Maladministration, Misconduct, Negligence or Serious Mismanagement: Who is failing how?

I did not spend years of my life investigating this so that everybody involved could eventually move on, collect another senior title and continue exercising power while what happened disappears into institutional memory.

That is one of the main reasons this website exists.

I started as one woman asking for permanent contraception.

What followed became an investigation into how NHS policy is made, what evidence gets considered, how women’s decisions about their own bodies are treated, how unequal healthcare pathways are justified, what happens when senior executives give assurances that later collapse under independent scrutiny, and what happens when you ask the most uncomfortable question of all:

If you look at The Timeline, you can now see the whole pattern in one place.

1. A restrictive policy.
2. A complaint.
3. Assurances from the Chief Executive.
4. An Ombudsman investigation.
5. Formal findings of maladministration.
6. A replacement policy that again restricts women’s choices.
7. No leadership review.
8. A Freedom of Information request asking for the evidence.
9. A statutory deadline missed.
10. An Internal Review admitting the failure.
11. No meaningful internal investigation into who was accountable.
12. Another complaints route closed.
13. A second transparency battle over male vasectomy commissioning.
14. And repeated external escalation because the organisation would not meaningfully scrutinise itself.

At some point, “things went wrong” is no longer enough.

What does maladministration actually mean?

Maladministration is primarily an administrative-accountability concept rather than a criminal offence.

It describes public administration that falls below the standards expected of a public body.

That can include:

• failing to follow proper procedures;
• failing to consider relevant evidence;
• failing to properly explain a decision;
• poor or incomplete record-keeping;
• unreasonable delay;
• inconsistent treatment;
• failure to act fairly or proportionately;
• failure to correct mistakes;
• and failure to learn from complaints.

The Parliamentary and Health Service Ombudsman’s own principles expect public bodies to make decisions properly, keep adequate records, explain themselves, act fairly and put mistakes right.

Its remedy principles also recognise that maladministration can result in injustice or hardship, and that where this happens a public body should consider remedies not only for the complainant but, where appropriate, for other people affected by the same failure.

In this case, maladministration is not simply my description.

The Ombudsman independently found it.

You can read more in What the Ombudsman Found — and What It Could Not Do.

What is the difference between maladministration and misconduct?

This distinction is important.

Maladministration describes what went wrong in administration.

Misconduct describes the behaviour of a person.

An organisation can administer something badly without proving that one particular employee committed misconduct.

But individual conduct becomes relevant when somebody fails to meet the standards reasonably expected of their role.

For senior NHS leaders, the Fit and Proper Person Test framework is especially important because NHS England explicitly identifies behaviours that may be relevant to serious misconduct or serious mismanagement.

Those include:

• dishonest conduct;
• discrimination;
• disregard for appropriate standards of governance;
• resistance to accountability and undermining due process;
• failure to report significant issues;
• repeated or ongoing tolerance of poor practice;
• and continued failures in managing important business, financial or clinical functions.

NHS England also says context matters: whether behaviour was deliberate or reckless, whether dishonesty was involved, whether problems were repeated or continued over time, what role the person played and what impact the conduct had on public confidence.

That framework becomes very relevant when we stop looking at each event in isolation.

What does serious mismanagement mean?

Mismanagement is not necessarily one spectacular act.

It can be repeated failure to properly manage systems, risk, people, compliance and organisational responsibility.

At Board level, that matters because senior leaders are not only responsible for what they personally type into an email.

They are responsible for creating and maintaining systems that work.

If statutory processes repeatedly fail, if governance safeguards fail, if bad policies survive, if complaints do not create learning, if accountability disappears between departments and if leadership is notified without meaningful correction, then the question becomes bigger than one administrative error.

It becomes:

What does negligence mean?

Negligence is different again.

A legal negligence claim ordinarily requires a chain something like:

1. a duty of care;
2. a breach of that duty;
3. causation;
4. and identifiable harm or damage.

So not every bad policy is automatically negligent.

Not every example of maladministration creates a successful negligence claim.

Not every failure of governance causes a legally recoverable injury.

But that does not mean the harm caused by policy is irrelevant.

Quite the opposite.

The real question is whether the NHS created or maintained a healthcare pathway capable of causing foreseeable harm, and whether that foreseeable harm was properly considered.

Can a commissioning policy actually harm a patient?

Of course it can.

A healthcare policy determines what happens to real people and real bodies.

If a woman asks for permanent contraception and the NHS makes that treatment unavailable, exceptional, delayed or conditional on trying another contraceptive first, the policy changes the healthcare she receives.

The chain can look like this:

That is not theoretical.

The NHS itself recognises that hormonal contraception can involve side effects and risks.

Commonly reported effects include headaches, nausea, mood changes, changes to bleeding, sore breasts, acne and weight changes, although the NHS also notes that evidence does not establish that every reported symptom is necessarily caused by hormonal contraception.

Some hormonal methods also carry small increased risks such as blood clots and breast cancer.

That does not make hormonal contraception “bad”.

For millions of women it is an excellent choice.

The issue is whether it is their choice.

A treatment somebody freely chooses after weighing its advantages and disadvantages is not ethically equivalent to a treatment somebody is pressured or channelled toward because the healthcare system has restricted the option they actually want.

Why does NICE make this harm argument stronger?

NICE’s contraception quality standard says women asking for contraception should receive information about, and be offered a choice of, all contraceptive methods.

That explicitly includes permanent methods.

Female sterilisation is one of them.

NICE says healthcare practitioners should help women choose the method that suits them best, and commissioners should ensure services work together so women can receive their preferred method.

So when an ICB creates a policy that effectively says:

You may want permanent contraception, but before we respect that choice you need to try or prove the unsuitability of another method,

there is an obvious question about whether the local policy is facilitating contraceptive choice or overriding it.

This matters even more because the documents I eventually obtained showed that clinicians themselves had raised concerns about LARC being treated as a condition rather than an option, and supporting material referred to patient choice as something that should be paramount. 

Does the Supreme Court Case Montgomery v Lanarkshire Health Board make bodily autonomy part of the negligence question?

Yes.

The Supreme Court decision in Montgomery v Lanarkshire Health Board is foundational because it rejected the older paternalistic idea that doctors get to decide what information or choices a competent adult needs.

The Court made clear that an adult of sound mind is entitled to decide which available treatment, if any, to undergo.

A doctor must take reasonable care to make sure the patient knows about material risks of the recommended treatment and reasonable alternatives.

The whole point is meaningful participation in decisions about your own body.

That creates an important question in this case:

Montgomery applies most directly to the clinical encounter between professional and patient.

My case sits partly upstream of that encounter, because the commissioning policy itself can determine what the clinician is allowed to offer.

That does not automatically make the policy unlawful under Montgomery.

But it does make the conflict with informed choice and bodily autonomy impossible to ignore.

Is loss of bodily autonomy itself a form of harm?

Yes, in my view it plainly is.

The law does not only care about whether somebody developed a measurable physical injury.

Bodily integrity, private life and reproductive autonomy are themselves serious legal and ethical interests.

Healthcare decisions involve what happens to somebody’s body.

Being denied meaningful control over those decisions can therefore be harmful even before we ask whether there was a blood clot, depressive episode, painful side effect or unintended pregnancy.

The relevant harms can include:

• physical side effects from an unwanted alternative treatment;
• psychological distress;
• loss of reproductive autonomy;
• repeated invasive appointments or procedures;
• delay in receiving preferred care;
• prolonged fear of unintended pregnancy;
• and the humiliation or distress of repeatedly having a competent adult decision questioned.

That is why I reject the idea that this case is simply about “funding criteria”.

Can unequal access create unequal health outcomes?

Absolutely.

The NHS Constitution recognises a right not to be unlawfully discriminated against and gives patients rights around informed choice and involvement in decisions.

ICBs also operate under statutory responsibilities relating to reducing inequalities in access to healthcare and in outcomes.

