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.

The Questions About the February 2026 Female Sterilisation Policy that Dr Priya Singh Wouldn’t Answer

A note about my conclusions: throughout this website I distinguish between established documentary facts and my interpretation of them. My opinion is that I have repeatedly been misled, stonewalled and faced institutional attempts to close down scrutiny rather than answer it. In places, I believe I have been lied to and that failures have been covered up. That is my opinion. 

Please feel empowered to review the evidence yourself and reach your own.

Why should women have to prove temporary contraception is unsuitable before permanent contraception is respected?

By spring 2026, the history was already extraordinary.

I had originally challenged an Oxfordshire policy that effectively prevented women from routinely accessing NHS-funded sterilisation.

The Parliamentary and Health Service Ombudsman later found serious failures in the evidence, decision-making, equality considerations, consultation and complaint handling surrounding that policy.

The ICB then introduced another Female Sterilisation Policy in February 2026.

On paper, this new policy appeared more permissive because female sterilisation was no longer simply described as “not normally funded”.

But it introduced another form of gatekeeping.

Women seeking permanent contraception were expected to undergo, or demonstrate the unsuitability of, a “therapeutic trial” of Long-Acting Reversible Contraception (LARC) before accessing sterilisation.

That immediately raised the same underlying question I had been asking for years:

Especially when men seeking permanent contraception through vasectomy were not being subjected to an equivalent requirement.

Did NHS Thames Valley ICB actually consider the February 2026 policy compliant?

On 28 April 2026, my correspondence with Dr Priya Singh was primarily about leadership accountability following the Ombudsman investigation.

But I also raised the new February 2026 Female Sterilisation Policy.

I told Dr Singh that I did not believe the underlying problem had actually been resolved.

I specifically challenged the requirement for a “therapeutic trial” of LARC before sterilisation.

My position was straightforward: if a woman is seeking permanent contraception, forcing her through a temporary contraceptive pathway before respecting that choice does not look like patient-centred informed consent to me.

It looks like gatekeeping.

I also pointed to the growing contrast with male sterilisation. NHS-funded vasectomy services were being made more accessible, including routes involving private providers and direct referral arrangements, while women continued to face additional hurdles before accessing permanent contraception.

Why couldn’t the Chair answer a question the Board should already have resolved?

On 1 June 2026, after Dr Singh had answered my separate questions about Dr Nick Broughton and the Fit and Proper Person Test, I turned squarely to the current policy.

I asked her to tell me whether NHS Thames Valley ICB considered the February 2026 Female Sterilisation Policy fully compliant with:

• the Equality Act 2010;
• the Public Sector Equality Duty;
• the NHS Constitution;
• Montgomery v Lanarkshire Health Board [2015];
• relevant NICE guidance;
• relevant WHO guidance;
• the Ombudsman’s findings in case C-2121396;
• and the principles of informed consent, bodily autonomy and patient-centred decision-making.

I deliberately made the question difficult to evade.

I asked her to answer:

YES — the ICB considers the policy compliant.

or

NO — it does not.

If the answer was yes, I asked her to explain how forcing women through a LARC pathway was compatible with bodily autonomy and informed consent.

If the answer was no, I asked the equally obvious question:

Why had the policy been approved and imposed on women in the first place?

On 3 June 2026, I received only an acknowledgement from the Office of the Chair confirming receipt of my email.

There was no answer to the compliance question.

On 6 June 2026, I chased again.

Still no substantive answer.

Why was another committee review needed only months after the policy was introduced?

On 8 June 2026, I wrote again.

I reminded Dr Singh that the February 2026 policy had already been approved, adopted and applied to women for months.

If the Board had approved that policy, surely somebody must already have established the basis on which it was considered lawful, ethical, clinically defensible and compliant.

This should not have required weeks of research after I asked the question.

The reasoning should already have existed.

I asked again for a detailed response.

On 9 June 2026, Dr Singh finally responded — but still did not answer the question.

Instead, she told me that, following further feedback about the application of the policy, female sterilisation was going to be discussed again at the NHS South East Regional Priorities Committee.

She wrote that:

That commitment matters.

I had asked whether the existing February 2026 policy was compliant.

The response was effectively: another committee is looking at it and we will come back to you.

By itself, that told me something important.

The policy I was challenging had only been operating for a few months and was already back under review.

If the February 2026 policy was sound, why was its LARC requirement removed?

On 16 June 2026, Dr Singh wrote to me again.

