Session 2010-11
Publications on the internet

To be published as HC 786-i

House of COMMONS



Health Committee

Complaints and Litigation

Tuesday 1 February 2011

Julie Bailey, Catherine Hopkins and Kieran Mullan

Mrs Dee Speers, Mrs Nicola Monte and Debra Hazeldine

Evidence heard in Public Questions 1 - 68



This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.


Any public use of, or reference to, the contents should make clear that neither witnesses nor Members have had the opportunity to correct the record. The transcript is not yet an approved formal record of these proceedings.


Members who receive this for the purpose of correcting questions addressed by them to witnesses are asked to send corrections to the Committee Assistant.


Prospective witnesses may receive this in preparation for any written or oral evidence they may in due course give to the Committee.

Oral Evidence

Taken before the Health Committee

on Tuesday 1 February 2011

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Nadine Dorries

Yvonne Fovargue

Grahame M Morris

Mr Virendra Sharma

Chris Skidmore

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Julie Bailey, Cure the NHS, Catherine Hopkins, Legal Director, Action against Medical Accidents, and Kieran Mullan, Director of Strategy and Engagement, The Patients Association, gave evidence.

Q1 Chair: Good morning, ladies and gentlemen. Thank you for coming along to what is the first evidence session of our inquiry into the handling of complaints by the National health service. Could I ask the three witnesses first of all to introduce yourselves and say a word or two about the organisations that you come from, starting with Julie Bailey, please?

Julie Bailey: Julie Bailey, founder of Cure the NHS.

Chair: I am sorry, but the acoustics in this place are dreadful. Could I ask you to speak up a little bit?

Julie Bailey: Julie Bailey, founder of Cure the NHS. Cure the NHS started out as a small group of relatives and patients in Stafford that had been harmed by the Mid Staffordshire hospital. We felt we needed to get together to form a group as nobody was listening to the problems that we had suffered at the hands of Mid Staffordshire hospital. We formed the group and very quickly became quite a big group of 40 or 50 people. From then on, once we received coverage nationally from the media, people contacted us on a national basis, from around the country. All have experienced similar problems to ours at the hands of Mid Staffordshire hospital. In the majority of groups that we have now, the people who are suffering are either the vulnerable or the elderly within hospitals throughout the country.

Chair: Thank you very much.

Kieran Mullan: I am Kieran Mullan from the Patients Association, which is a longstanding registered charity that campaigns very broadly under the motto "Listening to patients, Speaking up for change". We have a very wide range of issues that we will campaign on, largely driven through what we hear from patients and carers through our helpline. We have had a particular longstanding interest in the issue of complaints because that is something we hear about frequently. I would echo Julie’s comments that, unfortunately, the bulk of that material does revolve around the care of elderly patients in hospital.

Chair: Thank you.

Catherine Hopkins: Good morning. I am Catherine Hopkins, legal director at AvMA-that is, Action against Medical Accidents. We are a national charity that campaigns for patient safety and justice. We have a separate campaigning arm where we are looking at national issues in healthcare. We also have a helpline where we provide assistance for individuals, and we do provide a lot of assistance with pursuing a complaint. Members of the public can access advice leaflets and example letters on our website, or sometimes we end up providing a complete service for them, including providing a friend-a volunteer from AvMA who will go with the individual to a meeting. We have been supporting some members of Cure the NHS during the independent review stage at Stafford.

We also provide a certain level of support for lawyers who are acting in clinical negligence claims. I myself am a solicitor who has worked in private practice for more than 10 years. Before that I worked for 20 years in the NHS. I am a qualified midwife, health visitor and general nurse, so I have a background there. I have also done some lecturing on accident investigation, so I have a fairly round view on how things may go wrong in organisations and how complaints can be pursued.

Q2 Chair: Thank you very much. That is an unusual combined background that is clearly relevant to this subject. We are obviously very interested at the beginning of our inquiry to hear the perspective of the organisations and individuals who have made complaints or been responsible for representing those who have made complaints against the health service, to hear of their experience of that system in reality, to understand how it feels to be people who are seeking to bring complaints and the complainants’ perspective on the system.

I would like to start, if I may, with a question to Julie Bailey, because I was struck by the comment in your written submission that you felt there was a victim culture amongst NHS staff. You said that the board put protection of the hospital before individual complaints. If that is the experience of an individual body bringing complaints against the health service, there is clearly something wrong. I would like you to tell us a bit more about that perspective.

Julie Bailey: That is right. What we have found is that, once you start to complain about the system, from the very beginning they want to quash that complaint and they want you to turn it into a concern. When you say, "I want to complain about my treatment" or "I want to complain about my relative’s treatment", they will ask you straight away, "Is it a concern? Are you concerned about that?" You say, "Yes, I am concerned," and the reply is, "So that is a concern then, not a complaint. So you want it to be known as a concern." Straight away that is the complaint gone. You have expressed "a concern" and nobody learns from that concern because it is not logged as a complaint. From there, you face animosity straight away. You take your complaint to the nurse on the ward and the nurse on the ward says, "Do you feel it happened like that?" Then they try and twist it to say, "It happened like this."

What I meant by that was, when the Healthcare Commission report came out, in Stafford the first response from the trust itself-and, we felt, from the Government at the time-was to put up barriers and say, "That was then. This is now." There was a huge campaign to get behind the frontline staff, to support the staff, and the people who had suffered at Stafford were really very much pushed into the background. The attitude was, "That was the past and this is the future, and we need to get behind the frontline staff because they were very short staffed. That happened then and this is now."

We do feel that, whenever a complaint is made, it is the staff who are made to feel as if they are the victims and not the actual complainant. Each response we have received to a complaint which says that something happened on such and such a date, is basically as follows: "If you feel it happened that way, then we apologise." That is quite a common theme throughout the country.

Q3 Chair: Would the other two witnesses like to comment on this feeling that the service immediately goes on the defensive?

Kieran Mullan: It is important to note, for organisations like ourselves that put ourselves forward as ones that represent people who are unhappy with the service, that we almost inevitably will only see and hear from people who are unhappy. There may well be times when people are happy with complaints’ responses, and some of the surveys that show high levels of dissatisfaction will obviously, therefore, inherently be showing small levels of satisfaction.

One of the things that stands out to me from Julie’s evidence is the emphasis, from the Department of Health’s most recent policies for local resolution, for people to raise concerns immediately before they become a complaint. That, I think, might be the idea from central Government. You are therefore relying on people to take things very seriously, even if it is not a complaint, and to recognise when something should be made a complaint. But the reality on the ground is that it can turn into exactly what Julie has described, in some sense, as "Well, let’s not really make it a formal complaint." We have seen that position readily adopted. In relation to apologies for what you perceive to have gone wrong, that is something we see very commonly. Again, there is progress in some respects; previously you wouldn’t get people to apologise and that was a real bugbear. So again, for central policy to say, "Apologise, apologise, apologise" is valuable, but then apologies which are not substantive are not valuable to people and can actually make things worse.

The last point was about the perception that we should protect NHS staff and the victimhood that arises. Sometimes people see NHS staff trying to do their best in very difficult circumstances, and in such instances they often don’t complain. They might be in an accident and emergency department getting very poor care, but seeing that the staff are unable to provide good care because they just have too many patients to look after, maybe understandably, they have some sympathy for the staff. What I don’t think they recognise is that, in not making a complaint because they feel individual staff are not to blame, they are not registering their dissatisfaction with a service that should be accountable for the fact that it is not adequately staffed or whatever it might be that is making the staff unable to do a good job.

Catherine Hopkins: I certainly think there is some truth in what Kieran said, and I would agree with him that not all responses to complaints are unsatisfactory. From our position, however, we see that hospitals or trusts that are failing tend to provide that rather sort of conditional apology-a mealymouthed sort of response which only makes the complainant cross and become highly defensive. They have probably more complaints than the better trusts as well and so the situation is compounded here. You get more complaints, you don’t deal with them adequately and people are dissatisfied and understandably angry with the response. That is certainly something that we have seen.

Equally, we do sometimes see very good responses where people say, "We genuinely are sorry and we have changed our position." In my private practice a situation arose involving a child who died having had to go back to theatre. The child had had an adenoidectomy and bled, and had to go back to theatre. They didn’t put an IV infusion up and the child died quietly in the night. It was a combination of respiratory arrest and the child had had morphine and so on. The hospital’s letter of complaint said, "We have changed our practice when children have to go back to theatre after surgery." That was a highly satisfactory response. Saying, "Not only are we sorry we got it wrong but we have changed our practice" is a good response. A bad response is the response that Julie has mentioned.

Another bad response which we often see arises when complainants are blamed for the culture of victimising individual members of the medical or nursing staff. But it is not complainants that do it. Very often, the very first reason for complaining is to ensure that somebody else’s mother won’t be dealt with in that rude and dismissive way. People who complain, by and large, want something to stop and someone else not to suffer. Instead, however, the sort might be, "Nurse so and so did it. We have disciplined her." The complainant might reasonably respond, "That is not what we wanted when we complained. We didn’t want you to say that somebody has been victimised."

The most extreme example has to be when systems failure causes the mal administration of a drug, such as the Vincristine cases, where a drug is given intrathecally instead of intravenously. What happens is that a junior doctor finds himself on a charge of gross negligence or manslaughter. Yes, systems are looked at, but it may take a jolly long time for the physical changes in administration systems. I am still not sure whether these junior doctors get the adequate supervision from senior doctors. Instead, they are scapegoated and I think- I am sorry, I don’t think; AvMA thinks-that that is the reaction of the trust, not the intention of the complainant.

Q4 Dr Wollaston: Can I ask Mr Mullan and Ms Hopkins a couple of questions, please? The first one is to do with the significant rise in complaints since the new system came into force. What do you feel is the cause for the 13.4% increase? Do you think it is the new system or have complaints or problems genuinely risen?

Catherine Hopkins: Generally people are aware that they may complain and perhaps people are absolutely exercising their right to do that. That has to be one element, but also in areas such as staffs, where the system was failing, then the rise in complaints, as I said earlier, is an indication that the organisation has a problem.

Q5 Dr Wollaston: So you think that, within an individual organisation, if you see a rise that is significant, but otherwise, generally, you think it probably is people being more aware. Have I got that correct?

Catherine Hopkins: Yes.

Kieran Mullan: There are probably a number of factors. I don’t think we can underestimate the publicity that Mid Staffordshire generated when the report was first released, which would figure into the latest statistics. Over a sustained number of days, across all news media, there was significant discussion of poor care issues. For example, we have just recently done a campaign with the Daily Mail on poor care, and the year before we released our own report about poor care. Whenever we do any kind of sustained media engagement, we receive complaints. So you must imagine that people respond more to the organisations that they wish to complain about.