That means equality cannot be reduced to:

“Men and women both technically have some kind of sterilisation pathway.”

The actual pathway matters.

If men may receive:

• NHS-funded vasectomy;
• private-provider access;
• direct referral;
• or self-referral;

while women face:

• GP referral;
• specialist assessment;
• discussion of alternatives;
• LARC gatekeeping;
• approval criteria;
• and potentially much longer surgical waiting pathways;

then the difference creates a different health burden.

Women may spend longer using contraception they did not want.

They may experience additional side effects.

They may need more appointments.

They may remain at risk of unintended pregnancy for longer.

They may simply abandon their request because the pathway becomes exhausting.

Unequal access can therefore create unequal health burdens.

This is why my investigation into male vasectomy commissioning matters so much. You can read that story in The Gender Gap in Healthcare: The Vasectomy Pathway NHS Thames Valley Would Not Explain.

What evidence did the ICB show that it had considered these harms?

This is exactly what I have been trying to establish.

My Freedom of Information request asked for evidence around:

• the final approval process;
• equality analysis;
• clinical evidence;
• legal and ethical reasoning;
• comparison with male vasectomy;
• bodily autonomy;
• informed choice;
• and whether the post-Ombudsman reforms had actually been followed.

The disclosure I eventually received answered some things, but it also exposed major gaps.

The ICB expressly acknowledged that the detailed comparison I had requested between female sterilisation and the male vasectomy pathway had not been conducted in the earlier supporting work.  

The equality assessment disclosed to me was pre-Ombudsman, recorded no specific patient engagement, and there was still a question over whether later equality work described in the approval papers had ever been completed and disclosed.  

The ICB’s own material also referred to later post-Ombudsman work — including a refreshed report, a 14-item action tracker and further comments raising “significant concerns” — yet those were among the records I was still chasing.  

So one of my central concerns remains:

Does all of this automatically prove legal negligence?

No.

And that distinction matters.

A successful negligence claim normally needs a particular claimant to show a duty of care, breach, causation and damage.

For example, a woman who was inadequately informed about her options, was directed into a treatment she would otherwise have refused, and suffered injury because of it might raise a much more conventional negligence issue.

At commissioning level, the legal routes can be different.

They may include:

• public law and judicial review;
• the Equality Act and Public Sector Equality Duty;
• statutory NHS duties around healthcare inequalities;
• Article 8 and bodily autonomy;
• informed-consent law;
• the NHS Constitution;
• and maladministration resulting in injustice or hardship.

So I would not claim that every failure documented here is clinical negligence.

I would say something more precise:

Whether a particular woman could establish legal negligence would depend on what happened to her personally.

But the possibility of harm should have been part of the policy-making process before any woman ever needed to sue.

Does the failure to learn after the Ombudsman make later harm more serious?

In my view, absolutely.

The first time an organisation gets something wrong, it may say it failed to understand the problem.

That argument becomes much weaker after an independent Ombudsman has already identified the underlying failures.

The Ombudsman’s remedy principles expressly say public bodies should learn from complaints, change policies and systems where necessary and avoid repeating maladministration.

That makes the February 2026 replacement policy especially important.

The ICB had already been told that its earlier work around female sterilisation involved serious failures.

Yet the new policy still contained a requirement that women undergo, or demonstrate the unsuitability of, a LARC trial before sterilisation.

I challenged that restriction directly in my correspondence with the Chair of the ICB - Dr Priya Singh. 

Within months, the LARC requirement itself was being reconsidered.

So the question becomes:

For me, that makes the later events more serious than the original mistake.

What does Dr Nick Broughton’s role raise?

Dr Nick Broughton, Chief Executive and Accountable Officer of NHS Thames Valley ICB, sits at several major points in this history.

He issued the final Chief Executive response to my original complaint.

That response gave me false reassurance about how robustly the policy had been developed and reviewed. The Ombudsman subsequently found important shortcomings in the evidence, reasoning, equality comparison, consultation and complaint handling.

You can examine those contradictions in The Gaps Between Dr Nick Broughton’s Claims and the Ombudsman Findings.

After the Ombudsman report, I asked whether those findings had triggered any consideration of his Fit and Proper Person status.

They had not.

Chair Dr Priya Singh confirmed in writing that:

• the Board, its committees and associated groups had not considered leadership accountability following the PHSO findings;
• and Dr Broughton’s FPPT status had not been reviewed, reassessed or discussed because of them.

That is documented in her response.  

Then came the FOI failure.

As Chief Executive and Accountable Officer, Dr Broughton sat at the top of an organisation that missed a statutory information deadline. What's worse is that the Information Officer at the ICB invented a new deadline, giving themselves TWO MONTHS beyond the statutory deadline, and declined and avoided to give me Legal reasons and justifications for it. 

I directly copied the CEO and Accountable Officer Nick Broughton into later correspondence challenging the continuing breach.

I saw no visible intervention from him that resulted in immediate compliance.

To me, that raises questions about:

• leadership competence;
• oversight;
• tolerance of poor practice;
• governance;
• and fitness for senior office.

Those categories matter because NHS England’s FPPT framework itself treats disregard for governance, resistance to accountability and repeated tolerance of poor practice as potentially relevant to serious misconduct or serious mismanagement.

Why does Dr Nick Broughton’s national role make these questions even more important?

Dr Broughton is not only Chief Executive and Accountable Officer of NHS Thames Valley ICB.

In 2026 he was also appointed in ans so holds the NHS England role of National Priority Programme Director for Mental Health, Learning Disability and Neurodevelopmental Conditions.

That role involves national leadership affecting people with severe mental illness, learning disabilities and neurodevelopmental conditions.

Many of those patients may face far greater barriers than I do when challenging authority, understanding complaints systems, navigating policy and making institutions answer difficult questions.

I find that deeply relevant.

I am persistent.

I understand research.

I keep records.

I challenge language.

I use FOI law.

I escalate.

I publish.

A vulnerable patient with a learning disability may not be able to do any of those things.

I will examine Dr Broughton’s career, progression and current national responsibilities separately.

What does Dr Priya Singh’s conduct raise?

Dr Priya Singh, Chair of NHS Thames Valley ICB, has a central governance role.

I approached her because the Ombudsman findings raised obvious questions about the assurances previously given by her Chief Executive.

Her response established that there had been no leadership-accountability consideration and no FPPT review connected to those findings.  

I then separately challenged her over the February 2026 female sterilisation policy.

I asked whether it complied with equality law, informed consent, bodily autonomy, clinical guidance and the Ombudsman findings.

Instead of a straightforward answer, the correspondence stretched across repeated chasers and explanations while the policy itself was being reconsidered.

Eventually, correspondence was closed - by her - without answering my questions and challenges about the new policy and the gender gap inequality of permanent contraception and just giving me empty promises of updates - that never materialised to this day (16 September 2026)

You can read that history in Why NHS Chair Dr Priya Singh Couldn’t Defend the February 2026 Female Sterilisation Policy.

To me, the questions are about:

• adequacy of Chair oversight;
• FPPT governance;
• willingness to scrutinise the Chief Executive;
• openness;
• and resistance to accountability.

I am not saying a disciplinary body has found Dr Singh guilty of serious misconduct.

I am saying I believe the evidence warrants scrutiny of whether she fulfilled the accountability responsibilities of her role.

What does Mark Gittins’s Internal Review tell us?

Mark Gittins, Information Governance Consultant, conducted the Internal Review of FOI-TV-2606-105.

His review accepted that my request had not been handled within the statutory timeframe.

That was important.

But I challenged the review because I believed it did not properly establish:

• where the ICB’s own escalation controls failed;
• who was responsible at each stage;
• what executive oversight occurred;
• how disputed redactions had appeared;
• and what governance consequences followed from the admitted breach.

When I kept challenging those questions, Mr Gittins eventually said the ICB would provide no further response on the Internal Review.  

