NHS whistleblowing tsar hasn’t investigated a SINGLE case and won’t review any patient neglect claims until 2017
ANDREW GREGORY
Dr Henrietta Hughes started her £105,000-a-year position as National Guardian in October
The £105,000-a-year NHS tsar for whistleblowing has not investigated a single case, a Mirror probe reveals.
Last year health chiefs announced the National Guardian’s Office would help NHS staff raise concerns about patient neglect.
It was a measure demanded by Sir Robert Francis, who led the inquiry into 1,400 deaths at Stafford Hospital.
But we have learned National Guardian Dr Henrietta Hughes will not review any claims of poor practice until next year. She started in early October.
The first tsar Dame Eileen Sills quit in March before her April start date after the Mirror revealed she would work just two days a week.
Dr Hughes insisted her cases would be decided by a “stakeholder advisory group”, which involves people with experience of whistleblowing.
But her office admitted this was “in development” and will not be established “until early in the New Year”.
Blasting the delays, Lib Dem health spokesman Norman Lamb MP described the project as a “damp squib”.
He added: “This astounding failure to investigate a single case, 18 months after the role was first announced, means patient safety is being put at continued risk.”
Dr Minh Alexander, who revealed suicides at a mental health trust in Cambridgeshire, added: “I remain highly sceptical that the National Guardian’s office is any more than a wasteful publicity stunt.”
And Professor Sir Brian Jarman, who helped expose the Stafford Hospital scandal, said: “The National Guardian seems to be progressing at glacial speed.”
In response to the Mirror’s investigation, Dr Hughes told us: “I am committed to creating a culture of openness within the NHS where staff are encouraged to raise concerns, so that lessons can be learned and care improved as a result.
“Since starting my role in October, my office has begun to do this already by developing a network of freedom-to-speak-up guardians across NHS trusts, who are there to enable staff to raise concerns about patient safety and to advise and support staff who seek to do so.”
NHS whistleblowers ‘gagged and blacklisted’, says petition group
The Guardian 6 December 2016
Doctors, staff and patients criticise Care Quality Commission and call for radical change in health service regulation
NHS whistleblowers face being “fired, gagged and blacklisted” while disclosures go uninvestigated owing to the healthcare regulator’s lack of powers and resources, a group of doctors, staff and patients has warned.The Care Quality Commission (CQC) was criticised for being “low value” by the group, which has called for radical change in how the health service is regulated.
In a letter to the Times, the group, which has exposed huge failings, said the CQC had failed to detect poor care and governance since it replaced the Healthcare Commission in 2009. It cited an example where an inspection of a foundation trust cost £273,900 but failed to spot hundreds of uninvestigated deaths.
“The CQC protests that it has no powers to investigate individual cases,” the group said. “Many patients, bereaved relatives and whistleblowers are deeply frustrated that disclosures to the CQC have not resulted in change. On the contrary, if NHS staff whistleblow, they may still be fired, gagged and blacklisted.”
Sir Robert Francis QC said the watchdog had to do more to protect whistleblowers, in his report into failings at Mid Staffs.
Julie Bailey, whose mother was a victim of the problems at the trust, signed the letter with 13 other whistleblowers.
They include Dr Stephen Bolsin, who revealed failings at Bristol Royal infirmary’s paediatric cardiac unit, and Baby P whistleblower Kim Holt. Holt told the Times: “It’s very frustrating because I feel like the CQC have got all the information. They know what’s happening.
“They sit and listen and nod their heads and say, ‘That’s dreadful,’ but then they don’t do anything about it. [Whistleblowers] that I sat alongside in meetings at CQC have since lost their jobs.”
Sir Mike Richards, the chief inspector of hospitals, said: “The CQC takes concerns raised by staff extremely seriously and we act where appropriate, whether carrying out or bringing forward an inspection, raising concerns with the provider, or alerting another organisation, including the police.”
Patients at risk as thousands of safety warnings are ignored
6 December 2016 PAUL ROGERS/THE TIMES
Inspectors have acted slowly or not at all despite tens of thousands of NHS staff raising concerns about unsafe care.
NHS inspectors are ignoring thousands of warnings a year from staff raising safety fears, an alliance of whistleblowers has claimed.
Those who speak out are “fired, gagged and blacklisted” while regulators do little to help, according to the group of doctors, inspectors and patients who exposed some of the biggest health scandals of the past two decades.
Tens of thousands of NHS staff have contacted the Care Quality Commission (CQC) about unsafe care yet inspectors acted slowly or not at all, leaving patients at risk, the group claims in a letter to The Times. They are calling for a US-style body to investigate on behalf of whistleblowers rather than leaving them to face the system alone.
The letter is signed by whistleblowers including Julie Bailey, who exposed the Stafford Hospital scandal; Stephen Bolsin, who warned of baby deaths at Bristol Royal Infirmary; and Amanda Pollard, a former CQC inspector who spoke out about its failure to spot poor care. It says that “many patients, bereaved relatives and whistleblowers have felt deeply frustrated that their disclosures to the CQC have not resulted in safe change” — despite repeated pledges by ministers and health officials to encourage and protect whistleblowers.
NHS inspectors are ignoring thousands of warnings a year from staff raising safety fears, an alliance of whistleblowers has claimed.
Those who speak out are “fired, gagged and blacklisted” while regulators do little to help, according to the group of doctors, inspectors and patients who exposed some of the biggest health scandals of the past two decades.
Tens of thousands of NHS staff have contacted the Care Quality Commission (CQC) about unsafe care yet inspectors acted slowly or not at all, leaving patients at risk, the group claims in a letter to The Times. They are calling for a US-style body to investigate on behalf of whistleblowers rather than leaving them to face the system alone.
The letter is signed by whistleblowers including Julie Bailey, who exposed the Stafford Hospital scandal; Stephen Bolsin, who warned of baby deaths at Bristol Royal Infirmary; and Amanda Pollard, a former CQC inspector who spoke out about its failure to spot poor care. It says that “many patients, bereaved relatives and whistleblowers have felt deeply frustrated that their disclosures to the CQC have not resulted in safe change” — despite repeated pledges by ministers and health officials to encourage and protect whistleblowers.
The CQC, which inspects hospitals, GPs and care homes, has taken at least 33,000 calls to its hotline for staff to raise concerns in the past five years. The letter’s signatories say no attempt has been made to use the data to spot patterns indicating problems such as short-staffing or faulty guidelines.
A sickening whitewash: Fury as NHS boss who spent £10m to silence whistleblowers faces no action
By Paul Bentley, Deputy Investigations Editor For The Daily Mail
3 December 2016
- David Loughton, CEO at Royal Wolverhampton NHS Trust, kept his job
- He used taxpayers’ money to fight staff who raise concerns about safety
- Dr Raj Mattu was sacked after he exposed that two patients had died
- Their deaths had been a result of dangerously overcrowded bays
The NHS was accused of a whitewash this evening after a hospital boss who spent £10million suppressing whistleblowers was cleared by an official report.
David Loughton, who earned £260,000 last year, has been allowed to keep his job despite using taxpayers’ money to fight staff who raised serious concerns about patient safety.
The review into how Mr Loughton’s hospital trust is being run would only go as far as saying that he had ‘an impulsive and honest style’. It appears he will now face no disciplinary action and no sanctions will be taken against him.
David Loughton is the chief executive at The Royal Wolverhampton NHS Trust
Whistleblowers who were forced out of their jobs by Mr Loughton were not even interviewed for the report, and only found out the review had been published when contacted by the Mail.
In a further twist, it has emerged that the consultancy firm chosen by the NHS to do the review has been paid £78,837 by Mr Loughton’s trust for other jobs this year.
Deloitte was paid £45,444 for the review by watchdog NHS Improvement.
Mr Loughton, 62, chief executive at The Royal Wolverhampton NHS Trust, is renowned for fighting whistleblowers through the courts.
They include leading heart surgeon Dr Raj Mattu, who was vilified and sacked after he exposed that two patients had died in dangerously overcrowded bays in a hospital at another trust run by Mr Loughton.
Dr Mattu was cleared at a tribunal and in February was awarded £1.2million damages.
Manager Sandra Haynes Kirkbright was also suspended after raising concerns that Mr Loughton’s Woverhampton trust had mis-recorded deaths, making it look like fewer patients had died needlessly.
An investigation into her case condemned the trust for its ‘significantly flawed’ and ‘unfair’ treatment.
It described an account of how Mr Loughton made sure Mrs Haynes Kirkbright was ‘out of the way’ before a visit from hospital inspectors, telling staff to ‘kick this into the long grass’.
After the report into her case was published in May, NHS watchdogs ordered a review into the management of Mr Loughton’s hospital trust.
But the results of that review were only quietly published on the trust’s website earlier this week. And it emerged that Deloitte was instructed to focus on the hospital as it is now, rather than considering previous whistleblowing cases.
As a result, the report’s authors did not contact Dr Mattu, Mrs Haynes Kirkbright or former board members who have criticised the management. They did not check what they were told by Mr Loughton and his employees, writing in the review: ‘We have assumed that the information provided to us and management’s representations are complete, accurate and reliable.’
Describing Mr Loughton, the report stated: ‘The chief executive is a strong character with an impulsive style and can attract controversy from time to time. However, he is strongly supported.’ It added: ‘Any past behavioural challenges have tempered in recent years.’
Today Dr Mattu said: ‘They have taken at face value everything management has said. I have great experience of Mr Loughton and he ruthlessly attacks anyone who dissents. He has persecuted whistleblowers. This has been a disgraceful waste of taxpayers’ money.’
Dr Raj Mattu, from Warwick, was vilified and sacked after he exposed that two patients had died in dangerously overcrowded bays in a hospital at another trust run by Mr Loughton
Dr Mattu, right, pictured with his wife Sangita. The stress of 200 false allegations against the heart surgeon left him too sick to work
Mrs Haynes Kirkbright said: ‘I was not consulted at all on this report. I didn’t know a thing about it until the Mail told me.’
Professor David Ferry was outed last year by Mr Loughton’s hospital after he anonymously revealed in the Mail that 55 cancer patients were needlessly put through the agony of chemotherapy.
This evening, he said: ‘They have whitewashed everything. I told them about Dr Mattu, about Sandra, about my case, but they said this is about the future, not the past. They have rewritten history their way, whatever the facts are.’