It is difficult to say whether there has been a deterioration in care as a whole. We have seen for a number of years, from a number of different organisations as well as our own, real concerns about care of the elderly in hospitals. That is a concern, but, again, I wouldn’t necessarily think that that has increased over the past year. It is also interesting to note that the year before this rise in complaints, which has been in regard to hospitals, there was an almost equally significant rise in GP complaints over one year. Why you get such a big jump over one year again might be related to outofhours care that has received lots of publicity. It is very hard to tell.

I would perhaps caution against the approach of looking at absolute numbers as a significant barometer of anything to do with the complaints system, for a couple of reasons. Hospitals that are proactive on their complaints policy, that encourage and want complaints, will have higher numbers of complaints. That is one downside to looking at complaints numbers. Also, we know from lots of surveys that the majority of people who want to complain don’t complain, and so, even at the 150,000 figures we are at now, the survey suggests only about one in five people who want to complain do so. So I would look at the figures with caution.

Q6 Dr Wollaston: Can I follow that up? Could you clarify for the Committee what proportion of complaints do you think are vexatious complaints?

Kieran Mullan: In our experience, probably relatively small numbers, but I have never come across hard evidence. You would have to look at getting some kind of actuals from those organisations that deal with complaints in a systematic way, such as the ombudsman, for example, and perhaps ask some NHS organisations. I am not clear as to what the proportion is. What I am clear about is that, because there is such a reticence to complain and people are, in my experience, so forgiving of the NHS, most people that do lodge complaints have a genuine concern.

Catherine Hopkins: In terms of individuals who complain, I agree that it is a small number who make vexatious complaints. If we look at the people who contact our helpline and wish to make a complaint, we see that most people have a genuine complaint. But, again, if we look at ongoing contact that we receive, perhaps there are people who do raise vexatious complaints and they may well be a little more persistent in the way they pursue their complaint. Therefore, it may just have the appearance that there are more. But if you look at the individuals, we don’t believe that we are seeing a large number of people who ring our helpline and we think they didn’t have a complaint. We will give advice to everyone, but there are times when you feel that probably there isn’t a fundamental issue there.

Julie Bailey: A lot of people have been labelled a vexatious complainant if they are not being given the answers. I meet people every day who have been going for years just to get the truth, because once you or your relative have been harmed in a hospital it is something that you never get over. You just want those answers as to what happened. Only then can you feel you can move on and accept what has happened to you. A lot of people are labelled vexatious because they haven’t been given the answers, and a lot is because people don’t want to put their hands up because of the blame culture.

Dr Wollaston: Thank you for clarifying that.

Catherine Hopkins: Can I give an example there of a complaint that one of the members of AvMA assisted on, which involved a death in a private hospital? The surgeon told the parents of the dead boy that every time he did that operation he remembered what had happened; it had informed his practice and he had learnt from it. This is a very long time ago, but it is an extreme example which illustrates the point. The hospital never acknowledged they had anything wrong with their systems, and the complaint against the hospital lasted five years because they never looked at the issues.

Kieran Mullan: May I add one more point on this issue? If you look at the vast majority of hospitals’ vexatious complainants policies, most of them would describe one of the ways in which you might categorise someone as a vexatious complainant as when they don’t accept the medical records as factual. What is on the records is fact and they won’t accept that, so they might be a vexatious complainant. Obviously we have seen, I have seen, Julie’s group and others have seen lots of examples where the medical records aren’t accurate, and so that is a good example of the system as a whole. Sometimes the system has rules, and you can understand that people working within that system may well, for example, have exhausted the complaints process for that individual and that trust. They can’t do anything more for the complainant and there isn’t any point in the complainant continuing to contact them. But, from the complainant’s point of view, their reasonable expectations, as an individual, haven’t been met by the system as is.

Q7 David Tredinnick: Do you think that the resistance of hospitals to receiving complaints is because the complaints process is faulty and that if a hospital accepts a complaint the process is so arduous and difficult at the moment that it mitigates against patients?

Kieran Mullan : From the hospital’s point of view? No, I don’t think that the hospitals see the system as troublesome for them. There is a specific issue that has now been resolved in terms of time frames. Hospitals were expected to deliver responses within a certain time frame, and while it might have been well intentioned, I think it had some unintended consequences. Perhaps sometimes hospitals felt pressured to deliver complainants’ responses that were unrealistic within the time frame. Hospitals are resistant to receiving complaints because they don’t have as a priority, strategically, dealing with the individual concerns of complainants. It might be that if you are a strategic director and you have all these big ideas for your trust about moving things forward, transforming wards, and meeting targets, it can be quite inconvenient for an individual person to be saying, "Well, you haven’t got my care right." But then, in their defence, you have to remember that sometimes hospitals aren’t in a position to make the changes that they need to make to address things that cause complaints.

If you look at accident and emergency departments over winter, for example, I would imagine you would see quite regularly, every winter, people complaining, having to go into A and Es, waiting many, many hours. Unless the Government are going to significantly restructure the funding of acute trusts to allow them to massively increase their resources over accident and emergency periods, there is nothing hospitals can do about that. So, from their point of view, they probably find it frustrating to have to have those complaints when they are not in a position to change the system that they need to change.

Julie Bailey : I don’t think the complaints procedure is complicated. It is quite a good system if it is worked to, but it’s the whole culture now of not putting your hands up and saying, "We made a mistake here and we are going to learn from this mistake. This is how we are going to put it right." It’s as if the whole culture is in denial. We can’t blame the doctors; we can’t blame the nurses. There doesn’t seem to be a way of the management putting their hands up because then a complaint seems to go against the hospital. It is another complaint, another target that they are not meeting.

Q8 Grahame Morris: It is helpful to the Committee in terms of making an assessment of how the system is working, but you have concentrated on the first stage in relation to making a complaint against the acute trusts, and I value your experiences. Could you tell the Committee a little bit about the second stage, where the complaint goes to the health service ombudsman and what you think the strengths and weaknesses are of that?

Kieran Mullan: There are obviously strengths in having a system that introduces independent clinicians, for example, to review case notes, which is something that we feel very, very strongly people should be entitled to, that they should not have to rely on employees of the organisation they believe harmed them or their relative to provide the scrutiny of the care. That is why there is value in that.

Our biggest concern about the Ombudsman is that, for whatever reason you might want to explore with them, they take very, very small numbers of complainants, either as official investigations or what they describe as intervention where they don’t investigate a complaint but they will contact the trust. Combined, it is something like 2% to 3%-3%-of those people that take their complaint to the ombudsman. So we are talking about thousands of people who have, for whatever reason, felt that the response they received locally was not adequate, who do not receive any kind of independent scrutiny of that response. That would be our biggest concern.

The quality of the ombudsman’s investigations is very difficult to gauge systematically because, as with the NHS, I have never ever seen actual surveys, for example, that they have conducted of people that have used their service to find out whether or not they were pleased with it, particularly those people that don’t get an investigation or an intervention. There needs to be actual measurement of people that go to the ombudsman as well as people that complain to the NHS.

Catherine Hopkins: We also have that concern because we understand that about 10% of the referrals to the Ombudsman are taken up and that leaves a large number of people who are just referred back to the trust. They have gone to the ombudsman because they are unsatisfied with the response. There needs to be something to fill the gap that was previously filled by independent review.

Julie Bailey: We haven’t been successful in any cases in Stafford with the ombudsman. My own case wasn’t taken up. What the ombudsman did was contact the trust. There were two issues. One was over a drug policy and the trust said that they had now got a drug decision tree in situation, and they had also reviewed their staffing levels. We later found out that none of those things had been put into place. I believe they rely on the trust telling the truth.

Kieran Mullan: Can I come back on this because it is important? We have had combined discussion with the Care Quality Commission and the ombudsman on this specific issue because we shared those concerns. Catherine talked earlier about a good response being a description of changes that have taken place at the trust and in policies, and so on. While I agree that that is, on paper, a good response, as Stafford highlighted very well, there are years of responses that are supposed to be correcting the same problems. Something clearly wasn’t working. We have seen, for example, in Basildon, complaints over a number of years about the same issue. Clearly they weren’t implementing the plans they put forward.

Our understanding is that the ombudsman is now working much more closely with the Care Quality Commission to pass on recommendations. What we would like is this. If we think someone has gone to the effort of making a complaint and overcome all the hurdles to find their complaint was upheld, we think they should be entitled to a specific check as to whether things were implemented. My understanding is that the Care Quality Commission aren’t in a position to offer that specific check on individual upheld complaints to check that the changes promised to the ombudsman and to the complainant have been made.

Q9 Chair: Has the CQC formally said to you that it is not in a position to follow up undertakings given by trusts in response to complaints?

Kieran Mullan: They are in a position to do that in a broad sense, so they will receive ombudsman’s recommendations and they will take that into account in their risk profiles of organisations. If there were, for example, more than one very serious complaint about an organisation, then they might choose to go and investigate and check that has been upheld. Or if, for example, they were already reviewing procedures and care at a trust and they had access to an ombudsman investigation, they would take that into account. But they can’t provide an actual specific check as to whether something has been implemented for those 300odd cases that are upheld by the ombudsman.

Q10 Dr Wollaston: I want to follow something up. We heard two different figures. One of you mentioned 2% to 3%.

Kieran Mullan: It is 3%.

Q11 Grahame Morris: I have a supplementary following on from what Kieran said. In fact, in those 3% of cases where the investigation is being carried out and the trust has been found wanting, what powers does the health service ombudsman have to ensure the trust takes some appropriate action?

Kieran Mullan: It is an interesting question because the ombudsman has powers to make recommendations. Their wording is that, should a trust refuse to accept those recommendations, that would be incredibly serious and very unusual. They are never in a position where they are, in any sense, regularly making recommendations where a trust say, "We are not going to follow them." They don’t ever need to force a trust to take their recommendations because trusts take them. They do contact trusts, ask for action plans, all these little things which are useful, but I don’t think it is their practice to visit. We would say that, until you visit a unit, observe the care and see for yourself that that change has been made, you cannot be sure that it has been. If, after a few years, we had a more effective complaints system and we could see evidence that trusts were learning and making the changes, you might be able to be less handson, so to speak. But there isn’t any evidence of that, so we think that a handson approach is the only answer. I don’t think it is a matter of powers. It is a matter of policy that they don’t take that incredibly proactive approach that we would like.

Julie Bailey: What we have found with the public inquiry at Mid Staffordshire is that we have a sackful of action plans, several that have been sent to the ombudsman, but they were never put into practice. Nobody was there to check on them. We have got action plan after action plan going back 10 years, but they were never implemented. I am sure that is the same throughout the country.

