By Sarah Bloch-Budzier BBC News     30 March 2017

Senior surgeons say they tried to warn managers of dangerous delays to emergency surgery ahead of a child’s death at a top children’s hospital.

Kayden Bancroft was 20 months old when he died at Royal Manchester Children’s Hospital (RMCH), following repeated delays to urgent surgery.

Whistleblowers allege the trust’s focus was on “ballooning” waiting lists rather than emergency care.

The hospital admitted that failings occasionally occurred.

Central Manchester University Hospitals Trust said: “Royal Manchester Children’s Hospital faces huge demands for its services and occasionally failings regrettably do occur.”

Kayden’s grandmother, Julie Rowlands, has spoken of her shock at the way he was treated.

She said: “His care was appalling. He was basically put in a room, and left.

“And all we got, nearly every day, was, ‘He’s not having the operation today, he’s not having the operation today.’ They were coming up with excuses, ‘There’s no bed, or a car crash victim’s come in.’

“That’s all we got, all the time we were there, was excuses.”

One surgeon, Basem Khalil, told the BBC: “We just worry how many more children must die before management is held to account and before the right changes are made.”

Kayden was brought into Stepping Hill Hospital on 11 April last year, a Monday, after falling and banging his mouth on his bottle.

Staff discovered that he had a hole in his diaphragm, causing his bowel to enter his chest.

Staff requested a transfer to RMCH for an operation to repair Kayden’s diaphragm, but no intensive care bed was available.

The following day, he was transferred, but to an ordinary ward.

Kayden’s surgery was repeatedly delayed over the following week, as he deteriorated.

On Thursday, 14 April, the BBC was told, a locum consultant requested that a planned elective surgery list be cancelled to allow him to carry out the operation, but management instructed an operational manager “not to get involved”.

The trust told the BBC that it had no record of this request.

Brain injury

Late on Friday night, Kayden went into cardiac arrest.

Nurses struggled to get help, because an emergency phone line was down, and it took nearly 30 minutes to resuscitate the child.

He suffered severe brain injury and died two days later.

The trust’s own investigation found “significant problems with the organisation and delivery of [Kayden’s] care, which was not timely and resulted in his death”.

Senior surgeons at the hospital told the BBC that they had repeatedly tried to warn trust management about problems, including a shortage of emergency operating theatres and intensive care beds at the hospital.

But the trust told the BBC: “We believe that there are sufficient theatres in our children’s hospital to cope with the demand for emergency cases; however, on occasions some children do have to wait for urgent surgery while emergency surgery takes place.”

Mr Khalil said: “On Thursday, one of the surgeons had offered to cancel one of his elective lists, so that he could do Kayden as an emergency, but did not receive the support that he needed.

“That should not have happened.

“There should have been support to say if we have children on the emergency list, they need to be done, and they should take priority over elective lists.”

Mr Khalil added that the size of the hospital’s waiting lists had become dangerous.

Long waits

The BBC has seen internal figures to show that on 18 January this year, the number of children waiting for a procedure had reached 6,185, with 1,102 children having waited for over a year.

Mr Khalil said: “The waiting list in the children’s hospital has basically ballooned over the last few years.

“We now have hundreds of children who have waited over a year to have their surgery done.

“They were giving elective cases priority, but it almost became like a culture, that it is difficult to cancel elective cases to do emergency cases.”

A second surgeon, James Morecroft, who retired from RMCH this year, told the BBC: “There was a desire in the hospital to do the elective workload, perhaps at the expense of some of the emergency stuff.”

The trust said: “The trust would like to make it clear that at no time has it directed clinical staff to prioritise elective over non-elective care.

“As is the case at most similar hospitals, elective cases are regularly cancelled to  accommodate emergency patients.”

However the trust’s own investigation into Kayden’s death recommended the hospital carry out an urgent review into “prioritising non-electives above elective cases”.

It added: “Following the investigation, a number of immediate and longer term actions were agreed.”

Lawyer Stephen Clarkson, from Slater and Gordon, who represented the family, said: “The real tragedy here is that Kayden’s death was entirely preventable.

“If he had been operated on earlier, then he would have survived.