Mr Loughton, an NHS chief executive for 28 years, was awarded a pay rise of about £35,000 last year.
He joined Royal Wolverhampton in 2014 after 14 years at Coventry’s Walsgrave Hospital.
Mr Loughton said: ‘We are pleased with the review’s conclusions. Our number one priority is always patient care. Having an open and transparent culture is one of the ways in which we can ensure we remain committed to providing the best care we possibly can.
‘We are always seeking ways in which we can improve and we will take on board the recommendations the review makes.’
A trust spokesman said NHS Improvement commissioned Deloitte to do the review and ‘in line with many other organisations we have used the services of Deloitte’.
NHS Improvement said: ‘Deloitte were appointed following a formal and thorough tendering and evaluation process.’
Deloitte declined to comment.
Ministry of Defence medical officer denies ‘deliberately suppressing’ crucial facts in her report which led to a whistleblowing Army doctor, 69, being sacked
- Dr Stephen Frost, who called for inquest in Dr David Kelly, sacked by MoD
- Allegedly prescribed maimed veteran six times normal dose of morphine
- But soldier denies he had higher dose – which was left out of army report
- Dr Frost claims he was sacked for blowing whistle on MoD drugs racket
Dr Stephen Frost is accusing the Ministry of Defence of wrongful dismissal after he was sacked from the medical corpse
A Ministry of Defence medical official denied ‘deliberately suppressing’ crucial facts in a report which led to the dismissal of an Army whistleblower, a tribunal has heard.
Dr Stephen Frost – who led calls for an inquest into the death or weapons expert Dr David Kelly – was sacked after a maimed Afghanistan war veteran was wrongly prescribed morphine six times his normal dose.
The 69-year-old, who neither prescribed nor dispensed the tablets, was fired by the Ministry of Defence for allegedly not telling the soldier that he had been issued with the wrong tablets and was at risk of overdosing.
But an employment tribunal heard that the serviceman – whose left leg was blown off by an IED – insisted he had never been given 60mg tablets of powerful morphine sulphate.
He claimed he had only ever been given the correct strength of 10mg pills and Dr Frost said he did not show withdrawal symptoms – indicating he had never taken the higher dose.
The hearing in Manchester was told that if he had taken the wrong dosage he would have consumed 120 mgs of morphine every day for 16 days.
Dr Frost believes he was dismissed by text while on holiday for blowing the whistle on a drugs rackets at an Army base.
He has testified that he believed the soldier may have illegally sold the wrongly administered stronger pills on the black market and told colleagues there should have been a police investigation.
In a dramatic twist, Samantha Cotgrave, the former deputy clinical director of Army Primary Health Care Services (North), admitted that the soldier’s insistence he had not been given 60 mg were not in her interim report into the incident.
Dr Stephen Frost (pictured, left with solicitor Helen Clifford) led calls for an inquest into the death or weapons expert Dr David Kelly (right) and claims he was sacked for blowing the whistle on a drugs racket
She also admitted that she had failed to record a meeting between Dr Frost and the soldier outside a pharmacy where the patient was shown a distinctive orange 60mg tablet – as opposed to a brown 10mg one – and had told the doctor he had never seen one before.
John Hendy QC, for Dr Frost, accused Mrs Cotgrave of ‘having a closed mind’ and had deliberately suppressed the details in her report which was submitted to senior officers at Weeton Barracks, near Blackpool.
He told her: ‘You deliberately suppressed the fact that the patient had categorically denied receiving 60mg tablets. It did not fit in with the picture you were trying to paint.’
Mrs Cotgrave replied: ‘It was not intentional. I was not trying to paint a picture. There was overwhelming evidence that there had been a dispensing error.
‘The only tablets he could have had were 60mg because they were the only ones dispensed on that date.’
John Hendy QC, for Dr Frost, accused Mrs Cotgrave of ‘having a closed mind’ and had deliberately suppressed the details in her report which was submitted to senior officers at Weeton Barracks (pictured), near Blackpool.
But Mr Hendy challenged her: ‘Because you were convinced, you were prepared to leave out evidence to the contrary.’
Mrs Cotgrave said that her report was attached to all the witness statements so that the three senior officers could make a final decision.
Mr Hendy said: ‘So it was up to the decision makers to extract this from all the statements?’
Mrs Cotgrave replied: ‘It was not intentionally excluded. It was not my intention. I was not trying to portray a picture.’
She agreed that her report included a reference to Dr Frost not being ‘sure enough’ that an error had been made and pointing out that he was not the patient’s lead clinician.
Dr Frost, from Colwyn Bay in North Wales, claims he was dismissed because he had uncovered a potentially criminal appropriation of morphine at the military base.
He says that senior officers then tried to smear him by labelling him a conspiracy theorist and a Russian sympathiser when he challenged his dismissal.
The tribunal continues.
It’s ruined my career’: accounts of bullying in the NHS
The Guardian 26 October 2016 Sarah Johnson
Midwives, nurses, doctors, managers and other healthcare professionals speak out about the bullying they suffered and the effect on their health and wellbeing
A Guardian survey has found that there is a pervasive culture of staff bullying in parts of the NHS and that it has a detrimental impact on staff wellbeing and, in some cases, patient care.
Here are some stories from healthcare professionals submitted in our survey and to the Guardian about their experiences:
I was diagnosed with an acute stress incident with a critically high blood pressure
Everyone was frightened of this one man who thought nothing of sexually harassing female members of staff. When I challenged him on a decision that was not legal, his rage was spectacular. After one [meeting with him], I zoned out, temporarily losing feeling in my right hand and the ability to speak coherently. Thinking I may be having a heart attack or stroke, I attended A&E and was diagnosed with an acute stress incident with a critically high blood pressure. Anonymous manager
A bully almost managed to wreck my career as a doctor
When I was a junior doctor, the consultant I was due to work under had a reputation for having anger issues and suffering no fools. He used to take pride in making juniors cry and had T-shirts made which he used to hand out to people who were on the receiving end of one of his typical public outbursts. For the first few weeks, things were pleasant, fast paced and intense. But then, he became sharp with me – not tolerating mistakes I made, then blaming me and victimising me. I was blamed for not knowing anything about patients who had just arrived. My confidence disappeared. After a few months, I had mild depression. After a difficult crash call where the equipment was not on the trolley in the right place, I had a clinical incident form put in about me, suggesting my abilities as a doctor were insufficient and that I was not fit to progress to specialty training. There was no enquiry into what happened or how to help me. By sheer luck, I had an end of rotation meeting where it came out that I had been bullied like a previous doctor who went through the rotation. I thought I was just a bad doctor. I progressed to specialty training and continued my career. Anonymous doctor
When I reported bullying, I was told I needed to toughen up
Not long after I started on placement at a trust, a senior midwife turned to me and asked me what I would do if she ever withheld care for a woman I was looking after. I told her I didn’t think she would withhold care and that we all have a duty of care to the women we support. She laughed and then said my card was marked, in front of a number of other midwives. After that, I was advised that I needed to apologise to a midwife I had “pushed out of the way” during a delivery. That didn’t happen. I was disciplined for not changing the water often enough for a woman I was caring for despite the jug never being less than half full. I had paperwork torn up and told to rewrite it as it wasn’t worded the way my mentor liked. I was told to stop standing around chatting and to get “my arse in the kitchen” and do some washing up in front of about 20 members of staff at handover. I was spoken to so rudely in front of labouring women that two said they wanted to complain. I was shouted at and told I was stupid. When I reported these incidences, I was told I needed to toughen up. An investigation ensued but the findings were that the bullies said they were unaware that we felt bullied. I will never practise as a midwife despite having a passion for supporting women. Anonymous former midwifery student
I raised concerns after seeing nurses bully me and patients but it got me nowhere
The nurse/nurses that bullied me also bully patients. I raised concerns regarding the bullying and its infringement to patient care and safety using the whistleblowing policy. My superior claimed to have known the bullying had gone on for years; however she did not want to call it “bullying”. She intimidated me to drop the concern and the nurse/nurses in question are still working. My argument is, as a registered nurse, regardless of banding, we have to follow the same Nursing and Midwifery Council code of conduct, and bullying is breaking that code. Not only is bullying illegal in any organisation, it seems to be tolerated in the NHS. No one should be scared to go to their work, and, after a 13-15 hour shift, be emotionally exhausted due to their own colleagues rather than the job itself. Anonymous nurse
Bullying has changed me for life
It’s changed me for life. I’m no longer confident of getting anywhere in my career, the one I have been working at since I was 16; and all because of a group of people who turned my workplace into the film Mean Girls. I’m still on antidepressants, I missed out on promotion, my once exemplary sickness record is tarnished – I’m on a sickness stage that means I’ll eventually have to face a disciplinary. It was all done behind my back, all smiles to my face, so I can’t prove anything. I know some of what went on as people have told me what happened when I walked out of a room, but I can’t prove it. Anonymous allied health professional
I spoke to human resources but they were no help at all
When I spoke to HR their only advice was that I could make a formal complaint, but that that didn’t usually help. My line manager was helpless to do anything about it because we were admin staff and the nurses, who were bullying me, were “above” us. I just didn’t “fit” for some reason, though my colleague was bullied too. I left the job eventually because of health problems. I was previously under the impression that HR was there to help employees but I did not feel helped at all. I also think that in the NHS trust I worked for bullying came from the top of the organisation and worked its way down. Unfortunately we were at the very bottom. Anonymous administrator
Press release: Patient care remains at risk in Berkshire West while whistle blowers are victimised
Maha Yassaie 15 October 2016
Patient care remains at risk whilst a professional regulator acts on a vexatious referral against a whistleblower, and relies on a witness statement deemed unreliable by the NHS’ own investigator and DH’s legal advisors
For further information please email mhyassaie@gmail.com
I am an NHS whistle blower who made 3 protected disclosures, and although of previously unblemished record with a successful career, I was sacked by Berkshire PCT in Nov 2012. On July 2012 I was referred to my professional regulator (please see the full details below) in reprisal, and my former employer also contracted an external “independent” investigator to investigate me. Both the regulatory referral and engagement with the investigator were made before any official complaints had actually been made about me. The investigator contracted by the NHS coached witnesses against me. Staff who previously supported me changed their accounts.