She explained that the South East Region Priorities Committee had considered sterilisation on 14 April 2026 and again on 9 June 2026.

And this time there was a substantial development.

The Committee had recommended that women should be able to choose sterilisation after being fully informed about alternatives, without first having to undergo a trial of LARC.

In other words, one of the central requirements I had been challenging was now being removed.

Dr Singh told me:

• the recommendation would go to NHS Thames Valley ICB for adoption;
• the process would include Board-level scrutiny;
• it would include Quality Committee approval;
• the process was expected to be prompt;
• a new policy was expected to be implemented in early autumn 2026;
• and I would be informed as soon as the new policy became available.

Those are concrete commitments.

But changing the policy did not answer whether the February 2026 policy should ever have been approved.

The fact that the NHS was now fixing the LARC requirement did not answer whether it had been appropriate to impose that requirement on women in February 2026.

Quite the opposite.

Its removal made the question sharper.

And if the requirement was not defensible, how had it passed the governance process in the first place — especially after the ICB had just been through an Ombudsman investigation into failures involving this exact area of healthcare policy?

Why did I keep having to ask the same compliance question?

On 19 June 2026, I wrote back because Dr Singh still had not answered what I had actually asked.

I told her directly that my patience was running out.

I pointed out the chronology:

• the original female sterilisation policy had been challenged;
• the Ombudsman had found serious failures in how it was developed;
• there had been no leadership accountability consideration;
• a replacement policy had then been introduced in February 2026;
• and only months later that policy was already being rewritten.

I again asked Dr Singh to answer:

Did the ICB consider the February 2026 policy fully compliant — yes or no?

If yes, why was one of its core requirements being removed?

If no, why had it ever been approved and why was it still being applied to women?

Why did acknowledgements keep replacing answers?

On 23 June 2026, Dr Singh acknowledged my email and said:

I wrote again on 23 June 2026 because, once again, I wanted an answer to the question — not another acknowledgement that the question existed.

By 26 June 2026, the promised week was ending.

I emailed again:

Did she intend to answer the question?

Or was another self-imposed deadline going to pass?

This pattern had already become painfully familiar to me.

Why did Dr Priya Singh refuse to give a yes-or-no answer?

On 27 June 2026, Dr Singh finally sent a substantive response.

But she still would not answer yes or no.

She told me it was “not appropriate or accurate” to reduce complex healthcare policy to a binary question.

She then listed principles she said underpinned the February 2026 policy:

• patient-centred care;
• informed consent;
• clinical judgement;
• a least-invasive approach;
• recognition of biological differences;
• and alignment with legislation, national guidance and the Ombudsman findings.

Those statements may sound reassuring.

But once again, they did not answer my question.

I had not asked whether reassuring principles could be written around the policy.

I had asked whether the actual policy — including its LARC requirement — complied with the standards I had identified.

And by this point the regional committee had already recommended removing that requirement.

What did Dr Priya Singh promise would happen next?

Across the correspondence in June 2026, Dr Singh made several specific statements about what would happen next.

I was told that:

• the female sterilisation policy would be reconsidered following the South East Region Priorities Committee recommendation;
• the new recommendation would go before NHS Thames Valley ICB;
• there would be Board-level scrutiny;
• there would be Quality Committee approval;
• the process would be undertaken promptly;
• a revised policy was expected in early autumn 2026;
• I would be told “as soon as the new policy is available”;
• and, even after correspondence was closed, Dr Singh specifically preserved one exception: sending me a link when the policy was approved.

Why was correspondence closed while the central question remained unanswered?

The final part of Dr Singh’s 27 June 2026 response is particularly important.

She told me:

“We do not consider there to be any further substantive issues to address through this correspondence.”

She said this would be the ICB’s final response, apart from one exception:

She then said further correspondence on the same issues would not receive substantive replies unless I raised something materially new.

So the correspondence was formally closed while I still maintained that the central question had never been answered.

Why did I resort to Freedom of Information legislation?

By this point, I had learned not to rely only on promises that somebody would eventually explain the process.

I wanted the records.

So on 8 June 2026, while this correspondence with Dr Singh was still unfolding, I submitted a Freedom of Information request seeking the documentary evidence behind the February 2026 Female Sterilisation Policy.

I asked for material showing its approval, equality assessment, evidence base, legal and ethical rationale, comparison with vasectomy, treatment of autonomy and informed choice, and evidence that the Ombudsman’s recommendations had actually been incorporated into subsequent decision-making.