Catherine Hopkins: We find this is endemic in all areas of the NHS. We published a report last year about patient safety alerts where the National Patient Safety Agency was sending patient safety alerts out to trusts and trusts were supposed to register back with an organisation whether they complied or not, and they hadn’t. But there was no joinedup way of checking whether they had. You had one agency issuing the alert. One of the alerts was about nasogastric tube feeding. I was astonished to hear that that was something that was necessary, from my background. I couldn’t believe those issues were still going wrong. But then nobody was saying, "Who’s done it? Who has complied?"

It seems that it should be one of the standards that is checked, and not just selfreporting either, which is what it is or it was; it was selfreporting. The CQC should be looking, as part of its inspections, at things like, "These are the patient safety alerts", "These are the recommendations of the ombudsman", or, "This is the bundle of complaints about this particular issue you have received." As Kieran was saying, "Show us where you have improved" and do not just tick a box on a form.

Q12 Valerie Vaz: Part of that problem is that it is not published, and perhaps the recommendations of the ombudsman should be published so that people can see what the problems are. At the moment it does seem a bit like the report comes back, the complaints are upheld and that information doesn’t go anywhere. But if it is made public, obviously with redacted names, then maybe that would be a way around it.

Catherine Hopkins: Quite a few of these recommendations from other agencies are published. Rule 43 recommendations of coroners, where they will send letters to chief executives about issues that have arisen during the course of an inquest, can all be found on the internet. It is the lack of joinedup thinking. Nobody will have looked to see whether the ombudsman dealt with the issue which the coroner is now asking about.

Kieran Mullan: From our discussions with the CQC, there is improvement on that front. The CQC has a much more proactive approach to collecting data from across the system. Again, if you remember, the ombudsman’s complaints are tiny, tiny numbers, so across the system there is lots of access to information. It is that the CQC does not have the resources. There is no way at all that it has the resources to deliver that onsite regular inspection. It is using a much more inspectionbased model. It is using random assessments and unannounced visits at all times of the day and night, but it is the actual number that it can deliver which is instrumental in an assessment of all these different issues that we talk about. We are not convinced that it can do it, which is why we have put forward the idea that-again, this is because of where we are at the moment-there should be independent inspection based within hospitals, perhaps with one clinician who is assessing all of these different issues. Because we are dealing with very, very serious failings in care repeatedly across the NHS, we have to treat that with the seriousness that it deserves.

Q13 Valerie Vaz: That is partly my point because, if the information is just going round to the chattering NHS people, it is not going out to the patients or people who will be able to pick up, "This has happened to me." It just so happened that Julie was sitting in a cafe and she was a strong woman who was able to pick up all the other complaints. People came forward and that’s how we all understood what was happening with Mid Staffordshire.

Julie Bailey: But we have an ideal opportunity at the moment to force foundation trusts to publish all their data. Now is the time. Instead of allowing them to have closed board meetings, we should force them to have all their evidence in public so that they issue all the complaints, all the serious untoward incidents, their infection rates, and their staffing levels. This is what we should be doing. If all of that information was out in the public arena, then the public would have a choice. They will know if that hospital is safe.

Q14 Chair: It is very striking that, in discussing the role of the CQC and the trust’s board in publishing this material, you have not mentioned the potential role of the Commissioner, who is, in theory, the body that should not be paying the bills if they are not satisfied with the standards and the quality of what is delivered.

Kieran Mullan : They suffer from the same problem that the CQC does in the sense that, if hospital boards that manage organisations do not have an understanding of the quality of care and whether they are meeting NPSA alerts or not, and if they can’t grasp the issues, to expect external organisations who have to commission all the GP services, all the communities services, all the hospitals-

Q15 Chair: But it is for the commissioner to require the information that Julie quite rightly says ought to be delivered to be delivered to them. They don’t have to go and inspect it. They simply have to be held to account.

Kieran Mullan: I don’t necessarily agree that there is good information in the system that provides you with a robust idea of whether there is an issue at a trust. A lot of the poor care that goes on is not picked up on. You can’t compare one organisation to another effectively. From a commissioner’s point of view, it must be incredibly challenging to know whether you have a real issue with your provider, which is why we think there is a need for actual inspection. While we progress the information agenda, which will help enormously in all these issues, until we have moved down that road further, we do require that observation of care, that discussion with patients, and review of complaints in a very proactive way.

Julie Bailey : I disagree. I think all the evidence is there. That is what we, as a group, do in Mid Staffordshire. We look at all the evidence that is coming out of the trust now so that we know everything that is going on and we know if that hospital is safe. If each trust was made to publish all of its data, it would give the public an insight as to what is going on in that hospital. All the evidence is there. It is just correlating it.

Q16 Chair: The central finding of the Mid Staffordshire inquiry was not that nobody knew; it was that all the information was there.

Julie Bailey: It was all there, yes, if somebody had just taken all of that evidence together.

Q17 Yvonne Fovargue: May I move on to the support that is available now for people when they are making complaints, whether that is sufficient and is working or whether something else is needed? Catherine, in your written evidence you said that PALS sometimes acted as a barrier. Could you explain how that happens?

Catherine Hopkins: Our experience, talking to our clients, is that PALS officers often tried to provide an explanation and stopped the complaint there. It rather links in with what Julie was saying about, "It’s not a complaint, is it? You are raising a concern." The attitude of some PALS officers can be, "Let me see if I can explain this because you may not have quite understood the situation. That may be why you are raising a complaint." Essentially, they are there to provide explanations and help, but it is slightly skewed because you are saying, "You have complained about your treatment but actually I don’t think you have quite understood." That is where we feel it is a barrier to properly investigating a complaint. We would never suggest it was fobbing off, but it does effectively appear to be rather like fobbing off. It does not reach the complaints process. That is our concern.

Patients don’t see PALS officers as independent because they have an office next to the data protection people who are providing you with your copying, notes or whatever. The PALS group, as everyone knows, came from community health councils. They had an office in the shopping centre, or somewhere like that, and it was seen as independent, separate from the hospital organisation. When they moved into the office behind the reception desk in the hospital-sorry, I’m talking about my local hospital-it lost that, and I think that is a big concern. I have personal experience of having difficulties as well over an elderly relative. It is very difficult to feel that somebody is dealing with that independently and you are not just being fobbed off by someone.

Q18 Yvonne Fovargue: Is that the experience that you both have as well?

Julie Bailey: What we have found, from the people who contact us, is that they see PALS as part of the system. Very often the PALS workers were NHS staff who just moved on to PALS. The first contact is that they will send you back up to the actual ward that you are complaining about. From there, you will discuss it with a member of staff who is going to be looking after your relative. So very often-and this is one of the reasons why there are very few complaints or were very few complaints about Mid Staffordshire-is that you are very reluctant to complain in that situation. From what I saw in the eight weeks that I was on the ward with my mum, if a member of staff had come over and said, "Do you want to complain?", I would have been reluctant to if I was leaving my mum there. There is a reluctance. But, with PALS, they will send you back up to the ward and you discuss that with the ward staff and that is the complaint not made. You think those issues have been resolved but then it happens again to some other relative. Some other complainant has to go through the same thing. It is not logged. PALS seems to be part of the system.

Kieran Mullan: They are part of the system; they are employed by trusts. There is ICAS, which are independent, and LINks. There are these different bodies. If we are talking specifically about PALS, they are employees of a trust and often of a very junior grade. It absolutely, there, depends on their attitude and how the trust has chosen to place them within, I guess, the power structure of the hospital. I have met with PALS that seem to be quite high in that structure and report to the board; they seem very rigorous and do a good job. But then you can have PALS which just as easily could be one admin officer who works two days a week, who has no ability to influence and who will just be dismissed by the staff. So for PALS specifically, absolutely there is, of course, a role, to have people within NHS trusts who provide that daytoday advice, contact and information for patients. But when you move towards things like complaints and concerns, they are not independent; they are employees of the trust. For people looking for independence, you don’t get that from PALS.

Q19 Yvonne Fovargue: What about the links? You mentioned ICAS. Obviously, PALS is an important gateway. Is it a gatekeeper to ICAS almost or does it perform a good-

Kieran Mullan : It depends. Some PALS will be very proactive and tell people about and encourage them to go to ICAS, but, just as easily, other PALS will never mention ICAS or the complaints process or any of these things. It depends on the local people involved and their policies. ICAS is very valuable for those people that struggle to make complaints in a very real sense, such as writing letters, giving them confidence, going to meetings, all these other things. They do provide a very good service in that regard. Our concern is the issue of challenge and scrutiny. Sometimes people feel that ICAS is there to look at what the trust is telling you and give you advice on whether or not what the trust has told you is reasonable, and they don’t.

Julie Bailey: ICAS work in different ways in different parts of the country. I have met people who have been supported by ICAS, who have felt they were very challenging; they weren’t just there to rubberstamp and explain what was said. The problem is that people don’t know that ICAS exist. With regard to the people in Mid Staffordshire, I had not met one person who had contacted ICAS. If they were advertised more, more people would use them and there should be a structure so that we know what their role is.

Catherine Hopkins: The recurring theme here is that the provision over the whole of the country is inconsistent, with ICAS, with PALS or whatever. We have experience of suggesting to helpline callers that they contact ICAS. They said no, the ICAS in their area will only help if people are unable to write letters, effectively can’t write or have learning difficulties generally. That is one particular case; it is not universal.

The rather more universal problem that we see is not a problem but a way of working for ICAS. They are individual advocates for individual patients, so they are not looking at the bigger picture. With more resources, we would like to do more, but we are able, a little, to look at a bigger picture. We had a situation fairly recently where three people in a week contacted us about a hospital where there were delays in a SUI-a serious untoward incident-serious delays outwith the proper timetable. The caseworker who had knowledge of these three cases wrote to the chief executive of the trust saying, "Could you explain if there is a problem with your SUIs", without mentioning the clients’ names.

We do see that as our role if we are able to. We are a tiny organisation; we only employ 22 people, and most of us are part time. It is very small, and we would love to have a fantastic database that would immediately ping up the minute such and such a trust comes up on a call. We can’t do that yet, but where we can we will. But that is not how ICAS are constituted. The help they provide to the people they work for is good, but it doesn’t cover the point of looking at systemic problems.

Kieran Mullan: I would echo that. It is about having to be seen as an organisation with power and influence or be perceived to be that by the NHS. We published two volumes of patients’ stories this year and last year. These are people that have gone through the complaints process and, from the trust’s point of view, it has finished. As soon as we contact the trust to say we are going to be publishing these stories, they have the chief executive on the phone to them personally, who offers to drag them into the hospital and have meetings, and make lots of promises, because trusts have some sense that the Patients Association is an organisation that challenges, that meets MPs, and all these other things, so they want us to think that they have done a good job.