“It is deeply concerning that this happened at one of the country’s leading hospitals for children, and that is why it is so important that the trust looks closely at what went wrong and what can be done to make sure this doesn’t happen to anyone else’s child.”

• No doctors sacked for exposing care scandals have been given jobs back
• Jeremy Hunt accused of failing to act on landmark whistleblowing report
• Hospital staff have said punishments for speaking out are ‘Kafkaesque’
• Tory MP pointed to ‘evidence that whistleblowers are not being protected’

By Daniel Martin and Vanessa Allen and Richard Marsden for the Daily Mail

PUBLISHED: 11 February 2016

No doctors sacked for exposing care scandals have been given their jobs back at the same level, it emerged yesterday.

Senior medical figures accused Health Secretary Jeremy Hunt of failing to act on a landmark report into NHS whistleblowing.

In a dramatic intervention, 14 medics and campaigners wrote to a national newspaper saying there had been ‘no meaningful change’ a year on.

‘To our knowledge, not a single sacked whistleblower has been found comparable reemployment,’ they claimed.

Referring to the hounding of doctors and nurses by hospital managers, they added: ‘Not a single trust director has been reprimanded under the fit and proper persons regulation.’

Senior medical figures accused Health Secretary Jeremy Hunt of failing to act on a landmark report into NHS whistleblowing

Hospital staff say the punishments for speaking out are Kafkaesque – and make them feel as if they are living behind the Iron Curtain.

Andrew Percy, a Tory member of the Commons health committee, called for a parliamentary inquiry. ‘There is a lot of evidence that whistleblowers are not being protected, that many staff in the NHS are being intimidated or are fearful of coming forward,’ he said.

‘This is totally unacceptable and is evidence of why our committee needs to look at this again. The Department of Health needs to be cognisant of the concerns on this.’

Sir Robert Francis compiled last year’s report warning of a culture of ‘fear, bullying and ostracisation’ within the NHS that punished doctors and nurses who dared speak out.

DR MINH ALEXANDER

WORKED: Consultant psychiatrist with Cambridge and Peterborough NHS Foundation Trust, a mental health service provider, from 2007 to 2013.

BLEW WHISTLE ON: How instances of patient harm, including suicides and deaths in custody, homicides, rape and arson were sometimes not reported through the appropriate channels.

CONSEQUENCE: Took redundancy by ‘mutual agreement’. Told British Medical Association she thought it was going to be the end of her career.

EFFECT ON NHS CAREER: Has not applied for more NHS work over fears she has effectively been blacklisted.

SHE SAYS: ‘The suppression of staff… will not go away until decision-makers truly accept it is better to run a service in which staff and patients have a voice. Otherwise, the unhealthy culture, financial and human cost will continue… My decision to report concerns… did not make me popular.’

EDWIN JESUADOSON 

WORKED: Alder Hey Children’s Hospital.

BLEW WHISTLE ON: ‘Unnecessary’ fatalities among children who had had surgery. 

What he felt was a bullying culture in theatres with staff afraid to raise concerns, and lessons from errors not being learned.

CONSEQUENCE: Faced opposition from senior colleagues and, he believes, the trust itself. 

Left the hospital. Marriage broke down due to the stress.

EFFECT ON NHS CAREER: Has applied for NHS jobs and not been shortlisted. 

Fears he has been blacklisted as a troublemaking whistleblower. 

Now working in academic research in Melbourne, Australia.

HE SAYS: ‘It took a great deal for me to become a whistleblower. 

It was not a step I took lightly. The whole experience has been utterly administrating.’

It told how whistleblowers were too often derided as ‘snitches, troublemakers and backstabbers’.

Sir Robert, a barrister who chaired two major inquiries into the Mid Staffordshire hospital scandal, said many were unable to find work because of an ‘effective blacklist’.

The Government promised to enforce all his 20 recommendations, which were aimed at changing NHS culture to protect whistleblowers from reprisals. One measure was to ensure all trusts appointed a guardian to deal with concerns from health workers. But in the letter to The Times yesterday the guardians were described as toothless – often simply establishment candidates appointed by trust bosses.

