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.

How Serious Does NHS Maladministration Have to Be Before Chair Dr Priya Singh Investigates Chief Executive Dr Nick Broughton?

A note on language: I have previously explained why I personally regard some of the assurances I received from Dr Nick Broughton as in my own language - lies. That is my interpretation of the documentary discrepancies between what I was told by him and what the Ombudsman subsequently established.  

Why did I ask Dr Priya Singh, Chair of NHS Thames Valley ICB, about Dr Nick Broughton's accountability?

By April 2026, the question I was asking had changed.

I was no longer only asking whether the female sterilisation policy was wrong.

The Parliamentary and Health Service Ombudsman had already investigated how the policy had been developed and how my complaint had been handled. Its findings included failures to properly weigh and balance evidence, failures to explore relevant evidence, failures to document and explain decisions, unexplained departure from relevant clinical guidance, unfair and inconsistent consideration of female and male sterilisation, and a failure to consult appropriately.

Those findings mattered to me for another reason.

During my original complaint, Dr Nick Broughton, then Chief Executive of BOB ICB and now Chief Executive of NHS Thames Valley ICB, had sent me a formal final response assuring me that the policy had gone through a "robust governance process" and a "full assessment" of relevant evidence, guidance, cost-effectiveness, legal and ethical considerations.

I have already examined that contradiction in detail in:

 I Challenged NHS BOB ICB's Female Sterilisation Policy. Its CEO Dr Nick Broughton Told Me the Governance Was Robust - It Was NOT

and:

The Gaps between NHS CEO Dr Nick Broughton's Claims & The Health Ombudsman's Findings

What is the NHS Fit and Proper Person Test — and why did I raise it with Dr Priya Singh, Chair of NHS Thames Valley ICB?

The NHS Fit and Proper Person Test, usually shortened to FPPT, exists because people holding Board-level power in healthcare are expected to meet standards that go considerably beyond simply having the right CV.

The NHS England FPPT Framework applies to executive and non-executive Board members of Integrated Care Boards, NHS trusts and foundation trusts, as well as NHS England and the Care Quality Commission.

Its stated purpose is to strengthen individual accountability and transparency and improve the quality of NHS leadership.

The framework considers whether Board members are of good character, possess the necessary competence, skills and experience, and remain suitable to exercise substantial authority within the health service.

Importantly, this is not merely an appointment check performed once and then forgotten.

A full FPPT assessment is also expected annually.

That distinction is important to what followed.

What does NHS England say Dr Priya Singh, Chair of NHS Thames Valley ICB, is responsible for?

The NHS England framework is unusually clear about this.

Ultimate accountability for adherence to the FPPT framework resides with the Chair of the NHS organisation.

The Chair must take reasonable steps to ensure the FPPT system is effective, ensure Board members continue to be suitable for their roles, oversee the relevant records and assessments, and ultimately conclude whether a Board member is fit and proper.

If concerns exist about a Board member who nevertheless remains in post, the framework says the reason for the concern and the measures taken should be documented and retained.

The framework also states that Chairs themselves are subject to FPPT oversight. In the case of ICB Chairs, accountability for ensuring the Chair meets the FPPT requirements sits with the relevant NHS England Regional Director.

This matters because my question to Dr Singh was not really an HR question.

It was a governance question directed to the person NHS England places at the centre of that governance system.

What kind of conduct can become relevant to a Fit and Proper Person assessment?

Not every organisational error makes a Chief Executive unfit for office. Nor should it.

NHS England's framework is supposed to be proportionate.

But it specifically recognises that serious misconduct or serious mismanagement may be relevant. Its examples include:

• dishonest conduct;
• discrimination under the Equality Act 2010;
• disregard for appropriate standards of governance;
• resistance to accountability or undermining due process;
• failure to report significant issues properly;
• repeated or ongoing tolerance of poor practice;
• and conduct that causes departure from recognised standards or accepted practice.

The framework also says organisations should consider whether conduct was deliberate or reckless, whether dishonesty was involved, whether problems were repeated or continued over time, and whether the individual demonstrates insight and self-reflection when concerns are identified.

None of that means the Ombudsman's report automatically proved that Dr Broughton was unfit.

It does explain why I considered it entirely reasonable to ask whether somebody had at least examined the question.