Julie Bailey : It is about the publicity. I don’t think it’s about the Patients Association.

Kieran Mullan: Yes, of course, publicity, absolutely.

Julie Bailey: It is about the publicity, because we contact the trust and as soon as they hear there is going to be publicity they will do whatever we want.

Kieran Mullan: But that’s because they know we are an organisation that will seek publicity and publicise things, whilst ICAS don’t. That is not their role; they don’t do that. One of the things that I had heard was that the reason why Citizens Advice, which previously held an ICAS contract, lost the contract, unofficially, was that they had started to do things such as produce reports that were critical of NHS complaints handling and these other things. So I think it is important.

Q20 Chris Skidmore: This follows on the ICAS point. We have evidence in a submission from Department of Health that shows that only 8.6% of complainants are able to access ICAS. Do you think that is acceptable and, if not, obviously, how do you think we would go about increasing that access?

Julie Bailey: The first thing you need to do is to force the trusts, once again, to put out in their letter when they send out that initial response within the 48 hours that ICAS is available to help support the complainant. Despite all the spotlight being on Stafford, the letters of complaint going out still do not mention ICAS. They mention AvMA but not ICAS. So, even under the spotlight, we still don’t have that going out to complainants. They still don’t know that body exists.

Catherine Hopkins: I would just question, from what I had said before, whether this low percentage is due to capacity for ICAS or is it due to the lack of referrals to ICAS.

Q21 Chris Skidmore: I was going to bring up the capacity point.

Catherine Hopkins: We have had reports back from patients that it’s a capacity issue.

Q22 Chris Skidmore: What I was struck by in your evidence, Ms Hopkins, was the contract that your own organisation used to have with ICAS and the work you used to do in partnership together. I was interested to know why that ended. Was that simply a lack of money? It seemed that they had been using independent organisations and charities like yourself to plug the gap. That lack of specialist knowledge has now disappeared, it seems.

Catherine Hopkins: I’m afraid I don’t know. I’m a relatively new employee. I am told from behind me that it was resources at ICAS. Did you hear that?

Chris Skidmore: It was a resource issue.

Kieran Mullan: One thing to bear in mind, if you look at ICAS, is that some providers talk about the fact that many thousands of people get in touch with them but don’t want the more intense case support. They want the basic document on how to make a complaint and then they are happy to progress that. That does partly explain the relatively low takeup. I have spoken to people at trusts that say the same thing. They tell people about ICAS but not everybody wants that service. At the bare minimum, absolutely everybody should be told about it, and not just told about it in a kind of dry paragraph constructed by the trust that is probably not going to be very encouraging, but they need to have the service sold to them, to an extent, to encourage them to use it.

Q23 Chris Skidmore: Do you think ICAS is fit for purpose in its current form?

Kieran Mullan: It goes back to my original point. I think patients’ genuine advocacy should always involve people being able to access proper scrutiny of what they are being told, and ICAS does not systemically do that in a structured way. It might be that individual advocates try to do that, but that is not the actual inherent and contracted part of the service. There should be a proper independent scrutiny of answers.

Q24 Grahame Morris: Following on that, with the new structure, the changes that are coming through set out in the Health White Paper, do you think local HealthWatch would be a suitable avenue as advocates for the patients to replace some of the systems we currently have in place that don’t seem to be working?

Catherine Hopkins: Our view is that HealthWatch could fill a very valuable role in looking at trends particularly, because that is the big issue. The problem with complaints being dealt with in isolation is never going to lead to organisational change. We do think that HealthWatch, which will also have its top of the pyramid, could have a role if it works, effectively, in doing that.

Q25 Grahame Morris: Do you think it should have a role?

Catherine Hopkins: Yes, we do. I know there were some points that people have raised about conflict, and I am not entirely sure why. I would like to know more details of why people think there would be a conflict, because my understanding is that HealthWatch is going to be involved in advising on commissioning, but there can surely not be anywhere near as much of a conflict as the organisation that delivers the patient’s medical or social care being part of the complaints procedure. Obviously any complaint has to go there first.

Q26 Grahame Morris: It’s part of the information you require, isn’t it?

Catherine Hopkins: But, in terms of being independent, I would have thought, and it goes back to the Chair’s point, why aren’t the commissioning organisations being more vigilant about trends in the hospitals or the trusts where they are commissioning their treatment? They should be, I am sure, and that is definitely our view. If there is the idea that HealthWatch will continue to have this advisory role to consortia, then they should be able to say, "The trends here are such and such and therefore what are you going to do about that when you are commissioning that treatment?"

Q27 Chair: I don’t think there was any suggestion from us that there was a conflict.

Kieran Mullan: The White Paper suggested it.

Julie Bailey: What they have found in Stafford with the former groups, LINks and PPI Forums, is that they have failed us miserably. What we are concerned about is this. I would ask you all to look at this week’s transcript from the public inquiry where overview and scrutiny have given evidence to the public inquiry, and they just have not had a clue what they are supposed to be doing. Instead of scrutinising in the hospital, what we have found over the last week is that they have tried to protect the hospital. They have been aware of what has been going on but didn’t want to bring shame on the town and on the hospital. It is a real concern to us in Stafford that the same type of people that were attracted to these types of groups will join and form HealthWatch, which are now LINks and have been the PPI Forums. It seems to attract the same type of people, who don’t like to challenge, who like to have a nice cup of tea with whoever they are supposed to be scrutinising. I’m afraid I feel that is a society thing. People don’t like to challenge any more, but that is what we need.

Q28 David Tredinnick: On Grahame’s issue of conflict, I am slightly surprised by your answer, because the Government have made it clear that they are concerned that there might be conflict between individual complaints, advocacy and the commissioning process, but I don’t hear a great tremble on your table about this, which slightly surprises me.

Kieran Mullan: The idea, as I understand it, is that, if HealthWatch has had an actual role in commissioning decisions because it is consulted by the consortia, for example, and then someone makes a complaint about something that relates to a commissioning decision, it would be a conflict to ask HealthWatch potentially to look at that complaint. Catherine, your point, which was very well made, is that maybe that might happen, but it is certainly better than the current situation where people don’t have access to a really robust organisation at all.

David Tredinnick: In that case, shall we look at serious untoward incidents and how they would be dealt with?

Rosie Cooper: David, may I come in on the conflict bit?

David Tredinnick: Please, through you, Chair.

Q29 Rosie Cooper: It is really important. HealthWatch will be in two parts. The national HealthWatch will be a sort of committee of the Care Quality Commission. The problems there are not the conflict bit which you are talking about as in spotting trends and getting in there and informing decisions. There is a problem at that level perhaps with it having its own budget, properly supported, and being a functioning organisation as opposed to a nominal organisation which is used as cover in the same way as everything else.

Locally, HealthWatch-and again that would inform commissioning decisions down and inspection decisions-will be funded by the local authority. It will be on the Wellbeing Board and, if you like, it is almost scrutinising local authority health and care services or social care services. So there are potential conflicts.

It is how you drill in that independence of function. To go back to before PALS and everything else, it is all related to who is funding it and the degree of independence. Let me tell you, I used to be a chair of a hospital and, without misusing this phrase, I was always pleased to see complaints. It was the thermometer of the organisation. If we fixed the complaint, the hospital was a better place tomorrow than it was yesterday. I was known for loving complaints-and I wish there weren’t any-because they tell you what is going on. You get at it and sort it out. I believe that the health service has become defensive in an unbelievable way. Believe me, my father has been in hospital and I have spent every day I have visited almost having an argument about something at the hospital where they do try and make the person making the complaint feel awful for having made the complaint. But, truly, the thing that leaves me aghast at Mid Staffordshire is the responsibility of the board and the medical staff committee. I am still totally bewildered about not how it happened once but how it continued.

To come back to here, yes, we are on a different journey, but the new Health and Social Care Bill is riddled with conflicts, with doctors as providers, all of those kinds of things. Are we going to be talking about the same thing on a different platform? There are good things, such as HealthWatch, and the idea is really brilliant, but how do you give it its budget? How do you secure its independence at local and national level and how do you give it all the tools it needs to deliver? What you are saying is that it could be great, but it will also be subject to every single thing I have heard you say this morning and that is not good enough.

Catherine Hopkins: It will be interesting to look at the model of the old community health councils, which were funded by the NHS and were effective in some ways. I am quite sure they weren’t effective in all ways, but they were seen as an effective organisation and somehow or another independent of the healthcare providers.

Catherine Hopkins: Should it be looked at better to see what good bits from that can be incorporated into HealthWatch?

Kieran Mullan: Julie is a good example of this. It is about attitude more than anything else. It is actually the attitude. Because the division from the community health councils to the other forums became quite unpleasant, a lot of the people with the right attitude who were involved in the community health councils didn’t take themselves forward to the new organisations and have not done since. You have to make everyone involved in it look for those kinds of people. You have talked about the repeated failings and that things weren’t picked up on, and these same mistakes are happening again and again. Mid Staffordshire is this terrible example that everyone thinks is atrocious and people have been let down terribly, but, as far as I am aware, no one has ever really suffered, as a result, in terms of their pay, their career, or in any kind of systematic way. The chief executive of the trust resigned and had his pension and all these other things.

Q30 Rosie Cooper: I marched a finance director out of my hospital. So don’t say a failure is not always rewarded.

Kieran Mullan: No, of course, but it is about the consistency with which that scenario arises. If we look at Mid Staffordshire, this is an example of such terrible care, and that chief executive didn’t really seem to become accountable for that. How does that reflect accountability across the system?

Julie Bailey: Community care councils were before my time, but would they work now? Is it a cultural change, you know? The team then was paid by somebody, the same as LINks. Why did it work then? Would it work now?

Chair: I want to bring Mr Tredinnick in.

Julie Bailey: I am not convinced.

Q31 David Tredinnick: Building on what has been said, perhaps this is the moment, through you, Chair, to talk about serious untoward incidents and how they are going to be monitored in the future, because at the moment we have an obligation on the strategic health authority and the primary care trust to learn lessons from serious untoward incidents. How do you think this will happen in the future with GP commissioning and the national health service commissioning board? Do you have any views on this, please?

