healthcommem@parliament.

uk Submission from Mrs Ann Reeves to the Westminster Health Committee NHS

Complaints Inquiry

ann.poppy@gmail.com December 11th 2010 Death of Elsie Devine at the Gosport War Memorial Hospital (GWMH) Dear Mr. Dorrell and Members of the Public Administration Committee, I am delighted to be able to submit to the Health Committee written evidence for its inquiry into Complaints and Litigation and I hope that my submission will be of some assistance. I have tried to keep this submission to a minimal as I understand that the HSC would be deluged if no restriction was placed, I feel however some examples of PCT delaying tactics need to be highlighted and you will note my concerns while reading my experiences. My family and I have had been subjected to the most appalling abuse of our human rights and least of all my mothers right to life. Who would ever believe that this is Britain today and one would have thought the very least we are owed is a full, transparent response to the terrible deprivations at the GWMH including Justice for our mother.

Summary
November 21st 1999 the unexpected death of our Mother Elsie Devine who was administered 25mcg Fentanyl Patch (135mg morphine) only licensed for patients with chronic intractable pain dying of cancer (my mother had no pain and she did not have cancer) 50mg of Chlorpromazine, 40mg Midazolam and 40mg Diamorphine all without justification or logic, all drugs given within 24 hours.. it is no wonder she fell into a coma. No member of the family were informed of the drugs administered, not even Elsie herself was aware she would never see or speak to her family again as she told the external doctor she was happy, had NO complaints, waiting to see her daughter and that the tablets made her mouth sore. 15 minutes later she was put on the terminal pathway! January 2000 a letter of our concerns was sent to CEO of PHCT however, unbeknown to me there was already a Police investigation into the death of Gladys Richards in 1998. We were not informed and neither did the PHCT call in the Police with my concerns when they received my complaint. Instead they sent my family and I, whilst we were grieving our Mothers sudden death, in never-ending circles for 18-months with meetings, letters and lost time from work, further I was caring for my very sick husband who had under gone a bone marrow transplant which they were fully aware of. However that did not concern any of them as they covered up the death of our wonderful Mother under the

regime of Dr Barton and the incompetence of the CEO et al! Complaints procedure proven untenable. June 2001 an Independent review that took the PHCT16 months instead of 12weeks according to policies. This report was full of untruths written by members of the PHCT/NHS doctors and personnel. I.R. Untenable and proven! 2001 General Medical Council (GMC) no case to answer! Untenable and proven! PHCT advised me to see Community Health Council to help me write letters and arrange appointments. I made an appointment to see them but it was not an encouraging meeting. They informed me of another gentleman who was also complaining about Jane Barton and that they had arranged for a meeting with the PHSO but they closed him down to their disappointment I decided I was in the wrong place. CHC later were closed down. 2001 PHSOs 5-months investigation, the treatment given to our Mother was appropriate and the nursing care was reasonable! FOUND AND PROVEN to be a categorical lie. WE ARE NOW CAUGHT UP IN UKS NHS COMPLAINT SYSTEM THE CORRUPTION TRAP 11-years on still waiting answers. . December 2007 the CPS no case to answer on Dr Jane Barton, how can 93++ families all be so wrong? I can confirm seeing the death stubs and the mortuary data they were not wrong. March 2009 an Inquest into 12 deaths, the Coroner Mr. Bradley held an illegal Inquest. Jury concluded inappropriate treatment and without justification or logic contributed to my Mothers death. Proven the complaints procedure and the PHSO in particular is untenable! January 2010 GMC found and proven that Dr Barton contributed to the death of all 12 patients investigated and all to a criminal standard yet she is not struck OFF! Found and proven the GMC, the NHS complaints procedure the PHSO in particular untenable! March 2010 I wrote to Ms Ann Abrahams with a formal complaint and asked her to reinvestigate my complaint made in 2001. I questioned the honesty and transparency of the PHSO. It took 15 emails/letters sent to Ms Abrahams office, before finally an answer they would not investigate my concerns. Further demands for an internal review, Ms Abrahams stated that there was no justification for her to reinvestigate and she would not respond to any further correspondence from me, only acknowledge. This clearly discriminates against the members of society that is a breach of Article 2, Article 6, Article 8, Article 14, Article 13, of the European Court of Human Rights. Ms. Abrahams abuse of power still continues, as she knows she can with the full force of Parliament behind her. March 2010 requesting FOI/DPA from Hampshire PCT Hampshire PCT works to their own law. I had to repeatedly ask for FOI/DPA as they played out delaying tactics. I can make a complaint to the ICO but they are so over worked with complaints that it takes months, or is that another delaying tactic? On receipt of my DPA from Hampshire PCT, it was noticed they were allegedly tampering with evidence to the advantage of the PCT/NHS by planning to cover

