Annual Report 2007-08 - the Parliamentary and Health Service ...

Annual Report2007-085th Report – Session 2007-08Presented to Parliament pursuant to Section 10(4)of the Parliamentary Commissioner Act 1967 andSection 14(4) of the Health Service CommissionersAct 1993Ordered byThe House of Commonsto be printed on6 October 2008HC 1040London: The Stationery Office£19.15

ContentsForewordGovernment departments, 07agencies and public bodiesThe National Health Service 33Working with other Ombudsmen 51in the UK and beyondOur workload and performance: 57facts and figuresManaging our resources 87Governance 93ForewordMaintaining an independent voiceat the heart of our democracyThe work of my Office during the course of 2007-08 reflects its place in the constitution andits twin functions of delivering individual benefitto complainants and serving the wider publicbenefit. It achieves this larger ambition by drawingon its experience, expertise and independenceto right individual wrongs and drive improvementsin public services. It is this fruitful mix of individualbenefit and public benefit that gives the Officeits distinctive character.© Crown Copyright 2008The text in this document (excluding the RoyalArms and other departmental or agency logos)may be reproduced free of charge in any formator medium providing it is reproduced accuratelyand not used in a misleading context. The materialmust be acknowledged as Crown copyrightand the title of the document specified.Where we have identified any third party copyrightmaterial you will need to obtain permission fromthe copyright holders concerned.For any other use of this material please write toOffice of Public Sector Information, InformationPolicy Team, Kew, Richmond, Surrey TW9 4DU ore-mail: licensing@opsi.gov.ukISBN: 9 78 010295 7990In July 2007 the Government startedconsultation on its proposals forconstitutional reform with the publicationof a Green Paper, The Governance ofBritain. That process has provided anopportunity for me to reaffirm the placeof the Ombudsman in our constitutionalarrangements. When the WilsonGovernment established the Office in1967, part of its purpose was to supportParliament in holding to account theExecutive, the government of the day.The way it was to do that was by assistingMPs with the task of investigatingcomplaints made to them by citizensabout their dealings with centralgovernment departments. This was notjust an alternative to the civil justicesystem. It was to be a way of ensuringthat Parliament could guarantee anindependent and authoritative voicefor aggrieved citizens.The Court of Appeal’s judgment inFebruary 2008 in the long-runninglitigation arising from my 2006 report,Trusting in the Pensions Promise, hasalso provided welcome reinforcementof the Ombudsman’s constitutionalposition. That judgment has confirmedthat, although the Ombudsman’s findingsare not binding on Government, therelevant Minister must either acceptthem or alternatively establish goodreason for not doing so. In effect, thejudgment requires the Minister to have‘due regard’ to the Ombudsman’s findings.I consider that a satisfactory outcomeand a helpful contribution to a viableframework for future relations betweenmy Office and Government. It is ajudgment that sits well with what I seeas one of the Ombudsman’s key roles:playing an active part in the deliberativeparliamentary process.That key role has been evident in thepast year in connection with tax credits.In October 2007 I published a secondspecial report, Tax Credits: Getting itwrong?, to provide an update on therecommendations made in my first reportand to give an indication of progresstowards correcting the problems I had

previously identified. I am pleased tosay that HM Revenue & Customsaccepted all the recommendations inmy second report and is taking actionto implement them. This is, in my view,a good example of the deliberativeprocess in action, with my Office playingits proper part by eliciting a reasonedresponse and effective remedial actionfrom government.As part of my function of deliveringbroader public benefit, I have duringthe course of 2007-08 published newguidance in the form of Principles forRemedy, to complement Principles ofGood Administration published last year.I have recently finished consulting ona third publication, Principles of GoodComplaint Handling, which we willpublish in autumn 2008. These variousPrinciples draw on the experience andexpertise of my Office to propose anobjective framework within which publicauthorities should seek to work. At thesame time, the Principles help clarify theexpectations against which I will judgeperformance. In short, the principlesof legality, flexibility, transparency,fairness and accountability are whatI regard as the necessary ingredientsof good administration; and if goodadministration is in part an attempt tohumanise the workings of bureaucracy,remedial action is the attempt to restorethat sense of human value to those whohave been denied it. Principles of GoodAdministration and Principles for Remedyare different sides of the same coin.None of this work is conducted inisolation from Ombudsmen colleaguesat home and abroad, and thiscollaborative work is something to whichI draw further attention later in thisReport. At home, the past year has seenthe implementation of a new RegulatoryReform Order that for the first timeformalises joint investigations by myOffice and the Local GovernmentOmbudsman. It has already been put toeffective use in dealing with a complaintthat crossed the boundary between localauthority and central government socialand healthcare responsibilities.Further afield, the Council of Europe’sHuman Rights Commissioner,Thomas Hammarberg, has encouragedOmbudsmen throughout Europe toco-operate more effectively with hisOffice and with national human rightsinstitutions to help uphold human rightsprinciples in public administration. I wasvery pleased to welcome Mr Hammarbergto my Office during his recent visit to theUK and look forward to contributing tothe initiative that he has promptedin the year ahead, not least by liaising,when appropriate, with the new Equalityand Human Rights Commission and withthe Parliamentary Joint Committee onHuman Rights.The key organisational challenges will,however, occur much closer to home.In April 2009, a new system for handlingcomplaints in the NHS will come intoforce, with increased emphasis on theneed for local resolution and with theOmbudsman acting as the second stagein the complaints process, after NHSbodies and individuals themselves haveconcluded their involvement. Thisdevelopment, despite its short-termorganisational challenges, holds out theprospect of longer-term improvementsto the system and is one that I warmlywelcome. For my own Office it representsyet a further opportunity to deliverindividual benefit to those alreadyaggrieved and wider public benefit toall those countless citizens who willmake use of the NHS in the future. Itis therefore just one aspect of that largerproject of delivering meaningful individualand public benefit, upon which itcontinues to be my privilege to befruitfully engaged.Ann AbrahamParliamentary and Health ServiceOmbudsmanOctober 2008

Parliamentary and health service ombudsman annual report 2007-08Government departments, agenciesand public bodiesIn 2007-08 we received 6,964 enquiries relating to 7,341 complaintsagainst government departments, agencies and public bodies.The bodies and their agencies most complained about were:the Department for Work and Pensions; Her Majesty’s Revenue &Customs; what is now the Ministry of Justice; and the Home OfficeWe accepted 248 cases for investigation and reported on 290investigations. 68% of complaints were upheld in full or in part.EnquiriesFigure 1 shows the top five governmentdepartments and agencies complainedabout. The Department for Workand Pensions (DWP) and its agencies,taken together, topped the list,accounting for over a third of all thecomplaints made to the ParliamentaryOmbudsman. They were followed closebehind by Her Majesty’s Revenue &Customs (HMRC), primarily but notexclusively as a result of continuingproblems with tax credits. We notedan increasing number of complaintsabout the Border and ImmigrationAgency, formerly the Immigration andNationality Directorate of the HomeOffice and, from 1 April 2008, the UKBorder Agency; and about theDepartment for Transport and itsagencies. However, the number ofcomplaints about the Ministry of Justice,in its various incarnations, fell.Figure 1Top 5 departments by number of complaints receivedDepartment for Work and PensionsReceivedJobcentre Plus 1,063Child Support Agency 868The Pension Service 224Independent Case Examiner 147Disability and Carers Service 114Department for Work and Pensions 52Debt Management Unit 43Health and Safety Executive 25Pensions Ombudsman 19Rent Service 6Health and Safety Commission 5Disability Rights Commission 4Independent Living Funds 3Remploy Ltd 1Total 2,57407

Figure 1 continuedTop 5 departments by number of complaints receivedHM Revenue & Customs (HMRC)ReceivedMinistry of JusticeReceivedHM Revenue & Customs 1,791The Adjudicator’s Office* 512National Insurance Contributions Office 37Child Benefit Office 2Total 2,342HM Courts Service 152Legal Services Commission 102Tribunals Service 100HM Prison Service 53Information Commissioner 39Land Registry 34Ministry of Justice** 25The Office of the Public Guardian 18Prisons and Probation Ombudsman 9Office of Social Security and Child SupportCommissioners4Official Solicitor 4Legal Complaints Service 3The National Archives 2Advisory Council on National Records andArchives1Court Funds Office 1Immigration Appellate Authority 1Judicial Appointments and ConductOmbudsman1Total 549*not all complaints about HMRC**includes 9 against Department for Constitutional Affairs08

Parliamentary and health service ombudsman annual report 2007-08Home OfficeReceivedDepartment for TransportReceivedBorder and Immigration Agency 277Criminal Records Bureau 40Home Office 40UKvisas*** 39Identity and Passport Service 35Criminal Injuries Compensation Authority 32Security Industry Authority 27Criminal Injuries CompensationAppeals Panel8Driver and Vehicle Licensing Agency 194Driving Standards Agency 23Highways Agency 20Department for Transport 17Vehicle and Operator Service Agency 17Maritime and Coastguard Agency 6Total 277Office of the Immigration ServicesCommissioner3Parole Board 2Central Police Training and DevelopmentAuthority1Correctional Services Accreditation Panel 1Forensic Science Service 1National Policing Improvement Agency 1Total 507***UKvisas was joint Home Office and Foreign & Commonwealth Office,now Home Office only09

Parliamentary and health service ombudsman annual report 2007-08Figure 2Top 5 departments by number of complaints accepted for investigationHM Revenue & CustomsAccepted forinvestigationHome OfficeAccepted forinvestigationHM Revenue & Customs 91The Adjudicator’s Office* 68National Insurance Contributions Office 1Total 160Border and Immigration Agency 46Criminal Injuries Compensation Authority 1UKvisas** 1Total 48Department for Work and PensionsAccepted forinvestigationMinistry of JusticeAccepted forinvestigationJobcentre Plus 38Child Support Agency 18Independent Case Examiner 9Debt Management Unit 5The Pension Service 4Disability and Carers Service 3The Pensions Regulator 1Total 78HM Courts Service 7Legal Services Commission 6HM Prison Service 5Ministry of Justice 1National Probation Service 1Official Solicitor 1Tribunals Service 1Total 22Department for Environment,Food and Rural AffairsAccepted forinvestigationDepartment for Environment, Foodand Rural Affairs4Rural Payments Agency 2Consumer Council for Water 1Environment Agency 1Total 8*not all complaints about HMRC**UKvisas was joint Home Office and Foreign & Commonwealth Office,now Home Office only11

Figure 3Top 5 departments by number of complaints reported onDepartment for Work and PensionsReportedonFullyupheldPartlyupheldNotupheldJobcentre Plus 52 29% 38% 33%Child Support Agency 28 54% 36% 11%The Pension Service 13 31% 38% 31%Debt Management Unit 8 13% 75% 13%Independent Case Examiner 7 14% 0% 86%Disability and Carers Service 6 33% 33% 33%Department for Work and Pensions 2 50% 0% 50%Health and Safety Executive 2 50% 50% 0%Total 118 34% 37% 29%HM Revenue & CustomsReportedonFullyupheldPartlyupheldNotupheldHM Revenue & Customs 66 41% 27% 32%The Adjudicator’s Office* 26 15% 8% 77%National Insurance Contributions Office 1 0% 0% 100%Total 93 33% 22% 45%Home OfficeReportedonFullyupheldPartlyupheldNotupheldBorder and Immigration Agency 52 52% 33% 15%Criminal Records Bureau 6 17% 67% 17%UKvisas** 3 67% 0% 33%Security Industry Authority 2 50% 50% 0%Criminal Injuries Compensation Appeals Panel 1 0% 100% 0%Criminal Injuries Compensation Authority 1 0% 100% 0%Home Office 1 0% 100% 0%Identity and Passport Service 1 0% 0% 100%Total 67 46% 37% 16%*not all complaints about HMRC**UKvisas was joint Home Office and Foreign & Commonwealth Office,now Home Office only12

Parliamentary and health service ombudsman annual report 2007-08Ministry of JusticeReportedonFullyupheldPartlyupheldNotupheldHM Courts Service 17 47% 18% 35%HM Prison Service 3 0% 67% 33%Legal Services Commission 3 33% 33% 33%Information Commissioner 1 0% 100% 0%Land Registry 1 0% 0% 100%Ministry of Justice 1 0% 100% 0%Tribunals Service 1 0% 0% 100%Total 27 33% 30% 37%Department for Environment,Food and Rural AffairsReportedonFullyupheldPartlyupheldNotupheldDepartment for Environment, Food and Rural Affairs 6 17% 33% 50%Rural Payments Agency 3 67% 33% 0%Environment Agency 2 0% 0% 100%Consumer Council for Water 1 0% 0% 100%Total 12 25% 25% 50%13

Individual and public benefitOur Parliamentary work during 2007-08clearly illustrated the dual aspect ofthe Ombudsman’s role in achievingremedy in individual cases, while alsoproviding wider public benefit. Thiswider benefit stems from the effectiveuse of our evidence base and ourexpertise in providing a high qualitycomplaint handling service, togetherwith an acknowledged reputation forindependence and impartiality. Thisenables us to provide expertise in goodadministration and good complainthandling, drive improvements in publicservice delivery and inform public policy,demonstrating that the Ombudsman notonly provides a retrospective remedy forinjustice resulting from maladministration,but also seeks to secure prospectiveimprovements in the wider public interest.This approach was evident in the workwe undertook in relation to the threebodies that attracted the mostcomplaints in the year:• In relation to Her Majesty’s Revenue& Customs, including the Adjudicator’sOffice, we reported on 54 tax creditinvestigations in the year and alsopublished our second special reporton the subject, Tax Credits: Gettingit wrong?, making recommendationsfor systemic change, all of which wereaccepted.• In relation to the Department forWork and Pensions and its agencieswe reported on 98 cases relating to118 complaints. We also welcomedthe extension of the remit of DWP’sIndependent Case Examiner to includeall of DWP’s customer-facing agencies,something the Ombudsman hadrecommended as far back as 2003.• In relation to the Border andImmigration Agency we reported on52 investigations in the year and, in aseries of liaison meetings with theChief Executive of the Agency, madestrong representations about the needfor a more robust and effective systemfor handling complaints.More detail is given later about the workwe undertook with these three majorbodies during the year.A Framework of PrinciplesAfter wide consultation, in October 2007we published our Principles for Remedy,which offer complementary guidance toour Principles of Good Administration,published in March 2007. The Principlesfor Remedy follow the same six Principlesas our Principles of Good Administration:• Getting it right• Being customer focused• Being open and accountable• Acting fairly and proportionately• Putting things right• Seeking continuous improvement.Principles for Remedy gives our viewof the Principles that should guide publicbodies in providing remedies for injusticeresulting from their maladministration.We want public bodies to be fair and takeresponsibility, acknowledge failures andapologise for them, make amends and usethe opportunity to improve their services.During 2007-08 we developed the thirdin our series of Principles, which we havebeen consulting on in recent months andwill publish in autumn 2008. OurPrinciples of Good Complaint Handlingare based on the same six core Principlesas our Principles of Good Administrationand Principles for Remedy. With them weaim to ensure that public bodiesunderstand how we expect complaintsto be handled, and that complainantsunderstand how we will consider theircases. As with the existing Principles, wehope that they will prove useful to bothcomplaint handlers and complainants.Poor complaint handling by publicbodies was a recurrent theme across ourParliamentary investigations in 2007-08,and one we refer to frequently in thepages that follow. Often, the failureto provide an adequate remedy is anelement of poor complaint handling, andis a significant factor in the complainant’sdecision to refer the complaint to us forinvestigation, as in the following example.Poor complaint handlingOur investigation into the case ofMr W, a worker in the security industry,upheld his complaint that the SecurityIndustry Authority had not properlyhandled his complaint about a lostapplication and had failed to explainits procedure to him adequately.As a result of our investigation, theSecurity Industry Authority not onlyagreed to put things right for Mr W,but also accepted our recommendationthat it review its complaints processto prevent a recurrence of the problemsMr W had experienced.14

Parliamentray and health service ombudsman annuall report 2007/082Case StudyComplaints processwas not fully explainedIn July 2006 Mr W sent the Security Industry Authority (theAuthority) an application form for a door supervisor’s licence.The Authority wrote back to Mr W saying that his form wasincomplete; it enclosed not his identification documents, butthe application form of a third party, Mr A. Mr W told theAuthority that it had sent him Mr A’s application form and heasked where his own form was. The Authority said human errorhad probably led to Mr W’s application being separated fromhis documents and replaced with Mr A’s application. Mr W wasinvited to write in to complain.After several attempts, in November the Authority finallymanaged to contact Mr A, who confirmed that he had receivedsomeone else’s application form. He said he would return it tothe Authority. Having not received the application form back,the Authority contacted Mr A again asking him to return it as soonas possible. Following a further exchange of correspondence withMr W, in February 2007 the Authority refunded his £190application fee as a goodwill gesture. Mr W acknowledged thegesture but said he could not accept that the Authority tookall complaints seriously; that he had not been made aware of itscomplaints policy or procedure and had not been kept informedof progress. He said that the Authority had still not addressed allof his concerns.In some cases, the errors that ledto a complaint are compoundedat the complaint handling stageby well-intentioned but ultimatelycounter-productive efforts toresolve problems informally. In aninvestigation involving the Departmentfor Communities and Local Governmentwe found that a 14-month delayresulted in this way when theDepartment attempted to negotiatea voluntary agreement to settle thematter, before eventually startingformal modification procedures.We upheld Mr W’s complaint in full. We found that the Authorityhad probably sent his application form containing personal detailsto a third party. It is the seriousness of this error, at a time whencrime related to identity theft is much reported in the media, andin the knowledge that such crime can have a wide-ranging effecton victims, that led us to find the Authority’s actionsmaladministrative. However, we saw nothing to suggest that themistake was a result of systemic problems. The Authority did notanswer Mr W’s concerns about its complaints process and shouldhave done more to explain it to him.The Authority agreed to apologise to Mr W for not fully explainingits complaints process to him, and to review the complaintsprocess, with particular attention to the need to make informationabout it publicly available.15

3Case StudyPlanning mistake contributedto closure of storeSolicitors complained on behalf of their client, a major retailer,about an error in a letter issued by the Government Office forthe East Midlands, now part of the Department for Communitiesand Local Government (the Department) – on behalf of the thenSecretary of State – granting planning permission to adevelopment company. They also complained that the failure tocorrect that error had caused the client unnecessary expensesand a loss of business at one of its stores.We fully upheld the complaint. In granting planning permissionto the developer, a restrictive condition on goods that could besold was omitted, and a condition relating to the floor spaceavailable for food retailing was ambiguously worded, whicharguably increased the amount of floor space allowed. That errorwas compounded by incorrect assurances of prompt action torectify matters (as a result of which other parties, specifically thelocal council, failed to take action themselves which might havebeen successful). There was a failure to take account of all therelevant factors when deciding how to put things right. That ledto the Department spending some 14 months trying to negotiatea voluntary agreement before starting formal modificationprocedures, and then deferring those procedures while theSecretary of State considered a planning application from anotherdeveloper who had purchased the land to which the faultyplanning permission related.We found that the Department’s error and its failure to correctit promptly was not the sole cause of the store’s subsequentclosure, but that it did lead to injustice. That was because thecontext of all future planning decisions for the land in questionwas irrevocably altered, and the erroneous permission grantedbecame a significant factor in future planning decisions, eventuallyleading to the opening of a superstore directly opposite theclient’s store. That adversely affected the store’s profits, andcontributed to its closure.In the light of all the contributing factors, we considered itreasonable for the Department to meet, in broad terms, 20% ofa properly substantiated claim for losses from the store, togetherwith any additional unnecessary costs that it had incurred in tryingto have the Department’s error corrected. The Department agreedto apologise to the retailer and to make a payment in line withour recommendations.16

