One of the privileges of chairing the select committee that oversees the work of the Parliamentary and Health Services Ombudsman has been meeting campaigners committed to improving how the NHS responds to its mistakes.
Many selflessly use their personal experience to try and prevent others being harmed.
As a committee we see too many stories of families who have lost loved ones because of mistakes in the health service, and then been further traumatised by the NHS’ failure to investigate these tragedies properly.
Often, in recent years, too many families have felt let down by the PHSO too.
Shortly we will be examining the case of 19-year-old Averil Hart.
In December the PHSO found that her death in 2012 was avoidable.
Worse it found that the investigations by five separate NHS organisations collectively painted “a consistent picture of unhelpfulness, lack of transparency, individual defensiveness and organisational self-protection...”.
The Ombudsman also apologised for the PHSO’s own shortcomings, including taking three and a half years to complete their investigation.
Our new report on the work of the PHSO sets out a number of actions we want the new Ombudsman Rob Behrens to take to reinforce the start he has already made in rebuilding trust in the PHSO.
The PHSO tell us that complaints handling in local NHS trusts still lack resources and support from senior management.
The PHSO’s chief executive told us in December that the time it was taking to complete investigations was unacceptable.
We agree.
It also needs to get better at demonstrating that its investigations improve public services.
Ninety-nine per cent of its recommendations are accepted.
We now need to know if they make a difference.
But the PHSO is only the last rung in the complaints system.
The people it hears from often already feel doubly let down.
By the problem they are complaining about, and then by the response to their initial complaint.
Nine in ten of the complaints the PHSO investigates are about the NHS.
As a result, my committee has made a series of recommendations to government about improving investigations and complaints in the health service.
Following our recommendations, the new Healthcare Safety Investigation Branch has now started work driving up standards in the investigation of the most serious clinical incidents.
But there is more to do.
The PHSO tell us that complaints handling in local NHS trusts still lack resources and support from senior management.
Until that happens too many families will continue to feel let down when they make a complaint.
Too many opportunities to improve local NHS services by learning from mistakes will be missed.
We also need to find a way to ensure that where cases remain that have not been investigated properly that families are finally given the answers they are asking for.
This is not glamorous but it will make a huge difference to many people’s lives.
That is why my committee will continue to push the government, the PHSO and the NHS to deliver the improvements and changes they have promised.