28 April 2026: what did I ask Dr Priya Singh, Chair of NHS Thames Valley ICB?

On 28 April 2026, I wrote directly to Dr Priya Singh in her capacity as Chair.

I explained that the Ombudsman's findings had transformed the matter from a patient complaint into a question of Board-level governance, leadership accountability and public confidence.

I asked five straightforward questions.

1. Had the Board, Chair or any relevant committee considered leadership accountability after the Ombudsman findings?
2. Had Dr Nick Broughton's Fit and Proper Person status been reviewed, reassessed or discussed?
3. If so, through what governance route?
4. If not, why did the Board consider that appropriate?
5. Had NHS England, the Care Quality Commission or another external oversight organisation been informed?

I made clear that I was not asking for private personnel information.

I was asking whether the people responsible for governing the organisation had considered whether findings of this seriousness had any implications for its senior leadership.

5 May to 19 May 2026: why was my governance question initially redirected into a meeting?

My email was acknowledged on 5 May 2026.

Then, on 19 May, rather than receiving the Board-level written answers I had requested, I was offered a meeting with the ICB's Chief Medical Officer and Clinical Lead.

I declined.

Not because clinical input was irrelevant to the wider sterilisation issue, but because this particular question was not clinical- it was about governance, and that's the Chair's responsibility.

I had asked the Chair:

What did the Board do about leadership accountability after the Ombudsman's findings?

A meeting with executives or clinicians reporting within the same organisational structure could not substitute for the Chair answering that question.

I therefore wrote back on 19 May 2026 and explicitly reminded the ICB that NHS England's FPPT governance framework places overall accountability with the Chair.

29 May 2026: what did Dr Priya Singh, Chair of NHS Thames Valley ICB, finally confirm about Dr Nick Broughton?

On 29 May 2026, Dr Singh finally answered the questions directly.

And this is where the accountability story becomes extraordinary.

She confirmed:

When I asked what governance route had been used to assess his continued suitability, the answer was simply:

"Not applicable."

Dr Singh explained instead that the Ombudsman findings had been considered by the Quality Oversight Group, where actions were identified and undertaken.

She also made an important point: an FPPT review is not an automatic consequence of Ombudsman findings.

That is correct.

But it did not answer the question that concerned me.

If an FPPT review was not automatic, did Dr Priya Singh, Chair of NHS Thames Valley ICB, nevertheless consider whether one was warranted?

This is the distinction I think matters most.

I was not arguing that an Ombudsman report automatically equals "CEO fails FPPT".

That would be simplistic and would not reflect NHS England's framework.

I was asking how the Chair reached the conclusion that no leadership consideration at all was necessary.

Because the framework does not say fitness is considered only when a special investigation is automatically triggered.

Quite the opposite.

It says consideration of fitness is continuous and ongoing.

It says Boards need robust systems for assessing competence and character.

It says governance concerns, accountability, honesty, serious mismanagement and repeated poor practice can all become relevant.

And it places responsibility for ensuring Board members remain fit and proper with the Chair.

So after Dr Singh confirmed that:

• the Board had not considered leadership accountability;
• no relevant committee had considered it;
• Dr Broughton's FPPT status had not been reviewed;
• it had not been reassessed;
• and it had not even been discussed because of the Ombudsman findings;

I wanted to know what evidence supported the conclusion that no further leadership scrutiny was appropriate.

What did my Freedom of Information request reveal about Dr Nick Broughton's FPPT?

I trust you can see why I had already decided not to rely only on assurances.

So I submitted a Freedom of Information request seeking the recorded evidence.

The resulting response — FOI-TV-2604-039 — was authorised by NHS Thames Valley ICB and stated that the information was accurate as of 28 May 2026.

I asked whether any FPPT review, reassessment, discussion or recorded consideration had taken place in relation to Dr Nick Broughton following the Ombudsman findings.

The answer:

I also asked for any records in which the Ombudsman findings had been considered in relation to Dr Broughton's:

• FPPT status;
• suitability;
• fitness for role;
• leadership accountability;
• honesty or integrity;
• governance responsibility;
• or continued appointment.

The response stated:

That gave me something considerably more concrete than an institutional reassurance.

It gave me a recorded absence.

Why did the Ombudsman's referral to NHS England and the Care Quality Commission matter?