The key witness against me was deemed to have given unreliable evidence, even by the trust’s investigator. After it became clear that the trust was unable to discipline me for misconduct (alleged bullying, harassment, concern about financial management and commissioning of providers contracts) , it dismissed me on grounds of alleged “breakdown of relationships”. I took legal action for unfair dismissal, detriment as a result of whistleblowing and disability discrimination. The NHS offered settlement with a sum of £375,000 and agreed to my condition that I would not be gagged. The NHS gave written apologies acknowledging that I had been subject to flawed disciplinary process and that the referral to my professional regulator had also arisen from the flawed process.
The nightmare however did not end there as the General Pharmaceutical Council (GPhC)
ploughed on with the flawed referral against me. Ultimately the GPhC was unable to uphold
16 of the allegations against me as misconduct but upheld a seventeenth allegation in a softened form. My lawyers advised me if I were to submit an apology, simply to show I had ‘insight’ I could avoid a warning. I have decided not to do so, as apologizing for something that I did not do would be false and against my principles.
History
1. In 2001 after a competitive interview process I got my job as Pharmaceutical Advisor in
Wokingham PCT.
2. In September 2002, after just 8 months in post and in recognition of my achievements in appropriate, effective and affordable prescribing, my job was re-graded and I promoted to the PCT’s Chief Pharmacist position.
3. Again in 2003, due to the quality of my work and the substantial savings I made whilst improving quality of care, I was upgraded.
4. Once again, in 2005, due to my performance on promoting patient safety and cost-effective prescribing I was promoted. At that stage I was at the highest possible clinical grade
5. In 2007 after the mergers of 3 PCTs in Berkshire West I went through competitive interview and was appointed as the Chief Pharmacist of Berkshire West and shortly afterwards was also appointed as the Accountable Officer for controlled drugs.
6. From 2001 to 2011 I was highly regarded in Berkshire West as a senior clinical manager. I had an extremely professional and good relationships with the executive of the PCT. My team and myself were also identified as the most effective and motivated team and team leader in the PCT and I was highly regarded nationally for my patient-focused and clinically-driven cost- effective recommendations and processes.
7. From April 2011 to July 2012, I made three protected disclosures about patient safety and/or governance matters. Unfortunately since April 2011 as the result of my disclosures, I was subjected to hostile behaviour from the PCT executives and ultimate consequences of these disclosures were for the PCT to suspend, sack and then black list me.
Related Published Articles
For more details of my story, protected disclosure and black listing please see
1) “NHS whistle-blower investigator in ‘Freedom to Speak Up’ role” – The Telegraph
2) “Whistleblowers being ‘blacklisted by NHS’ as staff records state they were ‘dismissed’ even after being cleared at tribunal” – The Telegraph
GPhC and DH
8. When I was sacked I informed the GPhC in late 2012 that I was sacked for “breakdown of relationships”. The GPhC informed me that was an HR matter and they could not get involved in HR issues
9. On July 2013 I was informed by the legal advisors of the GPhC that I had been referred to them by NHS Berkshire on 11th July 2012, and that they were advised in March 2013 by the NHS that I had been sacked. They informed me that I was under investigation and asked for details of my legal team. The data provided by GPhC legal team showed that I was referred to the GPhC before even there were any allegation against me. This was very puzzling hence my legal team raised concerns about the date of my referral to the GPhC via its lawyers, Blake and Lapthorn, and requested full clarification and timeline.
10. Blake and Lapthorn confirmed in writing on 14th of August 2013 that GPhC first received the referral from NHS Berkshire on 11 July 2012. The complaint related to allegations of misconduct regarding bullying and harassment and concerns surrounding the financial management and commissioning of provider contracts. The latter allegation was the subject of a counter fraud investigation. At this point, I was in fact still in full employment and there was no allegation against me. In the same letter Blake and Lapthorn confirmed that on 27th March 2013 NHS Berkshire advised the GPhC that I was dismissed from my post and on the 29th April NHS
Berkshire had confirmed to the GPhC that the allegation of fraud against me had been dropped. I
have to emphasise that the NHS never gave me any details of the so-called fraud allegations, and I was never contacted by any investigators looking into any fraud.
11. In addition to the suspect and premature GPhC referral timing, it was clear that NHS Berkshire had originally reported me to GPhC using the initial and made-up allegations of misconduct that had to be dropped, and replaced with “break-down of relationship” as the investigation progressed and became the ultimate reason for my sacking. The NHS, despite my multiple written requests including letters to Mr Hunt and Mr Stevens, never corrected the false referral or even the fundamental change of the allegations.
12. Thus, the GPhC investigation started on the basis of false and malicious information, irregular timing and failure to disclose to me that a referral had been made. The NHS allowed and encouraged the very witness who, for the reasons of unreliability, they had excluded from the PCT’s internal investigation, and who treasury lawyers had also excluded from the Employment Tribunal investigation, to repeat her untrue statements at my GPhC hearing.
13. In September 2014 I forwarded the apology letter which was specifically written for GPhC by the Department of Health (DH), confirming the flawed nature of processes leading to my sacking.
14. In November 2014 some members of management of the new Berkshire West CCG referred me to GPhC for sharing and tweeting about my story.
15. My legal firm provided the GPhC with clear evidence showing the above witness was unreliable, that the investigator coached the witness and that I was described as “too honest” to work for the NHS.
16. Shockingly, GPhC carried on with their so-called investigation, during which the DH refused to confirm the truth about my case, even though I provided evidence to both GPhC and DH.
17. I wrote 5 letters to DH with a number of them directly addressed to Mr. Hunt. These letters specifically included key and structured evidence from the case proving that I was being victimised as a whistleblower. But the DH replies to my letters refused to acknowledge the facts and the gross wrong-doing, and instead simply went around the subject, making general comments about how the new National Guardian would sort out any future whistleblower issues. The DH denied any prior knowledge that the key witness against me was unreliable and refused to confirm that she was unreliable on the purported basis that they had no evidence of this. This was wrong and it was despite the fact that DH itself originally provided me with documents which showed the witness had previously been deemed unreliable. On several occasions I formally and in writing requested a meeting with Mr. Hunt or a representative from DH who was prepared to
go through my experience and evidence so that the scale of the poor treatment of whistleblowers and their active victimisation could be understood and appropriate actions taken. But my requests were denied.
18. My MP was very supportive and she wrote several letters asking either Mr. Hunt or a representative to look at the evidence that I provided, which she had reviewed and she asked Mr. Hunt to meet me. But her requests were equally ignored.
19. At the end my MP sent me a form and recommended that I refer the DH to Parliamentary and
Health Service Ombudsman.
20. At the GPhC, a hearing concluded was that the GPhC was not able to uphold 16 of the 17 allegation against me as misconduct (several of them were dropped and some classified as not being an issue of misconduct). However, the GPhC concluded that there had been one act of misconduct worthy of a warning. The witness, the person who had previously been deemed unreliable, had alleged that I forced her to complain against another pharmacist. The GPhC’s hearing concluded that I did not force her to make the complaint bur rather she had made that complaint on her own account. However the hearing concluded that she wanted her complaint to be dealt with unofficially but I encouraged her to do so officially. Not only did the GPhC not produce any evidence for its finding, it in fact stated that its witness’ lack of objectivity meant that her evidence should be treated with caution. Despite these facts the GPhC still simply based its biased report on the statement of the discredited witness. Even during the hearing there was more evidence of this witness’ unreliability to the point that GPHC’s lawyer advised that some of her comments should be disregarded because she was giving evidence on events to which she was not actually party. GPhC’s process was particularly perverse as my lawyer advised me that I was expected to accept the false allegation to show I had insight. I simply could not accept something of that was/is not true and I could not apologise for something that I had not done. Therefore, I received a GPhC warning to the effect that I must respect the wishes and view of colleagues and respect HR procedure and policies and any organisation in which I work as a pharmacist.
21. I lost a job which I loved and I was very good at because I was “too honest for the NHS” and I
would not endorse falsehood.
22. I was puzzled that the GPHC had claimed that it did/do not get involved in any HR matters BUT the baseless warning it issued, without any evidence and based on a witness acknowledged as wishes of colleagues and not respected HR procedure” .
23. For the hearing I had 12 credible and professional witnesses who demonstrated that none of the allegations against me had any merit but GPhC was surprisingly and disappointingly prepared to give some credence to the sole witness whose evidence had already been deemed unreliable.
24. The GPhC should have paid attention to the fact that some of the witness’s performance was under review (with full HR involvement) due to serious matters of circulating wrong medical protocols, and being under the influence of a pharmaceutical company. GPhC should have considered that all the allegations were out of revenge.
25. My legal team advised me strongly to appeal but I decided against it. I believe patient safety is at risk in Berkshire West and I did not want to delay making this protected disclosure publically hence the two articles in the Telegraph
26. As I was very disappointed by the way GPhC handled the vexatious referral, I wrote to Mr.
Duncan Rudkin the CEO of the GPhC on 13 June 2016 raising my concerns that I had not been fairly treated. The GPhC replied on 6th July 2016, and indicated that it did not agree that I had been unfairly treated. GPhC advised that I could appeal against this complaint outcome.
27. Importantly, in its reply, the GPhC stated that I was referred to them in 2013 after I was sacked, when I have written confirmation from them that I was referred to them in 2012 beforeany allegation had been put to me.
28. I appealed against this decision and I specifically questioned the accuracy of the GPhC’s latest
claim about the date on which they received the referral against me.
29. I have received a response from GPhC on 4th August 2016 advising that the original letter which I received from Blake and Lapthorn that stated that I was referred to the 11th July 2012 appeared to be inaccurate.
30. I find this latest claim by the GPhC implausible. My lawyers and I had previously sought clarification about the date of referral on more than two occasions. It is unlikely that Blake and Lapthorn would have made such a fundamental error as reporting a grossly incorrect date of referral. In any case, if such an error was made, what else has been misreported within the GPhC’s process?
31. Furthermore the fact that GPhC were basing their investigation on the old and later changed/dropped misconduct allegations from 2012 also confirms that the referral timing was in fact in July 2012.
Final Remarks & Recommendations
32. I continue to have serious concerns about patient safety in Berkshire West CCGs as several of the concerns that I raised in 2012 have not been investigated or addressed. Therefore I am making this public protected disclosure so that the clinicians and members of public are aware of my genuine concerns about real risks posed to patient safety and which must be investigated
and dealt with properly
33. Whistleblowers are still being victimised by the NHS, DH and the professional regulators whether by acts of commission or omission.
