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Case Studies

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Kay's Story (not clients real name)

The client wished to complain about the poor treatment she received whilst undertaking an inpatient alcohol detox programme, the environment of the hospital, and about the poor treatment she observed of other patients on the ward.

Melchor's Story (not clients real name)

A young Filipino man, with limited English, was held under section in a Psychiatric Intensive Care Unit (PICU) in Oxford for nearly two years.

John's Story

John is an ex-army veteran who was detained  in a prison in Oxfordshire. He was very unhappy with the service he was receiving from the prison health care service and wanted advocacy support to help him challenge his treatment.

An Innocent Prisoner

Mr Barrass complained about the treatment his mother received in a care home and he wants his mother’s story to influence the way complaints are investigated and the way care homes are regulated.

Service used:

Simon's Story

The support of an Independent Mental Health Advocate helped Simon gain the confidence to self-advocate and secure his discharge from a medium secure unit.

Nicole's story

Nicole needed support with an Exceptional Funding Appeal to try and overturn her PCT's decision not to fund an out-of-county treatment package recommended by her consultant.

An Innocent Prisoner

Service used:



In memory of my late mother Vera Lillian Barrass.


What does this mean?


In a developed, wealthy , educated , advanced country like ours ,we should be able to deliver proper care , but what happens if we fail , then when something  serious happens in care ,and we cant get justice , then what is the point in having a care system in the first place. 
11 years ago on the 26th May 2005 mum collapsed in the kitchen , it was found to be a serious stroke as you will have read in my DOCUMENT.
She would never be able to talk again, or walk, or eat ( feed by a feed tube ) I was totally devastated, my life changed for ever .  
I wasn't prepared for what happened to her in the next 4-5 years, her appalling care, and how she died.
I could have turned to drink ,and drugs, or severe  depression.
I did the complete opposite, I have spent the last 6 years investigating the system that put my family and mother through all of this, and thousands of others in the past, to ask why in one of the wealthiest country's in the world , did we all have to go through this.
9,000 phone calls , 200 letters , 3,000- 4000 e mails to the system's controllers ,politicians, councillors , charities , organisations.
This is 6 years of my life I have put into this, culminating in this DOCUMENT CARE MEANS CARE , JUSTICE IN CARE.


This document has now been sent to 40 + MP's in the House of Commons.

12 Peers in the house of Lords.


It has been accepted in the Parliamentary Accounts Committee, and the National Audit Office.


Our local MP has raised Care reform in Westminster Hall due to being inspired by my document on the 4th November 2015.


It introduced the Care Minister into this but has done nothing since, to call for a major meeting with key MP's to discuss this document. 


On the 27th April 2016 I sent an email to the care minister after he attended the care debate ,urging  him to call for this major debate on care.


I have recently sent this DOCUMENT to every member of the Select Committee's , Healthcare Dr Sarah Woolaston MP, and the PACAC Bernard Jenkin MP.


I have looked into the  Confederation NHS delivering dignity report Feb2012, the Parliamentary Administration Select Committee inquiry into Complaints March 2013,  the  Robert Francis QC report 2013, Ann Clwyd report into NHS Complaints 2014.


What I have discovered they all have in common , they all look into the NHS Hospital's , and all to do with the structure of the NHS, where is the Nursing Homes and the enquiries and investigations they are none existent . 


I believe the importance of this DOCUMENT ,it is the first lengthy investigation into the Nursing Home Sector  ever done ,and it needs recognising and taken serious, and being understood by the  Public  and Politicians.


In September  2012 I had a letter back from Bernard Jenkin MP chairman of the Parliamentary Administration Select Committee telling me what I was raising regarding the CQC and ombudsman's powers, looking into Nursing Homes, would have to go to Parliament through the Health Commissioners Act 1993, but that would not be for his Committee to take to Parliament , it would be for Dr Sarah Wollaston's Healthcare Select Committee to recommend , nothing has been done since!





The  three pronged system of the CQC and the Parliamentary Ombudsman, and legality ,should be abolished looking into the Nursing home sector, the Ombudsman has limited powers to investigate, the CQC do not look into individual cases ,and the legal system costs out way compensation for old people.