Kieran Mullan: Before we talk about the value of SHAs having a view of SUIs, we have all talked about the fact that we don’t believe they were doing a very good job of it. If you look in particular, for example, at mental health issues, strategic health authorities have legislative obligations to investigate certain circumstances in which patients and the public are involved in mental health harm, the circumstances of that, and you will see the same investigations from strategic health authorities with the same failings over and over again. I am not entirely convinced that the SHAs made a very good job of their requirements to monitor SUIs and investigate them, but, absolutely, surely that is not an argument to say that someone shouldn’t be doing it. I have not seen any explanation yet of where that function will move to. I understand that the Care Quality Commission will have SUIs reported to them. Maybe the idea is that the Care Quality Commission replaces that function of investigation, but we have already talked about the considerable constraints on their resources as is.

As to commissioning consortia, I imagine that will be quite difficult because you are going to have different consortia, perhaps commissioning different services from the same organisation. When there is a SUI, it could get quite confused as to whose responsibility it is to investigate it.

Q32 David Tredinnick: So it is a conflict of interest then?

Kieran Mullan: It is not a conflict of interest but more responsibility: whose job is it and what is it their job to do? A commissioner’s job is not the same as a performance manager’s job at a strategic health authority. They are different roles.

Catherine Hopkins : We have two concerns about the SUIs. One is that there is a central reporting system of some sort that is truly central. Something like the CQC could be better than strategic health authorities because they are still looking at individual areas. We think that that should be considered.

We also have concerns about the variability of the conduct of SUIs around the country. I have already talked about one particular trust, but we have also had situations where families aren’t consulted at all, despite what it says in the protocols for a SUI. One woman whose son died at a major mental health trust had been begging for help for ages and no help came. Somebody rang her the day after he died and asked something about the beginning of the SUI, and she said something like "It’s a bit late now", the day after her son had died. They took that as an indication that she wanted nothing do with the SUI at all and she heard no more about it until the existence of the report was revealed in the disclosure documents for the inquest. One of our roles, and we mention it in our submission, is that we provide advocacy and assistance at inquests. We had to get the inquest adjourned so that we had time to consider the SUI.

We have had another situation where, again, families were completely unaware that a SUI took place, and another where, despite the fact that a young woman died of acute pancreatitis after an ERCP examination, which was a very unusual circumstance, the trust did not think, until we wrote to them, that it was necessary to do it. We have this central reporting concern so that trends can be seen, but we also feel that they are not being consistently carried out in the way that it was envisaged in the protocols.

Julie Bailey: With the experience from Stafford, what we need is something very, very simple. We need very few bodies because what we have found is, with all these regulatory bodies, all this information, is lost. What we need is just a handful.

David Tredinnick: I must say I am suffering from acronym fog. Even this morning we have had so many different acronyms that I am trying to work out which administration had which body at which time and getting guidance from colleagues across the room. So I absolutely agree with what you are saying.

Q33 Rosie Cooper: Could I ask a quick question of Kieran about the accountability of the board of directors for the standard of complaints and the handling and the action afterwards? What kind of accountability do you think that should be? I think it should be absolute.

Kieran Mullan: Yes, When you consider the material of complaints that we have talked about, care of the elderly and very basic issues related to actual harm of patients, that is not the top priority of the board. If they are not fully accountable for that, then what is their role? The barrier to accountability in that respect at the moment is the lack of proper performance measurement of complaints handling. We can’t isolate particular trusts in an effective way and say which ones do their complaints handling well and which ones don’t. We have all talked about examples we have seen as good and bad, but we are not able to get any handle on trusts that do well generally and trusts that don’t do a good job generally. That is why we have advocated that, if every complainant was asked how well they thought their complaint was handled, that was done in a standardised way and that information was published, we might start to get a handle on those trusts that are doing a better job than others and then you can levy pressure on the boards of those organisations not doing a good job.

Q34 Rosie Cooper: In fact, the trust I chaired-I understand it doesn’t do it any more-used to produce a report. Every complaint in the hospital, in short form, went to the board: complaint, upheld or not upheld, and actions. Obviously, that could be interrogated by board members. You couldn’t have all the detail but just a short summary. That doesn’t go on now. Those board papers were available to the public and you need that level of scrutiny and responsibility.

Kieran Mullan: One of the techniques that I have come across that seems to be very effective is that some trusts will bring, when the patient or the complainant wants to, patients to the board to talk to them first hand about the impact the poor care had on them or their family, and that seemed to be very effective at engaging the board.

Rosie Cooper: I have addressed a whole hospital, the senior nurses, managers and whatever, and I am not sure it made any difference. There you go.

Chair: Could we move on, finally, to look at the link between the complaints process and litigation? Valerie would like to start there.

Q35 Valerie Vaz: I have to apologise now that I am a lawyer but I try to tell people, "Don’t go to law". One of the huge things that I noticed was that almost £807 million was spent by the NHS on litigation. What are your views are on that, how we can minimise those costs and is there any way we can set up a system where you have to balance what a doctor does and what people in the NHS do so that they are free to do what they do within reasonable limits but, yet, also take into account patient safety? What are your views on that?

Catherine Hopkins: There may be scope for looking at what are often referred to as the lowervalue claims and looking at alternative ways of settling those claims. As an organisation, although we don’t primarily only support litigants, we believe that people who have legitimate claims for injuries should be able to pursue their claims in one way or another. We would in no way think that people shouldn’t receive compensation for their injuries, but we don’t support outrageously large costs bills.

To take the lowervalue claims first, we think there could be an alternative way of doing it, as long as the patient is on an equal footing with the defendant healthcare provider. You have to bear in mind that a healthcare provider has infinitely more resources than an individual patient and therefore you have to look at ways in which they can get independent advice and assistance before settling a claim. We do see litigants in person who correspond with the NHS Litigation Authority who are offered derisory settlements and then they may ring us up and say, "We have been offered this amount in correspondence." We say, "We think you should go to a solicitor and get some advice." They find that their claim is worth considerably more, and it can be by the power of 10 or a 100 sometimes, believe it or not. That is one issue.

In the larger claims there is anecdotal evidence-and some of it is my own personal experience as a civil litigation solicitor, who specialised in acting for children with cerebral palsy, so I did catastrophic injury cases-of delay in the NHSLA admitting liability, and that increases costs considerably. Their delays are not necessarily a deliberate filibuster; they just don’t get on and investigate. You can send what is called a letter of claim, which is the letter that you send before you issue proceedings, in which you set out in detail the damages and the issues at stake. They will write back a sort of holding letter, which is almost the equivalent of the letter that we have heard can come back in a complaint situation. You know that it is because they do not have independent evidence and, therefore, they can’t admit liability because the consultant who was treating has said, "Absolutely not. I did nothing wrong."

I have actually witnessed a telephone conversation between NHSLA panel solicitors and a claimant’s solicitor where they said, "I am really sorry this has taken so long for us to admit liability, but we have only just been allowed to get independent evidence." On that case it was run on a conditional fee agreement and had reached the stage of exchange of expert evidence, which is twothirds of the way to trial after issue. There are a lot of costs there, and I have lots of examples like that. So those can be reduced.

I think that Sir Rupert Jackson missed a huge opportunity to look at reducing civil litigation costs. He has not reduced civil litigation costs. He has simply recommended that the claimant, the person least likely to be able to afford the costs, is going to pay. There are still going to be success fees and there are still going to have to be aftertheevent insurance policies to protect the claimant against an adverse costs order. The claimant will have to pay those, if they can get an ATE policy, which is another issue altogether, because the insurance companies may decide it is not a market to be in any more. We feel that the combination of withdrawing legal aid for clinical negligence and introducing nonrecoverability of success fees and insurance policies is going to be a serious impediment to access to justice for some of the most vulnerable people in the country.

If you go back again to seriously brain injured or spinally injured patients, they are not going to have the resources to pay their solicitor up to £2,000 for an initial medical report to screen, to see whether the solicitor will take it on as a conditional fee agreement. If they can’t get an insurance policy, they will be terrified about bringing litigation because every resource they have is at stake. If you have absolutely no resource and you are a child with spastic quadriplegic cerebral palsy, then you probably could do it because you have no resources to come after, but most other people will and they just will be frightened to do it.

We have this combination of the worst of both worlds. Sir Rupert Jackson said in his report that he made these recommendations on the understanding that legal aid provision for clinical negligence would not change. He seems to have reneged-and I apologise for that word; he seems to have gone back-on his view, because his latest open letter and evidence on the current consultations on funding does not support that view any more, but it seemed a safety net. So we now lose legal aid if the proposals go forward as they are and we end up with this massive burden on claimants. This is a huge concern. I am sorry I have gone on too long.

Q36 Valerie Vaz: I was trying to draw up how we can save on those costs. We are talking about getting to the end when we are in litigation and it is dragged out until the door of the court and then people settle. But it’s actually before. Is it something that we should tackle before? For instance, what stopped you from going straight to law?

Julie Bailey: In Mid Staffordshire the majority of people that came forward to me for advice didn’t want to take the litigation route. It is the same throughout the country. All people want a lot of the time is answers as to what happened to their relative and why. It is a torture not knowing, so you just see it as the next step. "I have taken on the complaints system. I have gone down the ombudsman route. I have gone through the NMC. I have gone to the GMC. Now I will take the legal route." A lot of people don’t want money; they don’t want compensation for what has happened. They just feel it is a way of getting answers and to take it away from the trust. They feel that the litigation route is an independent way of getting those answers.

Q37 Valerie Vaz: But sometimes you do need to protect people’s claims because they have a legitimate claim, like, for instance, if there has been an accident. If someone has killed someone accidentally, not deliberately, but if someone has died or there has been a huge issue regarding that, then obviously they need compensation. But I am thinking more along the lines of judicial review when you have the judge looking at the claim, complaint or issue, on paper, and then decides on that basis whether it should or should not go further. We are looking at an independent person, possibly a barrister or a lawyer in a mini-tribunal. Then the case goes on after that, and then you bring in the duty of candour, which means you have to get all the evidence.

Catherine Hopkins: That is quite a new idea. I have not ever heard of it.

Q38 Valerie Vaz: I just thought it up.

Catherine Hopkins: I thought you might have done. It would address quite a lot of the issues that surround the families that were affected at Mid Staffordshire. We acted for one particular family who featured quite a lot in the reports and things that have gone on because we provided support for them at the inquest and the family didn’t want to bring a claim, although in fact, in the end, they did receive some damages because there was a human rights claim there. The central issue was that, when the son of the lady who died went to talk to the ward sister, he said "What happened here?" The ward sister said, "I thought-", and I suppose I shouldn’t swear here, but he was outraged that she swore. She said, "Oh", you know, "something" and the conduct of a nurse really was the kernel of his complaint. His mother had fallen out of bed and cut her head, there was blood everywhere, but in fact the head injury itself was probably not too serious, but that is what happens with a head laceration. He was brought into the ward to see it all on the floor, mother on the floor, bed covers everywhere, and he said, "Gosh. Sister, what do you think of the situation?" He rather expected the sister to say, "I am very, very sorry. It’s appalling. The nurses should not have left your mother unsupervised." But, no, she said, "My first thoughts were, oh-" you know. That is what started this man’s complaint off. So, yes, those situations could be dealt with.

