Why go to the Ombudsman with your complaint ... ?
Many families get in touch through Averil's web site or via Twitter. The web site details our fight to expose the NHS negligence that led to Averil's death.
Often there is a familiar story.
Once a family's complaint has been held in limbo by the NHS trust involved for a year or two and lies dormant in the proverbial NHS waiting room, there are two simple choices; either you simply "give up" or you take your complaint to the Ombudsman.
The full title of the Ombudsman is the Parliamentary and Health Service Ombudsman (PHSO), and perhaps from this name one can expect that the members of parliament who oversee this institution will ensure that it does a good job at representing those that have suffered or have been failed by the NHS.
But don't be fooled by the fancy name, our experience is that the PHSO is an organisation that is not fit for purpose and sadly those who run NHS trusts knows this and act accordingly.
It is hardly surprising therefore that the NHS organisations that were responsible for Averil's death do not concern themselves with the outcome of the Ombudsman's inquiry. In fact as Keith McNeal, the Chief Executive at Addenbrookes hospital (where Averil died) said to us .. "who are the Ombudsman ? ".
When we originally arrived at the Ombudsman's door we were promised a speedy, in-depth investigation into Averil's death and a final report to be laid before parliament within 12 months.
Two years on, following a lot of pressure and help from the Patients Association, we finally have a draft report from the Ombudsman. But it's a report that fails in nearly every respect. One hundred pages of excuses for what happened in Averil's tragedy and yet so far from the revealing the true negligence that occurred.
There appears to be no accountability whatsoever and even when the Ombudsman knows that clinicians are lying, they refuse to investigate "wrong doing".
In many ways, by refusing to investigate these lies and the cover up of Averil's death, the Ombudsman becomes part of the lie, complicit in the wrong doing and responsible in no small part for the failure of the NHS to improve its care for some of the most vulnerable people in society.
A lost opportunity and a reflection on how the "establishment" protects itself when someone dies as a result of NHS negligence.
The Ombudsman's office has been under the spot light a lot recently for a multitude of high profile failings and virtually everyone who has been involved in the investigation into Averil's death has resigned.
One by one ....... Allesandro Pulszone, Russel Barr, Mick Martin, Dame Julie Mellor - have all gone and sadly we are still at a draft report stage. In summary a complete disaster.
Last week, I spoke to a mother whose daughter died in similar circumstances to Averil to see how her complaint was progressing. The local NHS trust had covered up her daughter's death in much the same way by destroying the evidence. She told me that she was in the process of taking her complaint to the Ombudsman, but having read the recent bad press about the way that they had handled complaints and the also recent resignations, she wondered if it was worth the grief to her daughter's family.
So why go to the Ombudsman with your complaint ?
There's no simple answer to this - but if we don't fight for the truth and for a better system to investigate failures in the NHS, then how will we ever get a better society, better NHS and most importantly better care for our loved ones.
My advice was to try.
But in trying, know that the system is badly broken and that you will have to fight every step of the way for the truth. You will probably have to do most or all of the work yourself and provide all of the evidence rather than rely on the "investigation" that takes place. Do not take their competence for granted and be aware that when you enter that concrete tower in London you may find, as we have, that sadly there is a black hole with little compassion, understanding or competence to investigate.
Our experience is that the Ombudsman is a failed and broken institution, where complaints and evidence get lost for months, if not years - and the result appears to be a watered down report that normally lets the NHS establishment continue business as usual, even when they have been responsible for a young person's death. There is no sense of accountability whatsoever.
The only real checks and balances on the Ombudsman are made by the persistence of families themselves and the charities like the Patients Association.
But still we live in hope, that just like Hillsborough, the truth will come out ....... and IT IS worth fighting for.
PS. For the record don't forget to tape all of the meetings that you have with the Ombudsman and ask for transcripts if they record them. Undoubtedly you will need them.