34. Genuine whistleblower, seeking a better NHS, are also black listed as my case has demonstrated.
35. Professional regulators need to be more effective and fair in the way they handle vexatious referrals against whistleblowers. The Freedom to Speak Up review recognised that whistleblower reprisal is a form of discrimination, and professional regulators should be combating such discrimination, not helping to reinforce it.
36. It is time that wrongdoers in the NHS are stopped and made accountable for their actions.
Without proper accountability the victimisation of genuine and caring whistleblowers will continue. Equally worrying, wrongdoers are & will do more wrong and patient are & will be at continuing risk.
NHS whistleblowing helpline dubbed ‘completely toothless’
BBC News Scotland 14 October 2016
THINKSTOCKA whistleblowing helpline for NHS Scotland is facing criticism following a steep decline in calls.
A new report has found that calls to the confidential “alert line” have fallen by 75% since it was set up two years ago.
Critics claim the service is “completely toothless” and staff are too frightened to raise concerns.
The Scottish government said it was part of a wider package of measures to support NHS staff.
They said potential whistleblowers should have the confidence to speak up without fear and know genuine concerns would be investigated properly.
Staffing levels
Public Concern at Work (PCaW), an independent charity, has been paid more than £50,000 to run the alert line for NHS Scotland since April 2014.
The service was initially launched as a pilot and during its first six months it received73 calls from concerned health workers.
But, in a new review for the Scottish government, the charity revealed just 18 whistleblowers called the helpline during the six months to 31 January 2016.
It also found that:
- Half of calls to the helpline related to patient safety – six of those involved unsafe staffing levels and poor clinical practice;
- One call related to the abuse of a vulnerable person;
- Callers included five nurses, two GPs, three paramedics and a dentist;
- One caller said they were dismissed from their job for raising a concern.
The data has raised further fears that some health workers are reluctant to raise concerns about unsafe working practices.
THINKSTOCKEarlier this year, an NHS staff survey revealed 24% of employees did not believe it was safe to challenge “quality, negligence or wrongdoing” by staff.
And last month, NHS Scotland’s chief executive, Paul Gray, admitted some staff fear being victimised for speaking out.
Whistleblowers have told BBC Scotland the advice line generally refers them back to the organisation they are complaining about.
That means the service is “of no value at all” and “completely toothless”, according to Dr Jane Hamilton.
The consultant perinatal psychiatrist said she used it to voice fears over safety at NHS Lothian after “exhausting” her options with the health board.
Escalate concerns
The campaigner, who no longer works for the NHS in Scotland, called for the establishment of an wholly independent service with investigatory powers.
“The bottom line is if it’s not independent and it has no powers, no statutory powers to investigate, then how can it be of any use at all?” she said.
Twelve callers turned to the alert line after first raising their concerns with managers, suggesting they had confidence in internal whistleblowing procedures, according to the PCaW report.
However, the report said there was a general trend of callers indicating their concerns had been ignored or have experienced victimisation.
Advisers suggested whistleblowers escalate their concerns with senior managers, the board or Healthcare Improvement Scotland.
Another campaigner, Peter Gregson, has lodged a petition with the Scottish Parliament, calling for the helpline to be replaced with an independent “hotline”.
Under his proposals, reports of negligence, malpractice and bullying would be referred directly to local NHS boards by the hotline provider.
The plan has won the support of a number of people in the medical profession.
‘Real challenges’
Cathy James, chief executive of Public Concern at Work, said: “PCaW run a free legal advice service for any worker in the UK who has witnessed malpractice and is unsure what to do.
“The service commissioned by NHS Scotland is substantially different to the one suggested by the petitioner. We believe that an investigatory service aimed at whistleblowing cases across the NHS could make a real difference to the experience of those raising concerns in the health sector, but this is not the service we provide to NHS Scotland or in any event.
“Raising concerns in any sector can present real challenges and far too often those who speak truth to power suffer as a result.”
She added: “Our service receives outstanding feedback from those who use it and it is incredibly valuable to have access to truly independent advice, but we cannot remove the risk of a negative response entirely – the real power here lies with the health boards and the regulators.
“As a society we must do more to celebrate and champion whsitleblowing rather than allow the suffering to continue. There is much work to do.”
‘External review’
Health Secretary Shona Robison, said: “All staff should have the confidence to speak up without fear and with the knowledge that any genuine concern will be treated seriously and investigated properly.
“The NHS confidential alert line provides a safe place where they can confidentially raise any concerns they may have about malpractice and wrongdoing in NHS Scotland.
“Increasingly, callers have raised their concern internally first, which may suggest staff feel more confident using internal procedures.
“The alert line sits alongside the wider package of measures we have developed over the past few years to support NHS staff.
“Work is also under way to establish the independent national whistleblowing officer who will provide external review on the handling of whistleblowing cases in NHS Scotland.”
NHS whistleblower ‘facing sack’ goes on hunger strike
Metro
An NHS worker who says she faces being fired for whistleblowing is going on hunger strike outside the Department of Health.
Jade Taylor, 46, has set up camp in Whitehall with placards, bags, and bottles of water. She has vowed to stay as long as she could – until she gets a meeting with Health Secretary Jeremy Hunt.
Taylor, who leads a community team in a mental health trust, started speaking up about her concerns over patient and staff safety after the mistreatment of her parents at Mid Staffordshire NHS Foundation Trust.
Their deaths prompted her to complain about a ‘plethora of concerns’ in her own trust, Berkshire Healthcare NHS Foundation, including allegations of bullying and the mistreatment of whistleblowers.
She started her hunger strike at 7pm on Monday before taking up her post in Whitehall yesterday.
‘The trust I work for are saying that I have lost trust and confidence in them,’ she said, speaking outside the DoH last night. ‘I am not accepting that.
‘I want them to properly investigate my concerns. I refuse to resign and I’m not going anywhere.’
Two years later her mother Maureen, who suffered from Alzheimer’s disease, was seen at Stafford Hospital’s A&E and was admitted to stay overnight.In 2006 Taylor’s 67-year-old stepfather Andrew Panayiotes received care at the now-defunct Mid Staffs trust. He died after contracting an infection following surgery to remove a tumour.
However, Taylor says her mother was discharged inappropriately on her own the next day, which caused considerable distress. She was 66 years old.
‘Because of these experiences – whistleblowing was a real issue in Stafford – because of that I’m not going to give up on raising my concerns.’
She says she raised issues with trust bosses and the Care Quality Commission over bullying, patient and staff safety, the ‘culture’ and the treatment of whistleblowers.
However she claims they weren’t dealt with properly, and she was ‘overloaded and bullied’ as a result.
Now Taylor claims trust bosses have called a meeting to consider her future this week. She isn’t attending the meeting, but will be represented by the Royal College of Nursing.She has been off work sick for about a year, due to stress and a mild heart condition.
Berkshire Healthcare NHS Foundation Trust said: ‘We are unable to comment directly about Jade’s case as it is ongoing and we respect her right to confidentiality.
‘However, we take concerns about patient safety and quality of care extremely seriously and have a strong culture of encouraging and supporting our staff to speak up.
‘To date, all whistleblowing cases raised with us have been thoroughly investigated to the full satisfaction of our regulators, and where necessary we have implemented improvements to address any lessons learned.’
Mentally ill prisoners left untreated says whistleblower
BBC News 11 October 201 From the section Lancashire
Dozens of prison inmates with serious mental health problems are left untreated, a whistleblower has said.
Anna Egginton-Murray, who quit Lancashire Care NHS Foundation Trust in September, said there was nobody with the expertise to treat serious cases in the prisons she worked in.
She knew about 100 inmates with major problems who were “put on a list” of prisoners with “unmet needs”.
The trust denied the list’s existence and said severe cases were treated.
The Ministry of Justice declined to comment when contacted by the BBC.
Claims backed
“It felt dangerous,” said Ms Egginton-Murray, adding: “It felt unethical and it felt very sad.”
Her claims were backed in written statements to BBC Inside Out North West from other staff who worked at the trust.
Cognitive behavioural therapist Ms Egginton-Murray treated prisoners with less serious conditions at Liverpool Prison and HMP Kennet, a prison for Category C inmates near Maghull.
She said there was nobody with the experience or expertise to deal with inmates when it became apparent they needed more specialised treatment.
Ms Egginton-Murray would discover a prisoner’s deeper problems during her consultations and felt frustrated because there was nowhere she could refer them.
‘Unmet need’
One inmate had post-traumatic stress disorder (PTSD) due to a childhood trauma and there was nothing she could do for him, she said.
She added: “There was a list of prisoners that were listed as ‘unmet need’ because there was no service there to meet their needs.”
Ms Egginton-Murray, who left her post after 11 months, claimed there were almost 100 prisoners on that list, adding that her job “became very burdensome… very difficult.”
“When you know there is nothing more you can do and you are faced with someone who is desperate for help and they’re asking for help, it leaves you in a very difficult position.”
The Lancashire Care NHS Foundation Trust said: “Prisoners with more severe mental health needs would not be put on a waiting list unless they are waiting for a secure in-patient bed outside of the prison.
“In the meantime their needs are managed within the prison.”
Draft guidelines from the National Institute for Health and Care Excellence (Nice) state that people in prison “have the same rights of access to health care as the general population”, but that “there is clear evidence that this is not the case”.
Turn that frown upside down! Grumpy doctors and nurses are told to ‘cheer up’ to improve levels of care and end a culture of bullying in the NHS
By KATIE STRICK FOR THE DAILY MAIL 10 October 2016
- Whistleblowing chief says NHS needs a ‘happier environment’ to improve
- Henrietta Hughes says grumpy doctors and nurses make atmosphere toxic
- Believes happier attitudes would improve care and end bullying culture
The NHS needs a happier environment to improve levels of care and end a culture of bullying, its new whistleblowing chief has said.
According to Henrietta Hughes, grumpy doctors and nurses contribute to a ‘toxic environment’ that harms patients and prevents staff from speaking out.
Speaking in her first interview as ‘National Guardian for speaking-up’, Dr Hughes, a GP, urged ‘every single person’ in the health service to be more positive at work.
According to whistleblower and GP Henrietta Hughes, grumpy doctors and nurses contribute to a ‘toxic environment’ that harms patients and prevents staff from speaking out (file image)
She said the NHS needed a greater dose of the ‘trust and joy and love’ hormone oxytocin.
