An apparent failure to fully investigate a high profile complaint has led to a renewed call for changes to the system.

HSJ has seen an internal probe at the office of the parliamentary and health service ombudsman. The probe concerned the office’s rejection of a complaint against NHS North West and found the watchdog’s justification did not “stand up to scrutiny”.

The review – commissioned by the ombudsman – concluded that key claims in the watchdog’s decision letter appeared to be directly contradicted by its own documents.

Complainant James Titcombe had asked the ombudsman last year to examine whether mal-administration by NHS North West in its role as a local supervisory authority for midwives had been a factor in poor care of his son Joshua at University Hospitals of Morecambe Bay Foundation Trust.

An inquest last summer into Joshua’s death in 2008 triggered a care quality scandal at the trust. Mr Titcombe believes the LSA should have taken more action following earlier deaths at the same unit.

The ombudsman rejected Mr Titcombe’s complaint in June. It claimed it had checked records of LSA investigations into other cases he highlighted but had not found “similarities in terms of clinical issues or personnel”.

However, a subsequent internal review, seen by HSJ, found that in an internal meeting an assessor at the ombudsman reportedly said: “We have not looked at the investigations themselves because they are about other cases.”

It concluded the ombudsman’s claims about “the extent of the enquiries carried out… do not stand up to scrutiny, unless there are other papers I have not seen”. It advised the watchdog to reassess the complaint.

Mr Titcombe said the case highlighted the need to implement a recommendation made previously by the Commons health committee to widen the ombudsman’s remit. Its current terms of reference limit the complaints it can investigate.

He told HSJ: “What they should be doing is asking, ‘Is there a patient safety issue? Does it need investigating?’”

Mr Titcombe added that the ombudsman currently applies “subjective criteria”. He said: “Before they do an investigation they have to be satisfied of a ‘worthwhile’ outcome. How can you tell there will be a worthwhile outcome before you investigate? I think Joshua’s case highlights how wrong that process is.”

Mr Titcombe said that if the ombudsman had investigated a previous complaint about the trust in 2009 – which it rejected – “the whole sequence of events that unfolded at Furness General Hospital could have been avoided”.

The ombudsman said it did not comment on complaints, and that it planned to share more information in future.