I also think a lot of those situations wouldn’t go to law because the damages are small. There is a huge difference, isn’t there, between that and the seriously injured, where your damages are required to provide you with a wheelchair and 24hour care? There is no alternative to litigation. But the costs could be lower if the NHSLA sorted themselves out and admitted liability earlier, because they do later. So they could do it earlier. We are not talking about cases where liability is disputed to a trial on liability. We are talking about admitting liability three years in when you have done a huge amount of work.

Q39 Valerie Vaz: How would we stop that? Would this system stop that?

Catherine Hopkins: I am not sure the system could stop that, but your system could, suggesting looking at the lowervalue claims, because, sadly, it is cheaper for the NHS to kill somebody than to maim them. I am sorry, that is a horrible headline, but it is. If a case is a fatal case, that could be dealt with by your system because there are statutory damages under the Fatal Accidents Act and smaller damages that are associated with that. I don’t think you could deal with the bigger claims in any other way apart from earlier admissions.

Kieran Mullan: The only issue-and it touches on what you have said about the nursing sister and the conduct of a member of staff-is that people sue because they want an effective response. They want both independent advice on what has happened, but they want the trust in some way to be held to account. The only effective means they see is that they can sue them and get some money back. In the same way, people before wanted an apology and they never got apologies, but now they are given apologies that don’t really mean anything. I can envisage a scenario where people get quite used to small payouts, for example, because of neglect of a relative in hospital, but they are not convinced that that has had any effect.

You need to have staff being held to account for poor care. People often think that means that relatives want someone sacked or struck off. I don’t think it is that they want that. They just want it to mean something, whether it is an entry in the staff member’s record or some sense that it is part of a disciplinary process that might not mean they are sacked straight away but if they did it again it would have results. At the moment, you have a situation where, because of confidentiality and employer contracts, the trust can’t even tell someone who has complained exactly what has happened contractually to someone who has been responsible for poor care. If I had complained, I would want to know whether that person has been given an informal or formal warning and if it is on their record. They are not allowed to tell people those kinds of things. What we need is a system that satisfies people across the board, and then you would not have anywhere near as many people suing. I would say everybody that I have been in touch with who has sued has done so because they didn’t feel the trust took the complaint seriously and made the change that they should have made.

Julie Bailey: Another problem is the NMC and the GMC. There seem to be very few complaints upheld and relatives feel that the one thing you don’t want is for another person to suffer the way your loved one has or the way you have. That goes a long way. You think, "If we take litigation, at least then there will be a mark against the trust. Some money has gone out. So there will be a recognition that that doctor has harmed my relative." It might go some way towards reducing costs if the NMC and the GMC were more effective bodies and took more action. Like Kieran says, we are not asking for staff to be struck off. We just want a recognition that the doctor or nurse has made a mistake and perhaps a little bit of retraining. Just those actions would go a long way.

Kieran Mullan: That relates to my concerns. Often people promote this idea of a noblame culture in the NHS. I have real issues with that because there is professional accountability and there is blame. People need to sit within that spectrum and it is not good enough for people just to say, "I’m incredibly sorry, I absolutely accept everything that has gone wrong and I will take training." Anybody doing a job has responsibility to deliver on what they are expected to do, and it may be that there are circumstances which are out of their control.

I have talked about people working in very understaffed environments where bodies like the NMC and the RCN, if we are talking about nurses-but it could equally be said about any healthcare professional-would try and protect individual staff from being held to account for the outcomes of things that weren’t really in their control. I can sympathise with that. But the end result is that nobody is held to account because the unions and the healthcare professionals protect their interest groups, perhaps reasonably, because it is not always their fault. Managers aren’t really accountable in any particular way. So you just have this mess where the outcome is that patients can receive poor care and nothing happens as a result.

What staff fail to recognise is that they make things difficult for themselves by taking that approach, when things aren’t their fault, by covering things up or resisting scrutiny. If they didn’t do that, higher up the chain people would be made accountable for things like understaffing units and those kinds of things. The person who loses out on this, the one person who doesn’t have a union representative, who can’t access a lawyer, who isn’t backed by some big organisation like an NHS trust, is the actual patient that suffers as a result.

Q40 Rosie Cooper: Absolutely; fair blame.

Kieran Mullan: Yes, fair blame.

Q41 Rosie Cooper: Fair blame, responsibility, put it right, move on.

Catherine Hopkins: Listening to patients comes at the top of that, I think.

Rosie Cooper: Absolutely.

Catherine Hopkins: Because they are the ones who actually see what is going on.

Chair: On that note, I am going to draw this session to a close because we are running now quarter of an hour late. Thank you very much indeed for your evidence. It has given us plenty of food for thought. Thank you for coming.

Examination of Witnesses

Witnesses: Mrs Dee Speers, Mrs Nicola Monte and Debra Hazeldine, gave evidence.

Q42 Chair: Ladies and gentlemen, can we move on to the second session, please. I would like, on behalf of the Committee, to welcome three witnesses to this part of this morning’s session. The important thing from our point of view is to move beyond institutions, theories and structures and so forth and just hear what it feels like from the point of view of the individual who is caught up in this system. That is why we were keen that three individuals should come, and thank you very much for volunteering to do it, to tell us what it feels like to be caught up in a system that I am sure was the very last thing in the world you wanted to be in. I would be grateful if you could each, in turn, first of all, introduce yourselves and then briefly tell the Committee what happened in your individual case and what it felt like. That is really the starting point for this part of the hearing. Mrs Speers, would you like to go first?

Mrs Speers: Do you want me to take it forward?

Q43 Chair: Forgive me; we have an interrupted line of vision.

Mrs Speers : Good morning and thank you very much for the opportunity to be here. It is the last place I want to be, to be honest, but I must say that I fulfil the headline of complaints and litigation because I have had two cases. Mine was a misdiagnosed TB meningitis that was missed and I was told, no, there was nothing wrong and I had to find out for myself. In the end, I went to litigation because I couldn’t get any answers. I wanted an apology and I couldn’t get any answers. Then that triggered a mental health condition in my son and he died, which is in the evidence. The whole situation is appalling. I am still in NHS complaints five and a half years later, unresolved.

Q44 Chair: What are the stages that this process has gone through? You put a complaint in five and a half years ago.

Mrs Speers: My son had an aggressive mental breakdown when I became ill, and it could be life as well-I don’t know-student debts, everything else. He had an aggressive breakdown and he was sectioned eventually, even though he presented the first time, according to national guidance, as in the highest risk category, but he was sent away with a leaflet to suffer for another three days. Then he harmed again and was taken in and sectioned. But the actual sectioning criteria and the Mental Health Act were all ignored by the sectioning psychiatrist as he was left to his own devices, basically. I still don’t know if he was murdered. I don’t know what the situation is. He was found fatally wounded in a bathroom as an inpatient for his own safety.

I never heard a thing. His possessions were sent home to me in a bin bag marked "NHS household waste". It is that, a bit like the swearing of the nurse, that has been the catalyst for this and I am determined to explore every aspect of NHS complaints. I have mountains of research crossreferenced to documents. There are SUI policies and investigations which are not independent, and it goes on from there. I am just conscious that I am taking these ladies’ time.

Q45 Chair: That is very helpful.

Mrs Speers: That’s basically where I am at. There are two cases.

Q46 Chair: That tells us what the problem is very clearly, very graphically, from our point of view. Thank you for that. Mrs Monte?

Mrs Monte: My name is Nicola Monte. I have spent quite a long time in Stafford Hospital, about 18 months in total across three years. My nightmare started in 2004. The longest period in one episode was eight or nine months of being an inpatient. I have a long list of issues that I have had to complain about and I will try to list them. I can expand on them if you wish.

Initially, incorrect diagnosis and severe problems around cleanliness led to me acquiring three hospital infections-E.coli, C.difficile and MRSA-at very severe levels. I have had MRSA skin infections, but it also led to blood infections that got into my marrow bone and caused me significant problems, and the infection caused sepsis to the brain. None of this was anything to do with why I went to hospital in the first place. It was just, being there for such a long time, I became part of the furniture and witnessed and experienced poor care, cleanliness issues, and the attitude of staff. I was just put in harm’s way and lurched from one disaster to another really. It destroyed my life.

I had a good job, a career, a good family life. Previous to this starting I had had my second child only two months before. So you can imagine being separated for such a long time from your baby. It has a massive impact on that relationship, and I have had to fight very hard to rebuild lots of elements of my life. Having to go through the complaints procedure and finding that the hospital just will not-I mean, obviously we tried to engage with them at the time of being in hospital to get local resolution to get the care I needed to keep me safe, to keep me alive, and it just wasn’t there. I would complain even to the chief executive about what was happening.

I can give you an example of a cleanliness issue. The issue I had was a bowel problem and I had to provide stool samples. These would have to be collected in a cardboard pot. I was on an open ward at the time and would leave the sample in the communal toilet, tell the staff and they were supposed to come and take it away so it could be analysed and recorded and stuff like that. But these stool samples from myself alone would accumulate, and there were other people doing the same thing, which would give rise to crossinfection, and I believe that is where the C. dif. came from initially. We tried to get the then chief executive to come down and see for himself what was happening and he just wouldn’t come down. They just wouldn’t accept what was happening under their own noses, and it was from there that led us to go down the official complaints route.

Q47 Chair: Thank you. It is very brave of you to be here and thank you for that. We will come back, if we may, just to discuss it, but perhaps we could ask Debra Hazeldine to tell us the history that brought you here as well. I am sure, in common with your two colleagues, you would prefer to be any place other than here this morning.

Debra Hazeldine: Absolutely. First of all, can I thank you for not only giving myself but giving my deceased mum the voice that she desperately needed? I lost my mum in Stafford Hospital in 2006. She was-this is very brief-diagnosed with bone cancer in March 2006 and it was over a period of a couple of days. It came completely out of the blue and it was very, very difficult to deal with. She responded very, very well to aggressive chemotherapy but, unfortunately, this affected her mobility and she had to be admitted into Stafford Hospital because we were assured that was the best place that she could get the physiotherapy 24/7 that she needed. She was put straight on to an open ward and very, very quickly she was infected with every hospital infection they could give her. She contracted C. dif. and MRSA. There were occasions when I fed my mum and helped my mum with her personal care, and the things I saw on that ward haunt me to this day.