The Ombudsman had recommended that its final report and the information supplied to me should also be sent to NHS England and the Care Quality Commission (CQC).

Dr Singh confirmed on 29 May that this had been done.

That does not mean the Ombudsman had ordered NHS England or the CQC to discipline Dr Broughton. It had not.

But both organisations are directly relevant to senior NHS governance.

NHS England oversees the FPPT framework and receives annual FPPT submissions through its regional structure.

The CQC's role is different: it does not normally decide whether an individual director is personally fit and proper. Instead, it assesses whether an organisation has proper systems for making those assessments and can intervene where those processes are not robust.

CQC guidance says that where it receives information raising concerns about a director's fitness, it can pass that information to the organisation and require it to explain what steps it has taken to assure itself that the individual remains fit.

That made my question even more straightforward:

1 June 2026: Why did I challenge Dr Priya Singh, Chair of NHS Thames Valley ICB, again?

On 1 June, I wrote back.

I summarised what her own response and the FOI evidence now showed:

• no Chair or Board consideration of leadership accountability;
• no committee consideration;
• no FPPT review or reassessment;
• no recorded consideration connecting the Ombudsman findings to Dr Nick Broughton's continued fitness for role.

I told her I found that extremely difficult to reconcile with her simultaneous assertion that governance assurance had been sufficient.

And I put it bluntly:

if this level of maladministration did not trigger internal consideration of leadership accountability, what would?

That is still my question.

Why do I personally believe Dr Nick Broughton's assurances should at least have raised an FPPT question?

This is where my previous investigation matters.

My original complaint had challenged the evidence, equality implications, clinical rationale, consultation and governance underpinning the sterilisation policy.

Dr Broughton's final response reassured me that appropriate governance and assessment had taken place.

The Ombudsman subsequently established substantial failings in exactly those areas.

As I have said elsewhere, in my opinion the gap between those statements is so substantial that I regard some of the assurances as false.

The NHS England FPPT framework itself says honesty, openness, trustworthiness, governance, accountability and competence matter when assessing senior Board members.

It even lists conduct characterised by dishonesty, disregard for appropriate governance and resistance to accountability among matters capable of becoming relevant to serious misconduct or mismanagement.

So I was not asking Dr Singh to prejudge him.

I was asking her to investigate, consider and document.

Her answer was that this had not happened.

Did Dr Priya Singh, Chair of NHS Thames Valley ICB, then answer my questions about the new female sterilisation policy?

At the same time, a second accountability problem was unfolding.

The ICB had introduced another female sterilisation policy in February 2026.

I challenged Dr Singh directly on whether that policy complied with the Equality Act, Public Sector Equality Duty, NHS Constitution, Montgomery, relevant NICE and WHO guidance, the Ombudsman's findings and principles of informed consent and bodily autonomy.

I repeatedly asked for a direct answer.

That becomes a separate chapter of this story because the policy itself deserves a detailed analysis.

Read: My Challenge to NHS Thames Valley ICB Chair Dr Priya Singh Over the February 2026 Female Sterilisation Policy

But the correspondence about that issue also revealed something important about accountability culture.

3 June to 27 June 2026: what happened when I kept pressing Dr Priya Singh, Chair of NHS Thames Valley ICB, for direct answers?

On 3 June, my email was acknowledged.

On 6 June, I chased again.

On 8 June, I wrote again because my questions remained unanswered.

On 9 June, Dr Singh said there would be further discussion at the regional Priorities Committee and promised a detailed response by 15 June.

On 16 June, she explained that the Committee had now recommended removing the requirement for women to undergo a trial of LARC before sterilisation, and said another policy would move through Board and Quality Committee approval.

But once again, that did not answer the question I had been asking: was the February policy actually compliant when it was approved and imposed on women?

On 19 June, I asked again.

On 23 June, I received an acknowledgment promising a response that week.

I challenged the absence of an answer again the same day.

On 26 June, I chased the missed deadline.

Finally, on 27 June 2026, Dr Singh replied.

She refused to answer the question in the yes-or-no terms I had requested, saying it was not appropriate to reduce complex healthcare policy to a binary answer.

She gave a series of general assurances about patient-centred care, clinical judgement, resources and the policy-development process.

And then she did something I had begun to recognise very well.