The draft for a Public Ombudsman is not going to work it is going to complicate the system even more , and all we have been doing for years is tampering round the edges of the CQC that is now more than ever being proved it is not fit for purpose anymore.


No we need and urgently need a one powerful body to regulate ,  inspect , and investigate the nursing home sector.


If you are frail elderly you are not only vulnerable , you are bottom of the pile ,end  of your life , so what , it doesn't matter, no rights, no justice for any of the frail vulnerable elderly ,we have had 20 years or more of appalling care to prove this, it needs a massive political debate of all colours to change this.



Figures from age UK 2012- 13 approx. 50,000 of the vulnerable elderly suffering mistreatment , abuse , neglect ,in nursing homes .

Radio 5 live 22nd Feb 2015, thousands of safeguarding complaints ,elderly , vulnerable ,2013-14, 1 in 5 homes failing key tests .

In the last 5 years 400 small nursing  homes closing down, putting  the frail elderly vulnerable in larger homes , without enough staff and qualified staff to deal with them , southern cross and many others that charities know about, prove this.

In the next 15 years there are going to be twice the amount of 85 year olds , and 3 times the 65 year olds picking up there pensions.

The system is in CRISIS now .

CQC  Chief Inspector Andrea Sutcliffe told BBC Breakfast TV in Oct 2014 " the standard of care homes in England is not good enough at the moment ".

CQC Chairman  David Prior said at the start of the CQC annual accountability at the healthcare select meeting on 16 th Dec  2014 , the CQC are still not fit for purpose "we have not got where we want to be. "  

In 2015 it was revealed by the CQC that nearly 40 per cent of the Nursing Homes are either needing improving or are inadequate . 

The Parliamentary Healthcare   Ombudsman , Dame Julie Mellor has been forced into raising the investigation figures using only the same staff by spending less time than before accessing the cases and more time investigating the cases , still spending less time than before, pushing the investigating figures up from 400 to 2000 .

When you are spending less time doing both what happens to the serious cases as before as my mothers , and cases like the titcombe babies case, and the Sam Morrish  boy's case down here in Devon.

At the end of 2015 the Ombudsman's finance team were found not only mainly interim ,but not working as effectively in certain area's, and with staff being reduced, they are in a mess. 

But what purpose are the Ombudsman there for they are not there to investigate nursing homes , they are there to investigate government depts. and the NHS hospitals.

The total cost to the taxpayer the two together is in excess of £400 million .

What are they getting for there money , an antiquated system , falling apart at the seams. 

That is why charities are inundated with complaints that the Ombudsman are not looking into there cases properly .


Mr Barrass asks "when will this appalling treatment under the name CARE for the vulnerable ,elderly,frail ,in nursing homes in this country end " .

The answer he believes after investigating the system for 6 years is in this document below.




On the 26th May 2005 my mother suffered in the medical terms a dense right sided hemiparesis total anterior circulation, stroke left her aphasic , with a dense right hemiplegia.

A serious stroke needing 24 nursing care , having multiple health problems and multiple health needs.

This is what care she received  and how she had to die.

Imagine what it must be like to be paralysed on one side ,unable to talk or call out for help ,press a buzzer, eat or drink, unable to walk , then imagine being fed and watered via a tube, the only quality of life you have is to see and hear people.
You are told you need a stimulating environment and responsive therapy.
Instead you are placed in a nursing home which is unsuitable for your needs.

Denied a correct chair for your quality of life, you cannot get out of your room for 4 months, then given a standard transit wheelchair deemed to be unsafe, under the health and safety factor ( had to support mums head once for 2 hrs with my own hand whilst wheeling her around in this chair ) , had to use this chair for 8 months, then when given the correct chair, but not enough staff to get out you out of your room on a regular basis.

Imagine being left in a soiled bed for 1 to 3 hrs,(one time left for 1 hr 20 mins the staff preferred to have there tea break first )However your mouth is not swabbed regularly so you develop crusty lumps around your teeth and on your tongue , nearly die in the first month of care , due to a chest infection not dealt with properly and promptly, blood tests not done on time, and then develop the worst case of constipation a hospital Dr has seen in 9 years, because you were not given the correct bowel medication, care home Dr say your family are fixated on this.