And the signatories pointed out that the national guardian, Dame Eileen Sills, has a restricted remit with no real powers in law. Appointed in January, she is also part-time, covering just two days a week.

The letter was organised by Professor Sir Brian Jarman, the former BMA president who did pioneering work on hospital mortality rates.

It was signed by seven NHS whistleblowers, including Dr Stephen Bolsin, who highlighted death rates at Bristol Royal Infirmary and Dr Kim Holt, who lifted the lid on safety concerns at Great Ormond Street.

The signatories demanded the establishment of an independent body with ‘powers to investigate and remedy poor whistleblowing governance by public bodies’.

DR RAJ MATTU

WORKED: Heart surgeon at Walsgrave Hospital in Coventry.

BLEW WHISTLE ON: In 2001, exposed the fact two patients had died in dangerously overcrowded bays where staff had difficulty reaching life-saving equipment.

CONSEQUENCE: A year later, suspended on full pay for seven years after being accused of bullying. Dismissed in 2010.

EFFECT ON NHS CAREER: Claims he was unable to return to old job and experienced increasing hostility from trust managers. Health deteriorated. Sacked while in his hospital bed. Won £1.22million damages after employment tribunal.

HE SAYS: ‘The way I have been treated is nothing short of an outrage and a scandal … trust managers tried to destroy me. It was a form of torture.’

GARY WALKER 

WORKED: Chief executive at the United Lincolnshire Hospitals NHS Trust.

BLEW WHISTLE ON: Concerns targets were a higher priority than patient safety.

CONSEQUENCE: Sacked and forced to sign £500,000 gagging contract. Broke silence with Daily Mail to hold individuals to account over Mid-Staffs scandal.

EFFECT ON NHS CAREER: Applied for around 150 jobs in NHS in England. Shortlisted for only two in five years. Now working for a health regulator in Northern Ireland.

HE SAYS: ‘Nothing has changed. We have more whistleblowers than ever on the unemployment lines and not one of them has been re-instated in their job. I would never advise anyone to whistleblow, unless they can do it anonymously.’

They called for a new appeal mechanism against ineffective local investigations by employers, full reform of whistleblower protection legislation and reform of NHS disciplinary processes.

Health minister Ben Gummer insisted good progress was being made on making the NHS safe for whistleblowers, and that all hospitals had been told to take action to support those who spoke out.

But yesterday one of the signatories, Professor Narinder Kapur, who was sacked after he raised safety concerns at Addenbrooke’s Hospital in Cambridge, told the Mail he had struggled to find work afterward and felt he was blacklisted.

The neuropsychologist is now working three days a week as a locum in Leeds, hundreds of miles from his family home in Harrow, north-west London. He said: ‘It’s the only job I could get.

‘The only way that NHS trusts will take back whistleblowers is if their willingness to do so is part of their appraisal by the health regulator.

‘Whistleblowers lose their jobs and their incomes, their physical and mental wellbeing suffers and their family life is ruined.

DR KEVIN BEATT

WORKED: Cardiologist at Croydon University Hospital.

BLEW WHISTLE ON: Told an inquest in 2013 he was forced to carry out part of a heart operation without nursing assistance, which contributed to the patient’s death. 

Concerns over inadequate equipment, bullying and harassment of junior employees, removal of key staff, a lack of competent nurses and the failure to properly investigate serious incidents.

CONSEQUENCE: Suspended shortly after the inquest and then dismissed.

EFFECT ON NHS CAREER: Won unfair dismissal case but finds it impossible to get an NHS job.

HE SAYS: ‘I’ve applied… but never got shortlisted. 

‘It’s akin to being in an Eastern Bloc country in the Cold War years.’

DR STEPHEN BOSLIN 

WORKED: Anaesthetist at Bristol Royal Infirmary.

BLEW WHISTLE ON: Reported concerns about infant deaths at the hospital in 1990. Bosses were dismissive and Dr Bolsin began to count the number of children dying, which showed the death rate was twice the national average. The next year, heart operations at the hospital were stopped. The cardiac unit was dubbed the ‘killing fields’.