Parliamentray and health service ombudsman annuall report 2007/084Case StudyDelay on asylum decisioncaused distress and hardshipMs V, a Nigerian national, is thought to have arrived in the UKsome time during 1988-89, to join her father, Mr V. In February 1993the Immigration and Nationality Directorate of the Home Office(IND) told Mr V that he had no basis to stay in the UK and wouldhave to leave immediately. IND had no further contact withMs V or her father until February 1998, when solicitors requestedfurther leave to remain, on the basis of Mr V’s marriage to aFrench national.Mr V was subsequently granted a European Economic Area (EEA)family residence permit until 10 February 2004. In February 2004Mr V applied for indefinite leave to remain as the family memberof an EEA national (with Ms V included as a dependant). In MayMs V applied for indefinite leave to remain based on her longresidence, and shortly afterwards IND refused Mr V’s application.They wrote to ask Ms V for further information in support of herapplication on 27 September 2006. In October IND was informedthat Ms V was pregnant. In December Ms V applied for incomesupport and other maternity-related benefits but was ineligiblebecause she had no National Insurance number. In January 2007Ms V told what was by now the Border and Immigration Agencyshe was homeless and pregnant. In March the Agency requestedfurther information in support of Ms V’s application.Ms V complained to the Ombudsman about the Agency’s delayin deciding her application, which she said had meant she couldnot obtain stable employment or claim state benefits. Her debtswere growing. She was almost nine months pregnant with twinsand concerned that her children would be removed if herapplication was not determined.We upheld Ms V’s complaint. Apart from its letter of27 September 2006 (which Ms V did not receive because itwas sent to the wrong address) the Agency took no meaningfulaction on her case between May 2004 and March 2007, and didnot consider prioritising it on learning that she was pregnant andhomeless. Although the Agency subsequently granted Ms Vindefinite leave to remain on 17 May 2007, that did not completelyremedy the injustice to her, as we considered that she would haveobtained a National Insurance number and successfully claimedbenefits, but for the Agency’s maladministration. The Agencyagreed to consider a claim from Ms V equivalent to incomesupport forgone between 1 January and 17 May 2007 andequivalent to child benefit and child tax credit forgone between20 March and 17 May 2007. In addition the Agency accepted thatMs V had been inconvenienced at a time when she could havebeen considered to be particularly vulnerable, and awarded hera consolatory payment of £300.The need for local leadershipPublic service providers should operatea complaint handling service that is fitfor purpose and responsive, and theirsenior managers should understand thevalue of taking on board the lessonslearnt from complaints. For these thingsto happen, it is necessary for managersat all levels to take a lead in ensuring thatcomplaints are taken seriously andhandled properly. However, this oftendoes not happen.Lack of local leadership in complainthandling by senior managers withindepartments and agencies was anotherclear thread running through ourcasework in 2007-08. In some cases itwas a factor in a complainant’s decisionto refer a complaint to us, when timelylocal resolution might well have beenpossible if a senior manager had takenappropriate action at an earlier stage.For instance, in the case of Ms V,a Nigerian national, the Border andImmigration Agency took no meaningfulaction on her asylum application foralmost three years and did not considerprioritising it even after she told themshe was pregnant and homeless. Leavewas subsequently granted, but it is clearthat local leadership was sadly lackingboth in the initial handling of the caseand in the Agency’s reaction to Ms V’sconcerns about the long delay inprocessing her application.17

Her Majesty’s Revenue & CustomsOf the 91 complaints against HMRCaccepted for investigation during2007-08, 85% were about tax credits.Similarly, 91% of the 68 complaintsaccepted against the Adjudicator’s Officewere about their handling of tax creditcomplaints.It is clear that, despite the considerableimprovements HMRC has made in itsadministration of tax credits, it still hasa long way to go to be appropriatelycustomer-focused. It is also clear thatmany tax credit recipients still do notunderstand how the tax credit systemworks, and their complaints can often,therefore, relate to the system workingas it is intended.Most of the tax credit cases referredto us for investigation in 2007-08 relatedto the recovery of overpayments. Moststemmed from the early years of thescheme (2003-06), after which, in the2006-07 tax year, HMRC changed thelevel of income disregarded from £2,500to £25,000. A number of factorshampered our ability to process HMRCcases during the year. The most significantthree are outlined below.• Section 18About 25% of the tax credit cases weassessed or investigated in 2007-08were affected by the ‘section 18’procedural error announced inParliament in July 2007. As a result ofthis error, HMRC is required to reviewapproximately 250,000 tax credit cases,which it says may take up to three yearsto complete. This has already led tosome delays in the resolution of casesbecause HMRC is unable to provideaccurate information to theOmbudsman, the Adjudicator or itsown complaints teams on an affectedcase, until the review of that case hasbeen completed.• Code of Practice 26Uncertainty over whether changesto the application of Code ofPractice 26 (COP 26: the guidanceHMRC use to determine whetherto waive overpayments) would beapplied retrospectively delayedmost of our tax credit assessmentsand investigations for several weeksat the start of 2008 until the positionwas clarified by HMRC.• Lost CD-ROMsOur ability to progress with someinvestigations was affected by the lossin November 2007 by HMRC of twoCD-ROMs. These contained thepersonal details of families receivingchild benefit. As a result of the loss,HMRC had to review the security ofall its external communication channelsand was accordingly unable tocommunicate with us by post, faxor email for a number of weeks, andunable to recommence sending ustelephone recordings (relevant to manycases) for over three months.Still getting things wrongIt is clear from the complaints receivedthat attempts by HMRC to recoveroverpayments made under the tax creditsystem continue to cause distress andhardship for a significant number ofpeople. As one complainant put it:‘Tax credits are supposed to help families,not cause them money worries’.In June 2005 the Ombudsman publishedTax Credits: Putting Things Right, herfirst special report on the issue. Thisconcluded that many of the difficultiesfamilies were facing were a result ofHMRC having developed a ‘one size fitsall’ system that was designed to requireminimum human intervention, beingmainly IT-based. The consequences ofthis systemic inflexibility are seen in thecase of Mr C.18

Parliamentary and health service ombudsman annual report 2007-085Case StudyPersonal circumstances notproperly considered whendemanding tax credit repaymentMr C undertook seasonal work from March to September 2005.In February 2006 the Citizens Advice Bureau sent HMRC a taxcredit application form, together with a letter asking for theaward to be backdated for the period of Mr C’s employment.The letter explained that Mr C had been unable to look afterhis financial affairs for some time because of mental healthproblems and hospitalisation.HMRC wrongly treated Mr C’s application as a fresh claim goingforward and awarded tax credits from 10 February 2006 onwards.An award notice was issued on 10 March, which also set out theaward for 2006-07. In June Mr C’s mother (Mrs M) told HMRCthat it had paid tax credits to Mr C to which he was not entitled.HMRC terminated the award and sent Mr C a notice saying thathe had been overpaid £578.88 for 2005-06 and £605.08 for 2006-07.Mrs M complained to theAdjudicator, who foundno grounds for asking HMRCto remit the overpayments:she said that it was clearfrom the March 2006 noticethat the award was for theperiod from 10 February 2006onwards, and it was notreasonable for Mr C tothink he was entitled tothe payments received.Mr C successfully appealedagainst HMRC’s decisionnot to backdate his awardfor the period of hisemployment and receivedarrears of £964.81.Mr C complained to the Ombudsman that recovery of theoverpayment would deny him his correct benefit entitlement(his income support payments had stopped when he wasawarded tax credits, and could not be reinstated retrospectively).He also complained that the Adjudicator had endorsed HMRC’sdecision not to remit the overpayment.We upheld Mr C’s complaint. HMRC knew in February 2006that Mr C had no ongoing entitlement to tax credits, but it didnot terminate the award until June. When considering whetherto remit the overpayments, HMRC and the Adjudicator tookinsufficient account of Mr C’s personal circumstances, whichwere such that he was in no position to check his award notice.HMRC agreed to remit the overpayments (accepting that thetax credit award had prevented Mr C from receiving his properincome support entitlement).19

6Case StudyWrong advice led to confusionabout tax credit overpaymentIn October 2007 the Ombudsmanpublished her second report, TaxCredits: Getting it wrong?, to providean update on the implementation ofrecommendations made in the firstreport and give an indication of progresstowards correcting the problemspreviously identified.Tax Credits: Getting it wrong? made sixrecommendations. These included theproduction of a clear and comprehensiveguide on the application of the revisedCOP 26, together with training for staffin its application and the desiredoutcomes. The report also recommendedthat HMRC develop feedbackmechanisms to enable staff to learn fromcomplaints about the unreasonableapplication of COP 26, and that HMRCensure that proper consideration is givento the impact of recovery decisions onthe individuals and families concerned.The Government accepted allrecommendations in the report and istaking action to implement them. A keyimprovement is the revision of COP 26to better reflect the balance ofresponsibilities on both tax creditclaimants and HMRC. HMRC must nowtake responsibility for acting promptlywhen told of a change in claimants’circumstances and for correcting errorsnotified to it, as in the case of Mrs K.HMRC has shown a clear will to improvethe experience of people claiming taxcredits, especially among the mostvulnerable groups. We hope this will leadto a significant reduction in cases beingreferred to the Ombudsman forinvestigation in the future.Mrs K received tax credits as a single person from 6 April 2003.On 20 June she told HMRC that Mr K had been living with her sincethe start of the tax year. HMRC sent her an award notice in Juneshowing that she was not entitled to tax credits for 2003-04 on hersingle claim. The notice incorrectly said Mrs K had no qualifyingchildren. When she queried that, HMRC told her to ignore thenotice. For the same reason, Mrs K ignored a notice received in Julywhich again said she had no qualifying children (and which said shehad been overpaid £1,673.57 on her single claim).In August 2003 HMRC awarded Mr and Mrs K tax credits for2003-04 on their joint claim. Mrs K’s previous weekly paymentshad been higher and so she assumed that HMRC had taken anycorrective action needed over her single award. The award noticedid not mention the overpayment. In June 2004 HMRC finalisedMr and Mrs K’s 2003-04 joint award, and paid arrears. It did nottell Mrs K about the outstanding overpayment. In NovemberHMRC finalised Mrs K’s single claim; the resulting award noticesaid she had not been entitled to tax credits from 6 April to20 June 2003, but did not mention the overpayment.In February 2005 Mrs K received a notice about her 2003-04single award which said she owed £1,673.57. She contacted HMRC,which said it had mistakenly added ‘responsibility end’ dates forher children. It said that once the dates were removed, she wouldno longer have the overpayment, or else only a small one causedby the payments HMRC had made to her after June 2003. Thatinformation was incorrect. Mrs K complained to the Ombudsmanthat HMRC had delayed telling her about the overpayment, whichshe said should have been deducted from the joint award arrears.She said that repayment would cause her financial hardship.We upheld Mrs K’s complaint. Legally, HMRC cannot offsetsingle award overpayments against joint award arrears, but Mrs Kdid not know that and understandably assumed that she owedHMRC nothing when arrears on the joint claim were paid. HMRCdid not inform Mrs K of the overpayment until February 2005.We were satisfied that it was reasonable for her to have thoughtthat her award was correct before then. HMRC misadvised Mrs Kin March 2005: removing the responsibility end dates wouldhave had no impact, and she had not received any payments onher single award after reporting that Mr K had moved in with her.HMRC agreed to remit the overpayment, and offered Mrs K aconsolatory payment of £50 for the unnecessary worry anddistress it had caused her.20

Parliamentary and health service ombudsman annual report 2007-087Case StudyCessation of bank paymentsleft income support claimantshort of foodMr L wrote to Jobcentre Plus on 11 February 2006 asking that themeans by which his income support was paid be changed frompayment direct into a bank account to payment by cheque. Heinstructed his bank to close his account and destroyed his bankcard. Jobcentre Plus did not receive Mr L’s letter until 14 February,by which time it had paid his weekly payment for 13 February intohis bank account. On receipt of Mr L’s letter, Jobcentre Plussuspended his payments, waiting for him to say if he was goingto open a new bank or Post Office account.When the next benefit payment did not arrive as expectedMr L contacted his MP (he said he did that because in the pastJobcentre Plus had ignored some of his letters until the MP hadbecome involved). The MP contacted Jobcentre Plus, which liftedthe suspension and sent Mr L a cheque for his missing payments.Jobcentre Plus apologised to Mr L and said that a consolatorypayment would be considered. The referral for a consolatorypayment included a letter from Mr L to his MP, in which hedescribed the effects of being without income support: he hadno electricity and hence no heat, light or hot water. He was alsounable to afford food. Jobcentre Plus accepted thatmaladministration had interrupted Mr L’s benefit payments,but concluded that the degree of inconvenience caused did notwarrant compensation. It also took account of the fact that Mr Lhad not contacted it about the payment problem, but insteadhad approached his MP. Mr L complained to the Ombudsman thatJobcentre Plus had left him without payment for three weeks, forwhich it had apologised but refused to give compensation.We partly upheld the complaint. It was maladministrative ofJobcentre Plus to stop paying Mr L’s benefit into his bank accountbut not to start paying it by cheque. It was not at fault, however,for making the 13 February payment direct into Mr L’s bankaccount, as it had not yet received his request to change thepayment method. It was reasonable, given Mr L’s history ofinteraction with Jobcentre Plus, for him to have initially sought hisMP’s help. For its part, Jobcentre Plus paid insufficient attentionto the facts of Mr L’s deprivation when considering theconsolatory payment.Jobcentre Plus reconsidered its decision and awarded Mr L £400for inconvenience and distress. It also agreed to apologise to himfor not making a payment in the first place. Jobcentre Plus alsoundertook to reply promptly to any future correspondence fromMr L in line with its service standards.Department for Work andPensionsWe reported on 98 cases relating to 118complaints against DWP and its agencies,including 7 relating to the handling ofcomplaints by DWP’s Independent CaseExaminer (ICE). We welcomed theextension of ICE in 2007 to include allof DWP’s customer-facing agencies,a change which the Ombudsman hasbeen calling for since 2003.As in previous years, two themes runningthrough our DWP casework in 2007-08were mistakes or shortcomings in theadministration and allocation of benefits,and failings in the handling of resultantcomplaints. In the case of Mr L, JobcentrePlus changed the method of benefitpayment at Mr L’s request, but then lefthim without benefits for three weeks,leading to significant hardship. Whenhe complained, it refused to make aconsolatory payment.21

In the case of Mr J, Jobcentre Plus tookfour and a half months to process aclaim for incapacity benefit. Whenhe complained, it awarded him £50but refused to award him interest onhis delayed payments because of anarbitrary rule on when interestcalculations should begin.Complaints are often triggered by a lackof co-ordination between different partsof the body complained against. AfterMr P’s wife died in 2003, his daughterenquired on his behalf to Jobcentre Plusabout the possibility of help with funeralpayments. Social fund staff correctly toldher that he was not eligible for a socialfund payment, but failed to inform herthat he could claim a payment from thebereavement benefit team.8Case StudyInflexible application ofincapacity benefit interestrule was unfairMr J claimed incapacity benefit in January 2006. Although therewas a complication with his National Insurance contributionsrecord, Jobcentre Plus was aware of the problem and had beentold by HMRC how to resolve it. That complication should nothave added more than about two to three weeks to the timetaken to decide Mr J’s claim, but Jobcentre Plus took four anda half months to decide it.After Mr J complained to Jobcentre Plus about the delaydeciding his claim, it offered him a £50 consolatory paymentfor inconvenience but no interest to compensate for the delayin receiving incapacity benefit payments. The decision not tomake an interest payment was based on guidance which said thatno interest was payable for an initial period (‘indicator of delay’),and that no payment would be made if the interest calculatedwas less than £10. In Mr J’s case, incapacity benefit had an‘indicator of delay’ of four months; therefore, the interest wasonly calculated for half a month. The amount calculated (£3.98)was less than £10 and so nothing was payable. Mr J complainedto the Ombudsman that that was unfair and indicated anunreasonably low expectation of service level.We upheld Mr J’s complaint. The calculation of interest fromfour months after he had claimed incapacity benefit was arbitrary,and we recommended that Jobcentre Plus recalculate the interestfrom a date appropriate to the circumstances of the case. Basedon the average time taken to clear incapacity benefit claims atthat time and the particular complication that affected Mr J’sclaim, Jobcentre Plus agreed to start its interest calculations fromsix weeks after the date of his claim. He was awarded £14.96 ininterest. We also considered that £50 was inadequate for theinconvenience Mr J had suffered and Jobcentre Plus agreed toaward a further £100.22

Parliamentary and health service ombudsman annual report 2007-089Case StudyFailure to refer widower forbereavement interview preventedbenefit claimMr P’s wife passed away suddenly in November 2003. Hisdaughter (Mrs Q), who had also been Mrs P’s carer, telephonedher local Jobcentre Plus office to report the death, and to askif her father was entitled to any help with funeral costs. Shewas put through to the social fund team who told her, correctly,that her father was not entitled to a funeral payment from thesocial fund. She accepted what she was told and made nofurther enquiries. Some 18 months later Mr P was told by arecently bereaved friend that he could have been eligible fora bereavement payment (but by then he was out of time tomake a claim).Mr P asked Jobcentre Plus to review his case. It interviewedhim and Mrs Q about the advice they had been given in 2003,but refused his request for a special payment. Mr P thencomplained to the Ombudsman; he said he had found it difficultto cope financially following the death of his wife, and the lackof a bereavement payment had added to his distress andcaused him avoidable inconvenience.We upheld the complaint. Although the social fund officer’sresponse was correct, it was maladministration not to havesignposted Mrs Q to the bereavement benefit team, whocould have told her about a bereavement payment. We alsofound that Jobcentre Plus was maladministrative in not actingon the notification of death and not offering Mr P abereavement interview, which was normal practice. Weconcluded that the guidance according to which the officerswere operating restricted their ability to provide a joined-upservice to customers, and had led to injustice for Mr P.We recommended that Jobcentre Plus apologise to Mr P,award him an extra-statutory payment of £2,000 in respectof the bereavement payment plus interest (£293.28) and aconsolatory payment of £200. Jobcentre Plus agreed to do so.During the course of our investigation, Jobcentre Plus revisedits guidance so that the relevant sections on funeral paymentsfrom the social fund and bereavement payments cross-referenceeach other.23