Why did Dr Priya Singh, Chair of NHS Thames Valley ICB, close correspondence while my questions remained unresolved?

At the end of her 27 June 2026 response, Dr Singh wrote that the ICB did not consider there to be any further substantive issues to address.

She stated that the email would be the final response, apart from sending me a link to the future policy.

And she said the ICB would not enter into further correspondence on the same issues unless I raised new or materially different information.

In other words:

This concerned me not only because of that email, but because by then it felt familiar.

Why does closing correspondence look like a wider pattern inside NHS Thames Valley ICB?

Across this case I have repeatedly experienced a similar sequence.

I raise a specific question.

The ICB provides a broader answer to something adjacent to it.

I point out that the question remains unanswered.

I chase.

I challenge the reasoning.

Eventually, the organisation declares its position final and stops engaging.

I saw versions of this during:

• my original complaint about the female sterilisation policy, where the responses repeatedly returned to the policy and Individual Funding Request process instead of addressing the evidence and decision-making problems I had identified;
• the later Freedom of Information Internal Review process, where after I challenged continuing delay and the adequacy of the review I was told that no further responses would be provided;
• my correspondence with the Chair, where Dr Singh eventually closed correspondence despite my continuing contention that the substantive compliance questions had not been answered;
• and subsequently in other attempts to obtain documentary evidence of how policies and governance decisions had actually been made.

I am not arguing that a public body is required to correspond indefinitely with someone who merely repeats the same point.

Public organisations need reasonable boundaries.

But there is an enormous difference between:

"We have answered your question and you dislike the answer"

and:

"We have not answered the question you asked, but we have decided the correspondence is over."

That distinction is central to my experience of this ICB.

How does this pattern sit with the accountability standards NHS Board members are supposed to follow?

The irony is difficult to ignore.

The NHS FPPT framework itself incorporates the Nolan Principles of Public Life.

Those principles include:

• Accountability — public office holders must submit themselves to the scrutiny necessary to ensure accountability;
• Openness — decisions should be made transparently and information should not be withheld without clear and lawful reason;
• Honesty — holders of public office should be truthful;
• Leadership — leaders should model these principles themselves and challenge poor behaviour when it occurs.

The NHS Constitution likewise says the NHS is accountable to the public, communities and patients it serves.

That is why I find the repeated closure of scrutiny so troubling.

Accountability cannot mean that a public body gets to decide unilaterally that it has adequately answered questions about its own accountability.

Does the absence of an FPPT review prove Dr Nick Broughton, Chief Executive of NHS Thames Valley ICB, is unfit?

No, but its presence and review might prove he is unfit. 

And I think that distinction is important.

The evidence I have does not establish that Dr Broughton fails the Fit and Proper Person Test.

Nor does an Ombudsman finding automatically require a Chief Executive to be disciplined or removed.

What the evidence establishes is narrower — but still significant:

My challenge is therefore about the absence of examination.

You cannot meaningfully say, "We examined this and concluded there was no leadership problem", if the recorded evidence says the leadership question was never actually examined through that route.

So:

How Serious Does NHS Maladministration Have to Be Before Chair Dr Priya Singh Investigates Chief Executive Dr Nick Broughton?

Who, then, holds Dr Priya Singh, Chair of NHS Thames Valley ICB, accountable?

The framework has an answer to that too.

Dr Singh is herself subject to the Fit and Proper Person requirements.

For ICB Chairs, the responsibility for ensuring the Chair meets the FPPT criteria resides with the relevant NHS England Regional Director.

That matters because accountability cannot stop with the person who decides whether somebody below them requires scrutiny.

There must also be a route to examine whether the Chair has properly discharged her own governance responsibilities.

That is one reason this case has progressively moved beyond NHS Thames Valley ICB itself and into external oversight routes.

What does accountability mean if nobody is ever personally accountable?

This is now one of the central questions of this entire project.

The NHS can apologise.

It can rewrite a policy.

It can say lessons have been learned.

It can create an action plan.

It can send a report to another organisation.

But somewhere in the chain, human beings made the decisions.

Human beings reviewed the evidence.

Human beings approved the policies.

Human beings answered the complaints.

Human beings signed the assurances.

And human beings decided whether anyone should be held accountable when an independent investigation later found that substantial things had gone wrong.