The statutory deadline was 6 July 2026.

That deadline passed.

And passed.

And passed.

I chased.

I chased.

I chased and filed an Internal Review Request - as per ICO guidelines.

By the time substantive disclosure arrived in September 2026, I had been waiting for roughly three months.

The response arrived more than two months beyond the statutory deadline. NO LEGAL justification was provided - this was an invented deadline by the ICB themselves. So, now they are - in my opinion - cool with breaking the law too. And the kicker - CEO Dr Nick Broughton is the one in charge of FOI requests - as per his title of Accountable Officer. But more on that in the posts tagged with FOI - you can find those in the Chronicles page. 

By 11 September 2026 — 95 calendar days after my original request — the ICB was around 48 working days beyond its statutory deadline.

That delay became a separate transparency battle in its own right.

What did the delayed FOI disclosure still fail to show?

When the documents finally arrived in September 2026, they still did not provide everything I had asked for.

The disclosure did give me useful evidence.

But it also exposed major gaps.

The material supplied showed that much of the documentation underlying the February 2026 policy pre-dated the Ombudsman’s final findings.

The ICB’s own response referred to further post-Ombudsman work carried out in February, April and June 2026.

It referred to:

• documented feedback on the Ombudsman findings;
• further regional committee consideration;
• a refreshed policy report;
• a 14-item action tracker;
• updated decision-making processes;
• and subsequent comments raising what the ICB itself described as “significant concerns”.

Yet key parts of that post-Ombudsman audit trail were not included in the disclosure.

The documents I received also did not show me the complete decision record I had expected to see for adoption of the February 2026 policy.

The Equality Impact Assessment supplied was an older document and the disclosed records indicated further equality work was supposed to occur.

And the ICB expressly confirmed that the detailed comparison I had sought between female sterilisation and vasectomy access had not been conducted in the earlier supporting work.

Why does this look like a wider transparency problem rather than one unanswered email?

Because this is now a pattern running through the entire case.

First I asked the ICB questions directly.

Then I asked its Chief Executive.

Then I asked the Ombudsman.

Then I asked the Chair.

Then I asked through Freedom of Information legislation.

Again and again, obtaining the answer has required another mechanism, another deadline, another chase, another escalation and another documentary search.

And I have now made multiple Freedom of Information requests relating to this case.

One examined leadership accountability and Dr Nick Broughton’s FPPT status.

Another sought the evidence behind the February 2026 Female Sterilisation Policy and its supposed post-Ombudsman governance.

A further strand has examined male vasectomy commissioning and access, including providers, self-referral, criteria, equality assessments and whether the NHS ever properly compared those pathways with the hurdles imposed on women.

Those FOI battles deserve their own articles.

Read the Freedom of Information articles documenting my battle for transparency with NHS Thames Valley ICB.

What am I still waiting for as of 12 September 2026?

As I update this article on 12 September 2026, I am still waiting for clarity on several things that should not require detective work by a patient.

• Where is the final revised Female Sterilisation Policy Dr Singh said I would be sent?
• Did the promised Board-level scrutiny occur?
• Did the promised Quality Committee approval occur?
• What happened to the “early autumn 2026” implementation timetable?
• Where is the complete post-Ombudsman documentary trail showing how the earlier governance failures were corrected?
• Where is the complete equality analysis comparing the female sterilisation pathway with male vasectomy?
• Why did I have to use Freedom of Information legislation to try to establish things the Chair told me would form part of a transparent governance process?

What does this pattern say about transparency at NHS Thames Valley ICB?

I do not think NHS Thames Valley ICB has been transparent with me.

I think I have repeatedly been given partial answers, reassuring language and future promises instead of the documentary accountability I was asking for.

I think some statements made to me during this case have been untrue.

I think serious failures have repeatedly been absorbed into process rather than confronted openly.

And where records capable of proving what happened have been delayed, omitted or extraordinarily difficult to obtain, I believe it is reasonable to ask whether institutional self-protection has crossed into cover-up.

That is my opinion.

Please do not take it on faith.

Read the evidence.

Read the Ombudsman findings.

Read Dr Singh’s emails.

Read the FOI responses.

And form your own view.

Where can I read the evidence?

You can read the correspondence with Dr Priya Singh, Chair of NHS Thames Valley ICB, the relevant Freedom of Information material, the Ombudsman evidence and the wider documentary history in my Evidence Folder.

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.