10Case StudyFailure to address maintenancearrears led to financial hardshipAs in previous years, a high percentageof complaints against DWP in 2007-08related to the Child Support Agency –although the number of complaintsaccepted for investigation was downto 18 from 68 in 2006-07. This decreasepartly reflects our decision to take a morestrategic approach and accept only themost appropriate cases for investigation.There have also been some signs ofprogress in complaint handling at theAgency, coinciding with the extendedremit of ICE last year. The Agency has alsopublished clear written guidelines in theleaflet How do I complain about theservice I get from the Child SupportAgency?. If we receive a new complaintabout the Agency, we check whether ithas been through the various stages ofthe Agency’s complaints procedure, andin particular whether it has been throughICE. If it has not, then we generally referthe complaint to ICE.Notwithstanding these improvements,we are still investigating cases thathighlight serious administrative failingsin past years. An example is the case ofMiss D. The Agency allowed significantarrears of child maintenance to build updespite repeated requests from Miss Dto resolve the problem. We note thatadministrative failings such as these arebeing addressed in the current reformof the child maintenance system with theestablishment of the Child Maintenanceand Enforcement Commission.Miss D complained that since December 2003 the ChildSupport Agency (the Agency) had failed to reassess childmaintenance on three occasions, which led to a build upof arrears. She also complained that the Agency failed to takeadequate action to collect the arrears from the non-residentparent. (By November 2006 the outstanding maintenancearrears owed to Miss D were £10,229.90.) She sufferedinconvenience and financial hardship.We upheld Miss D’s complaint. The Agency delayed acting on,or failed to act on, three specific requests by her for it to reassessthe maintenance liability, following changes in the non-residentparent’s circumstances. On the occasions the Agency did reassessthe maintenance liability of the non-resident parent it did notask him to make any payments towards the arrears. In 2006 thenon-resident parent appears to have gone abroad and so wasout of the Agency’s jurisdiction.In the light of the evidence that the non-resident parent hadalways paid the amounts of maintenance that the Agency haddemanded from him and had continued to pay maintenance fora period after its jurisdiction had ended, we found that he wouldhave made the payments towards the arrears that the Agencyhad failed to pursue effectively. However, there was insufficientevidence that the Agency could have secured more than the£30 per week interim maintenance assessment that he paid afterbecoming self-employed in July 2005.Miss D lost the opportunity to receive the maintenance she wasdue. At our recommendation, the Agency agreed to make her anexceptional advance payment of £6,480.16 for the arrears that ithad failed to pursue effectively. It also made an additionalconsolatory payment of £70 (on top of £220 it had alreadyawarded earlier for delays she had suffered) in respect of delaysin assessing and collecting arrears after Miss D’s first review requestand for the inconvenience of having to pursue her complaintthrough us.24

Parliamentary and health service ombudsman annual report 2007-08Occupational pensionsTrusting in the Pensions PromiseAs was reported last year, theOmbudsman’s March 2006 report onthe role of government bodies in thesecurity of final salary occupationalpension schemes led to judicial reviewproceedings brought by four complainantswho were unhappy with the Government’srejection of the findings and most of therecommendations contained in ourreport. As directed by the High Court inits judgment on those proceedings, theSecretary of State for Work and Pensionsreconsidered the Ombudsman’s centralrecommendation – that the Governmentconsider whether it should makearrangements to restore the full pensionentitlements of those who had lost allor most of their pensions when theirscheme wound up.As a result, on 17 December 2007 theSecretary of State announced that theGovernment had decided to extendthe scope of the Financial AssistanceScheme. The aim of the Government’sproposals was to give to all those wholost their pensions through no fault oftheir own, including members of solventemployer schemes, benefits that werebroadly equivalent to those availableunder the Pension Protection Fund.These changes both greatly improvedthe compensation available and alsoextended it, beyond those membersof insolvent employer schemes whowere within fifteen years of retirement,to all those who have lost their pension.The relevant legislation to effect thesechanges is now in place. We understandthat payments are now being made tosome of those previously excluded fromthe Financial Assistance Scheme.The Ombudsman welcomed thisannouncement, which constitutes fullcompliance with the key recommendationmade in our report and which remediesthe deficiencies in the Financial AssistanceScheme that were also identified in thatreport. The Public Administration SelectCommittee, in its Annual Reportpublished on 17 January 2008, said thatthis ‘represents a real achievement forthe Parliamentary Ombudsman, thetireless campaigners, and the politicalprocess as a whole’.As was also reported last year, aspectsof the judgment of the High Court inthe judicial review proceedings were thesubject of appeal proceedings, in whichthe Ombudsman played an active part.On 7 February 2008 the Court of Appealhanded down its judgment, holding that,while the Ombudsman’s findings were notbinding on the public bodies within herjurisdiction, the relevant body must eitheraccept such findings or establish cogentreasons for not doing so.The special relationship between theOmbudsman and Parliament was alsounderlined within the judgment, whichsaid that ‘the work of the ParliamentaryOmbudsman generally was both highlyvalued and entitled to respect’. Inaddition to assisting Parliament in holdingthe Executive to account, the role of theOmbudsman was said to be ‘vigorouslyto alert Parliament to an injustice whichhas occurred through maladministration’.25

Home OfficeBorder and Immigration AgencyWe reported on 52 complaints about theBorder and Immigration Agency (now theUK Border Agency) in the year.In conjunction with the Government’sGreen Paper The Path to Citizenship,the Agency published a series ofconsultation questions in February 2008on reforming the immigration system.While the specific questions did not fallwithin the remit of the Ombudsman, shedid respond with some generalobservations and recommendationsabout the need to simplify the system.The Ombudsman welcomed theGovernment’s aim of simplifying the legalframework for immigration. She has longbeen concerned that asylum seekers andimmigration detainees do not have accessto clear and comprehensive informationabout the avenues of complaint that areavailable to them in the UK. This problemis often compounded by flawedprocesses, avoidable delays and systemicfailings as the case studies of Ms H, Mrs Fand Mr E amply demonstrate.In responding to the consultation, theOmbudsman emphasised the need tokeep in mind two key principles: the needfor good administration and the need forgood complaint handling. She noted thatthe Green Paper states that simplificationis important in helping to increase theefficiency of the decision-making process,thereby reducing delay and the risk ofmistakes. While agreeing with this, sheemphasised the need to have a goodcomplaint handling system in place todeal with mistakes when they do happen,and stressed that effective complainthandling will help increase publicconfidence in the system.11Case StudyBorder and Immigration Agencytook five months to correctsimple mistakeMs H applied for indefinite leave to remain in January 2005.The Border and Immigration Agency (the Agency) granted leavein August 2006, and despatched the status documents to Ms Hon 5 October. Ms H promptly returned them to the Agency’sCroydon office, as it had attached her residence permit to herdaughter’s immigration status document and vice versa. She saidthat her cancelled travel document had not been enclosedalthough the covering letter had said that it was. The Agencyreceived the package on 11 October and sent it to its Liverpooloffice. No note was made of its arrival.Ms H asked her MP for help and on 4 January 2007 the MP’soffice told the Agency that Ms H urgently needed her statuspapers. The Agency could not find Ms H’s papers and conducteda search. It requested permission to destroy the original statusdocuments unseen so that replacements could be issued.Permission was granted and corrected documents were issuedto Ms H on 5 March.Ms H complained to the Ombudsman about the Agency’s delayin ruling on the leave applications, the time taken to correct themistake over the status papers and the failure to return hercancelled travel document. She said she had sufferedinconvenience and distress, her studies had been disrupted (shecould not enrol for a particular course as she had neither herpassport nor status papers), and she was concerned that she mighthave problems in future obtaining a new travel document as shecould not produce her previous one.We upheld Ms H’s complaint. At the time of her application,the Agency had received a number of similar applications, whichcaused delay. Her file was twice sent to storage before a decisionhad been made and it was not allocated to a caseworker untilsome 19 months after the Agency had received it. The Agency’smistake over the status papers was unfortunate and did notamount to maladministration, but it handled matters poorly afterthat. It received the incorrect status papers, but what happenednext is unclear since there was no record of their arrival inLiverpool. The Agency only took meaningful action when Ms H’sMP stressed the urgency of her case and took five months tocorrect a simple mistake.The Agency apologised to Ms H for its mistakes and awardedher £200 in recognition of the inconvenience caused. It acceptedit had mislaid her cancelled travel document, and confirmed thatin writing. (The letter will enable Ms H to prove why she no longerhas her old travel document).26

Parliamentary and health service ombudsman annual report 2007-0827

Parliamentary and health service ombudsman annual report 2007-0812Case StudyDelay processing applicationcaused woman to miss a funeraland weddingIn June 2004 Mrs F and her husband applied for leave for herto remain in the UK on the basis of her marriage to a UK resident.In June 2005 Mr F wrote to tell the Border and Immigration Agency(the Agency) that Mrs F needed to travel abroad as his father hadrecently died. The Agency received the letter but took no action.Nor did it respond to letters it received in February andMarch 2006 from Mrs F’s solicitors querying the delay processingthe application. Throughout July the solicitors sent furtherletters of complaint about the delay and requests for a reply.On 14 August the solicitors told the Agency that unless Mrs F’sapplication was decided by 3 September, they would refermatters to the Ombudsman.The solicitors and the Agency continued to exchangecorrespondence. In a letter dated 12 October, the solicitorscomplained that Mrs F’s application had been handled appallingly.They said she had made plans to travel to Nigeria for urgent familyreasons by 15 December and asked that her application be dealtwith immediately. On 20 December the Agency noted that itwas unable to make a decision because her application form anddocuments, including both her and her husband’s passports, werenot on the file.Mrs F complained to the Ombudsman in January 2007 that thedelays deciding her application for leave had led to her missinga funeral and her sister’s wedding. Furthermore, the Agency hadnot responded to her solicitors’ letters and had lost her passportand other documents. In June 2007 the Agency granted Mrs Ftwo years’ leave to remain as a spouse of a UK resident.We upheld Mrs F’s complaint. The Agency took no substantiveaction on her application between July 2004 and February 2007;it lost Mr and Mrs F’s passports and other documents; and did notrespond to the solicitors’ correspondence. The Agency offeredMrs F consolatory payments totalling £250 for the delay and failureto reply to her solicitors’ correspondence, and a further £1,250 forMr and Mrs F being unable to attend the funeral. The Agencyagreed to compensate them for the cost of replacing theirpassports, and to make a consolatory payment in respect ofhaving missed the wedding, on receipt of suitable supportingevidence. It agreed to apologise to Mrs F for its failings.29

13Case StudyMishandled correspondenceand delay caused stress andinconvenienceMr E entered the UK in June 2004 and claimed asylum. TheBorder and Immigration Agency (the Agency) refused his asylumclaim, but as an unaccompanied minor it granted him discretionaryleave to remain in the UK until his 18th birthday in April 2005.On 1 April 2005 solicitors wrote to the Agency on Mr E’s behalfto claim asylum, and on 6 April they applied to extend hisdiscretionary leave to remain. The Agency did not acknowledgethat application. In May the solicitors asked the Agency toacknowledge the application and for an indication of how longthe application would take to process. The Agency replied thatMr E’s file was in a queue waiting for an asylum interview tobe arranged. The solicitors say they did not receive this letter.In January and February 2006 the solicitors twice wrote to theAgency asking it to issue Mr E with a replacement ApplicationRegistration Card (which he had lost) or to interview him. TheAgency did not reply to either letter. In June the solicitorscomplained to the Agency about the delay deciding theapplication, and its failure to confirm that the conditionsattached to the previous grant of leave would continue whileit considered the application. The Agency placed the letteron file unactioned because it was not addressed to its complaintsunit. Two further letters of complaint went unanswered.Mr E complained to the Ombudsman about the Agency’s delayin deciding his application of 6 April 2005 and failure to providea written acknowledgement. He said the uncertainty about hisimmigration status had led to anxiety and mental health problems,and inconvenience dealing with organisations such as collegesand housing providers. We put Mr E’s complaint to the Agency,which decided, in light of its mishandling of the correspondence,to interview him and decide his application earlier than wouldhave otherwise been the case. Mr E’s application was refusedin March 2007.We upheld Mr E’s complaint. The Agency did not acknowledgehis application, so he could not prove he was in the UKlegitimately, and took nearly two years to decide the application.It failed to respond to complaints and important correspondencerelating to someone in a vulnerable situation. The Agencyapologised to Mr E and offered a consolatory payment of £150in recognition of the stress and inconvenience caused. Weaccepted that this was a reasonable remedy because we did nothave evidence to support the full extent of the injustice claimedby Mr E.30

Parliamentary and health service ombudsman annual report 2007-08Other Departments –Special reports to ParliamentMinistry of Defence‘A Debt of Honour’As was also reported last year, theGovernment eventually accepted andimplemented all of the Ombudsman’srecommendations contained in ourJuly 2005 report ‘A Debt of Honour’,which concerned the administrationof an ex gratia scheme for those Britishgroups who had been interned by theJapanese during the Second World War.The scheme has now been reviewed,the eligibility criteria revised, andcompensation payments have been paidas a result both of the Ombudsman’sreport and of the outcome of courtproceedings in relation to allegations ofrace discrimination in the administrationof the scheme and in the application ofits eligibility criteria.However, we continue to receiveenquiries and complaints from peopledissatisfied with these outcomes. Someof those enquiries and complaints raisenew issues about the way in which thescheme now operates or about howdecisions about eligibility for theassociated new compensation paymentsare being made.The Ombudsman remains concerned thatoutstanding issues remain to be resolvedregarding the appropriate scope for thescheme and that complaints continue tobe made about it.We will continue to monitordevelopments and the Ombudsmanenvisages that further dialogue with theMinistry of Defence might be necessaryin respect of these outstanding issues.Department for Business,Enterprise and Regulatory ReformPut together in haste: ‘Cod Wars’trawlermen’s compensation schemeThe Ombudsman’s report of herinvestigation into the Icelandic WaterTrawlermen’s Compensation Scheme,Put together in haste, was published inFebruary 2007 and contained fiverecommendations, all of which wereaccepted by what was then theDepartment for Trade and Industry. TheDepartment took action to comply withthe first and fifth recommendations.However, it has yet to comply with thesecond recommendation that it shouldundertake a review – which it said at thetime it intended to start immediately – ofthe eligibility criteria and scheme rules toensure that they were consistent with thepolicy intention underlying the scheme.The third and fourth recommendationscannot be implemented until the reviewhas taken place.The Ombudsman has been concernedfor some time about the extremelyslow progress in complying with herrecommendations and in May 2008 shewrote to the Permanent Secretary (atwhat is now the Department for Business,Enterprise and Regulatory Reform) toexpress her growing concern. In response,the Permanent Secretary has told theOmbudsman that the Department hasalmost completed its analysis of the bestway forward in relation to the scheme;and that, whilst it recognises that thishas taken a considerable time, this is anextremely complex matter and it isimportant to get it right. The Departmenthopes that Ministers will be in a positionto make a statement on the schemein October.The Ombudsman will continue tomonitor the situation closely and willreport further to Parliament if necessary.Department for Environment,Food and Rural AffairsThe introduction of the banon swill feedingIn December 2007 we published thereport of our investigation into acomplaint by the Associated Swill Usersagainst the Department for Environment,Food and Rural Affairs about the ban onswill feeding introduced after theoutbreak of foot and mouth disease in2001. Although the complaint was notupheld, the Ombudsman decided thatthe report should be put into the publicdomain because of the level of interestin the subject matter, and in particularthe link to the outbreak of foot andmouth disease.Since the report’s publication, theDepartment’s Permanent Secretaryhas written to describe the analysisand recommendations in the reportas ‘very useful’ in informing thedevelopment and strengthening of theDepartment’s business systems, and tooutline improvements both tomanagement and storage of data andto the keeping of records of key advicesupporting changes in legislation.Her Majesty’s Treasury (et al)Equitable Life: a decade ofregulatory failureWork continued throughout 2007-08on the investigation into the prudentialregulation of Equitable Life during theperiod prior to 1 December 2001. TheOmbudsman’s report of the investigationwas laid before Parliament and publishedin July 2008. The report can be found onour website at www.ombudsman.org.ukWe await the Government’s responseto the report and the Ombudsman willdo everything she can to assist Parliamentin its consideration of the report and ofthe Government’s response to it and alsoto assist the European Parliament in itsfurther consideration of the same issues.31

Parliamentary and health service ombudsman annual report 2007-08The National Health ServiceIn 2007-08 we received 4,011 enquiries related to 4,257complaints against the National Health Service.We accepted 703 cases for investigation and reported on 636investigations. 49% of complaints were upheld in full or in part.In addition to our casework, a major focus in 2007-08 wason preparing for our role in the new NHS system for handlingcomplaints, which begins in April 2009.EnquiriesFigure 4 shows the top ten types ofhealth body and individuals complainedabout. Under the current NHS complainthandling arrangements most healthcomplaints should come to us after theyhave been considered by the HealthcareCommission – so it is no surprise thatover 40% of health-related complaints –1,832 – were about the Commission.InterventionsThere is a growing category of complaintswhere we seek to achieve resolutionwithout recourse to full investigation.We call these ‘interventions’ and weclosed a number of cases in this wayduring 2007-08. In case study 14, Mr C’sfour-month wait for a medicalappointment was ended promptlyby our intervention.Figure 4Top 10 types of health body or individual complained about(apart from the Healthcare Commission)NHS Hospital, Specialist andTeaching Trusts (Acute)Received715Primary Care Trusts 442General Practitioners 360Strategic Health Authorities 314Foundation Trusts 242Mental Health, Social Care, Learning DisabilityNHS TrustsGeneral Dental Practitioners 144Ambulance Trusts 16152Care Trusts 12Special Health Authorities 1233

14Case StudyabcIntervention ended wait for footappointmentMr C complained first to the Healthcare Commission and thento the Ombudsman about the fact that he would have to waitfour months for an appointment with a podiatrist (four monthswas the average waiting time for routine podiatry care). During ourconsideration of Mr C’s complaint, we contacted Brent TeachingPrimary Care Trust to explain his ongoing concerns and to askwhen he was likely to receive an appointment with the podiatrist.As a result of that intervention, the Trust contacted the SeniorPodiatrist who agreed to contact Mr C by telephone on a specificdate to offer him an appointment.InvestigationsFormal investigations involve detailedand thorough examination of the factsof a case. They often run to months, oroccasionally years, of work. They are alsoin a minority, because most complaintsreferred to us are not consideredappropriate for full investigation.We accepted 703 cases for investigationrelating to 737 complaints. 70 of thesecases related to continuing care.Figure 5 shows the number of complaintswe accepted for investigation by typeof NHS body or individual, except for theHealthcare Commission (624).We reported on a total of 636investigations in 2007-08, of which 93were about continuing care. Overall,we upheld 38% of complaints in fulland partly upheld a further 11%, althoughwe upheld, in full or in part, 56% ofcontinuing care complaints. Figure 6shows the number of complaints wereported on by type of NHS bodyor individual, and the outcomes ofthose complaints.Figures 20, 21 and 22 in Chapter 4 ofthis report give full details of all ourinvestigations of complaints about NHSbodies and individuals and theiroutcomes, broken down by StrategicHealth Authority area. There are separatetables for continuing care complaints,other complaints, and all healthcomplaints because continuing care caseswere still a substantial component of ourwork in 2007-08. Further detail oncontinuing care cases is given on page 45.34