For me, organisational learning without any examination of individual leadership accountability risks becoming a very convenient form of institutional absolution.

Where can I read the correspondence between Dr Priya Singh, Chair of NHS Thames Valley ICB, and me?

I publish the underlying evidence because I do not want this website to depend on readers simply accepting my interpretation.

You can find my correspondence with Dr Singh, the FPPT Freedom of Information response, the Ombudsman material and the wider documentary history in the Evidence Folder.

Read the emails.

Read what I asked.

Read what she answered.

Read what the FOI subsequently confirmed.

Then decide for yourself whether this looks like meaningful NHS leadership accountability.

Sources and further reading on Dr Priya Singh's responsibilities as Chair and NHS Board accountability

• NHS England — Fit and Proper Person Test Framework for Board Members. The current NHS framework covering Board-member fitness, Chair accountability, annual assessment, good character, competence and serious misconduct or mismanagement.
• NHS England — Guidance for Chairs on Implementation of the Fit and Proper Person Test. Guidance specifically addressing the Chair's role in overseeing FPPT governance.
• NHS England — Leadership Competency Framework for Board Members. Includes Board-level expectations around equality, governance, assurance, culture and trusted relationships with communities.
• Care Quality Commission — Regulation 5: Fit and Proper Persons: Directors. Explains the regulatory basis for Board-member fitness and the requirement to address information raising questions about fitness or serious mismanagement.
• Care Quality Commission — Fit and Proper Persons: Directors. Explains CQC's role in assessing whether organisations operate proper processes for evaluating Board-member fitness.
• The NHS Constitution for England. Sets out NHS principles including accountability to patients, the public and communities.

The NHS CEO, Dr Nick Broughton, Said the Female Sterilisation Policy Was Robust. The Ombudsman Found Something Very Different

What exactly did the Chief Executive Dr Nick Broughton tell me?

BOB ICB's final response did not concede that something fundamental might have gone wrong with the female sterilisation policy.

Instead, it defended the process.

Chief Executive Dr Nick Broughton told me that the Thames Valley Priorities Committee had fully reviewed the policy and that the process included:

His letter also stated that policy recommendations were approved and adopted through a "robust governance process".

Those are strong assurances.

They invite the reader to believe that the NHS had properly gathered the relevant evidence, weighed it rationally, considered equality and ethics, followed proper governance, and arrived at a defensible policy.

The Ombudsman's investigation tells a very different story.

Did the NHS properly balance the evidence on female sterilisation regret?

The CEO's response: the policy had been through a full assessment of evidence, guidance and ethical considerations.

The Ombudsman's provisional finding: the evidence on regret had not been appropriately balanced.

The underlying papers themselves acknowledged that regret was subjective and difficult to quantify. Research showed wide variations in reported regret, dependent on circumstances and risk factors.

The evidence considered in relation to male sterilisation also said regret following sterilisation was experienced by a minority of people.

Yet female sterilisation policy was built around the idea of significant or substantial regret.

The Ombudsman found no adequate explanation for turning such a subjective measure into an objective commissioning barrier.

More importantly, it found that the committee had not given sufficient weight to informed consent and the Mental Capacity Act principle that an adult with capacity should not be treated as incapable of making a decision simply because somebody else thinks it is unwise.

The Ombudsman considered that comparable circumstances affecting men and women had not been handled fairly or consistently.

Were other contraceptives really shown to be more cost-effective?

This was one of the things that infuriated me from the beginning because the NHS's own papers appeared to contradict its policy.

The female sterilisation policy stated that other, more cost-effective contraceptive methods were available.

Yet evidence before the committee indicated that female sterilisation could become more cost-effective than LARC after six years in one study, and that male and female sterilisation were more cost-effective than LARC over 15 years in other modelling.

The Ombudsman's provisional view was remarkably clear: the committee had not demonstrated that alternative contraception was more cost-effective than female sterilisation.

It described the policy wording as appearing illogical given the evidence actually available.

It also identified something I had raised in my original complaint: the calculations had not properly dealt with wider costs, including the cost of side effects, alternative contraception, terminations and unintended pregnancies.

Even more strikingly, some of those broader costs had been considered when discussing whether male sterilisation should continue to be funded.

They had not been treated in the same way when deciding whether women should retain access to sterilisation.

Did the NHS properly consider the risks and side effects of forcing women towards other contraception?