That does not automatically prove misconduct by him.

But it does raise a serious question about whether an internal review mechanism that can acknowledge a statutory failure without meaningfully establishing accountability is functioning as an accountability mechanism at all.

To me, Mark Gittins’s role raises more than a question about whether the Internal Review was technically adequate.

He was the person tasked with reviewing an admitted statutory failure. His own review accepted that NHS Thames Valley ICB had missed the legal FOI deadline, yet when I asked the obvious follow-up questions — where did the controls fail, who was responsible, why had the ICB’s own escalation safeguards not worked, what happened with the disputed redactions, and what accountability followed — those questions were never properly resolved.

That starts to look, in my opinion, like poor governance and potentially mismanagement of the review process itself. An Internal Review should not simply acknowledge that something went wrong; it should help establish how it went wrong, whether the organisation’s safeguards worked, what needs correcting and who is responsible for making sure it does not happen again.

What concerns me even more is that, after I continued pressing those unresolved questions, Mr Gittins told me that the ICB would not provide further responses on the Internal Review. To me, that can reasonably be viewed as resistance to accountability: the review admitted the breach but then stopped engaging when scrutiny moved from “was the deadline missed?” to “who is accountable for allowing this to happen?”

I am not saying that this proves serious misconduct by Mark Gittins. But I do think it raises legitimate questions about professional judgement, adequacy of internal governance, willingness to investigate organisational failure, and whether the Internal Review function was being used to identify and correct problems or simply to administratively close them.

What does Hannah Iqbal’s position raise?

Hannah Iqbal, Chief Strategy and Commissioning Officer, appears in this story because of her senior organisational role and because she was included in later escalation around commissioning and FOI failures.

I have not seen evidence proving that she personally caused the original statutory breach. I would therefore not label her conduct misconduct on the evidence I currently have.

The question is more basic:

That remains an accountability question I think deserves an answer, because through this whole process and that many failures - she's been totally incognito and never showed up even once in correspondence. So that begs the questions: what is she paid to do, and what is she responsible for and failing at?

Hannah Iqbal’s position raises a different kind of question because I do not currently have evidence showing that she personally caused the original FOI failure.

But she is Chief Strategy and Commissioning Officer, a very senior executive role, and she was directly included in later correspondence about commissioning, transparency and the continuing failures. At that point the issue was no longer simply that one FOI had been delayed. The organisation had already admitted statutory non-compliance, serious questions had been raised about internal controls, and I was also challenging how current commissioning decisions — including vasectomy provision and equality between male and female permanent contraception — were being governed.

For me, the accountability question is therefore not only, “Did Hannah Iqbal cause the problem?” It is also: once a senior executive responsible for strategy and commissioning becomes aware of an admitted legal failure and serious concerns about the transparency and equality of commissioning decisions, what duty does she have to intervene, investigate or ensure that somebody does?

If a senior executive is notified of significant governance concerns within her area of responsibility and no meaningful corrective action follows, that can, in my view, raise questions of management failure, inadequate oversight and tolerance of poor practice. Those are exactly the kinds of issues that become relevant when assessing whether senior leadership systems are functioning properly.

I am not claiming that the current evidence establishes serious misconduct by Hannah Iqbal. It does not. But I do think her apparent lack of visible intervention deserves scrutiny. 

Senior leadership accountability includes what people fail to do after they know that something has gone wrong.

What does Lorri Josey’s refusal to investigate add?

Lorri Josey, Complaints Manager in the Public & Patient Experience Team, became involved after the FOI Internal Review.

I asked PPET to investigate something distinct from my information-law rights.

I asked them to investigate:

• staff conduct;
• failed internal controls;
• management response;
• executive oversight;
• and governance accountability for the admitted FOI failure.

Ms Josey repeatedly directed me toward the Information Commissioner’s Office instead. Her correspondence identifies her role as Complaints Manager in PPET. 

I repeatedly explained that the ICO can investigate information-law compliance but is not NHS Thames Valley ICB’s HR department, disciplinary process, management function or executive-governance mechanism.

No alternative internal investigator was identified.

Lorri Josey’s role raises a more direct accountability question because she was not simply a senior manager copied into correspondence. She was the Complaints Manager in NHS Thames Valley ICB’s Public & Patient Experience Team, and I specifically asked her team to investigate the organisational conduct and governance failures that had emerged from the admitted FOI breach.

I repeatedly explained that I was not asking PPET to conduct another Freedom of Information Internal Review. That process had already happened. I was asking who within NHS Thames Valley ICB would investigate the things the ICO could not investigate for the organisation: failed internal controls, staff conduct, management response, senior leadership intervention, accountability and whether remedial, governance or disciplinary action was required.

Initially, I was told that these matters could be dealt with through the FOI Internal Review. Once that review had concluded without resolving them, I returned to PPET and asked again for a corporate complaint to be opened.

Lorri Josey then maintained that the appropriate route was the Information Commissioner’s Office.

Eventually, PPET relied on Regulation 8(1)(g) of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, which excludes certain complaints concerning matters subject to Freedom of Information legislation from the NHS complaints procedure.

But that did not answer the question I was actually asking.

I specifically asked PPET to address Regulation 8(3) and explain what happened to the separate concerns about staff conduct, failed governance, management response and executive accountability. I also asked that, if PPET itself was not sufficiently independent or did not have jurisdiction, the concerns be escalated to another appropriate route — for example a senior independent director, Freedom to Speak Up function, NHS England regional governance route or another body capable of examining the conduct and governance issues.

I was not given a substantive explanation of why those separate issues could not be investigated internally. Nor was I given a policy or legal analysis explaining why no alternative internal or external governance route should be engaged. Instead, the matter was ultimately declared closed.

That is significant to me because a complaints function is not only there to tell people which matters it will not investigate. Part of effective complaint handling is identifying the substance of a concern, making sure it reaches the correct part of the organisation and ensuring serious issues are not simply lost because they cross departmental boundaries.

If a Complaints Manager is directly presented with allegations of failed internal controls, staff conduct concerns, admitted statutory non-compliance and possible senior leadership failures, and the response is effectively to redirect the complainant elsewhere without ensuring that anybody inside the organisation examines those matters, I think that can reasonably raise questions about poor complaint management, inadequate escalation, failure of organisational learning and potentially mismanagement of the complaints function itself.

It also raises a question about resistance to accountability. I had made the distinction between the FOIA dispute and the wider governance complaint repeatedly. The issue was not merely whether information should have been disclosed. The issue was what the organisation was going to do about the people, systems and leadership that had allowed the admitted failure to occur and continue.

I am not claiming that Lorri Josey has been formally found guilty of misconduct. She has not. But I do think her handling of my complaint warrants scrutiny because her role placed her at the point where the organisation had an opportunity to investigate itself, escalate the concerns to somebody who could, or identify a credible alternative accountability mechanism. None of those things appears to have happened.

In my view, closing the complaint without answering where those governance and conduct concerns would actually be investigated did not resolve the accountability problem. It became part of it.

Once again - let's remember: at senior level, accountability is not limited to personally causing a failure. It also includes what leaders do — or fail to do — once significant failures are brought directly to their attention.

The matter was eventually closed.

You can read the full story in The Accountability Vacuum Inside NHS Thames Valley ICB.

To me, that is evidence of a structural accountability problem.

What does the vasectomy FOI add to the equality and harm picture?

The male vasectomy investigation matters because it shows what easier access can look like.

I found NHS-funded vasectomy being delivered through private services, with self-referral available in some areas and expansion being discussed.

I then asked the ICB:

• who was commissioned;
• what referral routes existed;
• what safeguards applied;
• what equality assessments had been completed;
• and whether anyone had compared those pathways with women’s access to sterilisation.

The request was refused under Section 12 on cost grounds.