Parliamentary and health service ombudsman annual report 2007-08Figure 5Health complaints accepted for investigation by type of bodyor individualAccepted forinvestigationStrategic Health Authorities 70NHS Hospital, Specialistand Teaching Trusts (Acute)13Primary Care Trusts 12Foundation Trusts 8Mental Health, Social Care, LearningDisability NHS Trusts5General Practitioners 5Figure 6Health investigations reported on by type of body or individualReportedonFullyupheldPartlyupheldNotupheldHealthcare Commission 508 35% 10% 55%Strategic Health Authorities 93 52% 4% 44%General Practitioners 21 24% 29% 48%NHS Hospital, Specialistand Teaching Trusts (Acute)21 43% 24% 33%Primary Care Trusts 19 37% 32% 32%Foundation Trusts 18 50% 17% 33%Mental Health, Social Care, Learning Disability NHS Trusts 4 25% 25% 50%General Dental Practitioners 2 100% 0% 0%Ambulance Trusts 1 100% 0% 0%Total 687 38% 11% 51%35

Individual and public benefitOur health work during 2007-08 clearlyillustrated the dual aspect of theOmbudsman’s role in achieving remedyin individual cases, while also providingwider public benefit. This wider benefitstems from the effective use of ourevidence base and our expertise inproviding a high quality complainthandling service, together with anacknowledged reputation forindependence and impartiality. Thisenables us to provide expertise in goodadministration and good complainthandling, drive improvements in thedelivery of healthcare and informpublic policy, demonstrating that theOmbudsman not only provides aretrospective remedy for injustice orhardship resulting from maladministrationor service failure, but also seeks to secureprospective improvements in the widerpublic interest.In addition to our casework, a major focusin 2007-08 was on preparing for our rolein the new NHS system for handlingcomplaints, which begins in April 2009.In March 2005 we published MakingThings Better? A report on reformof the NHS complaints procedurein England. This informed a Departmentof Health consultation paper, MakingExperiences Count, a new approach toresponding to complaints, published inJune 2007, which set out proposals forimproving and integrating the handling ofcomplaints about health and social care.Now, the Department has developed anew system for handling complaints,which will launch in April 2009. We fullysupport these new arrangements, whichwe believe will enable complaints againstthe NHS to be dealt with more quickly,efficiently and fairly. We say more aboutthe new arrangements on page 39.A Framework of PrinciplesAfter wide consultation, in October 2007we published our Principles for Remedy,which offer complementary guidance toour Principles of Good Administration,published in March 2007. The Principlesfor Remedy follow the same six Principlesas our Principles of Good Administration:• Getting it right• Being customer focused• Being open and accountable• Acting fairly and proportionately• Putting things right• Seeking continuous improvement.Principles for Remedy gives our viewof the Principles that should guide NHSbodies and individual practitioners inproviding remedies for injustice resultingfrom their maladministration or servicefailure. We want NHS bodies andindividuals to be fair and takeresponsibility, acknowledge failures andapologise for them, make amends and usethe opportunity to improve their services.During 2007-08 we developed the thirdin our series of Principles, which we havebeen consulting on in recent monthsand will publish in autumn 2008. OurPrinciples of Good Complaint Handlingare based on the same six core Principlesas our Principles of Good Administrationand Principles for Remedy. With them weaim to ensure that NHS bodies andindividuals understand how we expectcomplaints to be handled, and thatcomplainants understand how we willconsider their cases. As with the existingPrinciples, we hope that they will proveuseful to both complaint handlers andcomplainants.Poor complaint handling by NHS bodiesand individuals was a recurrent themeacross our health investigations in 2007-08,and one we refer to frequently in thepages that follow. Often, the failure toprovide an adequate remedy is an elementof poor complaint handling, and is asignificant factor in the complainant’sdecision to refer the complaint to usfor investigation, as in the followingtwo examples.Poor complaint handlingIn the case of Mr P an NHS Trust (theTrust) failed to explain adequately whyit refused to respond to two complaintshe made on behalf of a friend sufferingfrom Alzheimer’s disease. Nor did theTrust demonstrate that it had consideredthe NHS (Complaints) Regulations or therelevant legislation in reaching its decision.36

Parliamentary and health service ombudsman annual report 2007-0815Case StudyPatient confidentiality was noreason to withhold responseIn October 2006 Mr P made two complaints to Bedfordshireand Luton Mental Health and Social Care Partnership NHS Trust(the Trust) on behalf of his friend of many years, Mr T, who suffersfrom Alzheimer’s disease and so was unable to make thecomplaints himself. Mr P’s complaints were about the care andtreatment provided by the Trust to his friend, and about thesuitability of a nursing home, which Mr P believed was contraryto Mr T’s best interests and against his wishes. The Trust toldMr P that they could not respond to his complaints, citing theneed to protect patient confidentiality and the Data ProtectionAct, but would take up the matters he had raised with Mr T’s sister,as next of kin.Mr P complained to the Ombudsman that the Trust’s refusal torespond to his complaints meant his concerns about Mr T’s careand treatment remained unanswered. We upheld Mr P’s complaint.While patient confidentiality is a legitimate consideration whendeciding whether a representative is a suitable complainant, theTrust did not adequately explain to Mr P why it should not respondto his complaints. Nor did it demonstrate that it had adequatelyconsidered the NHS Complaints Regulations or the relevantlegislation in reaching its decision. We found no evidence that theTrust had established whether Mr T was capable of providingconsent for the release of confidential information to Mr P, orconsidered if Mr T had given implied consent to release. There wasno evidence that the Trust had considered whether there was anyoverriding public interest reason for disclosing information to Mr P,or if any aspects of his complaint could be responded to withoutreleasing confidential information.The Trust agreed to apologise to Mr P for the failings we hadidentified and to reconsider his request to bring a complaint onMr T’s behalf, taking account of the issues we had raised in ourreport (in particular the need to provide Mr P with written reasonsfor its decision).37

16Case StudyComplaint about cancertreatment was not properlyhandledIn 2000 Mrs S’s husband was diagnosed with prostate cancer andhad radical surgery. Although the surgery was performed privately,the majority of his pre- and post-operative care was provided bythe University Hospitals of Morecambe Bay NHS Trust (the Trust).Serious post-operative complications necessitated furtheroperations and a long stay in hospital. Mrs S considered that herhusband had been poorly advised about treatment options andshe complained to the Trust. An Independent Review Panel (thePanel) considered her complaint and made severalrecommendations, some of which related directly to the clinicalpractice of the Consultant Urologist responsible for Mr S’s care.Mrs S complained to the Ombudsman that the Trust had notdone more to resolve her complaint prior to the Panel, and hadfailed to inform her of the action it had taken, or planned to take,to implement the Panel’s recommendations.We upheld Mrs S’s complaint. She did not receive an adequateresponse to her complaint in a timely manner. The Trust did notoffer her a meeting to discuss her concerns, and failed to bring thelocal resolution phase of the NHS complaints procedure to an endto allow her to escalate her complaint. It also allowed all aspectsof Mrs S’s complaint to be investigated under the NHS complaintsprocedure, when it knew that some of her concerns about theConsultant’s practice needed to be reviewed through a differentprocess. The Trust failed to give Mrs S details of the action it hadtaken, or planned to take, to implement the Panel’srecommendations, or reassure her that it was taking appropriateaction to implement them. She was left feeling that she had noother recourse than to approach the Ombudsman and theGeneral Medical Council to resolve her complaint.The Trust agreed to apologise to Mrs S for the failings we hadidentified and to send her details of the action taken toimplement the Panel’s recommendations that did not relate to theConsultant’s personal practice. It also agreed to use the case as alearning opportunity to assist it when considering what parts ofa complaint should be investigated under the NHS complaintsprocedure, and to make a payment to Mrs S of £500 in recognitionof the worry and distress its poor complaint handling had caused.38

Parliamentary and health service ombudsman annual report 2007-08In the case of Mrs S, we found that thehospital where her husband was treatedfor prostate cancer failed to give anadequate and timely response to hercomplaint about his care. It also failedto inform her of the action it had takenin response to the recommendationsfrom an Independent Review Panel.A new approach to NHS complainthandlingThe Ombudsman has argued forimprovements in the NHS complaintsprocedure for many years and is pleasedto see the changes that will beintroduced from April 2009.Under the existing three stage system,the second stage is provided by thereview function of the HealthcareCommission, with a possible thirdstage when a case is referred to theOmbudsman. The new system will haveonly two stages: a complainant whoremains dissatisfied after a case has beenconsidered locally will be able to refer thecomplaint straight to the Ombudsman.These reforms should reduce delays forboth the complainant and the NHSservice provider, and deliver more timely,responsive and effective outcomes. Weare working closely with the HealthcareCommission to bring about a smoothtransition to the new system.A further objective of the new systemis to achieve greater alignment betweenthe NHS and the social care system.We are working closely with the LocalGovernment Ombudsmen to make surethat there is a fully integrated approachto complaints that cross boundariesbetween health and social care (seeInjustice in Residential Care, page 53).The new system will also enable patientswith complaints about primary careproviders (GPs, dentists, opticians andpharmacists) to complain directly to thePrimary Care Trust if they choose, ratherthan to the service provider. We knowthat for many patients, complaining toa practitioner with whom they have anexisting relationship can be difficult.The importance of local resolutionIn the short term we expect to seean increase in the number of enquirieswe receive and cases we accept forinvestigation under the new arrangements– and we are planning for that. In thelonger term we will want to see areduction in the number of complaintsreferred to us as a result of improvedcomplaint handling at local level.Complainants often comment to usabout the length of time it has takento get to the end of the existing NHScomplaints procedure. In many of thecases we investigate, delay is identifiedas a particular cause of complaint. It isnot uncommon for us to investigateevents that occurred two or three yearsago, because the cases have taken thatlong to reach the Ombudsman afterconsideration by the NHS.Our experience, supported by researchcommissioned by the Department ofHealth for its consultation paper MakingExperiences Count, makes clear thatcomplainants want their cases to beresolved quickly and close to source.Clearly, timely and effective localresolution of complaints should be theguiding principle for all bodies withinthe Ombudsman’s remit.39

17Case StudyTrust failed to update amputeeson service improvementsMany of the cases we investigated in2007-08 illustrated serious failings atlocal level. In the case of Mrs Y acomplaint about the prosthetic serviceprovided to amputees by her PrimaryCare Trust was upheld by an IndependentReview Panel. The Trust agreed to makeseveral changes to its procedures, butthen failed to keep Mrs Y informed abouttheir implementation.The need for local leadershipImproved local resolution of NHScomplaints will not come about withoutstrong leadership at a senior level in Trustsand General Practices. Board members,chief executives and senior practitionersneed to create a culture that welcomescomplaints and actively seeks to resolvethem, dealing with people fairly and beingwilling to learn from mistakes and servicefailures. Many of the cases of poorcomplaint handling that we investigateshow why this strong, focused localleadership is so necessary to driveimprovements. In each of these cases,strong local leadership, a culture ofopenness towards complaints and adetermination to put things right couldhave prevented distress to those involved.In the case of Mrs G we recommendedcompensation by the Trust and theHealthcare Commission following thepoor handling of a complaint about thecare and treatment of her daughter, whodied after surgery. We found that theTrust’s response to the Commission’srecommendations was inadequate, andthat its actions had caused Mrs G tosuffer further distress.Mrs Y, an amputee, was concerned about the prosthetic serviceprovided on the Isle of Wight, to the extent that she felt her carehad been seriously compromised. Her concerns included a lack ofprosthetic expertise, the lack of a consultant-led multidisciplinaryteam, and the availability of information, protocols or guidelinesaround treatment options. She made a complaint to the Isle ofWight Primary Care Trust (the Trust), which ended with anIndependent Review Panel in January 2005. The Panel found thatMrs Y’s complaint was justified and made several recommendationswhich the Trust agreed to implement. The Trust told Mrs Y thatit was committed to implementing the recommendations. It alsocarried out a Prosthetic Services Review.Mrs Y complained to the Ombudsman that although shehad contacted the Trust on a number of occasions, it had notadequately communicated with her about how it wouldimplement the Panel’s recommendations, and had given her noofficial reassurances that appropriate changes to the servicewould be made. She hoped that her complaint would lead toimprovements for amputees with complex needs living on theIsle of Wight.We fully upheld Mrs Y’s complaint. The Trust accepted it hadnot kept Mrs Y formally informed and updated about theimplementation of the Panel’s recommendations. Furthermore,Mrs Y’s complaint to the Trust had been made personally, andthe Trust had wrongly assumed that she had been kept updatedabout progress by the Artificial Limb User Group.The Trust gave us a copy of the Prosthetic Services Review reportand the Prosthetics Action Plan, which our advisers consideredcontained useful recommendations. The Trust also acknowledgedthe need to commission specialist mainland services for complexcases, such as that of Mrs Y, and told us that a meeting had beenheld with the staff of a specialist centre in Bournemouth.Arrangements for Mrs Y to be seen there were also progressing.The Trust agreed to apologise to Mrs Y for the failings we hadidentified, and to arrange a meeting with her to address anyremaining concerns that she had.We also investigated the case of Dr R,a GP who retired on health groundsafter a poorly handled investigation bytwo Trusts of a complaint against her.We recommended substantial financialcompensation by way of remedy, andshe received a total of £25,000.40

Parliamentary and health service ombudsman annual report 2007-0818Case StudyInadequate responseto recommendationsMs G was 42 when she had a stroke in February 2002 and wasadmitted to hospital. She had a pulmonary embolus (a blood cloton the lung) and was prescribed Warfarin (an anticoagulating drug)which was stopped after six months. Tests were carried out todetermine her blood clotting levels and to search for a patentforamen ovale (a hole in the heart).After review as an out-patient, Ms G was discharged from carebut was readmitted in August 2002 and was found to haveanother pulmonary embolus. She was referred for an MRI scanwhich was due to take place in March 2003 but, before thishappened, she moved house. She was subsequently diagnosedelsewhere as having pulmonary hypertension and a large patentforamen ovale. She was transferred to Papworth Hospital fortreatment but died shortly afterwards.Ms G’s mother, Mrs G, complained in November 2003 about thefailure to diagnose pulmonary hypertension at an earlier stage.Mrs G had a meeting with Trust staff in April 2004, but this failedto resolve matters. In September 2004 Mrs G complained to theHealthcare Commission, which took clinical advice from aConsultant Cardiologist, who found a number of failings in thecare provided to Ms G.In April 2006 Mrs G again complained to the Commission, whichsaid that the Trust had complied with most of its recommendations,but asked it to respond on the issue of the review of guidelinesfor management of pulmonary embolism. The Trust sent a furtherreply to Mrs G in June 2006 which made no acknowledgementor apology for the failings identified by the Commission.Mrs G complained to the Ombudsman in September 2006.The complaints investigated by the Ombudsman were thatthe Trust had failed to respond adequately to the Commission’srecommendations following its investigation, and the Commissionhad refused to take any further action despite that failing bythe Trust.We found that the Commission had carried out an appropriateinitial review of Mrs G’s complaint, but that the Trust’s responseto the Commission’s recommendations was inadequate. TheCommission had failed to properly consider Mrs G’s subsequentcomplaint about the Trust’s response. The Trust’s actions hadcaused Mrs G to suffer distress and delay in receiving theexplanation and response to which she was entitled.As a result of the Ombudsman’s recommendations, the Trustmade a payment of £500 to Mrs G in the light of the seriousfailings in its complaint handling and to recognise the additionaldistress caused to Mrs G following the Commission’s review.It acknowledged and apologised for the failure of care towardsMs G. It also acknowledged other failings in the conduct of thecase and offered explanations for these. The Commission wroteto Mrs G to apologise for the failings identified by our report.41

19Case StudyPoor complaint handlingled to GP’s retirement onhealth groundsOn 3 September 2002 an altercation occurred between Mrs B,Dr R and a nurse while Mrs B was attempting to register as apatient at the practice where Dr R worked. On 6 SeptemberMrs B wrote to the Chief Executive of Medway Primary Care Trust(Medway) to complain about Dr R. On 16 September Medwayasked Dr R to respond to Mrs B’s complaint letter and informedMrs B that she could request an Independent Review of hercomplaint if she was dissatisfied with the practice’s eventualresponse. Mrs B replied that she had already received a responsefrom the practice, which she felt was unsatisfactory. Medwaytold Mrs B that she now had the right to request an IndependentReview, but did not say they had already asked Dr R to responddirect to her.On 2 October 2002 Dr R replied personally to Mrs B’s complaint,apologising for the delay in responding, caused by her absence onleave, and setting out her view of the incident. After a conciliationprocess failed to resolve the complaint, Mrs B requested anIndependent Review of the case. Responsibility for arranging thiswas delegated to Kent Primary Care Agency, which operatedunder the management of the Dartford, Gravesham and SwanleyPCT (now West Kent PCT).The Independent Review Panel (the Panel) met in June 2003 andpartly upheld Mrs B’s complaint. It said that Dr R had not breachedher Terms of Service for General Practitioners, because Mrs B hadnot been registered with the practice. The Panel’s report notedthat the complaint arose out of Mrs B’s attempts to register, butnonetheless said that ‘such a complaint falls within the guidelinesof the Health Service’s Complaints Procedure’. Dr R’s mental statewas such that the day of the hearing was her last day in generalpractice. She took sick leave and was admitted in Septemberto a psychiatric hospital with bipolar disorder. She retired fromgeneral practice on health grounds in March 2004.Dr R complained to the Ombudsman in August 2003, wanting aninvestigation into the process that had led to the Panel sitting atall. She felt she had been the victim of a ‘witch hunt’ and said thatthe Trusts’ mishandling of the complaint against her had cost herher career, and significantly disrupted her personal and family life.Our investigation found that key documents had not been sentto Dr R in a timely manner and that Medway did not inform Dr Rthat they had told Mrs B that she could ask for a review despiteasking Dr R to provide a local resolution letter. Dr R’s letter toMrs B was unreasonably dismissed throughout the investigationbecause it arrived very slightly late, despite valid reasons for thedelay. Both Trusts repeatedly failed to answer Dr R’s reasonablequestions about whether they had considered her letter to Mrs B,and whether Mrs B was even entitled to pursue a complaint underthe NHS complaints procedure. The Trusts’ investigation lacked42