The CEO's response told me clinicians could discuss the risks and benefits of the contraceptive options available.

But my challenge had never been whether clinicians were capable of explaining contraception.

My question was whether the policy itself had properly balanced those risks before making sterilisation unavailable except through an exceptional-funding route.

The Ombudsman found significant gaps.

The evidence considered by the NHS included recognised side effects and risks associated with other forms of contraception. Later records also showed women coming through the Individual Funding Request route because they had exhausted other contraceptive options through side effects such as low mood and weight gain or because of health risks.

By November 2021, the NHS itself was being asked to consider whether certain groups of women — including those unable to tolerate other contraception — should have access to sterilisation.

Yet the Ombudsman could find no proper record showing that this work had been completed and rationally fed back into the policy.

The action was simply marked complete.

The policy stayed essentially the same.

Was female sterilisation actually subjected to the consultation the NHS's own advisers said was needed?

This may be one of the clearest mismatches of all.

Before the policy was implemented, specialist advisers in ethics and health law had reportedly warned that withdrawing an NHS service represented a significant change and should be consulted upon.

They also recommended that male and female sterilisation should be considered together in the interests of fairness and consistency.

I specifically asked BOB ICB whether that consultation had happened.

The Chief Executive's response told me the process had included legal and ethical considerations.

It did not answer the consultation question.

The Ombudsman did.

The Ombudsman described that as a significant omission.

This matters because "we considered ethics" is not remotely the same thing as following ethical advice.

Did the policy treat women and men fairly?

The ICB had repeatedly pointed to differences between vasectomy and female sterilisation. Those differences are real. Vasectomy is generally simpler, cheaper and less invasive.

But that was not the whole equality question.

The Ombudsman found that the NHS had approached comparable issues in fundamentally different ways.

Both men and women can regret sterilisation.

Men were offered counselling about that risk.

Women faced restricted access partly because of that risk.

When considering the consequences of withdrawing vasectomy, the NHS looked at wider effects such as increased use of other contraception, emergency contraception, terminations and birth rates.

The Ombudsman found that equivalent considerations were not properly weighed when female sterilisation was restricted.

And men could access sterilisation by meeting eligibility criteria, while women faced the additional hurdle of having to demonstrate that their circumstances were exceptional compared with other women seeking the same procedure.

The Ombudsman concluded that this itself appeared to create health inequality in access.

Did the policy follow clinical guidance saying women should not be pressured into LARC?

The clinical guidance available to the NHS recognised LARC as highly effective.

But it also explicitly warned that women should not feel pressured into choosing LARC over female sterilisation.

That distinction is crucial.

Providing information about an alternative is informed consent.

Structuring access so that a woman effectively has to accept, attempt or justify rejecting the alternative is something very different.

The Ombudsman's provisional view was that the policy's reliance on the availability of other contraceptives was, in effect, pressuring women towards LARC.

It found that the NHS had not properly explained why it had departed from the clinical guidance it had itself considered.

What happened when new evidence emerged in 2021?

This is another part of the story that I find extraordinary.

By November 2021, the NHS was seeing enough requests for female sterilisation that its own paper reportedly observed that these women now appeared to represent a cohort, rather than exceptional individual cases.

That is important because the whole Individual Funding Request model depends upon exceptionality.

The system was effectively receiving evidence that the "exceptions" were not exceptional.

The committee agreed further work should be carried out on groups including women unable to tolerate other contraception, women who had undergone multiple caesareans and women for whom another pregnancy was contraindicated.

The action was later marked complete.

But the Ombudsman could find no proper documentary trail explaining how that work affected the policy.

The policy remained unchanged.

Indeed, an internal exchange later suggested uncertainty about whether the review was even still underway.

To me, this is the kind of thing that makes the word governance almost meaningless if nobody is required to show what actually happened.

So how "robust" was the governance process?

By the Ombudsman's provisional assessment, the ICB had:

• adopted a policy where evidence had not been appropriately balanced;
• failed to give proper regard to relevant legislation;
• failed to explain departures from clinical guidance;
• adopted a policy whose reasoning was not clearly recorded;
• failed to adequately investigate groups of women for whom alternative contraception was unsuitable;
• treated comparable male and female circumstances inconsistently;
• and inherited a major service change that had not undergone the public consultation it should have received.