I then substantially narrowed it and asked the ICB to fulfil its Section 16 duty to provide advice and assistance.

I reduced the request to current providers, current access pathways, current equality documentation and the latest comparison with female sterilisation. :contentReference[oaicite:10]{index=10}

The wider question remains:

If the NHS can make permanent contraception convenient, privately delivered and increasingly directly accessible for men, what evidence justifies imposing substantially greater friction on women?

When does repeated maladministration begin to look like systemic mismanagement?

This is perhaps the most important question in the whole article.

One mistake is a mistake.

One missed deadline can be a mistake.

One bad complaint can be a bad complaint.

But NHS England itself says seriousness can be assessed by considering whether issues are frequent or continue over a long period.

Now look at The Timeline.

• A female sterilisation policy was created using a process later found to be maladministrative.
• My complaint about it was itself handled badly.
• The Chief Executive gave assurances I believe were contradicted by the independent findings.
• No leadership-accountability or FPPT review followed those findings.
• A replacement policy introduced another major restriction on women’s choice.
• The Chair repeatedly avoided giving me the direct compliance answer I asked for.
• The ICB then missed a statutory FOI deadline by almost two months.
• Its own Internal Review admitted that failure.
• The wider governance questions were not resolved.
• Senior leadership was directly notified.
• The complaints function would not investigate the organisational consequences.
• The disclosure itself still appeared incomplete.
• A second FOI battle then developed around male vasectomy commissioning and equality.

I think it is entirely reasonable to ask whether this crossed the line from individual instances of maladministration into systemic mismanagement.

Does lack of intention excuse the harm?

No.

This is one of the most dangerous ideas in institutional accountability.

Harm does not require somebody to sit in a boardroom and decide to hurt women.

People can be harmed because:

• bad assumptions go unchallenged;
• evidence is not properly weighed;
• equality is treated as a formality;
• nobody considers the burden of alternative treatments;
• nobody compares unequal pathways;
• poor decisions are not reviewed;
• leaders are not held accountable;
• complaints become something to close rather than learn from;
• and vulnerable people eventually stop fighting.

That is exactly why governance exists.

Why does this matter to women who will never read this website?

Because most women will never spend years doing what I have done.

Most people will assume that if an NHS policy exists, somebody has properly checked it.

Most will trust the first rejection.

Most will not file an FOI.

Most will not know what a Public Sector Equality Duty is.

Most will not challenge an Internal Review.

Most will not email the Chair.

Most will not understand an FPPT framework.

That is why the people who hold public power carry such enormous responsibility.

Why is this connected to the wider NHS crisis?

An NHS can have excellent doctors and nurses and still fail patients through poor governance.

You can put more money into healthcare and still waste it through badly designed policy.

You can publish values about openness and patient-centred care while operating systems where senior accountability is almost impossible to trigger.

When governance fails:

• poor policies survive longer;
• health inequalities survive longer;
• patients experience unnecessary treatment burden;
• warnings are missed;
• money is wasted;
• staff learn that procedures can be ignored;
• and harm can continue because nobody stops the system long enough to examine what it is doing.

That is why governance is not administrative trivia.

In healthcare, governance affects bodies, health and lives.

Does the evidence warrant investigation for serious misconduct or serious mismanagement?

I cannot make the formal finding.

A regulator, employer or authorised governance body has to investigate the individual roles, obtain explanations and reach conclusions.

But I can ask whether the threshold for investigating has been reached.

The NHS’s own framework tells organisations to consider disregard for governance, resistance to accountability, dishonest conduct, repeated tolerance of poor practice and persistent management failures.

Those terms sit far too close to what I have spent years documenting for the answer to simply be:

No review is necessary.

Who appears to carry what accountability?

What am I not claiming?

For clarity:

• I am not saying a court has found Dr Nick Broughton dishonest.
• I am not saying a disciplinary panel has found Dr Priya Singh guilty of misconduct.
• I am not saying Mark Gittins, Hannah Iqbal or Lorri Josey have been formally found guilty of professional misconduct.
• I am not claiming that every woman affected by the policy automatically has a negligence claim.
• I am not claiming that every contraceptive alternative is harmful.

What I am saying is that:

• maladministration has already been independently established;
• foreseeable patient harm should have been part of policy design;
• the evidence disclosed to me does not show that all relevant harms and inequalities were properly weighed;
• further admitted governance failures occurred afterwards;
• and the accumulated pattern now raises serious questions that fit the NHS’s own language around governance, serious mismanagement and misconduct.

What should happen now?

I think external oversight bodies need to stop looking at these events one at a time.

The female sterilisation policy sits in one file.

The Ombudsman report sits in another.

The FPPT question sits somewhere else.

The FOI breach goes to the ICO.

The governance complaint gets redirected.

The vasectomy inequality becomes another commissioning issue.

Each issue can then be treated as small enough to explain away.

The pattern is the evidence.

That is why I created The Timeline.

I believe NHS England, the relevant regional leadership, local health scrutiny and any body responsible for appointing or overseeing senior NHS leaders should examine this history together.

Why I am not going away

I have already lost years to this.

I cannot get those years back.

But I can make sure the evidence does not disappear.

I can make sure decisions stay attached to the people and offices responsible for them.

I can make sure that when somebody is promoted or given a national role, unresolved questions about their previous leadership remain visible.

I can make it harder for the next woman to be told:

“That is simply NHS policy.”

As though policy appeared from nowhere.

Read the full evidence trail

• The Timeline — follow the complete case chronologically
• Evidence Folder — correspondence, FOIs, reports and documentary evidence
• What the Ombudsman Found — and What It Could Not Do
• Dr Nick Broughton’s Claims vs the Ombudsman Findings
• I Challenged the Policy — the CEO Told Me the Governance Was Robust
• When Maladministration Brings No Accountability
• Why Dr Priya Singh Couldn’t Defend the February 2026 Policy
• The Accountability Vacuum Inside NHS Thames Valley ICB
• The Vasectomy Pathway NHS Thames Valley Would Not Explain
• Why I Asked Oxfordshire Health Scrutiny to Investigate

Authoritative sources and frameworks

• NICE — Contraceptive information and methods — women should be informed about and offered a choice of all contraceptive methods, including permanent contraception.
• NHS — Side effects and risks of hormonal contraception — explains recognised side effects and risks relevant to the burden of alternative contraception.
• UK Supreme Court — Montgomery v Lanarkshire Health Board — informed consent, material risks, reasonable alternatives and bodily integrity.
• The NHS Constitution for England — patient choice, involvement, equality and rights within NHS healthcare.
• NHS England — Fit and Proper Person Test Framework for Board Members — serious misconduct, serious mismanagement, governance, accountability and repeated tolerance of poor practice.
• Parliamentary and Health Service Ombudsman — Principles for Remedy — correcting maladministration, remedying injustice or hardship, learning and preventing repetition.

Legal FOI Request Deadlines Ignored, Internal Procedural Failures Excused, Investigating Their Staff Rejected- Here's Evidence on The Accountability Vacuum Inside NHS Thames Valley ICB  Under CEO Nick Broughton's Leadership

What is PPET — and why did I expect it to investigate?

PPET stands for Public & Patient Experience Team.

Within NHS Thames Valley ICB, this is the function dealing with complaints and patient experience. The person corresponding with me was Lorri Josey, Complaints Manager, Public & Patient Experience Team, NHS Thames Valley ICB.

This distinction matters because I was not simply sending another email to the Freedom of Information team.

I deliberately went to the complaints function because what had happened was no longer only a question of whether my information request had been answered within the Freedom of Information Act.

The ICB's own Internal Review had already admitted that the statutory deadline had been breached.

The problems I wanted investigated were now organisational:

• why the statutory process had failed;
• why the ICB's own internal escalation safeguards had apparently failed;
• why the failure continued after it became known;
• how staff had handled the matter;
• how the Internal Review itself had been conducted;
• why disputed redactions had appeared in responsive records;
• why senior executives did not appear to intervene despite being directly notified;
• and who, if anyone, would be held accountable.