Parliamentary and health service ombudsman annual report 2007-08a sense of perspective and proportionality. It was driven purelyby process, with an absence of overall leadership and guidanceto determine whether the progress and direction of theinvestigation were appropriate to the nature of the complaint.We concluded our investigation in May 2007 and upheldDr R’s complaint.The two Trusts involved in the complaint agreed to pay the sumof £25,000 to Dr R to remedy the significant injustice to her, andto write personally to her to apologise for their failings. They alsoagreed to review their existing complaint handling procedures inthe light of our investigation.43

20Case StudySerious failings highlighted needfor review of careMr Z, aged 74, was admitted to Gloucester Royal Infirmary as anemergency in August 2002 with pneumonia. He was treated in theIntensive Treatment Unit until the end of August when he wastransferred to a respiratory ward. He later contracted MRSA,developed diarrhoea and was found to be infected with C.difficile.Mr Z was transferred to Standish Hospital at the start of October,where he suffered with recurrent C.difficile infection. Mr Z died inNovember 2002, with the cause of death noted as respiratory failure.Mrs A, Mr Z’s daughter, questioned whether the Trust’s actions hadcontributed towards his deterioration and death through failings inhis care and inadequate levels of hygiene. She also questioned theaccuracy of the death certificate. Mrs A believed that Mr Z had beencaused undue suffering and stress during his admission and that theirfamily had been caused unnecessary distress.Mrs A complained to Gloucestershire Hospitals NHS FoundationTrust (the Trust) in March 2003, which responded in July 2003.A local resolution meeting was held in August 2004. Mrs A wasunhappy with the action taken by the Trust and complained tothe Healthcare Commission in October 2004. After conductingits own investigation, the Commission said in May 2006 that itwould take no further action as it was satisfied with the Trust’sactions and responses. Mrs A asked us to investigate all aspectsof her complaint against both the Trust and the Commission.Although we did not uphold complaints about specific aspectsof Mr Z’s medical care, we found that, when taken in the round,the evidence we saw pointed to serious failings in the Trust’s serviceto Mr Z and his family. These included a lack of monitoring whileMr Z waited to be transferred from the Intensive Treatment Unitand a delay in carrying out a medical review. We also found therehad been extremely poor nursing care in relation to care planning,communication, pain management, infection management, patientprivacy and dignity, and monitoring of fluid intake/output.We concluded that Mrs A’s complaint should have prompteda wider review of nursing care which may have led to a moreco-ordinated approach to implementing improvements and, inturn, provided reassurance for Mrs A that her complaint was beingtaken seriously. We found maladministration in the Commission’shandling of Mrs A’s complaint, including failure to seek clinical advice,not providing her with regular updates and failure to assess thepriority of the case, which had exacerbated her worry and distress.The Trust agreed to write to Mrs A and her family to acknowledgeand apologise for the failings identified, and to review the areaswhere there had been serious failings. It agreed to provide Monitor(the body that authorises and regulates NHS Foundation Trusts) withinformation to demonstrate that its practices in the areas where wehad identified serious failings were in line with current standards, andto report back to Mrs A on the action taken in response to ourrecommendations. The Commission agreed to write to Mrs A and herfamily with an apology and pay £250 compensation in recognitionof the worry and distress caused by its poor complaint handling.44

Parliamentary and health service ombudsman annual report 2007-08Mr Z was an elderly patient who diedduring an in-patient admission. Ourinvestigation found that the NHSFoundation Trust providing treatmentfailed to undertake a wider review ofcare, which would have led to a moreco-ordinated approach to implementingimprovements.Applying the Principles for RemedyOur Principles for Remedy set out howNHS bodies and individual practitionersshould put things right when injustice orhardship results from maladministrationor poor service. We see far too manyexamples of cases where the NHS hasfailed to apply these Principles.Despite the power of an apology whensincere and well timed, providers andpractitioners are too often reluctant toapologise when something goes wrong.As the case of Mrs M demonstrates, anapology is often an important first stepto remedy. As a result of ourrecommendations in Mrs M’s case theTrust and the Healthcare Commission,which investigated the case before itwas referred to the Ombudsman, agreedto apologise to Mrs M for theirshortcomings and the injustice she hadsuffered. Just as importantly, the Trustalso gave her an assurance that lessonshad been learnt from her complaint.Continuing care – bringing mattersto a conclusionIt is the responsibility of the NHS toprovide funding for the long termcontinuing care of people who need itbecause of accident, illness or disability.But for many years there has beenconsiderable difficulty in deciding fairlyand transparently who should qualify.In February 2003 the Ombudsmanpublished her second report intocontinuing care, showing that somepeople were paying for their care whenthe NHS should have been doing so.There were follow-up reports publishedin December 2004 and March 2007.However, for a significant number ofpeople the injustice from problems withcontinuing care funding has taken time tobe resolved. This has meant that in recentyears work on continuing care has been asignificant part of our workload. However,2007-08 was a year of significant nationaldevelopments in continuing care. We arepleased to report that, in general, PrimaryCare Trusts, Strategic Health Authoritiesand the Department of Health madesignificant strides last year to improvethe quality of their assessments,complaint handling and retrospective 1reviews of funding decisions and toremedy any injustice to those who havewrongly been made to pay for their care.The work undertaken by our ContinuingCare Team in setting out principles andexpectations appears to have led to agreater consistency and an end to thestrategic flaws seen in earlier years. Therewas also a reduction in delays, which atleast in part resulted from our work withthe Department of Health. Consequently,continuing care complaints have beena decreasing part of our workload as therole of the Ombudsman in supportingchanges partly arising from her previouspublished reports draws to a close.In 2007-08 under 10% (70) of the healthcases we accepted for investigation wereabout continuing care, compared with2006-07 when more than 27% (239)of the health cases we accepted forinvestigation were about continuing care.Whereas in 2006-07 we fully or partlyupheld 85% of the continuing carecomplaints investigated, in 2007-08 thisfigure fell to 56%.In last year’s Annual Report we said that,subject to successful resolution of theremaining applications, we intendedto publish a final special report onretrospective funding. We have notbeen in a position to do this becauseof the continuing delay in finalising manyof the complaints, although there hasbeen progress.In September 2007, on ourrecommendation, the Departmentof Health set a deadline of30 November 2007 for people to makeany remaining retrospective claims forcontinuing care funding. It encouragedPrimary Care Trusts and Strategic HealthAuthorities to publicise this deadlineas widely as possible in order to raiseawareness among potential claimants.The Department also gave Primary CareTrusts and Strategic Health Authoritiesa target of 31 March 2008 to completeall retrospective reviews, barring certainexceptional cases.1A retrospective continuing care review is one where all or the majority of the period for which funding is claimed is before 1 April 2004. 45

21Case StudyApology acknowledged failingsin consent for breast surgeryIn December 2004 Mrs M was referred by her GP for amammogram which showed that she had small tumours in bothbreasts. A bilateral mastectomy (surgery to completely removeboth breasts) was recommended.In February 2005 Mrs M attended Torbay Hospital where she wasprovided with information about her condition. Mrs M discussedthe issue of scarring with the Breast Care Nurse and emphasisedthat the position and cosmetic appearance of the resulting scarswere both very important considerations for her. Later thatmonth, the Consultant Surgeon who was to perform theoperation gave Mrs M a consent form to sign; however, she hadyet to decide whether she would proceed with the proposedsurgery and did not sign the form immediately.In March 2005 Mrs M signed the consent form. She was admittedto Torbay Hospital in early April 2005, and underwent a bilateralmastectomy. When the bandages were removed, Mrs M washorrified to discover that, rather than two scars below the breastline, as she had been expecting, she had been left with whatappeared to be a single horizontal scar across her chest wall,above her breast line. Mrs M was shocked and extremelydistressed by the extent, position and appearance of her scarringand raised her concerns immediately with a member of the SouthDevon Healthcare NHS Foundation Trust’s staff. Mrs M wasdischarged the next day.Two days after her discharge, Mrs M complained to the Trustin writing about the appropriateness of the surgery and theconsent procedure in relation to the nature and extent ofpotential scarring. The Chief Executive responded to thecomplaint in September 2005 and said that the bilateralmastectomy was the correct procedure and that the surgeonhad acted appropriately.Mrs M remained dissatisfied and in October 2005 she complainedto the Healthcare Commission, which found that the procedurewas appropriate and the scarring within normal range. It did,however, find shortcomings relating to consent and asked theTrust to look at those issues (both in terms of reminders to staffabout the importance of ensuring that consent forms arecompleted fully, and giving patients the opportunity to askquestions when there is a time lag between consent being givenand an operation carried out) and to inform Mrs M of resultingchanges in policy. The Commission, in two replies (February andMarch 2006), concluded that despite the shortcomings identifiedconsent had been obtained on a properly informed basis.In April 2006 Mrs M complained to the Ombudsman. Mrs M madeclear that she had pursued her complaint in order to have itacknowledged that the operation she received was not the onefor which she gave consent, not to obtain financial compensation.46

Parliamentary and health service ombudsman annual report 2007-08We found that the bilateral mastectomy was an appropriateprocedure for Mrs M and that some parts of the consent processwere reasonable. However, we noted that there was no review ofthe consent at the time of the admission immediately before theoperation. We also concluded that, based on the informationgiven to Mrs M pre-operatively, it would have been reasonablefor her to expect two separate scars running horizontally acrossthe lower to middle part of her chest. We found that overall therewere sufficiently serious shortcomings in the consent processto undermine the validity of the consent.The investigation found that, having reviewed appropriateevidence and sourced appropriate advice, the Commission’sresulting decision that Mrs M’s consent was fully informed wasunreasonable. It did not properly reflect the evidence assessedor clinical advice received, and this caused Mrs M additionalinconvenience and distress.As a result of our recommendations, the Trust and theCommission agreed to apologise to Mrs M for the shortcomingsidentified in our report and the injustice she had suffered.In addition to the action it had taken as a result of theCommission’s recommendations, the Trust also agreed to giveMrs M an assurance that lessons had been learnt from hercomplaint and an explanation of the changes made to preventsuch failures being repeated.47

When the first of these two deadlinesexpired on 30 November 2007, therewere about 1,500 outstanding casesin the NHS, which the Departmentof Health told us would be concludedby the target date of 31 March 2008.Many of these cases had been the subjectof complaints to us in the past and weresent back to the appropriate NHS bodyto be re-reviewed with a robust,transparent process and an understandable,evidence-based decision letter. But justtwo months later the Department toldus that it was not, after all, confident thatthe NHS was on track to complete allreviews by this target date. It said thiswas due to difficulties Strategic HealthAuthorities were having in obtainingevidence and to the larger than expectednumber of cases that some had received.We were of course disappointed toreceive news of further delay. However,we welcomed the actions the Departmentof Health put in place to put pressureon Strategic Health Authorities, andthe deadline was met in most cases.The significant reduction from the30 November 2007 figure of about 1,500retrospective continuing care casesin the NHS to just over 100 cases on31 March 2008 shows progress. Sincethen there has been an ongoing reductionin the numbers. The Department’sRecovery and Support Team has beenworking with these Strategic HealthAuthorities to clear this backlog, and hasbeen keeping us informed of progress.New National FrameworkOn 26 June 2007 the Departmentof Health published the NationalFramework for NHS Continuing Careand NHS Funded Nursing Care in England– something that we recommendedin our 2004 follow-up report oncontinuing care. This came into operationon 1 October 2007, and establishednational criteria for eligibility forcontinuing care funding and a frameworkfor assessing who should receive it. Inessence, it aims to make funding decisionson who is eligible for NHS continuing care‘fairer, faster and easier to understand’.It is not retrospective, so does notapply to any claims made before1 October 2007. However, the set ofassessment tools it contains is beingused to improve the handling ofretrospective claims. Strategic HealthAuthorities tell us that this Frameworkis greatly helping them come to speedyand just decisions about those whoshould receive NHS funding forcontinuing care.48

Parliamentary and health service ombudsman annual report 2007-08An improvement in the qualityof continuing care complainthandling and reviewsWhen an individual makes a complaintabout a retrospective review of localfunding decisions for continuing care,they make that complaint in the firstinstance to their Primary Care Trust. Ifthey are dissatisfied with the outcome,they take it to their Strategic HealthAuthority and then, if the matter is stillnot resolved, to the Ombudsman.So far, the evidence suggests that thequality of these reviews has improvedduring the last year. We have beenencouraged by the quality of thosereferred to us. In particular, we arepleased that we have seen far fewerinstances of the sort of systemic flawsthat we saw in the past. These werecharacterised, for example, by poorportrayals of healthcare needs,inadequate assessment panels and failureto communicate sufficiently well withfamily members. We are also pleasedto report that we generally have goodrelations with Strategic Health Authorities,and usually discuss with them in advancethe cases we are proposing to send backfor their attention, with the result thatthey have complied with ourrecommendations in full, as expected.In last year’s Annual Report, we expressedour confidence that claimants would infuture receive a robust, fair andtransparent review of their eligibility.This confidence was well placed, and webelieve that the higher quality of reviewstems from the fact that we encourageStrategic Health Authorities, in ourreports on investigations and otherdocuments, to use our Principles of GoodAdministration when reviewing claims.We have emphasised to them that athorough, fair and robust review processmust include:• evidence that the person’s individualhealthcare needs were properlypresented;• a fair, proportionate and reasonableprocess of assessment/review, whichis inclusive of relatives and carers;• consideration of the person’s individualhealthcare needs by an appropriatelyconstituted and qualified panel, andcomparison of the healthcare needsto the eligibility criteria; and• a decision conveyed to the claimantthat clearly explains how it wasreached, the evidence used, andthe rationale.Many Strategic Health Authoritieshave told us that the Principlesof Good Administration and theaccompanying explanations havehelped them develop much bettersystems for reviews and assessments.‘I thought you would like to know that South CentralSHA, via West Berkshire PCT, has at long last paid methe outstanding amount owed as a result of youroffice upholding my complaint/s against the formerThames Valley SHA and Wokingham PCT… Pleasepass this on to all those who have helped in this longand frustrating business.’Mr Z, a complainant featured in our 2003 continuing care report49

Parliamentary and health service ombudsman annual report 2007-08Working with other Ombudsmenin the UK and beyondThis is the first Annual Report in which we have includeda separate chapter on our work with other Ombudsmen.PHSO has always looked for opportunities to workcollaboratively with other Ombudsmen in the UK andbeyond to ensure fair outcomes for complainants andto share and develop best practice. The recent RegulatoryReform Order and the increasing demands of complex casesand multiple jurisdictions make joint working an area ofgrowing importance. During 2007-08, we worked on jointinvestigations with two other Ombudsmen schemes: the LocalGovernment Ombudsmen in England and the Public ServicesOmbudsman for Wales. We accepted eight cases for jointinvestigation and reported on three.New powers of collaborationThe Regulatory Reform (Collaborationetc. between Ombudsmen) Order (RRO),which came into force on 1 August 2007,granted new powers to three publicsector Ombudsmen which will improveand streamline the way they can worktogether on complaints that cross theboundaries between their jurisdictions,for example complaints about healthand social care.The UK Parliamentary Ombudsman, theHealth Service Ombudsman for Englandand the Local Government Ombudsmenfor England can now share information,carry out joint investigations and issuejoint reports.Before the RRO came into force,if a case spanned their jurisdictions,the Ombudsmen had to conduct parallelinvestigations and publish separatereports of their findings. One high profileexample of this was a complaint madeby Mr and Mrs Balchin, reported on bythe Parliamentary Ombudsman and theLocal Government Ombudsman inOctober 2005. Mr and Mrs Balchin’scomplaint was against the Departmentof Transport and Norfolk County Councilin relation to the Council’s refusal topurchase Mr and Mrs Balchin’s formerhome in advance of an intended roadbypass scheme. Although theinvestigations reached a positiveconclusion (Mr and Mrs Balchin wereawarded £200,000 compensation, withthe Department and the Council eachcontributing half), the two investigationshad to be conducted separately and theOmbudsmen had to issue separate reports.51

Figure 7Joint investigations conducted during 2007-08In hand at1 April 2007Accepted inthe yearReported onin the yearIn hand at1 April 2008Health Service Ombudsman for England and LocalGovernment Ombudsman for England2 7 1 8UK Parliamentary Ombudsman and Local GovernmentOmbudsman for England1 - - 1Health Service Ombudsman for England and Public ServicesOmbudsman for Wales1 1 1 1UK Parliamentary Ombudsman and Public ServicesOmbudsman for Wales1 - 1 -Total joint investigations 5 8 3 10Although the number of cases acceptedfor joint investigation is still low, weexpect it to rise steadily in the next fewyears. There were ten joint investigationsin hand at the start of 2008-09 and morecases have been accepted forinvestigation since then. Working jointlyand effectively with other Ombudsmenin the UK where we can do so will providecomplainants with a better service. Ourown Principles of Good Administrationinclude, under ‘Being customer focused’,the need to respond to customers’ needsflexibly including, where appropriate,co-ordinating a response with otherservice providers.Injustice in residential careIn March 2008 we published our firstjoint report with the Local GovernmentOmbudsman for England using the newpowers under the RRO: Injustice inresidential care: A joint report by theLocal Government Ombudsman and theHealth Service Ombudsman for England.The report detailed the investigationsinto complaints made to the LocalGovernment Ombudsman and theHealth Service Ombudsman againstBuckinghamshire County Council andOxfordshire & Buckinghamshire MentalHealth Partnership NHS Trust 2 respectively.The complaints were made by Mr andMrs T about the care provided to theirson, Mr U, an adult with severe learningdisabilities (see case study 22). Ourinvestigations found that there had beenmaladministration by both the Counciland the Trust, both in the level of careMr U received and in the way in whichMr and Mrs T’s complaints were handled,which resulted in unremedied injusticefor Mr U and his parents.The involvement of both the Trust andCouncil in the case was a complicatingfactor from the outset. Although Mr U’sparents voiced their concerns to bothbodies, there was delay in responding tothese concerns, and a great deal ofconfusion as to which body shouldaddress the separate aspects of thecomplaint. Had the RRO been in forcewhen we first received the complaintsfrom Mr and Mrs T, we could immediatelyhave initiated a joint investigation whichmight have resulted in a faster resolutionof the complaints for Mr and Mrs T andMr U. Nevertheless, having the statutorypower to issue a joint report on ourseparate investigations was invaluablein ensuring that the Ombudsmen wereable to consider maladministration, andany resulting injustice, in the round.This, in turn, allowed them to focus onrecommending a remedy in the round,which reflected the injustice experiencedby Mr and Mrs T and their son, ratherthan the constraints imposed byjurisdictional boundaries and differentcomplaint procedures.Mr U’s case provides an example of wherehuman rights concerns were an explicitconsideration during the investigation.522During the period covering the events detailed in the report, the predecessor Trust was known as Buckinghamshire Mental Health NHS Trust.