up Dr Jane Bartons death rate. This exposed the FOI Offices disgusting behaviour, including attitude of staff in external emails regarding myself. More over you would think the staff would be fully aware of DPA in their training than to write in internal emails as stated below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responded: With reference to your statement that you will not be including documentation in an attempt to reduce the amount of duplicate paper work; I find this totally unacceptable and goes against my original "subject access request". Therefore, please ensure that I am sent ALL documentation from 2000 to date; what you consider to be duplicate information I very well may not. This re-request is deplorable and I ask that by return and in respect of my rights you hastily review and come back to me with your timescale to issue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

.$439!12!'%!4$3!)B#,!'4A!#,)($4),!<$B6C!?,!)B;;+:+,43!K!;#$%!%A!(,#)(,:3+>,!3*,!-./!*')! #,)($4C,C!3$!3*,!"M2!,4SB+#A!+4!'!3+%,6A!%'44,#!'4C!%A!#,)($4),)!*'>,!?,,4!3<+)3,CU9! $,&)#%7,1,8/)+#8/.)4#:&,;#23/+#</+80+2/48#04:,04<#+2%2);)426! I made a formal complaint to the PCT regarding these comments and an explanation but after a 5-week investigation by every Tom, Dick and Harry within the organisation, while being pushed from one person to another, it turned out to be another shambles of an investigation if there was one at all! Questions had still not been answered. Mrs Fleming (CE) Hampshire stated that communications had broken down and that meditation was required. Meditation is what my family and I requested in 2000 being a meeting with the nurses involved and Dr Jane Barton, but the PHCT did not consider that it would achieve any thing so what is the difference now! I made a request under the FOIA asking for the minutes of this investigation, although my request never got passed to the FOI Office and after requesting for a second time Mrs. Fleming CEO, writes; there are no minutes. Does Mrs Fleming care; NO as she knows there is never any accountability! I understood that PCTs have a statutory Performance Management responsibility to ensure services are fit for purpose Without evidence-based outcomes i.e. an Investigation Report or recorded outcomes from the personal action taken what evidence is there that a investigation took place? This is not fit for purpose! A further letter was sent to Mrs Fleming to answer my questions on November 21st 2010. I am still waiting a response and have attached this letter for your information.

Complaints
The reasons for the recent sharp rise in NHS complaintsare because we have a totally unsatisfactory complaints process. The effectiveness of the new complaints system introduced on 1 April 2009is because we dont have a system anymore; we have a processsince the Healthcare Commissions remit was closed without any public consultation. The effectiveness of the constituent parts of the complaints system: local resolution (supported by the Independent Complaints Advocacy Services); and referral to the Ombudsmandelaying tactics, just to keep people in work and complainants hoping they will find resolution. The role of Patient Advice and Liaison Services as a gateway to the complaints systemits too close to the Trust and not independent enough. The failure of some Foundation Trusts to report numbers of complaintsif this question recognises this failure and needs to be asked then the HSC needs to question Monitor, who are allegedly overseeing Foundation Trust Hospitals. The Governments plans for future complaints-handling arrangements (the White Paper says, on p. 19, Local authorities will be able to commission local Health Watch or Health Watch England to provide advocacy and support ... supporting individuals who want to make a complaint). Before we had the Community Health Council but it was closed down in 2001 to cut cost as the government obviously saw it as not fit for purpose. I can confirm that families that used

them including myself to assist on their complaints over their loved ones at the GWMH it was not Independent. It was another means to close you down and that is what they did to the families at the GWMH. So what has changed? Unless we have a truly independent, statutory complaints system under one umbrella, with accountabilty and above all honesty to the people we will continue to rely on non-independent advocates and an untenable PHSO process! How data from complaints will feed into the planned new commissioning arrangements (the White Paper says, at Para. 2.26, Building on existing complaints handling structures, we will strengthen arrangements for information sharing)question is will GPs, under Practice Based Commissioning (PBC) have the Statutory Performance Management responsibilities recently bestowed on PCTs and SHAs?

