The reality of the broken NHS complaints system.



In 2011 I went to my GP having suffered a bout of "flare ups" as a result of my condition. I was lucky that at the time I have a decent practice and a GP who took an interest in my condition. He referred me to the Royal Free hospital in London for further investigations.

The sequence of events which followed would collectively epitomize some the key issues within the "pillar to post" NHS when it comes to patient safety, human factors, record access and the damn right appalling state of the complaints system and safety investigations (or lack of).

I was referred to the Gastroenterology department where I saw a Professor of Gastroenterology. The consultation was nothing out the ordinary, although because my GP had taken an interest this was reflected in the referral letter and the Professor did remark on the letter in a manner that was somewhat derisory about my GP.

The outcome of the consultation was that my issues were likely due to adhesion as a result of childhood surgery but I was to be followed up with an MRI scan.

Shortly after my consultation I received a letter about my MRI and curiously a barium swallow x-ray  letter.  I've had a barium swallow previously for other reasons and I knew the purpose and could not understand the relevance in this context.

I contacted the Royal Free Hospital and asked why I was receiving it and if it was meant for me as it seemed odd. After a short wait on the phone it was confirmed it was intended for me.

The date of my appointment arrived and I was subjected to the usual ritual humiliation of being traipsed around a hospital in a gown before finally being called in by the radiographer/radiologist.

She discussed the procedure with me and then asked if I had any questions. I explained that I already understood what the procedure was and why someone would have it but I didn't understand why I was having it as it didn't relate to my complaint.

A brief puzzled conversation followed about my condition and symptoms and she went back to my record and and asked if I had any problems with swallowing food. I replied no, and she asked me to check the computer screen.

Sure enough there were all of my demographic details and upon reading the notes below it described someone having problems swallowing rice and pasta. This is not a complaint I have ever had and the penny dropped.

I was asked to wait and the radiologist came back with someone who I assume was more senior who apologized that there appeared to have been some sort of mix up and I was sent on my way without any further explanation.


The complaint

On the 20th May 2011 I wrote a formal letter of complaint about the incident as well as highlighting the hospital was in breach of Information Governance policies and Data Protection law as staff were leaving notes untended in public corridors.

I received a letter dated the 27th May to acknowledge receipt and to say they were investigating.

Weeks past and I receive a letter dated 5th July in which the Royal Free Hospital declared they had completed their investigation, confirming the barium x-ray was indeed for me and there was no issues with data protection.


I already knew this was categorically false. I'd seen the incorrect notes on the hospital computer   and watched the colour drain from the radiologists face as she realised the error. I'd also witnessed first hand notes systemically being left in corridor.

I sent a letter challenging their investigation highlighting that it was flawed. Everything went quiet.

Months passed and nothing happened and I received no response to my follow ups. I decided to reach out to the Parliamentary and Health Service Ombudsman (PHSO) who said they don't investigate unless the local complaints process has completed.

Given the Royal Free had ignored me and the PHSO policy most people would now be stuck in a dead end, however I challenged the PHSO on their policy. They agreed that given the time passed they would look in to it.

The PHSO got back to me and let me know the Royal Free Hospital was "still investigating" but would respond shortly. I find this hard to believe given their silence, but on the 7th November 2011 I finally received a letter confirming that my complaint was being upheld on all fronts. Imagine my surprise!

Obviously this was explained as an exception to their "usual high standards" which  something of a stock phrase used by the NHS to brush failings under the carpet. There was no mention of the cause, resolution or follow on actions to ensure the issue was rectified.

How did it go so wrong?

If I were to investigate such a case I would probably start with the referral letter and compare it to the notes and what happened. It would be immediately apparent something was amiss, given what I was referred for and what was in the record.

As to how the mistake was made it was likely a clerical error, but Royal Free failed to identify the cause or any corrective actions, or explain how it botched the initial investigation.

The letters included details of who was investigating my case which included :
  • Professor of Gastroenterology
  • Complaints Manager
  • Director of Nursing
  • Divisional Nurse Director
  • Head of Radiology
How did all these people review such a black and white error and reach the conclusion that nothing was amiss? I'm certain the radiologist knew full well that a mistake had been made as would anyone else who looked at the case properly for more than a few minutes.

There can only be a number of answers to this question ....
  • They did not bother investigating and tried to fob me off.
  • They investigated found the error and tried to bury it.
  • They were all equally and totally incompetent.
Regardless of the answer it is a shocking indictment of the NHS complaints system which forces patients to run the gauntlet with local services whose primary interest is themselves and making you go away.

NHS organisations investigating themselves is bound to end in disaster and the PHSO took no further action, despite me asking them to address the issue of lessons learnt. Their response when they phoned me was "I'm not sure what you want us to do".

Then it happened again!

In July 2013 I moved out of London and in 2016, some 5 years after I'd been to the Royal Free, I started receiving letters for my pre-operative surgery appointment. It was clear something had gone wrong again.

Once again I complained to the Royal Free Hospital who failed to act. This time I decided to reach out to the Information Commissioners Office as Royal Free Hospital were clearly in breach of the Data Protection Act, mishandling data and putting lives at risk.

After a short period I heard back from the ICO who said that the Royal Free had looked in to the matter, could not find the cause of the issue and neither the royal free and the ICO were taking any further action.

It's worth noting that over the last decade or so the Royal Free Hospital and others like them have been in the news for similar errors and indeed institutionalised bullying which will no doubt be playing a role in such investigations.

What needs to be done?

It is patently clear that the current complaints process is not fit for purpose and is in need of a complete overhaul something successive governments have failed to do, preferring to pay lip service rather than take action.

Important lessons can be learnt from other high risk sectors, in particular the likes of nuclear, aviation, oil and gas. Even closer to home where aviation meets healthcare with HEMS ( Helicopter Emergency Medical Service). Perhaps one of the most important lessons is the cultural change that Aviation went though after a number of high profile disasters.

Having organisations investigate themselves without any independent oversight is simply not working, and with problems of local bullying, harassment and cover-ups it is patently clear a change is necessary.

It's also clear that the regulatory bodies are failing in their duty to investigate issues and put in place measures that ensure patients are kept safe.

Frankly, I think we need to start over and dismantle the entire system. We need to create a new independent complaints body which is truly independent. It needs representation from real world patients (not just those who are pliable and compliant), with access to independent experts from around the world to preside over more complex cases and ultimately  provide transparency and accountability to the public.

Where cases go to court, no longer can we have a situation where the might of the NHS and government is pitched against individuals and their families. Perhaps a simple solution would be to require any organisations to match like for like any amount it spends on its own case .

It should be a legal requirement for staff to raise issues where they spot wrongdoing as was highlighted in the Mid Staffordshire Francis inquiry and which the government played down.

There needs to be much stiffer punishments for employees who pervert the course of justice and conspire to cover up cases with automatic jail time, especially where patients have come to physical harm or died.

Until people at the top start to face consequences nothing will change.