Those are not simply questions about whether section 10 of FOIA was breached.

They are questions about people, management, governance and organisational culture.

Why did I involve PPET before the FOI Internal Review had even finished?

On 23 July 2026, after the FOI team had repeatedly failed to respond properly to me, I requested a formal Internal Review.

But I copied PPET into the correspondence as well.

I explicitly separated the two issues.

The Information Governance team needed to examine the handling of my statutory FOI request.

PPET, I argued, should separately look at the repeated non-response, failure to remedy an acknowledged breach, lack of identifiable accountability and wider administrative and governance failures.

I was already seeing two different questions:

The first belongs to information-law processes and ultimately the ICO.

The second, in my view, belongs squarely inside the organisation's own governance and accountability systems.

Why did Lorri Josey initially say an Internal Review made a separate complaint unnecessary?

On 27 July 2026, Lorri Josey responded.

She told me PPET had checked with NHS Thames Valley ICB colleagues and had been advised that the concerns fell within the FOIA Internal Review process rather than the NHS complaints process.

Importantly, she explained that the ICB complaints process was intended for issues including:

but said that my concerns could instead:

That was the basis on which PPET declined to investigate separately.

Fine.

So I waited for the Internal Review.

Then the Internal Review happened - and I've already written about the Internal Review in this website.

And the premise of that refusal fell apart.

What happened when the Internal Review did not actually resolve the governance failures?

By 17 August 2026, the Internal Review had concluded.

It had admitted the statutory failure.

But it had not answered many of the organisational questions I had raised.

The FOI disclosure was still outstanding.

Questions remained about the ICB's failed escalation procedures.

Questions remained about disputed redactions.

Questions remained about who was responsible.

Questions remained about executive oversight.

And Mark Gittins had now told me that he would provide no further response to my substantive challenges.

So I went back to PPET.

This time I made the distinction impossible to miss.

I told Lorri Josey:

What exactly did I ask NHS Thames Valley ICB to investigate?

My formal corporate complaint on 17 August 2026 was structured around seven areas.

• Failure of the ICB's statutory and internal FOI controls.
• Adequacy and conduct of the Internal Review.
• The continuing statutory breach without an identified legal justification.
• Handling and unexplained redaction of responsive records.
• The conduct of the Internal Reviewer after I challenged him.
• Executive accountability and failure to intervene.
• The persistent absence of accountability across the organisation.

I asked PPET to register a formal corporate complaint and allocate it to a sufficiently senior and independent investigator.

I wanted the investigation to examine the people and systems involved, including Information Governance and Mark Gittins.

I also specifically asked it to establish what action had been taken by:

• Dr Nick Broughton, Chief Executive and Accountable Officer;
• Dr Priya Singh, Chair;
• and Hannah Iqbal, Chief Strategy and Commissioning Officer.

All three had been directly notified about the continuing failures.

I wanted to know what they actually did.

That is a governance investigation.

It is not an FOI appeal.

Why did Lorri Josey send me back to the ICO anyway?

On 19 August 2026, Lorri Josey replied.

She said she had "double-checked" her previous advice and received confirmation that it was correct.

The correct escalation route, she said, was the Information Commissioner's Office.

But she did not initially tell me what legislation, regulation, ICB policy or formal complaints rule she was relying upon.

I found that unacceptable.

"I have double-checked and been told I am correct" is not a transparent reason for denying somebody access to an accountability process.

Who checked?

Against what?

What provision applies?

Why?

If a public body is refusing to investigate a formal complaint, it should be able to explain the basis for doing so.

Why did I challenge the ICB's reliance on Regulation 8?

On 19 August 2026, I wrote back.

I recognised that Lorri Josey appeared to be relying on Regulation 8(1)(g) of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.

That provision is relevant where a complaint relates to a person's right of access to information under the Freedom of Information Act.

I was not disputing the basic point that the ICO should deal with my statutory information-rights dispute.

I had already sent that part to the ICO.

My challenge was that the ICB was treating everything connected with the FOI failure as though it automatically became an information-law question.

I specifically asked the ICB to address Regulation 8(3) and explain why the separate organisational and conduct issues I had identified should also be excluded rather than dealt with through an appropriate internal process.

I did not receive a substantive answer to that point.

Why couldn't the ICO simply investigate the people and governance failures for them?

Because the ICO is not NHS Thames Valley ICB's HR department.

It is not its disciplinary function.

It is not its executive-governance function.

It is not responsible for deciding whether Dr Nick Broughton exercised appropriate leadership after being notified of a continuing statutory failure.

It is not responsible for asking why managers failed to operate the ICB's internal escalation controls.

It is not responsible for determining whether staff complied with their internal organisational duties.

It is not responsible for deciding what management action, disciplinary action, governance action or FPPT consideration should follow.

I told Lorri Josey this directly.

If the ICB's systems failed, somebody inside the NHS still has to ask why.

If PPET was not the right team, why didn't it send the complaint to whoever was?

This was perhaps the simplest question I asked.

I told Lorri Josey:

If PPET cannot investigate this, tell me who can.

Refer it.

Escalate it.

Identify the appropriate internal governance mechanism.

If the concerns involve senior executives and that creates an independence problem, send them somewhere with sufficient independence to investigate.

I identified possible routes myself, including senior independent oversight and NHS England regional governance structures.

What I would not accept was an accountability vacuum in which:

That makes no sense to me.

What do the NHS's own Complaint Standards say should happen when things go wrong?

The Parliamentary and Health Service Ombudsman's NHS Complaint Standards are supposed to create an NHS complaints culture that is open, honest and accountable.

They describe effective complaint handling as thorough and fair.

They expect organisations to give accountable responses, identify mistakes, learn from them and take action to prevent recurrence.

Guidance for senior NHS leaders says they should ensure appropriate structures exist for fair and robust complaint investigations and that learning from complaints is used to improve services.

That is the opposite of what I felt I was experiencing.

I was not seeing curiosity about how the organisation had failed.

I was seeing a hunt for the next reason why somebody else should deal with it.

Why did the ICB close the complaint instead of identifying an accountability route?

On 28 August 2026, PPET sent its next response.

This time it explicitly cited Regulation 8(1)(g).

The ICB said my outstanding concerns arose from the handling of my FOI request and therefore would not be investigated through its complaints process.

Again, my Regulation 8(3) challenge was not substantively addressed.

No alternative internal investigator was identified.

No HR route was identified.

No governance route was identified.

No independent executive route was identified.

No one was named as responsible for examining the conduct issues.

Instead, I was told:

And I was warned that if I sent further correspondence about the FOI complaint, it might be read but not responded to.

There it was again.

The same ending.

Why did this start looking like a pattern rather than coincidence?

On 29 August 2026, I wrote back and laid out the history.

This was no longer the first time I had encountered this behaviour.

Years earlier, I had challenged the original female sterilisation policy through the ICB's complaints process.

The substantive questions about evidence, equality, clinical guidance, bodily autonomy, consultation and decision-making were not properly answered.

Dr Nick Broughton, Chief Executive, eventually issued his final response and closed the internal complaint route.

I went to the Ombudsman.

The Ombudsman subsequently found that the ICB had indeed failed to properly understand and engage with key aspects of my complaint.

Then I challenged Dr Priya Singh, Chair of NHS Thames Valley ICB, about the replacement female sterilisation policy and leadership accountability.

Again, I did not get direct answers to central questions.

Eventually, she declared further correspondence closed.

Then came FOI-TV-2606-105.

The statutory deadline was missed.

I challenged the Internal Review.

Mark Gittins eventually told me that further correspondence on those questions would receive no response.

Then I went to PPET.

Lorri Josey eventually told me the matter was closed, and future emails might not be answered.

The sequence had become painfully familiar:

Once might be poor complaint handling.