When my mum died, we took the complaint straight to the chief executive. We did decide, whilst my mum was in there-she was in there four months in total-that we would complain but I didn’t want to do that while my mum was there. We decided that, yes, we would complain and we made a complaint to the chief executive at the time. But, when my mum had died, there was even no dignity in her death because all of the forms that had been filled in for her to go to the mortuary stated that she had every infection going, as we knew, because I had cleaned my mum’s C. dif. and things, she would not be able to be viewed and she had to be buried in a sealed body bag.

I met with the chief executive and the complaints manager and they assured me that my mum had no hospitalborne infections and that should not have happened. All of the clinicians and the mortuary staff had just filled in the forms incorrectly and she had died of pneumonia. This set off alarm bells in me because I knew my mum up to the day she died had C. dif.

The last view I had of my mum, with my dad and my brother, for a few moments was her head protruding out of a black body bag. I then asked, "What happens now?", and they said, "We just have to put your mum’s head back in the body bag and bury her because she is a risk of an infection when she is buried." That led me to very vigorously follow the complaints procedure because I did not think that my mum had died of pneumonia. It took me an independent investigation and three years down the line to find out that she died of C. dif.

Q48 Chair: These are three stories, none of which should have happened, clearly. There is clearly nothing we can do to undo what has happened, but what is of concern to us this morning and what we want to make certain of is that the complaints procedure that the health service operates is one that hears voices like yours and is able to respond to them in order to ensure that the service learns from those terrible stories. The question for you this morning that would be of most help to us is to understand what you think should have happened and, given that you didn’t want to be there anyway obviously, given that what had happened had happened, what would have been the best way for the Health Service to have responded to that set of circumstances?

Debra Hazeldine: Ultimately, as Julie has said before, you want the truth, however bad that can be, if you have lost somebody or if you have suffered. I felt it couldn’t get any worse, having watched my mum die; it physically couldn’t get any worse. I wanted someone to follow their complaints procedure and they did not. They treated it with utter contempt. Not at any time did they follow the complaints procedure. I was unaware that I could take it to the Healthcare Commission. I didn’t have action plans. I had a letter that said, "Please find enclosed action plan." It was blank. So it spurs you on because you think, "If you haven’t even replied to my letter, there is no way that you have implemented anything to stop this from happening again", and that is all I ever wanted.

Q49 Chair: What you wanted most of all, surely-and correct me if I am wrong-if you initiate a complaint, is for somebody to say, "This is how it works and this is how we will undertake a proper inquiry into the circumstances that you are drawing to our attention."

Debra Hazeldine: Absolutely. I often say my mum did not die to be a learning curve for anybody, but there has to be a point you can follow. You have to be, as I said in my evidence, so bloody-minded, that it is soul-destroying to follow the current complaints system that we have, I feel. It may be a very good system, but it is only as good as the hospital that is implementing it. If they are not following their own systems, it is incredibly difficult for a lay person to then challenge them.

Mrs Speers: I completely agree with Debra here; I completely agree with her. Robust policy is in place all over the place and there are various regulatory bodies and everything else in the trusts, but it is not implemented. It is not implemented. I didn’t even know there was a complaints system. I had no information about the mental health system. I didn’t have a clue about the Healthcare Commission. I went to the Healthcare Commission and engineered a meeting in London between the senior management of the Healthcare Commission and the Mental Health Act Commission. They offered to take the complaint outside of the process. Why? What would that do? We refused. We said, "No, we are going to examine the complaints system and you resolve this complaint within the system that you have got for it." And I am still being batted back and forth. I have got lots of information on ombudsman’s stats and all the rest of it if you want them at any time.

Q50 Rosie Cooper: When you were in hospital or in the service, wherever you were, did you ever see on each and every ward leaflets describing complaints procedures and all the rest of it?

Mrs Speers: No.

Q51 Rosie Cooper: It is five years plus, six years, since I was a Chair, but at that time, when the hospital was audited, it was very clear that each ward ought to have those leaflets. As you have other leaflets, they should be there too.

Debra Hazeldine: Might I give you an example? I never knew that my mum had C. dif. and MRSA until I went to the bottom of the bed and read the notes. Nobody ever told me that is what she had. I said, "Have you got any information on C. dif. or MRSA?", and they said, "No, we don’t think so." As I walked out into the staff room, there were leaflets for the staff and I took their C. dif. leaflet, but there wasn’t anything for patients to have. You weren’t aware or you weren’t told that there was information. I know, to this day, if I had not asked why mum was constantly having diarrhoea I wouldn’t have known she’d had C. dif. It was not forwarded. The information wasn’t given voluntarily. You had to go looking for it constantly.

Q52 Rosie Cooper: You will find that every hospital does have that on everything, normally. You can’t have printed leaflets necessarily to cover everything always and updated, but they will have a database, which is updated. So it is always there and they can press a button, and somebody somewhere, had they cared enough, could have given it to you.

Debra Hazeldine: But none of the gel dispensers worked either so, if I couldn’t get gel to clean my hands, I hadn’t got a cat in hell’s chance of getting a leaflet.

Q53 Chair: And you don’t know which button to press anyway unless somebody tells you what the problem is.

Debra Hazeldine: Exactly.

Mrs Speers: You are under incredible stress. The last thing you see, the person you see, is that person there and you want to be able to work with them and you want to be able to support the staff to help them, but you can’t do it if you have got all these other things coming in at you and you don’t know the answers. The fact is you have to look at the truth. The truth is something that is there all the time and it won’t go away. You can’t ignore it. So every time you get that little question going, "Why? Why? Why?", you have to have it answered and there must be somebody there to answer it and they must know the answer.

Mrs Monte: Can I tell you about my experience back in 2004? When I contracted the first episode of MRSA I was actually in an isolation room at the time for the C. difficile. There was obviously a leaflet available in the hospital because a nurse walked into my room, flung a piece of paper at my bed in my direction and said, "You’ve got MRSA. Read this", and turned round and walked out again. In absolute shock and dismay, I picked up this piece of paper. It was meant to be a doublesided piece of paper with information on and they hadn’t taken the time to even look to see if the information was there. It hadn’t been photocopied correctly. The woman, the nurse, didn’t stay and discuss or talk to me about it. The only bit of information on there that was helpful was an infection control phone number and I used the patient phone line to phone this number. I was absolutely hysterical because, I thought, the only thing I know about MRSA is what I have seen on the television and I am going to die. It was an example of the appalling attitude.

At no point are you given any guidance on how to complain about this. My family had to complain on my behalf. Obviously, on a local level, I would try and complain myself, but my health deteriorated so dramatically that I couldn’t speak up for myself and I would be frightened to speak out. My family had to fight constantly to try and get meetings with hospital staff to try and get issues addressed locally. Nobody was listening to us. Nobody was giving us advice. My sisterinlaw did try and go to the PALS office but found them a total waste of time. They would just refer you back to the people that weren’t listening to you in the first place. There was no guidance there of what to do really. We had to find our own way. It’s very difficult when either you are suffering because you have lost a relative or you have gone through absolutely terrible trauma physically and mentally.

Chair: And it is not something anyone should ask you to do anyway.

Q54 Yvonne Fovargue: Thank you for sharing your stories with us. There is supposed to be support available. You have obviously been incredibly tenacious in pursuing your complaints. What support would have helped you, at that time, to pursue a complaint, to make it even just slightly easier?

Mrs Speers: For me it would have been one person, a named person that I could deal with that was like "The Commission for Joinedup Thinking", who could overview everything and just say, "Right, okay, you have done that. This is ICAS, you can do that and you can do that", because I wasn’t getting anywhere. I was literally being pushed from pillar to post, and they said, "Well, it’s not me". It’s like this all the time. It needs a focus and it needs one particular person to be dealing with a complaint, a named person, who will keep you informed.

You have things like trusts not implementing their policy, so they don’t report an SUI as an SUI to the strategic health authority. So they investigate it as a CIR and you think, "Well, what’s that?" You are told it is a critical incident review and you think that is critical: my son died, it is critical, so that must be right. Then in the middle of all of that you are told, "We are going to tape this meeting for you." We said, "Good, because we are going to tape it as well. Is that all right?" Then you find the transcript is different and it takes months to get.

The reason they chose a CIR in the first place is because an SUI takes longer in policy. Yet this took eight months instead of six weeks. So it goes on and on and I don’t want to keep it personal, and I hear exactly what you say, but it goes on all over the place. It is happening. I have lots of contacts with lots of people who have had SUIs whitewashed endlessly, shall we say. There is no alignment to policy. That is why we go to litigation, because in litigation the solicitors will refer back to rules. The rules are that you have to align; you have to align with guidance and policy. All guidance is optional. I heard earlier on that they were saying NHS managers are just NHS managers, but they have signed the code of conduct, so what happened with those pledges?

Q55 Yvonne Fovargue: Is it important that that named caseworker is independent?

Mrs Speers: Absolutely. It is something I was really thinking about last night, and you will have to excuse me, I have written things down for myself because of the meningitis thing and I don’t want to get it wrong. This would be really effective with PALS, ICAS or with an independent person, because the key to effectiveness in serious disputes in particular is something that is independence of funding. If you have a trust, it is "He who pays the piper calls the tune", I am afraid. I have got too cynical about this.

The ideal, I feel, would be to fund an advocacy service like ICAS, say, via the trusts, who are obliged to pay into a pool. Better still, I was thinking, the amount that they pay into the pool should be proportional to the percentage of complaints if they escalate from a particular trust beyond local resolution. That would provide an incentive to resolve the complaint rather than pass it on to the ombudsman, who doesn’t investigate them anyway. What they normally do is simply face it down and rely on the ombudsman to rule "No worthwhile outcome". What does that mean? Can anyone tell me what "No worthwhile outcome" means? In 98% of cases the ombudsman doesn’t investigate-98%. Less than 1.5% are ever investigated and this service costs us £34 million per annum. It’s wrong. It’s wrong.

Q56 Chair: Your phrase "A Commission for Joinedup Thinking" is one that you might find recurs, I suspect, in our evidence sessions.

Mrs Speers: I hope so.

Debra Hazeldine: Can I say that for me it would have helped if somebody had been independent to the hospital? It is the worst thing in the world to see somebody die like my mum, who was in remission from cancer, and we were told, "Go and tell your mum to celebrate. There is no medical reason that she should be in this hospital", but she still couldn’t manage the physio. We found out later in an independent case review that there were two SUIs that we had not even been informed about, that they had dropped her twice and fractured her ribs and her spine. So my mum was never going to get better. The worst thing in the world is to sit in a room with somebody that you feel is responsible for the appalling care that your loved one has received.