Parliamentary and health service ombudsman annual report 2007-0822Case StudyInjustice in residential careMr U is an adult with severe learning disabilities who needsone-to-one attention for about 95% of his waking time. InJune 2001 Mr U was moved to a residential care home run bythe Oxfordshire & Buckinghamshire Mental Health PartnershipTrust (the Trust). In July 2002, under an agreement,Buckinghamshire County Council (the Council) undertook toprovide services to care home residents on behalf of the Trust.From about February 2002, Mr U’s parents (Mr and Mrs T) becameconcerned about his clinical and social care which they felt washaving an adverse effect on his behaviour. They subsequentlycomplained to the Council about a number of matters, includingthat staff behaved inappropriately towards residents and thatonce they had found their son unwashed and unshaven with hisclothes covered in faeces and urine, and that staff had offered noexplanation, apology or help. Whilst at home during the Christmas2002 break, Mr U suffered from anxiety and refused to leave thehouse. His parents felt that was because he had a fear of returningto the care home. Mr and Mrs T looked after their son withoutany external support until March 2003, when he was returned tothe Council’s care. When his needs were finally assessed, and aCare Plan prepared, Mr U was moved to a different care homewhich provided the appropriate level of care and support.The Ombudsmen concluded that Mr U’s care needs were neverproperly assessed while at the original care home, and that therewere significant failings in the care he received. The Ombudsmenalso concluded that, as a result of the inability of both the Counciland the Trust to reach agreement as to their relativeresponsibilities for Mr U’s care and respond appropriately to theirconcerns, Mr and Mrs T were caused a great deal of anxiety anddistress in attempting to care for Mr U for a period at homewithout any support as they did not feel that he could return tothe care home about which they were so concerned. In addition,Mr and Mrs T paid expenses while their son was resident in thecare home which should have been paid for from his funding.As for Mr U’s human rights, Article 3 (inhuman or degradingtreatment), Article 8 (respect for private and family life and home)and Article 14 (prohibition of discrimination) were relevant, butneither the Council nor the Trust gave them proper or timelyconsideration. That was maladministrative and contributed to theinjustice suffered.People in detention and custodyInvestigations that arise from complaintsby people who are in prison, or held incustody or detention for other reasons,are often among the most complex.There are a number of reasons for this.They are, by definition, a disadvantagedgroup and often vulnerable, and maybe unable to complain through the rightchannels when they receive unacceptablelevels of service. In addition, as currentlyconstituted, the systems for handlingcomplaints from people in custody donot help. In England alone, there aretwo separate channels for handlingcomplaints relating to health provisionin immigration removal centres andprisons: one for healthcare providedby the NHS; and one for healthcareprovided privately. Scotland, Walesand Northern Ireland have their ownseparate channel for health complaints.In addition, there are separate channelsfor non-health complaints.Within such a complex and fragmentedframework, it is difficult to ensure thatpeople in custody have access to clearand comprehensive information aboutthe avenues of complaint that areavailable to them. It is therefore essentialthat Ombudsmen work together to helppeople navigate the complaints system.The objective must be to secure anindependent, comprehensive, coherentand accessible Ombudsman system forall people in custody.We recommended that the Trust and the Council each makea payment of £16,000, to remedy the acute anxiety and distressMr U and his parents must have experienced, and the expensesthey had unnecessarily incurred.53

We have had continuing contact withthe Department of Health, the NationalOffender Management Service, thePrisons and Probation Ombudsman andthe Healthcare Commission to sharelearning about prison complaints. Inparticular, we have provided theDepartment of Health and the NationalOffender Management Service withrelevant background informationto assist them in updating instructionsto Prison Service staff on dealing withcomplaints about healthcare.We have also liaised with the UK BorderAgency about the complaints proceduresapplying to immigration removal centres– some of which are operated by thePrison Service, while others are privatelyrun on behalf of the Agency. This contactwith the Agency has been useful inproducing a redraft of their guidance tostaff, which will correctly reflect the roleof the NHS, the Prisons and ProbationOmbudsman and the Parliamentary andHealth Service Ombudsman in dealingwith complaints about healthcare forpeople in detention or custody.The case of Mr W illustrates how jointinvestigation of a complaint may be thebest way to reach a suitable remedy.Mr W, a prisoner in Swansea Prison,was dissatisfied with the handling of hiscomplaint about his psychiatric careand complained to the ParliamentaryOmbudsman and the Public ServicesOmbudsman for Wales. His complaintwas about events spanning the time whenthe responsibility for commissioningprimary healthcare services at SwanseaPrison transferred from the Prison Serviceto the NHS in April 2006. The remit forinvestigating complaints about theprovision of primary healthcare servicesin prisons before that date falls to theParliamentary Ombudsman, and after thatdate to the Public Services Ombudsmanfor Wales. Using the provisions in theirrespective statutes, both Ombudsmenagreed that Mr W’s complaint was bestanswered by a joint investigation anda single, joint report.23Case StudyDelay in psychiatric assessmentadded to prisoner’s concern anddistressMr W was imprisoned in Swansea Prison in November 2005. Hewas subsequently assessed by the Prison Service GP who referredhim to the Prison Psychiatrist for a psychiatric review whichtook place on 28 November 2005. During this review, the PrisonPsychiatrist recommended that Mr W should be assessed byone of the prison’s visiting forensic psychiatrists. There is noevidence that such a referral took place at the time and in 2006Mr W complained to the Prison Service about the lack ofpsychiatric provision.Dissatisfied with the outcome of his complaints, Mr W complainedto the Parliamentary Ombudsman and the Public ServicesOmbudsman for Wales, who agreed to conduct a joint investigation.The Ombudsmen upheld Mr W’s complaint of delay in providinghim with a psychiatric appointment. The recommendation ofthe Prison Psychiatrist in November 2005 was not implementedfor some months. The Ombudsmen’s view was that it was notfor the other healthcare staff at the prison to decide that thepsychiatrist’s recommendation could be overlooked or deferredand that this was a potentially serious shortcoming. In the absenceof any reasonable explanation for the failure to promptlyimplement the recommendation, the Ombudsmen foundmaladministration by Prison Service staff.When Mr W was eventually seen by two separate forensicpsychiatrists in July and August 2006 it was decided that therewas no need to change the arrangements for providing him withpsychiatric oversight. Therefore the maladministration did notresult in Mr W being without appropriate treatment whilst heawaited his forensic assessment. However, it did add to theinjustice that Mr W felt, in terms of his real concern and distressat the time.The Ombudsmen recommended that the Prison Service provideMr W with an apology and an explanation of its actions. They alsorecommended that the prison’s Healthcare Service staff shouldbe reminded of the need to ensure that recommendations madeby clinicians are properly considered and acted upon promptly.54

Parliamentary and health service ombudsman annual report 2007-08The international perspectiveand human rightsWhile PHSO is keen to work effectivelywith other UK Ombudsmen, it is alsoimportant to be aware of the widernetwork of Ombudsmen in othercountries. This is especially true of theEuropean Network of Ombudsmen, ofwhich PHSO is a member. The value ofthese links lies in the fresh perspectivethey offer and in the sharing ofknowledge and best practice.We continue to develop our HumanRights Strategy and Mr U’s case earlierprovides an example of where humanrights concerns were an explicitconsideration during an investigation.The Ombudsman attended the SixthSeminar of the National Ombudsmenof EU Member States and CandidateCountries, in Strasbourg in October 2007,which focused on ‘Rethinking goodadministration in the European Union’.The Ombudsman was invited to givea speech on ‘Remedies, redress andsolutions’ and talked about whatOmbudsmen have to offer in terms ofindividual and public benefit. She tookthe opportunity to launch PHSO’sPrinciples for Remedy on the Europeanstage and also supported a jointstatement to ‘make the European Union(EU) dimension of the work ofOmbudsmen better known and to clarifythe service they provide to people whocomplain about matters within the scopeof EU law’.Court of Human Rights in Strasbourg.It was also in recognition of the needto bring human rights ‘out of the courtroom’ and into the administrativemainstream. The Ombudsman metMr Hammarberg on his visit to Londonin February 2008, when he visited PHSO’soffice in Millbank and discussed, amongother matters, our Human Rights Strategy.In March 2008 the Ombudsman metDr Nicola Brewer, Chief Executive ofthe new Equality and Human RightsCommission, to discuss matters of jointconcern, including the co-operationsought by the Council of Europe.Also in March 2008 the Ombudsmangave the keynote address at a seminarfor regulators and inspectors organisedby the Human Rights Division of theMinistry of Justice. The aim of the seminarwas to assess ways in which human rightsprinciples can be applied in inspectionand regulatory frameworks to ensure thatpublic services are not only human rightscompliant, but also embrace human rightsunderlying values.The need to uphold human rights wasa significant element of the statement,and was also the theme of the 10 th RoundTable of European Ombudsmen andthe Council of Europe Commissionerfor Human Rights, attended by theOmbudsman in Athens in April 2007.The aim of the Round Table was toseek greater co-operation betweenOmbudsmen, the Council of EuropeCommissioner for Human Rights,Thomas Hammarberg, and nationalhuman rights institutions. The initiativewas a response to the backlog of 90,000cases currently facing the European55

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Parliamentary and health service ombudsman annual report 2007-08Our workload and performance:facts and figuresBeing accountable for our performance against the plansand targets we have set ourselves is important to us. Overall,we made big strides during the year on a number of ourpriorities, for example in implementing changes required toimprove our services for the future, which dominated the year;and commencing key programmes of work around knowledgemanagement and outreach. However, in others, such as someof our operational service standards and targets, we have notachieved what we set out to deliver. This was due to a rangeof issues and developments during the year that we haveaddressed. Lessons learned have been taken on board andsteps taken to ensure that we continue to make the serviceimprovements achieved in previous years.Our 2007-08 Corporate Business Plan identified six keycorporate priorities for the year. These were:• achieving our service standards and improving outcomesfor complainants;• developing and using management information toimprove performance;• getting the most from staff, systems and financial resources;• managing change;• capturing, organising and sharing our knowledge; and• developing our external relations, influence and impact.57

405%Telephone405%Telephone403%Written403%Written191%Email191%EmailAchieving our service standardsand improving outcomes forcomplainantsEnquiries we receivedDuring the year we received 12,532enquiries against an assumption of 16,000(Details in figures 8a and 8b). Enquiriesto PHSO can be initiated by telephone,email or in writing and our response timeis monitored as part of our performancereporting framework. Both our servicestandards for acknowledging email andwritten enquiries (100% in 1 day and 2 daysrespectively) were met.Of the enquiries received, 6,964 related tocomplaints against Parliamentary bodies,4,011 were about Health and 1,557 wereabout bodies outside our jurisdiction.The top 5 Parliamentary departmentscomplained about in 2007-08 are detailedin figure 9.Under the current NHS complainthandling arrangements most healthcomplaints should come to us after theyhave been considered by the HealthcareCommission – so it is no surprise thatover 40% of the 4,011 health relatedenquiries were about the Commission.The top ten types of health body andindividuals, apart from the HealthcareCommission (1,832), complained about in2007-08 are detailed in figure 10.Figure 8aEnquiries by method of deliveryNumber of enquiries receivedand closed in 2007-08In hand at1 April 2007NetadjustmentReceived inthe yearClosed*In hand at1 April 2008Telephone 3 1 5,077 4,751 329Email 20 -2 2,396 2,287 129Written 644 7 5,048 4,651 1,047In person 0 0 11 9 2Total 667 6 12,532 11,698 1,507Figure 8bReceived in the year01%In 01%In person person*Closed including those accepted for investigation58

Parliamentary and health service ombudsman annual report 2007-08Figure 9Top 5 Parliamentary bodies complained about in 2007-08Department for Work and PensionsReceivedHM Revenue & CustomsReceivedJobcentre Plus 1,063Child Support Agency 868The Pension Service 224Independent Case Examiner 147Disability and Carers Service 114HM Revenue & Customs 1,791The Adjudicator’s Office* 512National Insurance Contributions Office 37Child Benefit Office 2Total 2,342Department for Work and Pensions 52Debt Management Unit 43Health and Safety Executive 25Pensions Ombudsman 19Rent Service 6Health and Safety Commission 5Disability Rights Commission 4Independent Living Funds 3Remploy Ltd 1Total 2,574Ministry of JusticeReceivedHM Courts Service 152Legal Services Commission 102Tribunals Service 100HM Prison Service 53Information Commissioner 39Land Registry 34Ministry of Justice** 25The Office of the Public Guardian 18Prisons and Probation Ombudsman 9Office of Social Security and ChildSupport Commissioners4Official Solicitor 4Legal Complaints Service 3The National Archives 2Advisory Council on National Recordsand Archives1Court Funds Office 1Immigration Appellate Authority 1Judicial Appointments and ConductOmbudsman1Total 549*not all complaints about HMRC**includes 9 against Department for Constitutional Affairs59

Figure 9 continuedTop 5 Parliamentary bodies complained about in 2007-08Figure 10Top 10 types of health body complained about in 2007-08Home OfficeReceivedReceivedBorder and Immigration Agency 277Criminal Records Bureau 40NHS Hospital, Specialist and Teaching Trusts(Acute)715Home Office 40UKvisas*** 39Identity and Passport Service 35Criminal Injuries Compensation Authority 32Primary Care Trusts 442General Practitioners 360Strategic Health Authorities 314Foundation Trusts 242Security Industry Authority 27Criminal Injuries Compensation Appeals Panel 8Mental Health, Social Care, LearningDisability NHS Trusts152Office of the Immigration ServicesCommissioner3General Dental Practitioners 144Ambulance Trusts 16Parole Board 2Care Trusts 12Central Police Training and DevelopmentAuthority1Special Health Authorities 12Total 2,409Correctional Services Accreditation Panel 1Forensic Science Service 1National Policing Improvement Agency 1Total 507Department for TransportReceivedDriver and Vehicle Licensing Agency 194Driving Standards Agency 23Highways Agency 20Department for Transport 17Vehicle and Operator Service Agency 17Maritime and Coastguard Agency 6Total 277*** UKvisas was joint Home Office and Foreign & Commonwealth Office,now Home Office only60

Parliamentary and health service ombudsman annual report 2007-08How enquiries were closedIn line with the new robust assessmentprocesses introduced in 2006-07, enquirycases are closed following decisions onwhether we can accept the complaint forinvestigation (that is, if it is within ourjurisdiction); and, if we can, whether weshould, through assessment of:• whether the body complained abouthas had a proper opportunity toresolve it;• whether there is evidence ofmaladministration leading to anunremedied injustice; and• whether there is a reasonable prospectof a worthwhile outcome to aninvestigation.In some cases, it may be possible toresolve cases through intervention shortof an investigation by working with therelevant parties to the complaint andwe will do this wherever possible (seeexamples of interventions on pages 10and 34).During the year, we:• closed 11,698 enquiries (assumption16,000);• closed 3,551 of these after furtherdetailed assessment of whether thecomplaint should be accepted forinvestigation (assumption 5,000);• ended the year with 1,316 enquiries inhand (forecast at or around 750); and• had a further 191 enquiries in handwhich had been referred back tocomplainants for further information.The shortfall in cases closed andincrease in cases in hand was partly dueto the reduction in enquiries receivedand partly to other factors, such asproductivity and resourcing issues whichare now being addressed. As a result ofthis, only 76% of enquiries were closedwithin 40 days against our servicestandard target of 90%.Figures 11a and 11b show how enquirieswere closed during the year.61

Figure 11aNumber of types of closed enquiries 2007-08Out of remitNot properlymadePremature Discretionary Withdrawn Accepted forinvestigationTotalEnquiry closures 1,813 4,901 2,231 1,080 722 951 11,698Percentage 16% 42% 19% 9% 6% 8% 100%Figure 11bNumber of types of closed enquiries 2007-08 (percentage)42%Not properly madeNot properly made19%Premature16%Out of remitOut of remit9%DiscretionaryDiscretionary8%Accepted for investigationAccepted for investigation6%Withdrawn6%Withdrawn‘Not properly made’ are cases which have not been put to PHSO in writing or,on the Parliamentary side, have not been referred by an MP.62

Parliamentary and health service ombudsman annual report 2007-08Overall, just over three quarters ofenquiries were either not properlymade, or premature or were about a bodythat was outside our jurisdiction. That isa cause of concern for us and we haverecently implemented a ‘Pathway’ approachon our website which will make it easierfor people to know whether PHSO is theright place for them to bring theircomplaints, and the right time to do so.Investigations we carried outDuring the year, we:• accepted 951 cases for investigation(assumption 1,400);• completed 959 investigations(assumption 1,400);• ended the year with 618 investigationsin hand at 31 March 2008 (forecast aimat or around 620); and• had 73 cases over 12 months old at31 March 2008 (target 60).The shortfalls in investigations acceptedand completed were partly due to the fullyear impact of the more robust processesintroduced last year for acceptance ofcases for investigation; and partly becauseof the reduced number of closedenquiries. However, the number of casesremaining in hand at the end of the yearwas almost the same as in 2006-07 (617).While we did not achieve the furtherimprovements we wanted to maketo reduce further the number of oldcases in hand (to 60), we have sustainedthe significant reduction made last year(from 243 to 73) which had previouslybeen a significant drag on our overallperformance. We will maintain a closewatch on the number of old cases.Figure 12Cases accepted for investigation and concluded in 2007-08 (case level)In hand at1 April 2007NetadjustmentAccepted forinvestigationin the yearDiscontinuedin the yearReported onIn hand at1 April 2008Parliamentary – tax credits 25 1 82 3 54 51Parliamentary – other 224 3 166 13 236 144Parliamentary Total 249 4 248 16 290 195Health – continuing care 70 5 70 3 93 49Health – other 298 0 633 14 543 374Health Total 368 5 703 17 636 423PHSO Total 617 9 951 33 926 61863

Figure 13Top 5 departments by number of complaints acceptedfor investigation in 2007-08HM Revenue & CustomsAccepted forinvestigationHome OfficeAccepted forinvestigationHM Revenue & Customs 91The Adjudicator’s Office* 68National Insurance Contributions Office 1Total 160Border and Immigration Agency 46Criminal Injuries Compensation Authority 1UKvisas** 1Total 48Department for Work and PensionsAccepted forinvestigationMinistry of JusticeAccepted forinvestigationJobcentre Plus 38Child Support Agency 18Independent Case Examiner 9Debt Management Unit 5The Pension Service 4Disability and Carers Service 3The Pensions Regulator 1Total 78HM Courts Service 7Legal Services Commission 6HM Prison Service 5Ministry of Justice 1National Probation Service 1Official Solicitor 1Tribunals Service 1Total 22Department for Environment,Food and Rural AffairsAccepted forinvestigationDepartment for Environment,Food and Rural Affairs4Rural Payments Agency 2Consumer Council for Water 1Environment Agency 1Total 8*not all complaints about HMRC**UKvisas was joint Home Office and Foreign & Commonwealth Office,now Home Office only64

Parliamentary and health service ombudsman annual report 2007-08Figure 14Health complaints accepted for investigation by type of bodyin 2007-08Accepted forinvestigationHealthcare Commission 624Strategic Health Authorities 70NHS Hospital, Specialist andTeaching Trusts (Acute)13Primary Care Trusts 12Foundation Trusts 8Mental Health, Social Care, LearningDisability NHS Trusts5General Practitioners 565

