previously. I told you I had received a personal legal ’settlement’ with the Trust and it was after that when I asked you to reopen the case based on the guarded admittances and the denials I saw in that case and at my son’s Inquest. I have also told you that the outcome of the legal case was productive with regard to contact and dialogue with the Trust for improvement to services and mutual benefit, bar certain admissions.

However we are taking here about the incident some years previous. It appears you have substantially shifted your position towards defending NHS maladministration. This was not entirely unexpected as you have shown that their stories carry the weight of office: whereas we who relied on trust have little standing, and ‘know nothing’. You have also apparently adjusted your terms of reference based on the defendants’ misinformation. I thought you were on a course to do better; considering the time and trouble taken to re-visit this injustice which may yet indicate a criminal content.
Let’s go back to why I approached the PHSO. In 2009 after an unsatisfactory NHS investigation I asked you to investigate the issues, all within your stated role, and specifically in relation to:

  • Failure to act on known information in relation to patient’s condition [named persons removed]. Any action was always down to us as uninformed carers to initiate. I hope this aspect is covered in your report, including why practitioners felt justified on making up their own rules with regard to mental illness and confidentiality, to frustrate efforts of contact.
  • Negligence and incompetence in relation to keeping my son and us advised and informed on three- way care using available services including the specially developed Meriden Family Programme for this specific scenario: management of patient care. You have so far defended this on the basis in effect the patient wasn’t asked—by practitioners—if he wanted to be involved in this care; so please explain how you consider how he could we could not have benefited – having no knowledge of it. Their psychiatrist [named] has already stated on record that “he didn’t think”. I hope you have explained this paradox where only the Trust/Centre can win i.e. ‘Don’t inform and patient can’t ask’ [named persons removed].
  • An explanation is also required for other anomalies in care and services e.g. No advice of Carers status and assessment as required by law [named persons removed]. I have given you other examples.
  • Negligence in approach to my son including insensitively confronting and threatening (abuse) of a vulnerable person by practitioners; causing mental harm at the time, and precipitating my son’s isolation from contact and eventual self-harm [named persons removed]. I hope you have tackled this and explained why it was acceptable especially when it had been pointed out to be damaging [named GP removed]. Please do not excuse this again with ‘didn’t think’.
  • Negligence in carrying out a complaint investigation to procedures as set out and required under specific and detailed prevailing terms, subsequently involving actual evasion, denial of responsibility, or cover-up of material evidence; to us, to the Coroner (and subsequently PHSO), and compounding mental suffering and actual harm over seven years [named persons removed] (Abrahams, Mellor).

In support of my claims I have furnished you with much correspondence citing actual evidence and many indicators of overall maladministration. It may have been endemic, as may have been unintended mistreatment of a vulnerable person – you have to show you appreciate that in your conclusions.

I understood that it was the role of the PHSO to thoroughly investigate the entire case with limits not set and influenced by the defendants’ claims, but by inclusive application of advice on best practice in medical care, availability of care, and on legal requirement. Here, practitioners did not follow the objectives of NICE guidelines. It is not relevant to only assess ‘Care no better than expected anywhere in UK…’ i.e. ‘never mind local procedures for improvement’. The corollary—as you are implying—is to say that nobody anywhere needs to try and improve health outcomes, and a degree of maladministration, negligence and abuse is permissible up to an expected scale. Is there a permissible amount or threshold for this? I think not. Maladministration is not related to best practice one iota – it is incompetence and corruption, and not related to any ‘typical standards’, in the UK. Your Report will have to explain why you consider the maladministration was acceptable.

You have also shown no effort in approaching the actual complaint I made against the PHSO using your published procedure, and which your workers Gavin McBurnie and Annette John promised would be dealt with separately. You jointly may have broken my son’s and my own UK rights in law: yet you have consistently avoided that subject and sought no advice in that direction. The Ombudsman Julie Mellor has said that far too many complaints are inadequately addressed at source (e.g. NHS), and that is why the PHSO is receiving far too many complaints which should have been addressed locally. Now you have told me that you don’t even intend to address this part of my complaint: evidence of PHSO perversity.

Every week there is revelation of major corruption and negligence in the NHS and the struggle which grieving relatives and parents have, to gain recognition of the trauma caused. It does not appear you have taken stock of your role in learning and reform, in your letter’s tone. I know as a fact that many heartbroken people just do not approach you because of your poor reputation, or because the trauma they suffered is too great and will not be countered by a harassing pursuit of ‘justice’ through the official route.