I wanted a voice. All I ever wanted was a voice and for somebody to investigate this and to come back and say, "We will put this, this and this into the procedure so this does not happen again." I would have felt so much better if somebody who was not paid by that trust, somebody independent, who had no allegiance to myself or the hospital, but could be completely neutral, could have gone on to do their investigation. That, for me, would have meant everything.

Q57 Chair: Were you aware of ICAS?

Debra Hazeldine: I was aware of absolutely nobody. I did take it to the Healthcare Commission and get it upheld, but at that point I had not got a clue.

Q58 Chris Skidmore: But did you go to PALS with your first contact with the system?

Debra Hazeldine: No. The week after my mum had died and the incident with the body bag we phoned the chief executive. It was at Christmas time; my mum died on 13th December. They were struggling to say, "He might not be able to see you." I felt that strongly we said, "Fine. As a family, we are coming to camp outside his office today and we shall not move until we see him", so we got a meeting with him. It was not an option.

Mrs Speers: My lovely family saved my life because they wrote to the chief executive. They got a legal letter because time was of the essence. They were treating me as a depressive and I had a TB meningitis, a renal TB, that was misdiagnosed because the consultant decided that I couldn’t have it because I was a middle-aged white woman that lived in a village and didn’t travel very much. "So let’s ignore the pathology report and just go on that one, shall we?" My lovely family got a legal letter and got me bluelighted out of that hospital into a hospital where they were stunning; they were absolutely stunning. There were issues of cleanliness, and so on, but I can’t fault the staff at all. They were wonderful and saved my life.

My life has been saved by the NHS, my son has been failed by the NHS and I have been failed by the NHS. In amongst all of that, there is my personal story, which I have always got mixed up over the time, so that is why I have sent two separate memoranda, the wider landscape and my son’s, because I am trying to keep it separate because there are so many failures on the wider landscape as well that it just all needs looking at.

Q59 Chair: That is why we are here.

Mrs Speers: Thank you.

Mrs Monte: In our experience, my sisterinlaw did initially go to PALS, as I have already mentioned. She didn’t feel we were going to get anywhere with them as they weren’t very effective and helpful. So my sisterinlaw went straight to the chief executive. But we didn’t find him particularly helpful either. We thought we were doing the right thing in going to the top man, as we thought.

Q60 Chris Skidmore: That’s interesting. You mentioned the chief executive and, although you have this formal thing with all the acronyms-ICAS, PALS and all that sort of stuff-the chief executive is still there, and, as the figurehead, people feel that they can go straight to the top. But then you have the whole selfinterest thing going on as well, so often the chief executive will not be the best person to contact.

Debra Hazeldine: My case was different at that point. My mum had passed away so I felt I hadn’t got anything to lose if I upset him anyway.

Q61 Chris Skidmore: No, but it’s interesting that things like ICAS and this don’t seem to work because then the chief executive people-

Debra Hazeldine: I didn’t know there was anybody above the chief executive. I thought that was it at that point.

Mrs Monte: I think, eventually, dealing with the chief executive led us to make a proper written complaint and it led us on to the Healthcare Commission. That was because at the bottom of that response letter it did say, "If you are not happy with our response", which I definitely wasn’t. At the end of the day, I wanted information, admission to the wrongdoing and an apology. Their idea of an apology was to say, "We are sorry that you feel your treatment and your care was lacking." That is extremely insulting and frustrating. It is that sort of attitude where they won’t listen. You want to engage with them so that you can help them prevent these sorts of issues happening to other people, and they are just not interested.

That leads you on to going down litigation routes and looking further and further, and sixandahalfyears down the line I still haven’t got answers; I still haven’t had the apology. It is just so frustrating. You are on a merrygoround where you are passed from pillar to post and unaware of lots of different organisations that could potentially help you. From what I have heard of evidence at the inquiry that I have been involved in, it is something that I have beaten myself up over, thinking, this happened to me in 2004 and lots of people have died since. I wasn’t in a position, physically or mentally, to be able to actively do anything at the time, but you think there are all these organisations and perhaps I should have gone to more people. It’s just relentless, but, at the time, you’ve got to deal with surviving and rebuilding your life, and it is just so difficult.

Mrs Speers: I agree with that strongly because I think-and you sound like you have been left the same-the way I feel I have been left is that I am responsible for mental healthcare because I know the others can’t be trusted because it is not going to happen. I know that it happens. I know there are good services around, but my experience is all I can talk about.

Q62 David Tredinnick: Mrs Monte, do you think the failure to give you an outright apology and giving you this kind of conditional apology, "We’re sorry that you didn’t feel very happy about it", had anything to do with legal liability? Do you have any clues as to why you feel they just couldn’t spit it out and say sorry?

Mrs Monte: It has a part to play, but at the end of the day we went down a litigation route because of what happened to me, because we felt the devastating effect and how it changed all of our lives and will continue to have an effect on my life in limiting what I can do. We needed compensation to be able to live. My husband nearly lost his business, I lost my job, my career, and that is without going into the personal implications of the effect it has on you.

Mrs Speers: I described it like you have to find a new normal because that is the only way you live. You have got to find a new normal because your old normal has gone and you have got to grieve that life that has gone. So you are grieving that life and then you are grieving this life, and then you are grieving the fact that you can’t get any resolution.

David Tredinnick: Thank you very much.

Mrs Speers: Thank you.

Q63 Dr Wollaston: Did you feel, Mrs Monte, that once you had made your complaint as an inpatient you were treated worse as a result of that by the staff?

Mrs Monte: In some respects, yes, with some people. There were some excellent nurses that gave me good care throughout and we had a very good personal relationship. I got to know a couple of nurses extremely well at the end of the day. I spent 18 months of my life in there and you get to watch and learn a lot about what is going on. As I mentioned, nobody particularly came and physically threatened me as such, but you do feel that your care is going to suffer. You wonder whether the fact that it has taken them an hour and several attempts at buzzing to get attention is because of the fact that your family are making-we’ll call it in hospital terms-such a fuss and trying to raise issues and get basic care needs met. As an example, with regard to the nurse I mentioned who threw that leaflet at me, on a later admission that nurse came back into my room-I was in an isolation room again-and she sort of said to me, "I have been off sick because of you complaining about me. Do you realise the suffering you have caused me?"

Q64 Dr Wollaston: Oh, dear, the victim.

Mrs Monte: And that’s like, excuse me, my life has been turned upside down and you couldn’t even spend five minutes with me explaining what that piece of paper means to my life. She has got the cheek to come and say that to me, you know what I mean. There are people within the system that definitely would respond to you differently through complaining-not all, but some.

Debra Hazeldine: Can I give an example of that? Quite frequently, two or three times a day out of the four months that my mum was there, I did go in to help her to feed because food trays were left at the end of the bed and she had lost so much weight. She wasn’t given fluids and she wasn’t given food. I had the staff tut at me and say, "Doesn’t she know the damn visiting times?" So I had to go to the consultant and request that he write in the notes that I could visit at any time, and he did that for me, which speaks volumes really.

Chair: What we have heard this morning speaks libraries, and, I am sure on behalf of the Committee, I would like to thank all three of you for very bravely coming and answering our questions and putting yourselves before us this morning. Is there anything else?

Q65 Valerie Vaz: I have just a final question, and we are really grateful because it is very important that we hear your stories. I would like to know when you started going on the complaints process, whether you have all finished and at what stage you are now.

Debra Hazeldine: I started in 2006 and it was upheld in 2008 because the hospital was so slow coming back to the Healthcare Commission with their information, but I didn’t get closure, and it was three years on. I didn’t get closure until 2009 when there was an independent case review instigated that then told me the cause of my mum’s death was C. dif. That was what I wanted-the truth-and that gave me the closure.

Mrs Monte: My experience was sixandahalf years of complaining and I still haven’t really got anywhere. I haven’t got the answers I wanted. I haven’t got the honesty. Recently, I have reengaged with the trust and finally I am getting some honest, open dialogue with them.

On a litigation front, I am still trying to do something. Obviously, in terms of litigation, I am way out of the time frame for doing anything about it and I feel that is why perhaps the hospital are being honest and open with me now. I think the only justice or closure I can get from this is by actively engaging with the inquiry and doing this today, to try and get a message out there and hope that people will start listening and learning from my experience so that it doesn’t happen to other people. It’s madness. They could have learnt these lessons back in 2004 but nobody would listen to us.

Mrs Speers: There is no way that we should be put under this pressure. You are not putting us under pressure, but there is no way the NHS should have put us under this pressure, that we have to come to the highest level in the land to be heard, to get our voices heard, to get our loved ones’ voices heard.

I can talk on my personal case and you are asking where I am in the complaints process. As to my personal complaint, litigation covered it within 18 months and it was all sorted out. My son’s case has not been resolved yet. I am still in it. I have been to the ombudsman and I’ve been sent back to the Healthcare Commission. They upheld the complaint. The ombudsman sent me back and identified the case manager, who got the complaint to a certain level again, got lots of recommendations again, another raft of recommendations, and then when I said, "Who is monitoring the investigations?", they said, "He’s left. He’s gone for a job with the Care Quality Commission."

So this is the biggest problem. You get this moving around, and I mentioned in my evidence boomerang bosses, because that is what happens. Just before an "independent" inquiry comes out, you get the boss saying, "I think I will go for a job with the Department of Health", or "I will go to the strategic health authority and the health transformation team", but I will still have my full CEO pay and I will still have my full pension." And that is not right, because the thinking, the head, goes with them, and the flawed thinking where they are being rewarded for failure is going with them every single time. Four members of a senior management team have left this, and if there is a very good senior management team there now, brilliant. I will see if they implement the recommendations, but I think the Care Quality Commission need to implement recommendations because they have inherited the Mental Health Act Commission remit.

Q66 Chair: What is important to all of you, as I have heard it, is that you need to have clear access.

Mrs Speers: Absolutely.

Q67 Chair: If something goes wrong, you need to know where to go, have confidence that they are independent, that they are going to follow it up and if they make a recommendation it is going to be acted upon.

Mrs Speers: Yes.

Debra Hazeldine: The main thing for myself is that it doesn’t happen again and nobody has to watch their mum die as mine did.

Q68 Chair: I hope and believe you will have made a contribution to increasing the chances-I am not going to guarantee you that we will get there-of those outcomes being achieved. That is what we are here for and thank you very much indeed.

Mrs Speers: This looks like it is the "Ministry of Joinedup Thinking" and I thank you for that.

Chair: You are very flattering. I hope it is true. Thank you very much indeed.