CONSEQUENCE: He initially continued working in the NHS but felt ostracised and was passed over for private work.

EFFECT ON NHS CAREER: Dr Bolsin and his wife moved to Melbourne, Australia, where he has practised ever since.

HE SAYS: ‘In the end I just couldn’t go on putting those children to sleep, with their parents present in the anaesthetic room, knowing that it was almost certain to be the last time they would see their sons or daughters alive.’

‘It’s like getting four life sentences for standing up and doing the right thing.’Another whistleblower, Gary Walker, who was sacked as an NHS trust chief executive after he raised concerns that hitting targets was a higher priority than patient safety, told the Mail he had applied for around 150 NHS jobs and was shortlisted only for two.

He said: ‘The NHS has such a culture of command and control that it can’t cope with anyone speaking out. It’s a terribly bullying culture and that has not changed. If anything it has got worse.

‘We have more whistleblowers than ever on the unemployment lines and not one of them has been reinstated in their job. I would never advise anyone to whistleblow, unless they can do it anonymously.’

A retired police inspector brought in to investigate allegations of misconduct against a whistleblower at one NHS trust told how he was himself sacked after raising concerns that the accusations were unfounded.

The former officer said: ‘I was expected to be the assassin. I had had a distinguished career and had retired from the police with unblemished character. ‘The trust’s own policy said that such investigations had to be completed fairly but I would say the allegations were unfounded.’

DR OTTO CHAN

WORKED: Consultant radiologist at Barts and the London.

BLEW WHISTLE ON: X-ray files and scans belonging to thousands of patients were dumped unchecked in boxes.

CONSEQUENCE: Dismissed in 2006 after trust management carried out a ‘clipboard exercise’ to quiz his colleagues for any other instance of possible misconduct. Branded a ‘troublemaker’.

EFFECT ON NHS CAREER: Was offered work at another hospital – until his old trust got in touch with its executives. Now back in the NHS, working part-time at the Royal Free and Whittington hospitals in London.

HE SAYS: ‘It’s almost impossible to get future employment in the NHS if you’re dismissed. Chief executives of different trusts stick together.’

PROFESSOR NARINDER KAPUR 

WORKED: Neuropsychologist at Addenbrooke’s Hospital in Cambridge.

BLEW WHISTLE ON: The use of under-qualified staff in clinics, which he warned was putting patients at risk.

CONSEQUENCE: Sacked in 2010. A tribunal ruled he was unfairly dismissed but he was not reinstated.

EFFECT ON NHS CAREER: Professor Kapur said he was effectively blacklisted as a ‘trouble-maker’. He is now working three days a week as a locum in Leeds, hundreds of miles from his family in North London.

HE SAYS: ‘Whistleblowers lose their jobs and their incomes, their physical and mental wellbeing suffers and their family life is ruined. 

It’s like getting four life sentences for standing up and doing the right thing.’

He said that when he reported concerns about the investigation into the whistleblower, he was initially ignored then ‘I became the whistleblower, I became the problem’. Following his dismissal he received an out of court settlement after launching his own unfair dismissal proceedings.

Only last week, Dr Raj Mattu was granted £1.2million in damages after a tribunal found he had been wrongly dismissed for exposing the deaths of two patients in dangerously overcrowded bays at his hospital.

He was hounded for over a decade in a ‘witch-hunt’ costing the taxpayer more than £10million. He has since been unable to get a job in the NHS.

He told the Mail: ‘This letter should be a very serious warning to the chiefs of the healthcare system in England, that despite many soundbites and promises of protecting patients and then whistleblowers, there has been no palpable change since the Francis report.

‘I would strongly caution anybody who is thinking of whistleblowing from doing so.

‘I would want to protect them and their families from enduring the nightmare that I have had to live with for 15 years, and their lives and careers being ruined.’

And Dr Minh Alexander, forced out after she exposed suicides at a mental health trust in Cambridgeshire, said: ‘The suppression of staff who speak up is a very old problem and will not go away until decision makers truly accept that it is better to run a service in which staff and patients have a voice.’

DR KIM HOLT

WORKED: Consultant paediatrician at St Ann’s Clinic in Tottenham, North London.