Litigation
The cost of litigation against the NHSthis reflects the rise in complaints and number of complaints left unresolved (over 98%) by the PHSO process. Reasons for the inflation of litigation costs in recent yearssee above and for us to seek justice we have to borrow or use our savings to find the money to pay for litigation. The impact of conditional fee (no win, no fee) arrangements on litigation against the NHSin the absence of legal aid funding, the offer of no win, no fee, gives complainants hope of closure and some hope of resolutionthis is not achievable in the NHS Complaints process. The effect of litigation on the development of an open reporting and learning culture in the NHSthere is a closed non-transparent culture in the NHS. One, which amends or loses records, fails to submit key documentation to Inquest hearings, which fails to implement guidance including the guidance from NHS Litigation Authority on saying sorry and that is all you will ever achieve but you will only learn this from the true experience! The Governments intentions regarding the implementation of the NHS Redress Act 2006. This is legislation that needs to ensure people are not in a worse financial situation than before the maladministration. The possible benefits of a statutory right to compensation for treatment injury from an independent fund, without the need to prove negligence, as required under tort lawyou are asking people to be lawyers! Citizens must be able to rely on public systems to support them but I have my doubts if this would ever happen, educate and discuss tort law but dont assume everyone is aware of it. People are often suffering deep grief and confusion after death and injury; we need a fully supportive system in place that puts the patient and complainant first and not treated like a vexious complainant! Encouraging the use of mediation before litigation is initiatedwe allegedly have a complaints processmediation is usually used when complaints have broken down, but it seems to me it has become an easy option for not answering questions. Adhere to guidance, put patient safety first and implement policythis will improve litigation costs! There will always be failures, but the avoidable death of a patient under the duty of care of an NHS Trust MUST be investigated to a

minimum standardby a competent independent investigator. There has to be a law on controlled drugs and only administered with signed permission of the patient or family member ELSIES LAW do not assume conversations happen because they DONT! The vast number of deaths at the GWMH is sickening and yet we cannot get justice. I have the death stubs and mortuary data so it is quite clear to me why this government does not want to expose the practice of Dr Jane Barton through a criminal court or a PUBLIC INQUIRY. Tony Blairs echoing words that there will never be another Shipman he made sure there was not and this government is following on. This opens up the words of Mr..Cameron and Mr..Clegg before the election with their policy of openness and transparency NO lessons have been learnt from the vast complaints at the GWMH that is evident by Mid Staff Hospital now having a Public Inquiry!

Conclusion
My family and I never imagined that we would still be here 10- years on and driven by the lies, disgusting attitude and treatment of all these organisations/bodies that I have had dealings with. They have played out the most despicable lies to us from 1999 and it is still on going today. The alleged Murder of our Mother while Dr Jane Barton walks free drives this family on. To have our Mothers personal possessions handed back to us in 2-black bin liners, I think it sums up the people working at the GWMH, who were dying before their time. There was NO regard for their possessions, let alone life, it is the epitome of inhumanity. Only open, transparent and honest Complaints Procedure under ONE umbrella will improve standards and yearly reports published maybe then people will see some justice with rid of all these quangos! We should not have to fight for justice after death; the law should be there to protect us when we are alive. I look forward to reading your report and in particular regarding what action if any will be taken against the Parliamentary Health Service Ombudsman (PHSO). I can support all written here with a mass of documentation4-arch files of it! For evil to flourish all it takes is for good men to do nothing! With Regards Ann Reeves Cc David Cameron-Prime Ministers Nick Clegg Deputy Prime Minister Andrew Lansley Secretary of State for Health Kenneth Clarke Minister of Justice Chris Huhne MP

Mary Macloed MP Stephen Lloyd MP Norman Lamb MP