To add some focus here, we are not talking about ‘Who stole the strawberries’; we are taking about contribution to a death. My son had a right to care levels bestowed by ECC treaty, UK Act of Parliament AND a common right to Care which was available in his area. It is simple negligence which did not provide it, no matter how you as PHSO draw your artificial lines in choosing what to investigate or what malpractice is considered acceptable. The CQC have recently asserted “Not involving people in their own mental health care can lead to breaching their human rights”. I trust this was also a consideration in your conclusions.
This is my initial reaction and I will be looking at the Report when I feel mentally able in the following days, considering the tone you have set. The compounding trauma you have caused and still maintain on top of my loss has diminished my will to live but I can see that you would not understand that; any more that you could understand my son’s response to his ‘Care’ and treatment by the authorities – particularly by his GP, who had that duty of primary care to manage the situation, and had 6 years to do that.

I would regard that last comment of mine as grossly unfair were it not for the supportive evidence of many other injured parties so frustrated by Services.  The PHSO will continue to be an ineffective voice unless you start to seriously tackle medical maladministration, and—specifically in this case—the core reasons raising the level of self-harm in young people who have been actively and negligently disengaged by services generally, and here in Solihull. I know many Solihull workers in Services across the board, who recognise the problems and are working hard to help; but denial at Primary Care level will not help reform. It is very discouraging to think that their efforts ultimately will not be considered and appreciated by the PHSO in current cases of common or medical negligence.

Other topics you raise:

Compensation: In no way has compensation yet been approached or assessed with me – please provide details, via PHSO managers, how this is arrived-at. I have told you the Trust has paid a legal settlement in respect of ‘costs’. If you are suggesting any real compensation I would of course be willing to deduct that amount from a properly assessed figure for the loss of my son’s life, and for the mental trauma caused by extended prosecution with PHSO, of rights and justice.

Your comments with regard to the law are neither here nor there, since you have already told me you have no training in any field other than methods used to attain PHSO closure. I therefore do not accept your phso-tied approach to ‘Resolution’ and will make best use of any records, facts or statements made by health professionals or PHSO caseworkers to publicly demonstrate maladministration.

Feedback: Given your offer and opportunity I will be happy to supply feedback on your services but in the past the PHSO has revealed on enquiry that it is ‘selective’ in forwarding complainants’ details for response; a maladministration seemingly to avoid an ‘imbalance’ in PHSO statistics: please ensure a level playing field in this regard if your surveys are to have any credence.

I will try and draw any positives from your Report where you say the complaint is partially upheld but you should be prepared for public criticism of omissions and maladministration. The Report being your final version, I do not expect any further communications from you personally in relation to my original complaints. My complaint against the PHSO will as always be considered a separate matter.

I trusted you to be honest, and will be prepared for a pleasant surprise; but if you have ignored my evidence and not formed conclusions relating to collective failures, or for learning and reform, there will be little progress.

The Ombudsman J. Mellor only recently stated—in a pressured reassurance to Parliament of PHSO efficacy: “When [a service] fails to carry out a proper investigation it is automatic maladministration”. I’ll be interested to see what actions you recommended in support of that policy, since Maladministration has a pervasive effect on the proper provision of any Service. The repercussions of her statement in relation to the PHSO’s own performance, are yet to be realised.

These are my views on the matter.”

(name and address)

“I have shared this email with a number of services for information and education, where there may be an ongoing interest. I would draw their attention to the length of time taken for PHSO (Ombudsman) final response (2009-2016), the quality of which they may draw their own conclusions from this initial comment.”


13th JANUARY 2016: I was told early Dec the case would be completed soon. Great news expected; for another Christmas without my son Nick being around? No thanks; I’ll leave it. A couple of weeks on 7 years makes no difference. Having received what the PHSO is calling a “final investigation report” I’ve put it aside. I have yet to read it because obviously I have all the time in the world to get down to it, to see how the PHSO relish re-awakening all the old problems they set. It takes some effort just to read the covering letter which is basically still of the old PHSO mindset that the NHS need protecting whatever the outcome for complainant. Just the tone of ‘how they have listened’ and what they have ‘chosen’ to investigate, starts my heart thumping to relive the trauma which should have been dealt with years ago when -but only initially- there was trust in the process. For now I will just copy the covering letter, whilst I digest the full content.

This was the covering letter:

“12 January 2016

Your complaint about Birmingham and Solihull Mental Health NHS Foundation Trust and Shirley Medical Centre

Thank you for your comments on our draft report. Please find our final investigation report enclosed with this letter. You will see that we have made some changes to the wording of the report to take account of comments made by you and others.

We have carefully considered all of your comments. We had already taken many of them into account during the investigation, and in the report, as you have covered these points in previous correspondence and when we met. We know that you disagree with our approach to reaching our findings, but we have to compare what happened to established good practice: we cannot fairly criticise organisations for not providing the best conceivable service in every circumstance.

Some of your comments relate to issues that we have not investigated. For instance, you make various criticisms of the Trust’s and the Centre’s handling of your complaint that do not fall within the summary of what we agreed to investigate (as set out in my letter of 20 July 2015). We do not propose to expand the scope of the investigation to include them at this late stage.