BLEW WHISTLE ON: Was one of four doctors who warned that understaffing and poor record-keeping posed a serious risk to patient safety in 2006.

CONSEQUENCE: The warning was ignored and Dr Holt faced bullying then suffered depression and went on leave.

EFFECT ON NHS CAREER: Dr Holt says she was offered £120,000 to sign a confidentiality contract but refused. She was eventually allowed back to work after her clinic was transferred to a different NHS trust. She received a formal apology from her former trust.

SHE SAYS: ‘The whole culture towards whistleblowers is pretty toxic. It’s a miracle that I’m back in my job.’

LADY MAHA YASSALE (NO PICTURE) 

WORKED: Chief pharmacist for Berkshire Primary Care Trust.

BLEW WHISTLE ON: Patient safety concerns about prescriptions, made in protected evidence which cannot be disclosed.

CONSEQUENCE: Suspended and dismissed after numerous allegations were made unrelated to Lady Yassaie’s work. Launched employment tribunal proceedings but received an out-of-court settlement before the case was heard.

EFFECT ON NHS CAREER: Lady Yassaie lost another NHS job in 2014 after, she believes, management found out about her earlier case.

SHE SAYS: ‘There is nothing to protect whistleblowers at all. 

None of my concerns have ever been looked into properly.’

Justin Madders, Labour’s health spokesman, said: ‘Jeremy Hunt cannot dismiss these concerns any longer and needs to start taking whistleblowers’ rights seriously. Unfortunately, reports of bullying and harassment in the NHS are still too commonplace.’

A spokesman for the Department of Health said some cases against managers under the Francis rules were ongoing with none declared unfit yet.

She said no figures were kept on the jobs of whistleblowers.

A consultant dentist who said he had become the victim of a witch hunt at a Shropshire hospital has won legal claims against his former employers.

Read more at http://www.shropshirestar.com/news/2017/02/26/whistleblower-dentist-wins-legal-claim-against-shropshire-nhs-trust-after-witch-hunt/#RsqPwtuLK2TC3puO.99

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.

 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.

David Drew August 2016

* UK law designed to protect whistleblowers from retaliation in the workplace is inadequate.

* PIDA does not meet most international standards

* New report recommends wide ranging legal changes in the public interest.

* Francis Freedom to Speak Up protections look weak in comparison

According to a new report published by international NGO Blueprint for Free Speech and the Thomson Reuters Foundation the UK law designed to protect whistleblowers from retaliation in the workplace is inadequate and does not meet most international standards.

The report, PROTECTING WHISTLEBLOWERS IN THE UK: A New Blueprint, follows a 3 year study of the experiences of UK whistleblowers. Although applicable to all whistleblowers it singles out health (the scandal-ridden NHS) and social care whistleblowers as a special case:

In no other industry in the UK is the case for stronger whistleblower protections clearer than the healthcare field.

Lessons learnt from NHS whistleblower protection failings should be applied to all sectors.

Blueprint outlines key failings and suggests robust solutions to ensure that whistleblowers in the UK are protected and disclosures made in the public interest are supported.

What’s wrong with PIDA?

PIDA is retrospective. It offers compensation after the fact. Too little (if at all) and too late.

Employment Tribunals are not the informal low cost solutions they were set up to be when it comes to whistleblower cases. Expensive taxpayer funded lawyers rule the roost.

There is no administrative (regulatory) alternative to the ET system where whistleblowers can seek protection before retaliation begins.

Technical legal principles have been imported into PIDA from other areas of law. These diminish protection and the capacity for remedy.

PIDA has no direct civil or criminal penalties to prevent or discourage bullying harassment or victimisation.

PIDA now rates poorly against international standards. Of 27 recognised standards 13 are completely missing from UK law. In a scoring system PIDA achieved a mark of only 38%, well below many other countries. This is particularly concerning when PIDA is held up by Sir Robert Francis, in his Freedom to Speak Up report for example, as a recognised best practice standard.

Proposals for protection

The Blueprint report advocates urgent legislative change. The areas that need particular attention are:

Pre-emptive protection from all forms of retaliation – before jobs are lost or careers ruined.

