A tenacious movement of accused adults and their advocates used the complaints systems with spectacular success, and secured his suspension.
The IPCC has inherited the flaws of its predecessor and the complaints systems are considered a pointless paper exercise, which further undermines public confidence.
It will lead to many fundamental changes and requires a new approach in trusts thinking about complaints systems, medico-legal issues and responding to patient concerns.
This can be intensely frustrating for patients who have learnt to enjoy choice in every other area of their life, and seriously undermines complaints systems for redressing wrongs.
Last month Ann Clwyd MP published a review of NHS hospitals' complaints systems with the subtitle "Putting patients back in the picture".
"Telecom providers should have effective complaints systems and if consumers are not satisfied there should be redress mechanisms to ensure a fair outcome," says the body behind the day, Consumers International.