‘If you think about that scene in Love Actually where everybody is meeting at the airport, that’s the oxytocin feeling,’ Dr Hughes told The Times.
‘So wouldn’t it be better if oxytocin was the predominant neurotransmitter in the NHS?’
Her role as a National Guardian was created as a result of Sir Robert Francis’ report into the ‘horrific’ victimisation of staff who drew attention to poor levels of care, which called for an end to the health service’s climate of fear.
On top of the national guardian, local whistleblowing guardians will also be appointed at every hospital.
Dr Hughes said her role was ‘to create a really positive culture in the NHS so that all staff feel safe to speak up.’
She also raised her concerns that medics are too afraid to come forward, saying: ‘Staff are seeing things which could potentially be a risk to patient safety and they don’t feel safe to speak up about it. That’s a really worry.’
She added: ‘If you bring a positive attitude to work with you then you start seeing all those benefits of working well as a team.’
‘If you come to work feeling distrustful, you’re going to transfer that emotion on to the way you deal with your patients.’
Dr Hughes said her role was ‘to create a really positive culture in the NHS so that all staff feel safe to speak up’
The problem is one that must be tackled by every member of staff in the NHS, Dr Hughes warned.
She said: ‘It’s about every single person seeing this as their responsibility…If you’re a consultant and you’re responsible for ensuring the safe care of your patients, then it’s your duty to have good relationships with your colleagues.
‘And if you’re struggling with that, do something about it.
‘At the farthest extreme, if you’ve got someone who’s responsible for the safer surgical checklist and they don’t see it as something they need to be involved in, you could end up having the wrong leg taken off.’
Although critics have argued that her role will be mainly ineffective without official investigatory powers, Dr Hughes was adamant that most NHS workers were keen to raise standards.
She said: ‘I’m really hoping to work in partnership as a supportive and developmental arm rather than something which is seen as punitive.’
The ‘two big barriers’ still preventing staff from whistleblowing are fear of victimisation and the expectation that nothing would be done, Dr Hughes warned.
She said she wanted the NHS brand to ‘carry with it the confidence for patients and the public that if something has been identified as a problem, the organisation is doing something about it.’
Kim Holt from the whistleblowers’ organisation Patients First told The Times: ‘It’s all fine and well going with a positive attitude but if you’re subjected to relentless attack and hostility nobody is going to be happy and positive and smiling.
‘It would be lovely to think that the world was full of people who all behaved in an appropriate way, but there are people who have been allowed to continue with negative behaviour in the workplace and that needs to be rooted out.’
Arguing that Dr Hughes focus on positivity was ‘a bit utopian’, Dr Holt added: ‘It needs to be backed up by your manager and by your organisation. When the workforce sees that they are supported for speaking out rather than driven out, that’s what makes the difference.’
Anthea Mowat from the British Medical Association told The Times: ‘Everyone in the NHS, especially those in managerial and leadership positions, must lead by example to make this a reality.’
ARI surgeons under investigation cleared by watchdog
The Press and Journal
Surgeon Zygmunt KrukowskiThe former Queen’s Surgeon is among eight consultants who have been cleared of any wrongdoing following an investigation into the conduct of medics at the north-east’s flagship hospital.
And the General Medical Council probe – which lasted nearly two years – is understood to have cost NHS Grampian about £5million.
It has also been claimed health bosses have had to draft in staff from other areas to help fill vacancies after most of the surgeons being investigated left the Aberdeen Royal Infirmary department.
There are currently four positions still to be filled.
Professor Zygmunt Krukowski, who was the Queen’s personal physician when she was in Scotland, was suspended from his job in May 2015 following a probe into his practices at ARI.
His colleague Dr Wendy Craig was also suspended by the health board.
Both quit NHS Grampian in April, with Prof Krukowski understood to have retired, while Dr Craig is now working in the north-east of England.
Now an insider has claimed the cost of paying the consultants’ salaries, legal payouts, hiring locum doctors, and outsourcing operations was at least £5million – and could rise.
They said: “Ultimately, this is wasting millions which should be directed towards improved patient care.
“Instead, specialities are left uncovered with procedures carried out haphazardly by those not previously practising or fully trained in key areas.”
The investigation was triggered by a controversial report published by the Royal College of Surgeons England at a turbulent period for the health board, with a number of high-profile resignations, including that of then-chief executive Richard Carey.
The report found “significant numbers” of surgeons had shown “unprofessional, offensive and unacceptable behaviour”, with rows between medics in front of trainees and patients among the complaints.
However, the quality of the report has been criticised amid claims it is partly based on hearsay and uncorroborated allegations made by some staff.
North-east MSP Ross Thomson has raised concerns about the RCSE’s report.
He said: “If all of the consultants who were referred to the GMC following the Royal College of Surgeons of England report have now been cleared, then that raises serious questions about the quality of the evidence that was gathered and presented to NHS Grampian.
“These were very serious allegations and the whole episode will have been extremely distressing for the consultants involved and their families.
“I would be interested to read the findings of the GMC in terms of their deliberation of these complaints and the apparent decision to take no further action.”
Last night, the GMC confirmed it had concluded its inquiries.
Its chief executive, Niall Dickson, said: “We have closed these cases based on a careful review of all the evidence available to us.
“That evidence included an independent report by the Royal College of Surgeons of England which was shared with us by the health board.
“Patient safety is our first priority and we acted appropriately in our duty to look at those concerns further.”
It is understood that three of the surgeons subject to investigation are still employed by Grampian.
However, it is believed the remaining five, including Prof Krukowski and Dr Craig, were also subject to an internal inquiry and have now either retired or moved on elsewhere.
NHS Grampian has said its surgery team is led locally by Professor Duff Bruce.
The health board also said it would not comment on legal issues or individual salaries but said it relied on existing staff, medics from other health boards, and locums to fill in when necessary.
A spokeswoman added: “If a member of staff is being investigated by the GMC and is still employed by us, they continue to be paid.
“This is consistent with national policy for NHS workers. We work closely with our regulator and the GMC makes the decision whether or not to investigate any individual doctor.”
RCSE declined to comment.
The first medic to be cleared was Malcolm Loudon, the whistleblower who first contacted the Scottish Government about failing leadership at ARI in 2014.
Mr Loudon’s revelations ultimately led to three separate inquiries being launched into ARI and Woodend Hospital.
The crisis led to the departures of board chairman Bill Howatson and chief executive Richard Carey.
A review by Healthcare Improvement Scotland (HIS) – ordered by the Scottish Government – also expressed concerns about the conduct in general surgery and its impact on patient care.
The review by the RCSE was commissioned by Grampian’s former medical director Dr Roelf Dijkhuizen, who later retired.
The report was kept secret for more than a year, despite the Press and Journal making two attempts to view it under freedom of information rules.
At one stage, the health board released the 69-page report but blocked out 49 pages with thick black ink.
Then, in April of this year the Scottish Information Commissioner ruled the health board should disclose a further 4.5% of the report.
Last night, Mr Loudon said questions still had to be answered over the relationship between the health board and the GMC’s Scottish representative.
He said: “I’m delighted to hear that all my colleagues have been cleared in the same fashion as I was.
“Now it’s time that questions were answered about the roles of both NHS Grampian and the employee liaison officer of the GMC in Scotland.
“It seems that the employment liaison officer has acted as a funnel for NHS Grampian to push through information to the GMC.”
Niall Dickson, chief executive of the General Medical Council, said: ‘This was a complex investigation, made more so by the requirement to seek responses and advice from a range of experts and advisers, while respecting the administrative processes of other bodies which some doctors were engaged with.
“However, we are confident that we have closed this matter in an appropriate length of time while ensuring all concerned were treated fairly.”
Related Articles
Sir Robert’s Flip Flops
NHS Gagging. How CQC sits on its hands.
whistleblowers not allowed to join whistleblowing events organised by NHS Employers
From: Minh Alexander
Subject: Inclusion of whistleblowers in NHS Employers’ learning process
Date: 19 September 2016 at 14:26:37 BST
To Mr Danny Mortimer 19 September 2016
Dear Mr Mortimer,
Inclusion of whistleblowers in NHS Employers’ learning process
I write to ask if NHS Employers could re-consider its position of not allowing whistleblowers to join its whistleblowing events.
I along with other whistleblowers asked to attend NHS Employers’ forthcoming event, “Raising Concerns Share and Learn Forum” but access has been declined. This will restrict the range of experience and discussion at this event.
I note that NHS Employers has posted three blogs by trusts’ local Freedom To Speak Up Guardians, copied below for convenience. These seem to me to be ‘good news’ items, which lack sufficient facts about how the local guardian model is actually performing, or whether and how it is being evaluated. This is of concern given that Robert Francis’ local guardian model was not evidence-based to begin with. [1] To illustrate important information that does not feature in these blogs, I give some examples:
1) The local Guardian for UHMBT has omitted to mention (or perhaps did not know of), recent trust whistleblowing cases which resulted in litigation expenditure by the trust, and did not discuss evidence of how exactly UHMBT has learned from this.
2) The local Guardian for TSDFT has omitted to mention that his trust was famously found by an Employment Tribunal to have mistreated two whistleblowers who raised concerns about a former Chief Executive. The blog does not account for this failure, nor does it give solid evidence of organisational learning.
3) The local Guardian for HRCHT omitted to mention (or perhaps did not know of) 27 super-gags by the trust with a total settlement value of
£1, 211, 036, or how such matters will be handled in future.
Whistleblowers are very concerned that the NHS will take a tokenistic approach to the local Guardian project, and will not appoint those with the most appropriate insights and experience on how organisations cover up.
I should additionally mention that two of the trusts in question had opportunities to employ whistleblowers with lived experience as advisors, but did not.
I hope that NHS Employers can acknowledge what is lost if whistleblowers are excluded from the NHS’ learning process.
I look forward to hearing from you.
With best wishes,
Dr Minh Alexander
cc Chair of Health Committee
[1] Critique of Francis’ model of Trust-appointed Guardians, 21 June 2015
https://sharmilachowdhury.com/2015/06/21/critique-of-francis-model-of-trust-appointed-guardians/
_____________________________________________________________________
THREE LOCAL FREEDOM TO SPEAK UP GUARDIAN BLOGS POSTED BY NHS EMPLOYERS:
My experience as a Freedom to Speak Up guardian
19 / 8 / 2016 Midnight
Wayne Walker, Freedom to Speak Up (FTSU) guardian and multi-skilled technician at Torbay and South Devon NHS Trust, describes his experience in the guardian role. This is the first in a series of blogs by Wayne.