Twice starts to concern me.

When I see the same behaviour through the Chief Executive, the Chair, Information Governance, an Internal Reviewer and the complaints function, I start asking whether this is how the organisation itself operates.

What happened when I gave PPET one final opportunity to identify an investigator?

On 29 August 2026, I gave the ICB one final opportunity.

I asked PPET to address Regulation 8(3) and answer one simple question:

If nobody would investigate them, I asked the ICB to say so clearly and identify the legal, regulatory or policy basis for that position.

I gave a deadline of 31 August 2026.

That date passed without the substantive answer I had requested.

Why was "in due course" no longer good enough?

On 2 September 2026, Lorri Josey wrote again.

She said she would share my email with ICB colleagues, seek further confirmation and respond:

"in due course."

At another stage of this battle, perhaps I would have waited.

By September 2026, I was done.

I had already spent years chasing this organisation.

I had repeatedly been given vague timeframes.

I had watched legal deadlines expire.

I had watched people promise answers and then fail to provide them.

I had watched correspondence get closed while substantive questions remained unresolved.

"In due course" is not a timeframe.

And I was no longer prepared to keep my life permanently open-ended around whenever NHS Thames Valley ICB might eventually decide to answer questions about its own accountability.

Why did I finally close the correspondence myself?

On 3 September 2026, I wrote to Lorri Josey for the final time.

I told her I was done waiting for NHS Thames Valley ICB to get its own accountability processes in order.

I had asked repeatedly.

I had explained the distinction between the ICO's responsibility and the ICB's responsibility.

I had identified the legislation I believed was relevant.

I had suggested alternative accountability routes.

I had given them a deadline.

I had given them another opportunity.

I had still not been told who inside the organisation would investigate what had happened.

So this time I closed the correspondence.

There is an important difference.

I was not ending scrutiny because I did not want to answer it.

I was ending an internal exchange because I had exhausted reasonable attempts to make the organisation scrutinise itself.

I would pursue the issues externally instead.

What does this repeated behaviour say about NHS Thames Valley ICB's culture?

This is where my concern has moved beyond individual emails.

Organisational culture is not what an institution writes on its website.

It is what people repeatedly do.

NHS organisations can write that they value:

• transparency;
• openness;
• accountability;
• learning;
• patient involvement;
• equality;
• and continuous improvement.

Those words are cheap.

The test comes when somebody turns up with evidence that something may have gone wrong.

Do you investigate?

Do you answer?

Do you identify who was responsible?

Do you look honestly at leadership?

Do you correct the failure?

Or do you redirect, delay, reframe, deflect and eventually stop responding?

From my experience, the behaviour I have seen across NHS Thames Valley ICB tells a very different story from the values written in its policies.

Is this what top-down resistance to accountability looks like?

In my opinion, yes.

When the same behaviour appears at multiple levels of one organisation, I stop believing that every example is an unrelated mistake.

I saw it from the Chief Executive.

I saw it from the Chair.

I saw it through Information Governance.

I saw it through the Internal Review.

I saw it through PPET.

Different people.

Different functions.

Same endpoint.

Scrutiny is tolerated until it becomes uncomfortable. Then communication is shut down.

That is my interpretation of the documentary record.

Please read it and form your own.

What happens when nobody inside an NHS organisation will investigate the NHS organisation?

You create an accountability vacuum.

And that is dangerous.

Because healthcare organisations exercise enormous power.

They decide what treatment gets commissioned.

They decide what pathways patients have to navigate.

They decide what evidence is sufficient.

They decide how equality duties are interpreted.

They decide how complaints are investigated.

They decide whether senior leadership needs scrutiny.

They handle statutory information requests about their own decisions.

If the same organisation can make the decision, investigate the decision, investigate the complaint about the decision, review its own investigation and then decide that nobody needs to investigate the governance failures exposed along the way, that starts looking frighteningly close to institutional self-policing without meaningful accountability.

Why does this matter far beyond one FOI request?

Because healthcare governance is not paperwork.

The quality of governance affects what care people can access, how quickly failures are corrected and whether dangerous decisions are caught before they hurt people.

Weak accountability creates space for poor decisions to survive.

Poor decisions can restrict treatment.

They can create inequality.

They can leave patients without care they need.

And in healthcare, failures that remain unexamined can ultimately contribute to real harm.

This is why I become angry when accountability is treated like an administrative inconvenience.

These organisations are not selling shoes.

They make decisions about people's bodies, health and sometimes their survival.

The standard should be higher, not lower.

Is the NHS good at talking about values but bad at proving them?

That is increasingly my view.

NHS documents are full of commitments.

Openness.

Transparency.

Patient-centred care.

Learning culture.

Equality.

Accountability.

Governance.

But when I ask for evidence showing those principles being applied to an actual failure, I repeatedly find something else.

I find missing records.

I find unanswered questions.

I find delays.

I find people sending responsibility elsewhere.

I find nobody apparently willing to examine the people at the top.

And eventually I find another email telling me that communication is finished.

Values are not what an organisation says about itself. Values are what it repeatedly does when following them becomes inconvenient.

Do I think this organisational culture is rotten?

Yes.

In my opinion, this is rotten.

I am not saying that every person working at NHS Thames Valley ICB is incompetent or acting badly.

I am saying that the accountability structure I have experienced appears rotten.

A healthy organisation should be able to examine itself.

A healthy organisation should not be frightened of evidence.

A healthy organisation should not make a member of the public fight through five different internal functions simply to find somebody willing to ask, "How did we fail and who needs to fix it?"

And a healthy organisation certainly should not keep ending conversations when those questions refuse to go away.

If this can happen here, how widespread is the problem across the NHS?

I cannot prove from my case that every NHS organisation behaves like this.

But I would be deeply surprised if this culture exists nowhere else.

That is exactly why external oversight matters.

NHS England.

The Care Quality Commission.

The Parliamentary and Health Service Ombudsman.

The Information Commissioner's Office.

Health scrutiny committees.

Boards.

Audit and governance functions.

All of them should be asking whether organisations are merely publishing accountability frameworks or actually living by them.

Why am I now pursuing accountability outside NHS Thames Valley ICB?

Because I have tried the internal routes.

I complained.

I challenged the Chief Executive.

I challenged the Chair.

I used Freedom of Information law.

I requested an Internal Review.

I challenged the Internal Review.

I asked PPET to investigate the governance failures.

I explicitly separated those failures from the ICO's information-law role.

I asked for an alternative internal route.

I asked for somebody — anybody — inside the organisation to take ownership of investigating what had happened.

I did not get one.

So I am no longer spending endless weeks trying to convince NHS Thames Valley ICB that it should investigate itself.

I will take the evidence to organisations whose job is to scrutinise it from the outside.

And I will continue publishing the documentary record here.

Where can I read the correspondence with Lorri Josey and PPET?

You can read my correspondence with Lorri Josey, Complaints Manager in the Public & Patient Experience Team at NHS Thames Valley ICB, together with the FOI Internal Review, leadership correspondence and wider evidence trail in my Evidence Folder.

I encourage you to read it rather than simply taking my interpretation at face value.

This is my opinion. Read what I asked. Read what they answered. Read where they stopped answering. Then decide for yourself what kind of accountability culture the evidence shows.

Sources and further reading

• The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009
• Parliamentary and Health Service Ombudsman — NHS Complaint Standards
• PHSO — NHS Complaint Standards at a glance
• PHSO — Guidance for NHS senior leaders on meeting the Complaint Standards

I Investigated the NHS Female Sterilisation Policy Myself. The CEO's Response Answered None of it, and The Ombudsman Found Tons of Maladministration

A note about language: this is my account of what I experienced and how I interpret the evidence. When I describe later assurances as misleading, or say that I came to regard some of them as lies, that is my conclusion from the mismatch between what I was told and what the documentary record later revealed. 