And crucially, the Ombudsman said the ICB did not appear to have put those failures right.

I struggle to reconcile that with the phrase "robust governance process."

Was the complaint itself properly investigated?

No — and this matters almost as much as the policy itself.

My original complaint identified many of these problems before the Ombudsman ever became involved.

• I raised the evidence on regret.
• I raised cost-effectiveness.
• I raised consultation.
• I raised bodily autonomy.
• I raised side effects and health risks of other contraception.
• I raised the unequal treatment of vasectomy and female sterilisation.

The Ombudsman's provisional assessment found that the ICB repeatedly failed to engage with those issues.

Instead, the responses disproportionately focused on explaining the existing policy and the Individual Funding Request process.

In one of the most important sections of the report, the Ombudsman said the final CEO response only partially addressed the evidence question. It specifically noted that BOB ICB had not answered what research supported the claim about regret, why the difference between male and female policies did not amount to discrimination, or how bodily autonomy had been considered.

It also noted that my question about consultation had simply not been answered.

What did the Ombudsman ultimately say about my concerns?

For me, one paragraph cuts through years of institutional reassurance.

After independently examining the evidence, the Ombudsman said its provisional findings suggested that my views about the policy were likely to have been right.

It recognised that I had consistently and clearly laid out the evidential basis for my argument that the decision-making process was flawed.

That is difficult to square with an organisation whose own complaint process had spent months failing to answer those same questions.

Were the NHS CEO Dr Nick Broughton's statements lies?

This is where I separate the documentary finding from my personal conclusion.

I can say what I think - I have the right to my opinion - and you, dear reader, have access to the Evidence and can make your own opinion.

When the Chief Executive of an NHS organisation tells me a process was robust and the policy was developed following a full consideration of guidance, evidence, law and ethics — and an independent Ombudsman later finds evidence to the contrary, with unexplained departures from guidance, inconsistent treatment of men and women, inadequate records, missing consultation and poor complaint investigation — I regard those original assurances as lies. 

Whether that resulted from deliberate dishonesty, institutional defensiveness, negligence, poor briefing or a culture in which senior leaders make claims about governance without interrogating whether they are true is a different question.

And, frankly, none of those explanations is reassuring.

Was this a cover-up?

Again, I use that term as my interpretation rather than as a legally established finding.

A cover-up does not always require a secret room full of people agreeing to conceal something. But honestly, if you keep reading about how defensive and evasive the ICB's leadership and organisation overall continued to be through and beyond the Ombudsman's investigation - you'd likely see it the way I do - the fish rots from the head down - and it truly stinks under the leadership of Nick Broughton.

Institutional concealment can be much more banal.

A complaint raises uncomfortable evidence. The organisation repeats its policy. The complainant is redirected towards an individual process. Questions are not answered. Delays accumulate. Senior assurance is provided. The complaint is closed.

If the person accepts the response, the underlying problem disappears administratively even though nothing has actually been resolved.

That is what I believe was happening here.

I think the system expected me to stop.

I did not.

What did the Ombudsman recommend should happen next?

The Ombudsman's provisional recommendations show how seriously it regarded the problems.

It proposed that BOB ICB should formally acknowledge and apologise for the failures, share the findings with the body responsible for recommending commissioning policies, explain how the female sterilisation policy would now be reviewed, ensure the same failures were not repeated, consult properly, examine the human factors that allowed the failures to occur, and improve its complaint-handling processes.

It also proposed that the final findings should be shared with NHS England and the Care Quality Commission.

That is a very long way from "everything went through a robust process."

Why does this matter beyond my own case?

Because I only got this far because I did not believe them.

I had the time, anger, research skills and stubbornness to keep opening documents, comparing dates, finding minutes, challenging assertions and eventually asking an independent body to investigate.

Most patients should never have to do that.

And most will not.

That leaves a frightening question.

This case has taught me that authority is not evidence.

A senior signature is not evidence.

A policy saying it was reviewed is not evidence that it was reviewed properly.

And an organisation calling its governance robust does not make the governance robust.

Sometimes you have to keep asking the deeply annoying question:

Show me.

Where can I see the evidence?

You can read my original complaint, the BOB ICB Chief Executive's response, the Ombudsman material and the wider documentary history in my Evidence Folder.