My experience as a Freedom to Speak Up guardian
I’m one of seven Freedom to Speak Up (FTSU) guardians based in the south west – a beautiful part of the country. I’ve lived and worked here since I was 22 and have been employed in the NHS for the past 20 years. Day-to-day, the team I work in maintains the hospital building and complex medical equipment. We are often behind the scenes, but like so many essential services are very important cogs in the system.
For the past 18 years I’ve been on call 24/7, often working at 3am in the morning. This is a side of the NHS that many people forget about – but the NHS does not close. Working in the hospital is different to a regular job, we’re directly effecting people’s health – one thing we all need, to be able to enjoy this journey we call life.
I first spotted an advert for the FTSU guardian role in January 2016, which led me to do some further research. I began to discover great people like Julie Bailey, Sir Robert Francis and Helene Donnelly – to name a few. They were really making a difference to people’s lives in the NHS, people not dissimilar to those in my organisation who want to speak up but think it will become more hassle than it’s worth, or depend on others to raise concerns.
I began to feel very passionate about the subject and when that happens it stirs your beliefs, purpose and respect for the NHS – a great employer to many people.
The interview for the FTSU guardian role was very rigorous, but I believe it had to be. The knowledge of policies, procedures, processes, employment law – the list goes on, all fall under this role. My previous experience as a union representative for ten years gave me a good base knowledge for those questions. Knowing these technicalities about the role is essential to be an effective guardian. When a member of staff raises a concern, you need to know whether it is an issue concerning acceptable behaviour, an employment issue, terms and conditions, data protection or to do with compliance.
When I started in my new role as a guardian, one of the main things I loved about it was meeting people and hearing about their passions and role in the organisation. However, I did find that some senior staff didn’t like the idea of concerned staff being able to question their decisions – the body language says it all sometimes!
As a collective of guardians, we’ve presented to a variety of people, from board level to managers to consultants. Standing up and discussing a subject that is feared including how we would like to change organisational culture, how we would like staff to be empowered and how we want them to speak up about patient safety is a pretty difficult task. Our talks did generate a lot of interesting feedback – mainly from the people who ask lots of questions. Like anything though, there are a few myths circulating that could install fear in staff – but we just remind them that they can speak to us in confidence so hopefully we can address them.
In my role, I do sometimes question why such a caring community finds it hard to share their concerns through fear of detriment. Of course not all NHS communities are the same, but we as Freedom to Speak Up guardians/advocates/ambassadors want to make that change so that individuals feel confident to step forward.
My goal is a simple one – to make sure staff feel free to speak up about patient safety and effectiveness of the service so we can provide safe and compassionate patient-centered care. And the people who can make that work? You, the 1.3 million staff in the NHS.
Further reading
You can read more guardian related blogs from Christopher Hall and Heather Bruce in this section using the retain and improve and raising concerns filters.
Nearly a year as Freedom to Speak Up Guardian
22 / 4 / 2016 12.25pm
Heather Bruce is the Freedom to Speak Up (FTSU) Guardian for the University Hospitals of Morecambe Bay NHSFT. This is her first blog explaining how the role has developed since she was appointed in July 2015
This has been a very busy year for me and that’s my excuse for taking so long to do my first blog!
It’s more than ten months since I was appointed and it has been an exciting and challenging time.
Initially the work involved promoting the culture of raising concerns across the trust. With more than 6,000 staff and a distance of 45 miles between our two biggest sites, this has taken some considerable time. But with much walking of the sites on my part, 4,000 leaflets and posters and promotion through the intranet, I am becoming well-known and staff are embracing the culture of raising concerns. Our behavioural standards framework was launched simultaneously and our staff have found this empowering in standing up for their patients and themselves.
Now the majority of my time is taken up with helping staff to raise concerns where appropriate and to continue to support my colleagues. We have had some positive results from escalating issues and thereby improving services.
I still work as a radiographer two days a week and I am the industrial relations rep for the Society of Radiographers. Being clinically based and through my contacts with staff side, I have an ease of access to staff, which has increased the credibility and independence of the role. In line with the recommendations of the freedom to speak up review, I work alongside our lead non-exec director for FTSU and our medical director and I have direct access to our chief exec, Jackie Daniel.
In August 2015, NHS Employers set up their quarterly “Raising concerns Share and Learn” forums and I have attended each of them. That has provided me with access to an invaluable network of freedom to speak up guardians. Finding out what works and what doesn’t seem to, has been very useful.
At the moment, all new staff receive the freedom to speak up message at induction. The next steps I will be taking is to liaise with learning and development on a training programme that we can use to reach out to all staff, using the e-learning package that is being developed by Health Education England. I am also hoping to set up training workshops for managers to support them in responding to concerns.
For me this has been a great opportunity to contribute to improving patient care and supporting our staff through the cultural transformation that has been initiated since the publication of the Mid Staffs Inquiry and the freedom to speak up review.
My experience so far as a freedom to speak up guardian
15 / 12 / 2015 10.30am
Chris Hall is a freedom to speak up guardian at Hounslow and Richmond Community NHS Trust. in his second blog, he describes the importance of sharing good practice and his attendance at NHS Employers raising concerns share and learn event.
As more NHS trusts appoint freedom to speak up guardians and their equivalent, it becomes increasingly important that those already in the role share their ideas and experiences. Last month, I had the opportunity to attend the share and learn meeting hosted by NHS Employers in central London. This was my first real opportunity to exchange ideas for role development face-to-face with my peers. Some guardians had been in post for longer than me, others for less time, but what became clear was that without exception we all wish to make this new role a big success. There was much discussion and exchange of ideas, and a real spirit of mutual support and collaboration.
On a practical level, we were able to share some of the diagnostic and record keeping tools being developed. Also, as individual trusts work on raising and maintaining awareness within their workforce, examples of publicity campaign materials were shared.
With the imminent appointment of the new national guardian, hosted by the Care Quality Commission, who will oversee and support the work of guardians across the country, our hope is that the ideas generated from these early collaborations will influence the development of this national role, and also be of practical help to those trusts who are yet to introduce the role locally.
One of the recommendations of the Freedom to Speak Up review by Sir Robert Francis QC was for a single national whistleblowing policy for the NHS. A draft policy created by Monitor, the NHS Trust Development Authority (TDA) and NHS England has recently been published for consultation. Some of my fellow guardians and I had the opportunity to review this document and we have ideas that could be incorporated into the policy.
As the number of guardians across the country grows in the coming months, I hope this feeling of openness and enthusiasm is maintained. There will be many who bring new ideas and experiences to the table, all contributing to our mutual goal of an improving culture of openness in the NHS.
Boss of scandal-hit hospital with 287 unexplained deaths apologises for suffering patients endured @Jeremy_Hunt @theresa_may
The Mirror
18 SEP 2016
BY MARTYN HALLE
Libby McManus has issued the apology after taking over from former hospital chief executive, Julie Lowe
North Middlesex Hospital, Edmonton. The hospital was found to be in breach of nearly a dozen laws designed protect the public
The new boss of a scandal-hit hospital where there were 287 unexplained deaths has apologised for the harm and suffering patients endured.
Libby McManus was drafted in to run the North Middlesex Hospital in North London after a damning Care Quality Commission investigation uncovered a series of damning failures.
Among them was the case of a patient – who was found dead and with rigor mortis after being left for four hours in A&E.
Inspectors also found evidence of elderly people suffering abuse, neglect and lack of fluids on wards for care of the elderly
Julie Lowe, the former chief executive of the North Middlesex has been moved on and been secretly found a new NHS job.
Libby McManus has taken over the Chief Executive role in the wake of the damning report
In a meeting with The Sunday People Libby McManus said: “I want to apologise to all those relatives and patients who have suffered in the past.
“We are starting to do things differently now and we are confident that in time we can turn things round.”
Mrs McManus also promised to look at some of the mortality data for the hospital highlighted by Professor Brian Jarman whose work exposed the scandal at Stafford Hospital where there were up to 1200 avoidable deaths.
He said the failings at the North Middlesex had all the hallmarks of the harm and suffering experienced by patients at the Midlands Hospital.
An investigation by the People has found the Edmonton based hospital in breach of nearly a dozen laws designed protect the public following the Stafford Hospital scandal.
North Middlesex Hospital Accident and Emergency unit has been at the centre of the allegations
The snap, unannounced Care Quality Commission inspection of the North Middlesex in April, provoked by a story in The People six weeks earlier, found the trust in breach of many regulations designed to prevent Zero Harm.
Concern about the North Middlesex Hospital has largely focused on its appalling A&E department where several patients have died due to poor care and neglect.
On Friday the People confronted Liz MacManus with the evidence of neglect.
Patient safety campaigner Fiona Bell, who attended the meeting, has called on the Health Secretary to probe the failures at North Middlesex.
She said: “Mr Hunt has to act now and call an investigation into why he and others failed to Act when all the warning signs were there for two years.”
Ms McManus – a nurse by training – has promised to consult Professor Jarman over mortality data.
She said: “We want to understand where we went wrong as part of going forward.”
A full four day inspection of the trust by 30 Care Quality Commission inspectors starts on Tuesday with the findings published later this year.
Shamed NHS boss and why she MUST go
Health chief was told FIVE YEARS ago that patients were at risk but failed to follow advice… so why is she still in a £240k job?
- Katrina Percy ex chief executive of Southern Health NHS Foundation Trust
- Report accused Trust of not considering patient safety its ‘core business’
- Percy allegedly warned suicidal patients kept in rooms with ligature points
- Inspector claims she ignored warnings despite high hanging rates in Trust
Whistleblower Mike Holder has accused former NHS chief Katrina Percy (pictured) of ignoring health and safety warnings
Pressure was growing last night for an under-fire NHS boss to quit her £240,000-a-year job after fresh allegations her trust ignored warnings that could have saved lives.
A whistleblower says Katrina Percy failed to act after being told Southern Health NHS Foundation Trust was housing suicidal patients in rooms full of places they could hang themselves.
Health and safety consultant Mike Holder wrote in a damning report that the trust, responsible for 45,000 vulnerable people, did not consider patient safety part of its ‘core business’.