Please feel empowered to make your own conclusions by accessing and going through the Evidence!

How did a request for sterilisation turn into me investigating NHS policy?

I did not start out wanting to investigate an Integrated Care Board.

I wanted permanent contraception. I wanted access to an approved health-care procedure accessible on the NHS.

But the more I tried to understand why female sterilisation was effectively unavailable to me through the ordinary NHS route in Oxfordshire, the more I realised that the problem was much bigger than one decision about one woman.

I found the commissioning policy.

I found the Thames Valley Priorities Committee papers behind it.

I found the meeting minutes and read them.

I followed the references.

I looked at what the committee itself had recorded about cost-effectiveness, regret, LARC, male sterilisation, ethics and consultation.

And then something started happening that has repeated itself throughout this entire battle: the deeper I looked into the evidence, the less the official position seemed to make sense.

By July 2023, I was angry enough to put all of it into a formal complaint.

It ran to 12 pages.

And it was not a vague accusation of sexism. It was a detailed challenge to the logic, evidence and governance behind the policy.

What exactly did I challenge in that 12-page complaint?

I challenged the ICB on almost every layer of the decision.

I asked whether it could genuinely defend funding permanent contraception for men while making female sterilisation unavailable except through an exceptional-funding process.

I asked whether that could really be described as an equal and comprehensive healthcare service.

I challenged whether pushing women towards alternative contraception was genuinely healthier once side effects, risks and individual circumstances were taken seriously.

I asked whether making access to permanent contraception harder for women was compatible with bodily autonomy and informed consent.

I asked whether the policy was actually consistent with the NHS Constitution, GMC guidance, NICE guidance and the broader principles governing medical decision-making.

And finally, I asked the most basic question of all:

Those were not rhetorical questions to me.

I wanted evidence.

If sterilisation cost around £1,000, where was the evidence that decades of contraception were cheaper?

One of the first things I challenged was the policy's statement that female sterilisation was not normally funded because of the availability of "more cost-effective methods of contraception."

I had already found material in the NHS's own committee records that appeared to complicate — and in some cases directly undermine — that claim.

The records referred to female sterilisation costing around £1,000.

They also recorded cost-effectiveness modelling indicating that female and male sterilisation could become more cost-effective than Long-Acting Reversible Contraception over longer periods of contraceptive use.

So I asked a very simple question: more cost-effective over what period, and for whom?

I then did my own rough comparison.

Using the retail contraceptive-pill prices available to me at the time, I calculated an average price of approximately £22.04 per month. Over 20 years, that came to approximately £5,289.60.

That was more than five times the approximately £1,000 sterilisation figure I had found in the NHS documentation — before accounting for future price increases or inflation.

I was not pretending that my calculation was an NHS health-economics model. It wasn't. I was making a point that should have been obvious to the people actually responsible for commissioning:

Instead, I was looking at a policy that simply asserted that more cost-effective alternatives existed. Where was the evidence?

And what about the costs that are much harder to put into a spreadsheet?

This was another issue I raised that I felt was being treated as though it barely existed.

Contraception is not just a line in a commissioning budget.

It is something a woman experiences in her body.

I challenged the ICB to consider what happens when an alternative contraceptive method causes bleeding, pain, mood changes, loss of libido, thrush, weight changes, anxiety, or other side effects.

I challenged whether the NHS had accounted for additional healthcare use created by managing those problems.

• What about repeat GP appointments?
• What about changing methods repeatedly because one does not work for the individual?
• What about psychological distress?
• What about an unintended pregnancy?
• What about termination?
• What about the emotional cost of spending month after month anxious that your period is late when you know with absolute certainty that you do not want to become pregnant?

I wrote from my own experience of that anxiety too.

I explained that my periods were irregular and that, despite using condoms and spermicide, I could still find myself looking at an app telling me I was several days late and wondering whether I was pregnant.

I knew I did not want children.

I knew I did not want to go through an abortion.

I knew hormonal contraception had not suited me.

So I asked why the NHS appeared to consider the theoretical future regret of sterilisation more seriously than the actual physical and emotional burdens women may experience through the alternatives it preferred them to use.

If the NHS was so worried about regret, why was regret treated so differently for women?

The policy's other major justification was anticipated regret.

This angered me perhaps more than anything else.

Because regret is not a medical contraindication.

It is a possible future feeling - not a guaranteed outcome. Moreover, there was NO EVIDENCE provided to support these claims. 

And in my complaint I challenged the entire logic of treating that possibility as a reason to restrict the decision of a competent adult.

In fact, I found research suggesting that regret was far from universal. So, in my complaint letter I also cited work reporting relatively low regret among women sterilised over the age of 30. I cited research discussing women who regretted being denied sterilisation. I cited newer work examining psychological outcomes among voluntarily childfree women who obtained or were denied the procedure.

But my wider challenge went beyond statistics.

I asked: why does the NHS assume responsibility for protecting women from regretting sterilisation, but not from regretting parenthood?

• People regret marriages.
• People regret careers.
• People regret surgeries.
• Some people regret becoming parents.

Yet we do not build public policy around the idea that competent adults should be prevented from making important life decisions because they may later feel differently.

Why was this one different?

Why could a young woman be trusted to become a parent, but an adult woman could not be trusted to choose permanent contraception?

This was where I challenged what I saw as the pronatalist assumption buried underneath the policy.

We culturally treat choosing to have children as normal.

Choosing permanently not to have them is treated as something requiring interrogation.

In my complaint I deliberately used a provocative comparison: society can accept a 16-year-old becoming a mother — an irreversible decision carrying responsibility for another human being — while an adult woman in her thirties can find herself treated as though she may not understand the consequences of deciding never to give birth.

To me, that exposes a profound asymmetry.

Parenthood is permanent too.

And arguably far more consequential, because it involves not just your own body and future but another person's life.

Yet the presumption runs one way:

I found that deeply paternalistic.

And, as a woman who had been thinking about sterilisation for more than a decade, I found it personally insulting.

Why was men's permanent contraception treated as a decision, while women's was treated as an exception?

I also raised the inequality between female sterilisation and vasectomy directly.

I knew the procedures were not medically identical.

That was never my argument.

The question was whether those clinical differences justified the difference in autonomy.

Men could be offered vasectomy as permanent contraception.

Women in Oxfordshire faced a policy saying sterilisation was not normally funded and an Individual Funding Request route requiring them to establish exceptional clinical circumstances.

That meant a woman did not simply have to understand the risks and permanence of the procedure.

She effectively had to establish why she was different from other women who also wanted it.

That is not the same kind of decision-making pathway.

One is built on informed consent - the other on gatekeeping access and making decisions for patients without their involvement.

And I asked the ICB bluntly whether it could seriously argue that such a system was not gender discriminatory.

What did the NHS's own guidance say about pushing women towards LARC?

This was one of the contradictions I had already found in their own records.

The committee papers referred to guidance from the Faculty of Sexual and Reproductive Healthcare, the Royal College of Obstetricians and Gynaecologists and the World Health Organisation.

That material acknowledged that some Long-Acting Reversible Contraceptive methods can be as effective as sterilisation.

But it also recorded that women should not be pressured into choosing LARC over female sterilisation.

Then, in the very same policy-development history, the NHS moved toward a policy under which sterilisation would not normally be funded because alternative contraception existed.

That left me asking what I still think is an extremely obvious question:

I could see that contradiction as a member of the public sitting at home reading the papers.

So why could I not find evidence of the people responsible for decisions affecting huge numbers of women properly confronting it?

Where was the justification for departing from clinical guidance?

This became a recurring frustration.

I was not saying commissioners were forbidden from ever reaching a different conclusion from a guideline.

Healthcare commissioning involves limited resources and difficult choices.

But if a public body departs from recognised guidance, particularly where autonomy, equality and access to healthcare are involved, there should be a reason.

There should be analysis.