Figure 15Top 5 departments by number of complaints reported onDepartment for Work and Pensions Reported on Fully upheld Partly upheld Not upheldJobcentre Plus 52 29% 38% 33%Child Support Agency 28 54% 36% 11%The Pension Service 13 31% 38% 31%Debt Management Unit 8 13% 75% 13%Independent Case Examiner 7 14% 0% 86%Disability and Carers Service 6 33% 33% 33%Department for Work and Pensions 2 50% 0% 50%Health and Safety Executive 2 50% 50% 0%Total 118 34% 37% 29%HM Revenue & Customs Reported on Fully upheld Partly upheld Not upheldHM Revenue & Customs 66 41% 27% 32%The Adjudicator’s Office* 26 15% 8% 77%National Insurance Contributions Office 1 0% 0% 100%Total 93 33% 22% 45%Home Office Reported on Fully upheld Partly upheld Not upheldBorder and Immigration Agency 52 52% 33% 15%Criminal Records Bureau 6 17% 67% 17%UKvisas** 3 67% 0% 33%Security Industry Authority 2 50% 50% 0%Criminal Injuries Compensation Appeals Panel 1 0% 100% 0%Criminal Injuries Compensation Authority 1 0% 100% 0%Home Office 1 0% 100% 0%Identity and Passport Service 1 0% 0% 100%Total 67 46% 37% 16%*not all complaints about HMRC**UKvisas was joint Home Office and Foreign & Commonwealth Office, now Home Office only66

Parliamentary and health service ombudsman annual report 2007-08Ministry of Justice Reported on Fully upheld Partly upheld Not upheldHM Courts Service 17 47% 18% 35%HM Prison Service 3 0% 67% 33%Legal Services Commission 3 33% 33% 33%Information Commissioner 1 0% 100% 0%Land Registry 1 0% 0% 100%Ministry of Justice 1 0% 100% 0%Tribunals Service 1 0% 0% 100%Total 27 33% 30% 37%Department for Environment,Food and Rural AffairsReported on Fully upheld PartlyupheldNot upheldDepartment for Environment,Food and Rural Affairs6 17% 33% 50%Rural Payments Agency 3 67% 33% 0%Environment Agency 2 0% 0% 100%Consumer Council for Water 1 0% 0% 100%Total 12 25% 25% 50%67

Figure 16Health investigations reported on by type of bodyReportedonFullyupheldPartlyupheldNotupheldHealthcare Commission 508 35% 10% 55%Strategic Health Authorities 93 52% 4% 44%General Practitioners 21 24% 29% 48%NHS Hospital, Specialistand Teaching Trusts (Acute)21 43% 24% 33%Primary Care Trusts 19 37% 32% 32%Foundation Trusts 18 50% 17% 33%Mental Health, Social Care, Learning Disability NHS Trusts 4 25% 25% 50%General Dental Practitioners 2 100% 0% 0%Ambulance Trusts 1 100% 0% 0%Total 687 38% 11% 51%On our customer service standard forinvestigations:• overall, we improved completionof cases within six months from 43%in 2006-07 to 45% but remained shortof our target of 55%, reflecting theincreasing complexity of cases takenon for investigation; and• we also improved overall performanceagainst our standard for completion at12 months from 79% to 87%, exceedingour target of 85%.Figure 17Performance against service standards for Parliamentaryand HealthCompletion time from acceptance for investigationto reportTarget Health Parliamentary TotalWithin 6 months 55% 53% 29% 45%Within 12 months 85% 92% 75% 87%68

Parliamentary and health service ombudsman annual report 2007-08Outcomes of our investigationsOverall, during the year we fully upheld37% of complaints investigated (34% in2006-07); partly upheld 18% (28%); anddid not uphold the remaining 45% (38%).The picture is quite different forParliamentary and Health investigationsas figure 18 indicates. We upheld thecomplaint in full or in part in 68% ofParliamentary investigations. In Healthinvestigations we upheld the complaintin full or in part in 49% of cases.Compliance with recommendationsOver 99% of the recommendations wemade during the year have been acceptedor are currently being considered by thebody or practitioner complained about.The majority of recommendations inour Parliamentary investigations werefor financial compensation forinconvenience or distress, underlining anapology. Others included financialcompensation for loss, or some actionto remedy the failure identified.The majority of recommendations inour Health investigations focused onan apology or reconsideration of thedecision. Others included action to remedythe failure identified, or some action toprevent a recurrence (for example, a reviewof or changes to procedures, or stafftraining). Financial remedies have alsofeatured, for example as compensation fordirect financial loss or in recognition of thedistress and inconvenience caused by poorcomplaint handling.We have experienced particulardifficulties with two individual primarycare practitioners – one locum GPand one dentist – who were reluctantto comply with our recommendationsfor financial compensation for poortreatment and/or poor complainthandling. We will not hesitate to ‘nameand shame’ the NHS practitioners inour published reports in such cases and,where we have concerns that theiractions or omissions constitute a riskto the health and safety of patients, wewill bring our concerns to the attentionof the relevant professional regulatorand/or to their employer.Figure 18Outcome of complaints investigated in 2007-08Reported on:fully upheldReported on:partly upheldReported on:not upheldParliamentary – tax credits 40% 20% 40%Parliamentary – other 35% 34% 31%Parliamentary Total 37% 31% 32%Health – continuing care 51% 5% 44%Health – other 36% 12% 53%Health Total 38% 11% 51%PHSO Total 37% 18% 45%69

Figure 19: Parliamentary complaints by body complained about in 2007-08In hand at1 April 2007NetadjustmentAccepted forinvestigationin the yearDiscontinuedin the yearReportedonReportedon: fullyupheldReportedon: partlyupheldReportedon: notupheldIn hand at1 April 2008Charity Commission 1 0 0 0 0 0% 0% 0% 1Department for Business, Enterprise andRegulatory Reform – Coal Authority1 0 0 0 0 0% 0% 0% 1Department for Business, Enterprise andRegulatory Reform – Yorkshire Forward1 0 0 0 1 0% 0% 100% 0Department for Business, Enterprise andRegulatory Reform (formerly Departmentof Trade and Industry)Department for Children, Schools andFamilies – Children and Family CourtAdvisory and Support Service1 0 0 0 1 0% 0% 100% 01 0 0 0 1 100% 0% 0% 0Department for Communities and LocalGovernment2 0 0 0 2 100% 0% 0% 0Department for Communities and LocalGovernment – Planning Inspectorate0 0 1 0 1 0% 100% 0% 0Department for Communities andLocal Government – Standards Boardfor England2 0 0 0 2 0% 50% 50% 0Department for Culture, Media and Sport– Big Lottery Fund0 0 1 0 1 100% 0% 0% 0Department for Culture, Media and Sport– English Heritage1 0 0 0 1 0% 0% 100% 0Department for Culture, Media and Sport– Sport England2 0 0 0 2 100% 0% 0% 070

Parliamentary and health service ombudsman annual report 2007-085 0 4 0 6 17% 33% 50% 3Department for Environment, Foodand Rural Affairs0 0 1 0 1 0% 0% 100% 0Department for Environment, Foodand Rural Affairs – Consumer Councilfor Water3 0 1 0 2 0% 0% 100% 2Department for Environment, Foodand Rural Affairs – Environment Agency5 0 2 0 3 67% 33% 0% 4.Department for Environment, Food andRural Affairs – Rural Payments Agency0 0 1 0 1 100% 0% 0% 0Department for Innovation, Universitiesand Skills – Learning and Skills Councilfor England1 0 0 0 1 0% 0% 100% 0Department for Innovation, Universitiesand Skills – National Endowment forScience, Technology and the Arts0 0 3 0 0 0% 0% 0% 3Department for Transport – Driver andVehicle Licensing Agency2 1 0 0 2 50% 50% 0% 1Department for Transport –Highways Agency7 2 5 0 8 13% 75% 13% 6Department for Work and Pensions –Debt Management UnitDepartment for Work and Pensions 3 -1 0 0 2 50% 0% 50% 031 0 18 0 28 54% 36% 11% 21Department for Work and Pensions –Child Support Agency7 0 3 1 6 33% 33% 33% 3Department for Work and Pensions –Disability and Carers Service71

Figure 19 continued: Parliamentary complaints by body complained about in 2007-08In hand at1 April 2007NetadjustmentAccepted forinvestigationin the yearDiscontinuedin the yearReportedonReportedon: fullyupheldReportedon: partlyupheldReportedon: notupheldIn hand at1 April 2008Department for Work and Pensions –Health and Safety Executive2 0 0 0 2 50% 50% 0% 0Department for Work and Pensions –Independent Case Examiner8 0 9 0 7 14% 0% 86% 10Department for Work and Pensions –Jobcentre Plus50 5 38 2 52 29% 38% 33% 39Department for Work and Pensions –The Pension Service12 1 4 0 13 31% 38% 31% 4Department for Work and Pensions –Pensions Regulator0 0 1 0 0 0% 0% 0% 1Department of Health 0 0 2 0 2 50% 0% 50% 0Department of Health – Commissionfor Social Care Inspection1 0 1 0 2 0% 100% 0% 0Department of Health – General SocialCare Council1 0 0 0 1 0% 0% 100% 0Department of Health – HealthcareCommission0 0 1 0 1 0% 0% 100% 0Foreign & Commonwealth Office 5 0 0 0 5 60% 20% 20% 0HM Revenue & Customs 40 3 91 5 66 41% 27% 32% 6372

Parliamentary and health service ombudsman annual report 2007-08HM Revenue & Customs – ChildBenefit Office2 0 0 0 0 0% 0% 0% 2HM Revenue & Customs – NationalInsurance Contributions Office2 1 1 0 1 0% 0% 100% 3HM Revenue & Customs –The Adjudicator’s Office0 7 68 2 26 15% 8% 77% 47HM Treasury 2 0 0 0 0 0% 0% 0% 2HM Treasury – Valuation Office Agency 1 0 0 0 0 0% 0% 0% 1Home Office 1 1 0 0 1 0% 100% 0% 1Home Office – Border and ImmigrationAgency33 0 46 8 52 52% 33% 15% 19Home Office – Criminal InjuriesCompensation Appeals Panel1 0 0 0 1 0% 100% 0% 0Home Office – Criminal InjuriesCompensation Authority1 0 1 0 1 0% 100% 0% 1Home Office – Criminal Records Bureau 6 0 0 0 6 17% 67% 17% 0Home Office – Identity andPassport Service1 0 0 0 1 0% 0% 100% 0Home Office – Security IndustryAuthority2 0 0 0 2 50% 50% 0% 073

Figure 19 continued: Parliamentary complaints by body complained about in 2007-08In hand at1 April 2007NetadjustmentAccepted forinvestigationin the yearDiscontinuedin the yearReportedonReportedon: fullyupheldReportedon: partlyupheldReportedon: notupheldIn hand at1 April 2008Home Office – UKvisas 2 1 1 1 3 67% 0% 33% 0Ministry of Defence – Service Personneland Veterans Agency1 0 2 0 1 0% 100% 0% 2Ministry of Justice – HM Courts Service 16 0 7 1 17 47% 18% 35% 5Ministry of Justice – HM Prison Service 3 3 5 0 3 0% 67% 33% 8Ministry of Justice – InformationCommissioner1 0 0 0 1 0% 100% 0% 0Ministry of Justice – Land Registry 1 0 0 0 1 0% 0% 100% 0Ministry of Justice – Legal ServicesCommission4 0 6 0 3 33% 33% 33% 7Ministry of Justice – NationalProbation Service*1 0 1 0 0 0% 0% 0% 2Ministry of Justice – Official Solicitor 0 0 1 0 0 0% 0% 0% 1Ministry of Justice – Tribunals Service 2 0 1 1 1 0% 0% 100% 1Ministry of Justice** 1 1 1 0 1 0% 100% 0% 274

Parliamentary and health service ombudsman annual report 2007-08Northern Ireland Court Service 0 0 1 0 0 0% 0% 0% 1Office of Fair Trading 0 0 1 0 1 0% 0% 100% 0Office of the Director General of WaterServices (OFWAT)0 0 1 0 0 0% 0% 0% 1Total 279 25 331 21 346 36% 31% 33% 268*National Probation Service refers to complaints made under the Victim’s Code**Includes Department for Constitutional Affairs.75

Figure 20: Distribution of continuing care health cases by Strategic Health Authority area 2007-08 (case level)Strategic Health Authorities –continuing careIn hand at1 April 2007NetadjustmentAccepted forinvestigationin the yearDiscontinuedin the yearReportedonReportedon: fullyupheldReportedon: partlyupheldReportedon: notupheldIn hand at1 April 2008East MidlandsStrategic Health Authority7 0 3 0 9 44% 11% 44% 1East of EnglandStrategic Health Authority13 2 3 0 16 63% 6% 31% 2LondonStrategic Health Authority2 0 10 1 4 50% 0% 50% 7North EastStrategic Health Authority0 0 3 0 2 50% 0% 50% 1North WestStrategic Health Authority20 0 15 1 21 48% 5% 48% 13South CentralStrategic Health Authority8 0 8 0 11 55% 0% 45% 5South East CoastStrategic Health Authority7 1 8 0 11 36% 0% 64% 5South WestStrategic Health Authority6 2 6 1 7 86% 14% 0% 6West MidlandsStrategic Health Authority4 0 4 0 5 20% 0% 80% 3Yorkshire and the HumberStrategic Health Authority3 0 10 0 7 43% 14% 43% 6Total 70 5 70 3 93 51% 5% 44% 4976

Figure 21: Distribution of non-continuing care health cases by Strategic Health Authority area 2007-08 (case level)Strategic Health Authorities –non-continuing careIn hand at1 April 2007NetadjustmentAccepted forinvestigationin the yearDiscontinuedin the yearReportedonReportedon: fullyupheldReportedon: partlyupheldReportedon: notupheldIn hand at1 April 2008East MidlandsStrategic Health Authority3 1 0 1 1 0% 100% 0% 2East of EnglandStrategic Health Authority5 -1 0 0 4 75% 25% 0% 0LondonStrategic Health Authority10 -1 3 2 6 0% 33% 67% 4North EastStrategic Health Authority3 0 0 0 0 0% 0% 0% 3North WestStrategic Health Authority8 0 2 0 8 63% 25% 13% 2South CentralStrategic Health Authority8 0 0 0 5 60% 20% 20% 3South East CoastStrategic Health Authority4 -1 2 1 3 33% 33% 33% 1South WestStrategic Health Authority4 -2 2 0 3 0% 67% 33% 1West MidlandsStrategic Health Authority1 1 0 0 2 50% 50% 0% 0Yorkshire and the HumberStrategic Health Authority1 0 1 0 2 0% 50% 50% 0Healthcare Commission 251 3 623 10 509 33% 13% 55% 358Total 298 0 633 14 543 33% 14% 53% 37477

Figure 22: Distribution of health cases by Strategic Health Authority area 2007-08 (case level)Strategic Health Authorities In hand at1 April 2007NetadjustmentAccepted forinvestigationin the yearDiscontinuedin the yearReportedonReportedon: fullyupheldReportedon: partlyupheldReportedon: notupheldIn hand at1 April 2008East MidlandsStrategic Health Authority10 1 3 1 10 40% 20% 40% 3East of EnglandStrategic Health Authority18 1 3 0 20 65% 10% 25% 2LondonStrategic Health Authority12 -1 13 3 10 20% 20% 60% 11North EastStrategic Health Authority3 0 3 0 2 50% 0% 50% 4North WestStrategic Health Authority28 0 17 1 29 52% 10% 38% 15South CentralStrategic Health Authority16 0 8 0 16 56% 6% 38% 8South East CoastStrategic Health Authority11 0 10 1 14 36% 7% 57% 6South WestStrategic Health Authority10 0 8 1 10 60% 30% 10% 7West MidlandsStrategic Health Authority5 1 4 0 7 29% 14% 57% 3Yorkshire and the HumberStrategic Health Authority4 0 11 0 9 33% 22% 44% 6Healthcare Commission 251 3 623 10 509 33% 13% 55% 358Total 368 5 703 17 636 36% 13% 52% 42378

Parliamentary and health service ombudsman annual report 2007-08Requests to us for informationDuring the year we received 207 requestsfor information under the Freedom ofInformation Act and Data Protection Act(over 250 were received in 2006-07). Wereported last year that due to the volumeof requests and specific difficulties withresponding to many of these (due to thespecial legislative position of theOmbudsman), we did not always meetthe statutory timescales for respondingto requests. In 2007-08 we addressed thisissue and significantly reduced both thevolume of cases in hand to 13 and thetime taken to reply.Figure 23Information requests resolvedWithin relevant time limit 135 (52%)Outside relevant time limit 127 (48%)Complaints about usAs a measure of the performance of ourown service, over the year we:• received 773 complaints about us(significantly down from 1,219 in2006-07);• resolved 964; and• ended the year with 99 in hand (296in 2006-07), exceeding our target ofhaving no more than 120 in hand at theyear end.Since 1 January 2008 all complaints aboutus have been handled within a new‘single-tier’ system, our service standardfor which is to provide a substantiveresponse on 90% of these within 16weeks. During the year we achieved 58%,which we will be seeking to improve onover the first full year of the new system.Of the complaints we received about us:• 431 were about our handling ofenquiries;• 137 were about health investigations;• 190 were about parliamentaryinvestigations; and• 15 were about the Freedom ofInformation Act and the DataProtection Act.Of these:107 were fully or partly upheld,a significant improvement over the157 in 2006-07, within which:• errors upheld about our decisionswere down from 34 to 22;• errors partly upheld were downfrom 69 to 32; and• service complaints were reducedfrom 54 to 53.79

Judicial reviews of our decisionsand actionsThere were ten applications for judicialreview of our decisions and two countycourt claims in the year.Of the ten judicial reviews, nine wererefused permission to proceed (althoughone of these is now the subject of anappeal and another a renewal application).The other judicial review was grantedpermission to proceed but was dismissedby the court.One of the county court claims wasdismissed by the court; the other waswithdrawn by the claimant.Casework qualitySeveral steps were taken in the yearto improve the quality of our casework,which will be continuing in 2008-09.In October 2007 we introduced a newDelegation Scheme and AccountabilityFramework related to exercising decisionson casework; and a new Outcomes andLearning Directorate was set up to ensurethat the lessons from our work arecaptured and used appropriatelyinternally and externally. We have alsoundertaken assurance work to ensure thatwe apply our Principles of GoodAdministration and Principles for Remedyin practice in our casework and in ourservice to customers.Joint investigations with theLocal Government OmbudsmenWe have developed our approach toworking with the Local GovernmentOmbudsmen for England followingenactment of the RRO enabling jointinvestigations to be carried out. Weensured that all key stakeholders werenotified of the RRO provisions, and inMarch 2008 we published our first jointreport, Injustice in residential care.Several further joint investigations are intrain and will be reported on in 2008-09.Developing and using managementinformation to improveperformanceImproving our corporateperformance frameworkThis year we developed and implementedan improved corporate performanceframework, which is based on an adaptedbalanced scorecard and which reflectsour strategic and business plans. Ourframework includes Key PerformanceIndicators (KPIs) to measure, monitorand review long-term performanceagainst our strategic objectives;performance against our annual internaltargets and service standards; and theeffectiveness of our performance inmanaging our business. This is shownin the following diagram.Progress on quality can be seen in thereduced number of upheld complaintsabout our decisions.80