Mr Holder told The Mail on Sunday he emailed his dossier directly to Ms Percy, who was then the trust’s chief executive, nearly five years ago – but his warnings went unheeded.
Among his claims, Mr Holder alleges that Southern Health:
- Failed to remove ‘ligature points’ – where a noose could be attached to lethal affect – from rooms used by vulnerable patients;
- Did not investigate a five-fold surge in attempted hangings by patients in the five years prior to his report;
- Ignored him when he told them safety systems were ‘dysfunctional’ – a failing he feared would result in patients being able to kill themselves.
Mr Holder had been commissioned by the trust to investigate health and safety in 2011 but resigned after three months because he was so concerned by what he found.
He said: ‘I firmly believe people died unnecessarily because Southern Health, with Katrina Percy at the helm, failed to follow my advice.’
His views were backed by relatives of patients who hanged themselves in trust facilities using ligature points that should have been removed.
Roger Colvin, whose ‘beautiful and kind’ wife Teresa, 45, killed herself, said: ‘I am absolutely sure her death was preventable. She went there believing it was a place of safety, but they failed her.’
An internal review found ‘no evidence of negligence or incompetence of any individual board member’ at the trust and announced Ms Percy could keep her job.
But two weeks ago she stood down as chief executive of Southern Health, claiming ‘media attention’ was making it impossible to do her job.
However rather than give up her £240,000-a-year remuneration package, including her £190,000 salary, she moved sideways to a job created for her, giving strategic advice to GPs. She was the only applicant.
Calling on her to resign immediately, Mr Colvin, 64, a company director, said: ‘She was aware of risks to patients and did not take specific action – she should go.’
Last night, former health Minister Norman Lamb called on Southern to sack Ms Percy if she was ‘not humble enough’ to resign herself.
He said: ‘When there have been so many apparent failures, leaders have to take responsibility. You can’t simply shift sideways to a job, with that level of salary, which last week was not even deemed necessary.’
The Lib Dem MP said he thought the trust had ‘a fair basis for terminating employment’. Demanding the board ‘urgently reconvene’, he said: ‘They need to recognise it’s not sustainable to persist with this appointment.’
Conservative MP Sir Nicholas Soames agreed: ‘I think Miss Percy should have gone quite some time ago. The idea that this job should have been created especially for her is appalling, grotesque, and she must go now.’
He believed the situation at Southern Health revealed ‘a terrible failing of corporate leadership at the top of the health service’.
Southern Health last night told The Mail on Sunday ‘considerable improvements’ had been made since 2012, with more than £2 million spent making its buildings safer, but gave no indication Ms Percy would quit.
TRAGIC DEATH OF TERESA COLVIN AT SECURE HOSPITAL
Riding instructor Teresa Jane Colvin strangled herself using a telephone cord from a communal kiosk within 48 hours of being admitted to Woodhaven Hospital in Southampton.
The danger posed by the kiosk, which was out of the sight of staff, had been officially noted in 2009 – three years earlier. But nothing was done.
Her devastated widower Roger Colvin said: ‘After the event, I was staggered to find the cord – which had been so long you could do your washing on it – had been shortened.’
So had cords at Southern’s other secure units. ‘They could have done that before Teresa died,’ said Mr Colvin. ‘It wouldn’t have been expensive.’
Southern admitted liability for 45-year-old Mrs Colvin’s death.
Last night Mr Colvin told The Mail on Sunday he was ‘astounded’ to hear Southern had been explicitly warned of ligature point risks in 2011.
He said: ‘For management to ignore these risks, pointed out by their own health and safety expert, is unacceptable.’
Mrs Colvin suffered bouts of Post Traumatic Stress Disorder after suffering abuse as a child but they only tended to last a few days, said her husband. She was often ‘very well’, putting huge energy into her horses and beloved labradors.
He said: ‘She was a beautiful woman, I loved her dearly. And now she is gone.’
The trust first hit headlines last December when a report commissioned by NHS England concluded it had failed to investigate 450 ‘unexpected’ deaths between April 2011 and March 2015.
That report only took place because a grieving mother, Dr Sara Ryan, asked why her epileptic son Connor Sparrowhawk, 18, had been left alone in a bath at one of Southern’s units in 2013.He had a seizure and drowned.
It took three years for the trust to accept responsibility for his death.
But Mr Holder’s report, in February 2012, reveals bosses were warned about an apparent cavalier attitude to patient safety long before Connor died.
Mr Holder compiled the report a week after resigning, three months into a six month contract as interim head of health and safety.
In his resignation letter to Ms Percy, he said he was not supported by the trust’s board, and believed patient safety was way down its agenda.
Rather than deal with his resignation personally, Ms Percy handed it on.
Dr Huw Stone, medical director at the time, asked Mr Holder to spell out his ‘serious concerns’ in more detail. Mr Holder thus compiled a 13-page report supported by numerous email exchanges with staff.
In it, Mr Holder concluded: ‘It is my professional opinion that health and safety is considered an adjunct to the trust’s core business rather [than] an integral element of it… health and safety is not considered as an essential element of the trust’s undertaking.’
He told Southern Health such an attitude – in an NHS trust responsible for society’s most vulnerable and unstable – manifested itself in poor safety checks and record keeping of incidents where people came to harm.
Mr Holder said: ‘I essentially warned them: “Your safety systems are dysfunctional and because of this patients will succeed in killing themselves”. But they didn’t listen.’
I essentially warned them: ‘Your safety systems are dysfunctional and because of this patients will succeed in killing themselves.’ But they didn’t listen.
Mike Holder
In particular, he identified a dramatic increase in patients trying to hang themselves in Southern’s secure units over the previous five years. He discovered little action had been taken to eliminate potentially lethal ligature points, such as door handles, lights, beams and pipes, he said.
He recalled: ‘What I found was really quite shocking.
‘Ligature incidents’ had risen five-fold between 2007 and 2011, from 76 to 407, he discovered, adding: ‘Nobody had ever done this [research] work before, or if they had, there was no evidence of it.’
Southern’s way of assessing potential ligature points across its estate was also inadequate, he found, so he started a review.
In early February 2012, he put his findings to a senior manager, who suggested the trust had to ‘tolerate a certain degree of risk’.
Furious, Mr Holder emailed back a warning that under law Southern had ‘an absolute duty to ensure the safety of its patients, particularly those that are vulnerable’.
Powys Local Health Board in Wales had been fined £30,000 and ordered to pay £46,850 costs after a suicide, because the NHS body had ‘failed to provide a safe environment for a vulnerable patient’, he told them.
Two weeks later, frustrated at the lack of action, he resigned.
Mr Holder, an experienced chartered safety practitioner who has worked for construction firms and a commercial diving operation, said: ‘I thought “This is going to end badly for me. If something bad happens, they will use me as a scapegoat”.’
In his report, he further wrote that management erroneously believed ‘that ligatures are being managed effectively’, despite a ‘consecutive and significant increase in [ligature] events over the last five years’.
His report also identified ligature points in patients’ rooms at Ravenswood, a secure unit outside Fareham, Hants, and concluded the trust was breaching multiple health and safety laws.
Two months after his report, Teresa Colvin killed herself using a telephone cord ‘as long as a washing line’ at Southampton’s Woodhaven Hospital.
And in August 2014, biochemistry graduate James Younghusband, 30, hanged himself in his Ravenswood room from a downpipe that should have been removed.
The following February – three full years after Mr Holder’s warnings – the Care Quality Commission concluded Ravenswood was ‘unfit for use’ because ligature points posed a danger to suicidal patients.
Katrina Percy blandly responded: ‘We know that there will always be things we can learn from and ways we can make our services better.’
That was not all. This April, the CQC ordered Southern to make ‘urgent improvements’ to protect patients ‘at risk of harm’, concluding ‘it did not adequately ensure it learned from incidents to reduce future risks to patients’.
Percy, battling to stay in post after the 2015 unexpected death report, claimed ‘good progress’ had been made, adding: ‘My main priority is, and has always been, the safety of our patients.’
But Mr Holder said: ‘What I saw at the trust was like The Apprentice, except no one was told, “You’re fired,” however many deaths there were.’
What I saw at the trust was like The Apprentice, except no one was told, “You’re fired,” however many deaths there were
Mike Holder
He added: ‘In any other organisation, the board would force her to resign. I’m absolutely amazed that she has not been held to account.’
The Mail on Sunday approached Ms Percy at her £500,000 five-bedroom Hampshire home yesterday, but she said: ‘I am not giving interviews. Please talk to the trust.’
A spokesman for Southern Health NHS Foundation Trust said: ‘We express again our sincere apologies and condolences to the family and friends of James Younghusband and Teresa Colvin.
‘We fully accept they were failed by the trust and we are working extremely hard to ensure we never let this happen again.
‘The safety of people using our services is of utmost importance. Mike Holder’s report was reviewed in 2012 and considerable improvements have been made since.
‘Reducing risks associated with ligatures is a top priority. We have spent over £2 million to remove or minimise the risks of ligature points.
This includes a major renovation of Ravenswood House. We have appointed a dedicated ‘ligature manager’ and provided additional training and support to staff.’
- The Samaritans can be called free, at any time, on 116 123.
The Numerophobic CQC
Patient Safety Campaigner
Hot Air about Just Culture
Richard von Abendorff Patient Safety Campaigner and Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, 31 August 2016
‘Just culture’ is a term for principles of respectful governance, with fair and proportionate accountability and a focus on learning. Politicians and senior NHS officials say they want just culture [1] but so far, it has been elusive in the NHS. Why so?
The literature often focuses on how just culture should apply to the NHS frontline and provider organisations, and less so on commissioners, watchdogs and politicians. [2] This distracts from the root causes of unjust culture.
In his statement of 6 February 2013 about the MidStaffs Public Inquiry, Robert Francis noted failure at all levels of the NHS:
“Regrettably there was a failure of the NHS system at every level to
detect and take the action patients and the public were entitled to expect.” [3]
The Public Administration Select Committee noted last year that culture comes from the top:
“Throughout the past five years, the recurring theme of our findings and recommendations reflects the importance of effective leadership in creating effective organisations. Our work has shown that it is the positive or negative attitudes and behaviour in the people and the culture of an organisation which determines success or failure..….the same issues will keep arising until there is a comprehensive determination to address the attitudes and behaviour of all the most senior Ministers and officials.” [4]
The deficit of just culture in the NHS can be traced to the top. Numerous NHS inquiries into healthcare failures have shown the contribution of poor leadership by politicians and senior officials in creating a culture of fear and reputation management, and wilful blindness to harm and risk to patients.