On 23 rd October 2009 during the early hours of the morning , my mum died in a North Devon Hospital.
The last 6 days of her life saw her experience great suffering beyond anything she had already endured in the 4 years leading up to this time and place

Her feed tube needed changing ,could and should have been changed one month earlier.
Due to this, complications set in .
( which involved a drug , flu vaccination, super public catheter ) .

Mums last 6 days not checked by a Doctor , no management on at the weekend, allowed to have a feed tube change on Monday ,when clearly condition at weekend needed looking into.


1. The parliamentary ombudsman would not investigate this only access!
2.We have 20 questions and issues unanswered by the p ombudsman!
3.Find they had 9 limited powers to investigate!
4.The legality side, costs outway compensation for the elderly.
5.After 5 years investigating this , nowhere to go to get this looked into properly or fairly!
6.This raises serious questions for everyone!
7.If they cant look into mums case properly or fairly !
8.They cant look into anyone else's properly or fairly!
9.How can this be right!

Why did my mother go to have a feed tube change to keep her alive , to die 3days after!
Why was my mother put through all of this !
For what reason!
I simply ask the question WHY.


1.Are the parliamentary Ombudsman fit for purpose to look into private nursing homes?

2.Are the CQC fit for purpose when they still do not look into individual cases in nursing homes?

3.Have nursing homes got enough staff and quality staff to take care of vulnerable patients who need 24 hour care?

4.Should patients like my mother ever have been put into these homes ?


5.Should there be special NHS units for 24 hour care patients with multiple health needs like my mums ?


6.What rights have the old , frail, and vulnerable got in private nursing homes?


7.With the limited powers both bodies have anyone who cannot get there cases looked into properly and fairly , if they wanted to go back to get the nursing Home management to get answers ,the Nursing Home management do not have to turn up , this cannot be right.


8. Any visitor related to a patient , if they complain too much or are viewed as a nuisance can be banned from visiting , yet the patient 's family may be paying £400-£700 a week for there care ,yet can have the accused up for trespassing, this cannot be right. 


9.Safeguarding patients,  if you havn't the staff or quality of staff to look after the patient, and  there still has been no law passed for whistle blowers to protect them ,that is simply not going to work.


10. Duty of Candour in Nursing Homes bought in by Parliament in April 2015 ,to protect the families , honesty , sincerity ,openness and fairness doesn't work ,and is not worth the paper it is written on, because the data protection act is there to protect the Nursing Homes.

11.Continuing health care funding for the very vulnerable paid by the tax payer to private nursing homes, yet have loopholes in the system not to be investigated thoroughly ?

12.Care means Care whether it is Private or NHS, when anything serious happens in nursing homes, and it involves the hospital NHS, both sides will not comment what the other side have done , yet are both caring for a patient, so the patient gets caught in the middle of all of this not getting clear answers to what has happened to them?

13.Equipment ie specialist equipment , profiling beds etc, no law to make the nursing homes provide , the CCG were set up to deal with this, but still problems with no law to provide?

14.Because of the system as it is ,when anyone finds anything out no one will talk after fear of legal action, there has to be a new system free from legal interference?

15.Because of continuing health care paid for 24 hr vulnerable patients, paid by the taxpayer, it is the Government NHS responsibility not the legal responsibility to investigate accountability and answers for the families of love ones who have been affected ?


1. A big national Political debate on CARE is needed urgently about all of what my investigation raises.

2. The PASC should hold meetings only about the nursing home sector and nothing else ,so they know more and can scrutinise more!

3.The CQC and the parliamentary Ombudsman are not fit for purpose anymore to inspect , regulate , and investigate nursing homes and a new one body only needs to be set up , with more powers to regulate , inspect ,investigate nursing homes doing the job together, to investigate all individual cases , to get accountability , free from legal interference .

4.Because the system as it stands at the moment , no one will ever get justice.
No one under the word 'Care' should ever have to go through this .
John Malcolm Barrass.
Tuesday 21st June 2016..