There should be records.

You should be able to see the bridge between the evidence and the policy.

What I was finding instead felt like a gap.

The papers would acknowledge one set of considerations.

The final policy would state something much simpler.

And the reasoning connecting one to the other was often extraordinarily difficult to locate.

This was why I invoked the NHS Constitution, NICE, GMC guidance around informed decision-making, and the principle of bodily autonomy.

I wanted BOB ICB to explain how its policy could be reconciled with those standards.

If their own ethical advisers said consultation was needed, where was the consultation?

Another thing I had found in the records was advice relating to Public Consultation.

The material indicated that ethics and health-law advisers had raised the point that withdrawing or significantly changing access to an NHS service was significant and should be consulted upon.

I went searching.

I went through annual reports.

I went through meeting records.

I tried to find evidence that the required consultation had actually taken place.

I could not find it.

So I asked them.

That is what makes what came next so important.

Why did it anger me that I seemed to be considering more than the people making the policy?

This is perhaps the most emotional part of the entire episode for me.

I am not an NHS commissioner.

I am not employed by a Clinical Effectiveness Team.

I was not sitting on the Thames Valley Priorities Committee.

I was a member of the public who wanted access to healthcare.

And yet sitting at home with publicly available documents, I was asking questions about:

• long-term cost versus short-term procedure cost;
• direct versus indirect healthcare costs;
• side effects of alternative contraception;
• psychological and relationship consequences;
• regret after sterilisation versus regret after denial;
• informed consent and mental capacity;
• male versus female access;
• bodily autonomy;
• clinical guidance;
• public consultation;
• postcode inequality;
• and the cultural assumption that motherhood is the default future for women.

These people were making policy capable of affecting the lives and bodies of hundreds of milions of women across a region.

Why was I having to ask whether those things had been considered?

And more importantly:

where was the evidence that they had?

So what did the Chief Executive finally tell me?

After months of delays, partial replies and chasing, I finally received BOB ICB's formal response by Chief Executive Dr Nick Broughton on 22 November 2023.

The first page acknowledged the breadth of my complaint.

It recognised that I had raised funding, commissioning, male versus female sterilisation, gender discrimination, contraception, medical side effects, cancer risks, ethical guidance and whether women were being treated with equality and respect.

And then it said:

"To answer the questions, we have described how decisions about clinical commissioning policies are made..."

That sentence captures the problem almost perfectly.

I had asked substantive questions about the quality and logic of the decision.

The answer largely described the existence of a decision-making process.

Yet - explaining a process is not the same as providing evidence that you have followed that process.

What was I told about the supposedly "robust" governance?

The CEO told me that policy recommendations were approved through a "robust governance process".

He told me that the female sterilisation policy had been fully reviewed in 2017.

He said that review included a:

He said that when the policy was reviewed again in 2021 there had been no meaningful updates requiring it to change.

And he told me that the ICB regarded sterilisation as the "least preferred option" for female contraception because other contraceptive alternatives existed.

Then the response returned once again to the Individual Funding Request process.

If a woman could demonstrate clinical exceptionality, her clinician could apply.

That was presented as the answer.

But where were the answers to the questions I had actually asked?

This was the point at which my confidence in the organisation collapsed.

Because telling me a review was "full" did not answer how the evidence on cost-effectiveness had been balanced.

Calling the governance "robust" did not tell me where the public consultation was.

Saying that legal and ethical considerations had been assessed did not tell me how bodily autonomy had been weighed.

Saying that clinicians could discuss contraception did not answer why the policy itself preferred LARC over sterilisation.

Saying there were alternative methods did not answer whether the risks, side effects and longer-term costs of those alternatives had actually been compared fairly.

And explaining an IFR process did not answer why women were required to prove exceptionality when men seeking vasectomy were not being treated through the same conceptual framework.

The response acknowledged my questions and then seemed to move around them.

And no - NO EVIDENCE of following any of these was provided. And the later investigation found that such evidence does not exist.

Was the message basically: "We've checked ourselves, everything is fine"?

That is how it felt to me.

I had sent a 12-page complaint saying, in effect:

I have read your evidence. Parts of your own record appear to contradict your policy. I cannot find evidence that important steps were taken. Please explain this.

And the response I got back amounted, in my reading, to:

Perhaps the expectation was that this would close the matter.

A Chief Executive, Dr Nick Broughton, had sent the response, after all he is the highest authority - I should trust him, right? No. Wrong.

The organisation had formally answered.

The complaint could now be marked complete.

But a senior signature does not turn an unanswered question into an answered one.

Why didn't I simply believe them?

Because I had already seen too much of the underlying material.

This is one of the defining features of everything that happened afterwards.

I kept asking for evidence rather than accepting statements about evidence.

I kept asking for the record rather than accepting assurances about the process.

I kept asking "show me".

And every time I did that, new questions appeared.

That continued during the Ombudsman investigation.

It continued when I later started using Freedom of Information requests.

It continued when I tried to establish how later replacement policies had been developed.

Again and again, I found the same structural problem: an official statement would tell me that a process had been followed, something had been considered, something had been reviewed, something had been compliant.

And when I asked for the documentary chain proving it, things became considerably less straightforward.

Why did this response push me toward the Ombudsman instead of ending the complaint?

Because by that stage the complaint process itself had become part of the problem.

I no longer trusted BOB ICB to investigate BOB ICB.

I had raised specific evidential contradictions.

I had raised ethical concerns.

I had raised equality concerns.

I had raised questions about consultation.

I had raised the treatment of regret.

I had raised cost-effectiveness.

I had raised the physical and psychological consequences of alternative contraception.

I had raised autonomy and informed choice.

I had raised the radically different pathway for men.

And after all of that, the final answer still essentially told me the process had been proper.

I could either accept that assurance or ask somebody outside the organisation to examine what had actually happened.

I chose the second option.

What makes the CEO's, Dr Nick Broughton, final response so alarming in hindsight?

At the time, I already thought it had failed to answer my complaint.

What I did not yet have was an independent investigation going through the same documentary trail.

That came later.

And it is why this episode matters so much in the wider chronology of this battle.

The Ombudsman did not simply accept the ICB's statement that everything relevant had been considered.

It looked at the evidence.

It looked at the committee records.

It looked at the complaint handling.

It looked at the underlying decisions.

And many of the questions I had been asking in that original 12-page complaint came back again — this time as concerns identified by an external investigator.

And why does this pattern still matter now?

Because it did not end in 2023.

As the case continued, I repeatedly encountered the same tension between institutional assurance and documentary proof.

The Ombudsman later scrutinised the original decision-making.

Freedom of Information requests later became necessary to establish what evidence sat behind subsequent policy decisions.

Questions about equality analysis, consultation, policy approval and compliance did not magically disappear because a new policy was written.

The longer this has gone on, the more convinced I have become that this case is not simply about female sterilisation.

It is also about a deeper accountability problem:

What happened when the Ombudsman finally looked behind those assurances?

That deserves its own article, because the comparison is extraordinary.

In the next part, I compare the CEO's, Dr Nick Broughton, statements directly with what the Parliamentary and Health Service Ombudsman's investigation found when it examined the underlying evidence.

The questions become very simple:

Was the evidence really properly balanced?

Was the cost-effectiveness claim actually supported?

Was regret handled fairly?

Were men and women treated consistently?

Was clinical guidance properly followed or were departures from it explained?

Did the consultation happen?

And did BOB ICB actually investigate the complaint I had made?

Read Part Two: The NHS CEO Dr Nick Broughton Said the Female Sterilisation Policy Was Robust. The Ombudsman Found Something Very Different

Where can I read the original evidence?

I do not want anyone reading this site to have to rely solely on my interpretation.

My original 12-page complaint, BOB ICB's final response and the wider documentary record are available in the Evidence Folder.

Read them.

Compare what I asked with what I was told.

That comparison is where this story really begins.