The deficit of just culture in the NHS can be traced to the top. Numerous NHS inquiries into healthcare failures have shown the contribution of poor leadership by politicians and senior officials in creating a culture of fear and reputation management, and wilful blindness to harm and risk to patients.
The Department of Health suppressed 3 major reports on NHS culture and quality improvement in 2008, which were critical of the Department’s leadership of the NHS. [5] [6] [7] They were not released until 2010, and only via a Freedom of Information request. It appears that the Department of Health did not wish to reveal findings that:
* The NHS had a culture of “fear and compliance” and “shame and blame”
* Managers in the NHS “look up, not out” (that is, NHS managers manage to please those above in the hierarchy, as opposed to prioritising the interests of patients and families)
* Patients and families were not central to those at the top of the NHS, and were little mentioned – “We were struck by the virtual absence of the mention of patients and families”
* That there was “an absence of an improvement imperative within the Department of Health and the NHS”
At the Midstaffs Public Inquiry, evidence was given by several senior officials about negative political interference in the NHS, and a driving imperative not to “embarrass the Minister”. [8]
In another matter, a leaked email by a civil servant revealed collusive practices to prevent a whistleblower, Raj Mattu, from gaining access to a Minister. [9] Similar ruses to ensure political deniability are common and continue. NHS whistleblowers often appeal to the Secretary of State and Department of Health as a final port of call when they have exhausted attempts to raise safety concerns with regulators. However, the typical response of the Department of Health is to dismissively claim that it does not get involved in ‘employment issues’ and to refer anxious and frustrated whistleblowers back to the regulators who have failed them.
Similar stonewalling is experienced by NHS complainants, despite official lip service to the immense value of feedback provided by complainants. Years of repeated reports about failure of NHS complaints governance have not resulted in improvement, and the number of complaints has actually increased. [10] Families find out time and again that loved ones died or suffered preventable harm because the NHS failed to properly learn from previous incidents or to mitigate known risks, and sometimes families do not get answers at all.
Complainants and whistleblowers alike are often badly mistreated if they raise concerns about NHS failure. [11] Politicians have decades of evidence of such malpractice, but it has never been effectively discouraged. The truth is that the NHS is not allowed to learn, because of the political pressure to suppress matters that may embarrass Ministers, and to avoid exposure of the fact that the NHS has long been under-funded. Indeed, there is evidence that wide-spread gagging of NHS staff continues despite headlines in 2013 that Jeremy Hunt supposedly banned gags. He did not. He simply asked NHS trusts to do better, but omitted to ensure effective oversight. [12]
Just culture requires that politicians and senior officials should also be held accountable for care failures that arise from poor stewardship of the NHS, and systemic failings. Staff struggling in a seriously underfunded, understaffed service that is in perpetual crisis can be expected to make mistakes. Politicians and senior officials who produce policy that makes unrealistic and unachievable demands, and
creates oppressive and exploitative working conditions for NHS staff are guilty of disrespect. Such tensions have been highlighted by the junior doctors contract row. However, as Lucian Leape et al have noted, this form of disrespect is often normalised in health services. [13][14] When disrespect is evident, or justice is not seen to be done, this will naturally intimidate staff and deter them from speaking up.
Severe NHS cuts of all forms continue despite the obvious safety concerns of the workforce. Senior establishment figures in the Health community are united in voicing increasingly urgent concerns about NHS under-funding. [15] [16] Yet key recommendations of the MidStaffs Public Inquiry are being jettisoned one by one. Jeremy Hunt has made much of ‘intelligent transparency’ and has said that he wanted the CQC to be ‘chief whistleblower’. However, CQC’s inspection reports present safety data in an inconsistent and incomplete way, which makes it hard to track the effects of government policy on patient safety. [17] [18] CQC has also been criticised for failing to regulate the Duty of Candour properly. [19] Moreover, CQC has failed woefully on implementing Regulation 5 Fit and Proper Persons. [20] [21] Not one manager whose fitness to lead has been seriously called into question has been removed by CQC. NHS England asked NICE to stop its safe staffing work, and NHS Improvement has been criticised for dismantling NICE’s previous work on safe staffing. [22] [23] NHS Improvement has castigated trusts for spending on staffing, even where trusts were responding to CQC requirements to increase staffing levels to safeguard patient care. [24] Waiting time standards have also effectively been cast off. [25] [26] [27] Most recently, the leak of a DH risk assessment raised questions of whether the Secretary of State had unsafely ploughed on with the 7 day NHS initiative, despite even the concerns of his own officials. [28] Since the leak, the DH has not produced evidence that it has any means of mitigating the risks identified by civil servants. The Chair of Health Committee entered the fray with strongly worded criticism:
“Cannot keep piling ever greater responsibilities onto an overstretched service without realistic resource and workforce to cope”.
“Expect problems when thin evidence is used to bolster an under resourced political objective instead of policy following the evidence.” [29]
In just culture, accountability is acknowledged as an important part of creating psychological safety, and recklessness is considered a matter for sanction. The following are listed by Stedman as blameworthy acts that merit sanction:
· Reckless behaviour
· Disruptive behaviour
· Working significantly outside your capability
· Disrespectful behaviour
· Knowingly violating standards
· Failure to learn over time
· Failure to work as a team
· Covering up [30]
How then do the Secretary of State, the Department of Health and the Department of Health’s arms length bodies measure up against this sort of ruler? We contend that they do not measure up at all well, based on the evidence.
After the publication of the MidStaffs Public Inquiry, Jeremy Hunt wrote to NHS providers to say that he wanted lasting change to create a more open, compassionate and safer NHS, and not just “short term noise”. [31] But it seems from the escalating stream of news about NHS staff shortages, increasing rationing, service closures and repetition of the same clinical failures that although Mr Hunt loudly banged the patient safety drum, patients have in reality not been protected.
Professor Brian Jarman rightly described the NHS as a denial machine. [32] It remains so. Until there is mature political leadership of the NHS, based on evidence, diligent governance and just culture as opposed to hot air about just culture, this will continue.
References
[1] From a blame culture to a learning culture. Speech by Jeremy Hunt, 10 March 2016
https://www.gov.uk/government/speeches/from-a-blame-culture-to-a-learning-culture
[2] The NHS must move from ‘no blame’ to a ‘just culture’. James Titcombe Health Service Journal 8 August 2016
[3] Statement by Robert Francis about the Midstaffordshire Public Inquiry 6 February 2013
[4] Our work in the 2010-2015 parliament. Seventh report of session 2014-2015. Public Accounts Committee, 28 March 2015
[5] When managers rule Patients may suffer, and they’re the ones who matter. Prof Brian Jarman BMJ 19 December 2012 BMJ 2012;345:e8239
[6] Achieving the Vision of Excellence in Quality. Recommendations for the English system of quality improvement. Institute of Health Improvement. 2008
[7] Quality Oversight in England – Findings, Observations and Recommendations for a New Model. Joint Commission International 2008
[8] Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2013
[9] Bid to block whistleblower’s access to ministers. Civil Service World 14 May 2014
http://www.civilserviceworld.com/articles/news/bid-block-whistleblower%E2%80%99s-access-ministers
[10] Data on Written Complaints in the NHS 2014-15. HSCIC 26 August 2015.
[11] Complaints and Raising Concerns. Health Committee. Fourth report of session 2014-2015. 21 January 2015.
[12] Letter by Jeremy Hunt to NHS trusts about ensuring open culture 2013
Click to access open-culture-letter.pdf
[13] Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Lucian Leape at al Academic Medicine Vol.87, No 7/ July 2012
[14] Perspective: A Culture of Respect, Part 2: Creating a Culture of Respect Lucian Leape et al Academic Medicine, Vol. 87, No. 7 / July 2012
[15] Deficits in the NHS 2016. Kings Fund July 2016
[16] Feeling the crunch. NHS finances to 2020. Nuffield Trust August 2016
[17] How safe are NHS patients in private Hosptals. Leys & Toft Centre for Health and the Public interest December 2015
Click to access CHPI-PatientSafety-Dec15.pdf
[18] CQC Deaths Review. All Fur Coat. Minh Alexander 13 August 2016
[19] Regulating the duty of candour A report by Action against Medical Accidents on CQC inspection reports and regulation of the duty of candour Hannah Blythe August 2016
[20] CQC’s Fit and Proper Parade. Minh Alexander 29 July 2016
[21] CQC to review whether fit and proper person rule needs to change. Will Hazel Health Service Journal 24 May 2016
[22] NHS England asks NICE to suspend safe staffing programme. NICE statement 4 June 2015
[23] NHS Improvement accused of ‘dismantling’ NICE safe staffing work. Shaun Lintern Health Service Journal 14 June 2016
[24] Third of ‘excess pay growth’ trusts were told by CQC to improve staffing.
Sharon Brennan Health Service Journal. 12 August 2016.
[25] Hospitals given green light to miss waiting time targets, Nick Triggle BBC 21 July 2016
http://www.bbc.co.uk/news/health-36854557
[26] NHS Indicators, July 2016. House of Commons briefing paper, Number 7281 6 July 2016
[27] Feeling the wait. Patients Association Annual Report on Elective Surgery Waiting times. August 2016
Click to access Waiting-Times-Report-2016-Feeling-the-wait-The-Patients-Association.pdf
[28] Secret documents reveal official concerns over ‘seven-day NHS’ plans.
Denis Campbell. Guardian 22 August 2016
[29] Tweets 23 August 2016 by Dr Sarah Wollaston MP and Chair of House of Commons Health Committee
[30] Blameworthy acts in a blame free safety culture. Roger Stedman November 2012 http://rogerstedman.com/wp/blameworthy-acts-in-a-blame-free-safety-culture/
[31] Letter to trusts by Jeremy Hunt about Mid Staffordshire Public Inquiry 2013.
Click to access jeremy-hunt-mid-staffs-public-inquiry-letter.pdf
[32] Labour’s ‘denial machine’ over hospital death rates. Telegraph 14 July 2013 http://www.telegraph.co.uk/news/health/heal-our-hospitals/10178552/Labours-denial-machine-over-hospital-death-rates.html
SHARMILA CHOWDHURY 