I note your comments about the amount of money we provisionally recommended that the Trust and the Centre pay you. These are not fines, but recommendations to compensate for injustice. We did not find that Nick’s death was in consequence of the Trust’s or the Centre’s failings, so the amounts are not to compensate for your loss of your son. Rather, they were in recognition of the injustice we found that you suffered as a result of the Trust’s failings. However, as I explained in my email of 8 January, we have removed the recommendation that the Trust make you a payment, because they told us about the settlement reached between your lawyers and theirs: a payment associated with same issues that you complained about to us.

I should point out that we have made some changes to the report based on comments from the Trust. In particular, we have removed reference to the Meriden family programme from our findings, because the Trust says that it would not have been suitable (since the programme requires input from the patient as well as the family). I know you disagree, and in your comments you say again that you should have been referred to the programme. But the key point, which stands, is that you should have had access to carers’ support services.

The other significant change we have made based on the Trust’s comments is that, in 2008, Nick was not on CPA and therefore you were not entitled to a carer’s assessment. We have removed the finding of service failure by the Trust in 2008. You will see, though, that this does not affect our overall conclusions. We maintain that you suffered injustice as a result of the Trust’s failings in 2004.

Having looked at all of the responses to our draft report, our final decision is to partly uphold your complaint. I know you wanted us to go further than that, but I hope our report has explained why we have not.

What happens now?

We are also sending copies of our final report to Birmingham and Solihull Mental Health NHS Foundation Trust (the Trust) and Shirley Medical Centre (the Centre), and to several clinicians who were involved in Nick’s care.

We recommended that the Trust and the Centre apologise to you, pay you some compensation, and take other action to satisfy us that the failings we found have been rectified for the future. The Centre has agreed to do that. The Trust has not yet agreed, but we expect them to carry out our recommendations and will monitor their compliance. We asked that they complete the actions we recommended within one month (for the apologies and compensation payments) and three months (for the extra work). We will let you know when this has been done.

Some important information you need to know

There are legal restrictions on sharing the information we give you with other people. Our reports often contain confidential information too.

You can share our final report with others if you want to. However, please do not share any documents we may have given you during our investigation, which includes copies of our draft investigation report. If you have any questions about what you can share, please contact me using the details given above.

How did we do?

If you have any feedback about our service or decision, we would like to hear from you. Please contact us on 0345 015 4033 and select option 3 or email us at feedbackaboutus@ombudsman.org.uk.

We would like to remind you that an independent research company acting on our behalf may contact you in the future in connection with surveys or research to help us improve our services. If you would prefer not to take part, please let us know by calling

0300 061 4222 or by emailing us at customersurvey@ombudsman.org.uk.

If you have already told us that you do not want to take part, then you do not need to tell us again. Information passed to and collected by the research company is kept in the strictest confidence and is used for research purposes only.

Yours sincerely

Gwyn Richards”

[PHSO caseworker] 


JULY 2015: At the time of this update I am still waiting for the Ombudsman (PHSO) team for investigation of back-cases to contact me with regard to the promised investigation. There appears to be a substantial backlog of unresolved cases but this is not being reported as such. A 2015 Parliamentary Act appeared to suggest that a 12 month maximum wait would be extraordinary – but my 6 year wait is phenomenal. Considering what I have had to go through and all the information offered, the PHSO have still no real conception of the complaint I’m making… apparently.

I had been told verbally that someone would contact me in due course and I had been given 2 names of investigators. After initial contacts in October-December 2014 I was contacted again by another member G McBurnie who said they would be able to start when their post as an opereational director had been formalised – as I understood it. This was new recruit to the PHSO—then a practising locum GP—and I was led to believe that this might have been soon after an initial meeting with him. This follow-up materialised much later by yet another new contact being made by an ‘established’ PHSO investigator (which didn’t augur well for outcome) who would visit me to talk about my experiences and try to detail the (more) precise nature of my ongoing complaint. With a condition. We would not be discussing my complaint about the Ombudsman’s tactics, procedures and operating principles, renewed formally in December 2013 – and still not responded-to in July 2015. So at this point I have received a transcript of what we discussed and the points I re-asserted with reference to the terrible and tragic outcomes from both GP and NHS Trust failures. At 52 pages, I have no intention of going through this trauma yet again. They ‘get it’ or they don’t get it. They have a chance to sort out their problems, and if the same broken procedures are applied the same broken outcome will be evident.

I have no written confirmations of their investigations into the GP Practice or the NHS Trust who so mismanaged my son’s needs (and our combined needs as Carers) up to his death, nor of the ongoing investigation into the incompetence and abuse I have had to suffer from the PHSO themselves.

I am sincerely hoping that there will be an explanation not only of the bad care and attempt to under-inform me (i.e. cover up actions), but also why it has taken so long to take a detailed look at the case and why the PHSO was unable to deal with it under their much-promoted ‘Principles‘, not one of which have been paid any attention. I would be very concerned that certain NHS practitioners are inflicting similar harm on other patients, and have been doing so—potentially—for over six years past.