Parliamentary and health service ombudsman annual report 2007-08Figure 24PHSO’s balanced scorecardKPIs to measuresuccess againstthe outcomesDelivery ofindividualbenefitDelivery ofpublic benefitKPIs to measuresuccess againstthe outcomesEffective and efficientleadership and managementof PHSOKPIs to measuresuccess againstthe outcomesOur KPIs can be found in our 2008-11Strategic Plan. Our internal targets andservice standards can be found in our2008-09 Corporate Business Plan. Bothplans are available from PHSO’s websiteat www.ombudsman.org.ukA key element of our performancemanagement system is an effectiveresearch plan designed to populate ourKPIs with information from our internalsystems and from external sources.This was designed during the year andhas been implemented.Improving our case managementand data qualitySignificant steps were taken during theyear to improve the quality of our datathrough enhancement of our casemanagement system, replacement ofour human resources system and regularaudits of data produced.81

Applying our Principles to ourown work• Getting it right: reducing the numbersof complaints about us; ensuring we arecomplying with legislation applicable tous; effective auditing of our policiesand procedures.• Being customer focused: publishingour reports in a variety of formats toimprove accessibility; establishing andpublishing customer service standards;using feedback from our surveys andfrom complaints about us to help usimprove our service.• Being open and accountable:maintaining clear audit trails for ourdecisions; publishing our policies andprocedures; demonstratingaccountability through reportingopenly on our performance.• Acting fairly and proportionately:making evidence-based decisions takingaccount of materiality and risk; puttingin place internal processes which ensurethat our decisions and remediesrecommended are consistent and fair.• Putting things right: improving ourcomplaints procedures and processesto make them easier and clearer forcustomers to navigate and use.• Seeking continuous improvement:reviewing the effectiveness of changeswe have made to our structures andprocesses; acting on lessons learnedfrom this and our performance; investingin new ways of working and ourinfrastructure to support better delivery.Getting the most from staff,systems and financial resourcesApplying our Principles of GoodAdministration to our own workEnsuring that we live up to our ownprinciples of what makes for goodadministration is of fundamentalimportance to us, both internally andin the way we carry out our casework.We maintain a constant focus onimproving how we do our work andputting in place improvements wherenecessary in the service we provide.Investing in our people and takingforward our Equality and DiversityStrategyPHSO successfully achieved Investorsin People re-accreditation in 2007-08and we directly invested nearly £400,000in the learning and development of ourstaff over the year, supported by adedicated team. Particular emphasis thisyear was on management training witha Management Development Programmeand an Aspiring to ManagementProgramme being introduced. Substantialeffort was also put into improving theeffectiveness of our performancemanagement systems. We will bebuilding further on this in 2008-09.We have continued to implement ourEquality and Diversity Strategy withrelevant awareness training. A WorkforceDiversity Action Plan was agreed includingtargets of increasing the number of blackand minority ethnic staff working forPHSO to better reflect the profile ofpotential complainants. Performanceagainst this is being regularly monitored.82

Parliamentary and health service ombudsman annual report 2007-08Managing our resources effectivelyOur summary financial results areincluded in this report. Performanceagainst the financial targets in our2007-08 Corporate Business Plan wasas follows:• our net resource underspend of£174,000 was within our target limit forunderspending of less than £500,000;• our capital underspend of £199,000 wasoutside our target limit forunderspending of £100,000 due toa decision to defer replacement ofIT hardware;• we recovered 100% of income due inthe year, although excess incomerecovered was £53,000 above the£40,000 target we set due to factorsoutside our control;• we remained within the Net CashRequirement sanctioned by Parliament;• we paid 99.2% (2006-07: 99.6%) ofsupplier invoices within our targetof 30 days;• our resource budgets were managedto within 1% of tolerances set, withinour target of limiting variance to nomore than 2%; but capital budgets wereoutside the 5% tolerance at 12.9% dueto the deferment of IT spendingmentioned above; and• our depreciation charges for the yearof £1,298,000 were within our targetof being no more than £200,000 morethan our capital investment of£1,360,000 (actual variance – £62,000)which evidences the maintenanceof our capital base.Over the year our staffing numbersreduced by 21.6, and full-year turnoverwas very high at 25%, which had animpact on our performance. This was duemainly to the effects of our restructuringprogramme. A substantial amount ofresource was invested in 31 recruitmentexercises aimed primarily at strengtheningour casework, management and corporatecapability. 48 of the 52 positionsadvertised were filled successfully at thefirst attempt, with 3 of the other 4 beingfilled subsequently.Average sick absence in 2007-08 for PHSOemployees was 5.9 days per full-timeequivalent (fte), which was well within ourtarget of being no more than 7 days perfte. This was also significantly lower thanthe public sector average and on a parwith the private sector.Managing changeReorganising the way we do thingsOver the course of this year weimplemented a fundamentalorganisational restructuring undera programme called Organising forthe Future, the key aim of which wasto strengthen our capacity to deliveron our strategic objectives.The new structures were successfullyimplemented by November 2007. Thisincluded a new Customer Services andAssessment Directorate to improve ourfront-end processes for handlingcustomer enquiries and assessing whethercomplaints should be investigated. It alsoincluded setting up an Outcomes andLearning Directorate to ensure that thelessons from our casework are capturedand disseminated, and to provideenhanced capacity to develop effectivecasework guidance, supportingimprovements in the quality of our workand caseworker skills. The embedding ofthe new structures and the new ways ofworking has been supported withdevelopment awaydays and team events.Performance has been affected by a highnumber of caseworker vacancies, an issuewhich is being addressed.Corporately, we put in place a newDivision to manage our PolicyInformation and Communications.This includes four teams covering externalliaison and outreach; policy and research;internal and external communications;and knowledge and informationmanagement. These functions arerecognised as essential to the futuredevelopment and effectiveness of PHSO,and continuing to strengthen theircapability will be a priority in 2008-09.83

Capturing, organising and sharingour knowledgeManaging our knowledge andinformation betterGetting the most from the extensiveknowledge and information held bothby the organisation and our staff isessential to improving the effectivenessof PHSO. In 2007-08 we launched andcommunicated internally and externallyour programme to manage theimprovements we recognise are requiredin this area. A new and experienced seniormanager was appointed in February 2008as Head of Knowledge and InformationManagement to lead the programme,and a practical plan and associatedgovernance for delivery of theprogramme were developed.This includes five interconnectedworkstreams covering people;information content; culture; processes;and technology. During the year keyactivities included completing a jointreview with The National Archives of ourrecords management arrangements, whichprovides a clear plan to ensure that thesereflect best practice as well asexpectations in accordance with our ownPrinciples of Good Administration. Wealso developed and implemented a newcorporate business classification(taxonomy) for our caseworkmanagement system to support ourcasework related reporting ability.Developing our external relations,influence and impactApplying Principles of GoodAdministration and Principles forRemedy in our caseworkOur Principles of Good Administrationwere published in March 2007 and ourPrinciples for Remedy in October 2007and we have applied them increasingly inour casework throughout 2007-08. Ourcasework conference for staff in 2008focused specifically on sharing goodpractice in applying both sets of Principlesin our casework.Strengthening our outreachIn light of customer and stakeholderfeedback we have recognised the needto strengthen how we approach andexecute more effective relationships withthe bodies we deal with. We thereforedeveloped and agreed an externalrelations strategy and established a newteam, External Liaison and Outreach,to deliver it. This year the team has beenfocusing on setting out guidance tocommunicate better to our stakeholdersthe approach we take in consideringcomplaints and the expectations we haveof bodies within jurisdiction. A keyproduct from this will be a newdocument, the third in the Ombudsman’strilogy of principles – the Principles ofGood Complaint Handling – which isbeing consulted on and will be launchedin autumn 2008.84

Parliamentary and health service ombudsman annual report 2007-08Working towards new NHScomplaint handling arrangementsThroughout 2007-08 we worked closelyin support of the Department of Health’sintention to introduce revised complainthandling arrangements for health andsocial care. This included respondingpositively to their consultation document,Making Experiences Count, which washeavily influenced by criticisms we havemade of the current system in our report,Making things better? A report onreform of the NHS complaints procedurein England, published in March 2005.We strongly supported the Departmentof Health’s proposals for abolishing thesecond stage complaint handling rolecurrently carried out by the HealthcareCommission and the introduction of newarrangements for a simpler process, withthe emphasis on NHS bodies dealingmore effectively with complaints madeto them.In the latter part of 2007-08 wecommenced planning for the changesneeded in PHSO to deal withimplementation of the new arrangementswhich will take effect from 1 April 2009.This will significantly increase theworkload of PHSO and substantialresources will be invested in 2008-09 toensure that we are ready to take this on.Reporting on our caseworkand learningThe following reports to Parliament werepublished in 2007-08:• Tax Credits: Getting it wrong? –October 2007• The introduction of the ban on swillfeeding – December 2007• Injustice in residential care –March 2008.As a result of the creation of our newOutcomes and Learning Directorate in2007-08 we are now much better placedto publish regular summaries of cases andthe first of these, Remedy in the NHS,was published in June 2008.The investigation into the prudentialregulation of Equitable Life also continuedduring 2007-08 and the report of thatinvestigation has now been published,in July 2008.85

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Parliamentary and health service ombudsman annual report 2007-08Managing our resourcesThe Parliamentary and Health Service Ombudsman’s fullResource Accounts 2007-08 will be laid before Parliamenton 6 October 2008 and will be available on our websiteat www.ombudsman.org.uk or from The Stationery Office.Summary Financial Statements for the year ended 31 March 2008Statement of the Parliamentaryand Health Service OmbudsmanThe following Financial Statements area summary of information extracted fromPHSO’s full annual accounts for 2007-08,which were signed by the Ombudsmanon 17 September 2008. While thesummary below does not containsufficient detail to allow for a fullunderstanding of the financial affairsof PHSO, it is consistent with the fullannual accounts and auditor’s report,which should be consulted for furtherinformation.The Comptroller and Auditor General,who has been appointed by theParliamentary and Health ServiceOmbudsman as auditor, has given anunqualified audit opinion on PHSO’sResource Accounts.Statement of the Comptrollerand Auditor General to the Housesof ParliamentI have examined the Summary FinancialStatement of the Parliamentary and HealthService Ombudsman comprising asummary financial review, resource outturn,operating cost and cash flow statementsfor the year ended 31 March 2008 and asummary balance sheet at that date.The Ombudsman is responsible forpreparing the Summary FinancialStatement. My responsibility is to reportto you my opinion on its preparation andconsistency with the full Resource Accounts.I have conducted my work in accordancewith Audit Bulletin 1999-06, The auditors’statement on the summary financialstatement issued by the Auditing PracticesBoard. My certificate on the full accountsof the Parliamentary and Health ServiceOmbudsman describes the basis of myopinion on these accounts. I have also readthe other information contained in theAnnual Report to the accounts andconsidered the implications for my opinionif I become aware of any apparentmisstatements or material inconsistencieswith the Summary Financial Statement.In my opinion the Summary FinancialStatement is consistent with the fullResource Accounts of the Parliamentaryand Health Service Ombudsman for theyear ended 31 March 2008.Ann Abraham17 September 2008Parliamentary and Health ServiceOmbudsmanT J BurrComptroller and Auditor General87

Financial reviewPHSO’s net operating cost for 2007-08was £24,345,000, comprising expenditureof £24,785,000 spent in carrying out itsactivities offset by operating incomeof £440,000. Excluding £93,000 of incomethat must be surrendered to theExchequer and £186,000 funding fromthe Consolidated Fund for the salaryand on-costs of the Ombudsman, PHSO’snet total resource requirement for theyear was £24,252,000, which was anunderspend of £174,000 (0.7%) of PHSO’s2007-08 funding as approved by Parliament.This underspend was within our internaltargets of not exceeding our total netresource expenditure sanctioned byParliament and limiting any underspend toless than £500,000.Capital investment expenditure forthe year was £1,338,000, mainly utilisedon completing our accommodationrefurbishment project. Our netunderspend of £199,000 met ourtarget of not exceeding our totalcapital investment sanctioned byParliament (£1,537,000). However, itexceeded our internal target of limitingany underspend to less than £100,000.This was due to a decision to deferreplacement of IT hardware.PHSO’s reserves have increased by£21,000, which mainly reflects the increasein the gross value of the asset base as aresult of the capitalisation of the costsof our accommodation refurbishmentproject, net of related depreciation.88

Parliamentary and health service ombudsman annual report 2007-08Summary of resource outturn 2007-082007-08 2006-07EstimateOutturnGrossexpenditureA in ANettotalGrossexpenditureA in ANettotalNet totaloutturncomparedto estimate:saving/(excess)Outturn£000 £000 £000 £000 £000 £000 £000 £000Request forresources24,773 347 24,426 24,599 347 24,252 174 22,679Total resources 24,773 347 24,426 24,599 347 24,252 174 22,679Non-operatingcost A in A- - - - - - - -PHSO’s net cash requirement for the year of £23,956,000was within our cash financing limit of £24,941,000 asapproved by Parliament.Operating cost statement for the year ended 31 March 20082007-08 2006-07£000 £000Administration costs:Staff costs 12,777 13,458Other administration costs 12,008 9,764Gross administration costs 24,785 23,222Operating income (440) (369)Net administration costs 24,345 22,853Net operating cost 24,345 22,853Net resource outturn 24,252 22,67989

Balance sheet as at 31 March 200831 March 2008 31 March 2007£000 £000 £000 £000Fixed assets:Tangible assets 6,443 6,354Intangible assets 519 6386,962 6,992Current assets:Debtors 1,300 968Cash at bank and in hand 122 3911,422 1,359Creditors (amounts falling duewithin one year) (1,445) (1,597)Net current liabilities (23) (238)Total assets less current liabilities 6,939 6,754Creditors (amounts falling due aftermore than one year) (688) (825)Provisions for liabilities and charges (1,145) (844)(1,833) (1,669)5,106 5,085Taxpayers’ equityGeneral fund 4,660 4,709Revaluation reserve 446 3765,106 5,08590

Parliamentary and health service ombudsman annual report 2007-08Cash flow statement for the year ended 31 March 20082007-08 2006-07£000 £000Net cash outflow fromoperating activities (22,679) (22,110)Capital expenditure andfinancial investment (1,461) (4,958)Payments of amountsdue to the consolidated fund (5) (68)Financing 23,876 27,349Increase/(decrease) in cashin the period (269) 21391

The Board as at March 2008Ann AbrahamParliamentary and Health ServiceOmbudsmanTrish LongdonDeputy OmbudsmanBill RichardsonDeputy Chief ExecutivePhilip AylettDirector of Policy Informationand CommunicationsLinda CharltonDirector of Equality and Diversity(left on 30 March 2007)Andrew Puddephatt OBEAudit Committee ChairPaula CarterAdvisory Board MemberTony RedmondExternal Board MemberCecilia Wells OBEExternal Board Member92

Parliamentary and health service ombudsman annual report 2007-08GovernanceThe post of Parliamentary and Health Service Ombudsmancombines the two statutory roles of Parliamentary Commissionerfor Administration and Health Service Commissioner for England. 3The Ombudsman is solely responsible and accountable for theconduct and administration of all work carried out by the Officeof the Parliamentary and Health Service Ombudsman and forthe decisions made in each case.The Advisory BoardTo enhance the governance of PHSO,improve the transparency with whichit operates and bolster the independenceof the role, the Ombudsman appointeda non-statutory Advisory Board in 2004.This comprises the Ombudsman herself(as Chair and Chief Executive in line withher statutory accountability) and fournon-executive members who bring anexternal perspective to the Office’s work.With the exception of the Chairman ofthe Commission for Local Administrationin England, who joined the Board at theOmbudsman’s invitation, all the AdvisoryBoard members were appointed througha process of fair and open competition.The role of the Advisory Board is to actas a ‘critical friend’, providing supportand advice to the Ombudsman in herleadership of PHSO, and to bring anexternal perspective to assist her in thedevelopment of policy and practice.The Board provides specific adviceand support on:• Purpose, vision and values• Strategic direction and planning• Accountability to stakeholders,including stewardship of public funds• Internal control and risk managementarrangements.The Advisory Board has no rolein casework processes or decisions.The Advisory Board has two formalsub-committees which have key rolesin supporting the effective governanceof PHSO:• An Audit Committee which isresponsible for providing adviceand assurance to the Ombudsmanas Accounting Officer, and to theExecutive Board on the adequacy andeffectiveness of internal control andrisk management. It also overseesinternal and external auditarrangements which cover all areasof PHSO’s work, including both financialand non-financial systems. TheCommittee has four members: anexternal Chair appointed by theOmbudsman through a process of fairand open competition; theOmbudsman herself; and two furtherexternal members.• A Pay Committee which is responsiblefor providing advice on payarrangements in PHSO, and specificallyfor determining the pay of senior staff(except the Ombudsman herself, whichis set separately under statutoryarrangements). Its membership is theOmbudsman (as Chair) and any twoof the external members of theAdvisory Board.3The Ombudsman’s powers are set out in the Parliamentary Commissioner Act 1967 and the Health Service Commissioners Act 1993.93

The Executive BoardAn Executive Board, chaired by theOmbudsman and comprising the DeputyOmbudsman, the Deputy Chief Executiveand the Director of Policy Informationand Communications, exercisesmanagement of PHSO’s functions andactivities. The Executive Board isresponsible for the delivery of PHSO’sstrategic vision, policies and servicesto the public and other stakeholders.The Executive Board meets regularlyand is responsible for co-ordinatingactivity across the organisation. It is theprimary forum for making executivedecisions about operational, resource,communications and other administrativematters in order to deliver PHSO’s ThreeYear Strategic Plan and annual CorporateBusiness Plan, and for monitoringperformance. The role of the ExecutiveBoard in decision making carries arecognition that on occasion there willbe some issues for which the decisionmaker is the Ombudsman alone.OmbudsmanAnn AbrahamDeputy OmbudsmanTrish LongdonDeputy Chief ExecutiveBill RichardsonDirector of PolicyInformation andCommunicationsPhilip AylettOperationsCarole AuchterlonieChristine CorriganValerie HarrisonJack KellettHilary YorkCorporate ResourcesGraham PayneJon WardLegal AdviserAnne HardingPrinted in the UK for The Stationery Office Limitedon behalf of the Controller of Her Majesty’s Stationery OfficeID5934499 10/08Printed on Paper containing 75% recycled fibre content minimum.94

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