Modern burdens of proof that provide fair odds for whistleblowers to defend their rights

Substantial penalties for those who retaliate against whistleblowers, and for those who ignore orders to cease retaliation.

Full compensation to cover all costs and loss to whistleblowers

Mandatory independent investigations of bona fide reports of misconduct and corrective action.

A requirement for employers to make a range of disclosure channels available to workers, including anonymous reporting

Training for managers in the public and private sectors.

An obligation on prescribed bodies to investigate allegations and provide a response with reasons for any action or inaction. (Regulators such as CQC and NHS Improvement continue to claim that they have neither the power nor the duty to investigate disclosures even of avoidable patient deaths.)

Winners into losers

Blueprint conducted in-depth reviews of 50 cases filed with Employment Tribunals and conducted 12 detailed formal interviews with whistleblowers. Vignettes of Sarah, Anne Brigitte Claudia and others attest the length of time in each case to get a verdict (average 20 months). And the paltry sums awarded in compensation. They only hint at the personal suffering, the stress and anxiety, the damage to health and family. These women (they often are women) fought long and hard. And not just that, the fight was fundamentally unfair. These are mainly low paid workers who saw something wrong and reported it. They won at a price most are not willing to pay. When we get effective whistleblower legislation it will be in part their struggle that has secured it.

The Freedom to Speak Up Report

It is 18 months since Sir Robert Francis’s F2SU report was published. He acknowledged the widespread horrific victimisation of NHS whistleblowers “because they tried to do the right thing for patients”.

Francis had the same material (and more) at his disposal as Blueprint. He came to pretty much the same conclusions on legal protection:

PIDA legislation is limited in its effectiveness. At best it provides remedies after detriment, including loss of employment. Even these are hard to achieve. Too often by the time a remedy is obtained it is too late to be meaningful.

However, he ducked the robust solutions we find in Blueprint. Before the start of his review Francis told a group of us who had been instrumental in his commissioning that he would not be making any recommendations that Jeremy Hunt was going to reject:

Although the existing legislation is weak, I have not recommended a wholesale review of the 1996 Act for two reasons. First, I do not think legislative change can be implemented quickly enough to make a difference to those working in the NHS today. What is needed is a change in the culture and mind-set of the NHS so that concerns are welcomed and handled correctly.

Francis offered no real solutions to whistleblower victimisation. No change in law other than a couple of twiddles. No prevention or deterrence of retaliation. No level playing field. A National Guardian with no statutory or investigatory powers. Compare that to Blueprint’s robust proposal for an independent agency to ensure early intervention and protection. Francis’s answer to the need for managerial accountability was the now discredited Fit and Proper Person Test which has not held a single victimising manager to account.

Only if the good intentions of any law are matched by a change in culture can a safe alternative to silence be created, he opined. But, as Jeremy Hunt told Parliament, that kind of culture change will take a generation. No, says Blueprint, introduce robust laws to protect whistleblowers now. Most public health advances requiring change in individual behaviour

and culture has necessitated legislation. As with smoke-free legislation etc. culture change would follow on its heels.

By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, 13 August 2016

After the abject failures by CQC, DH and other oversight bodies were revealed by the Mazars [1] report on failure to investigate hundreds of unexpected patient deaths by Southern Health, Jeremy Hunt predictably asked CQC to review the way the NHS handles deaths. [2]

What better way of keeping it in the family, whilst fobbing off the public with some superficially reassuring headlines.

Never mind that CQC has long been implicated as an essential part of what Professor Brian Jarman called the NHS Denial Machine. [3]

CQC itself is only reviewing what trusts do. Purportedly, there is other work by the DH that “may” result in changes to regulatory process. There is passing reference to this in CQC’s review blurb, but I am not aware that any details of this work have been published. [4]

After I posted criticism of CQC and the limited remit of the deaths review in the twitter hashtag #CQCDeathsReview, I was approached via twitter by a CQC official who assured me that the enforcement of good practice would be reviewed as well. This person invited my contribution and offered me a meeting with the deaths review team. When I asked for more information, a telephone call was offered. When I asked for written information and the actual terms of reference of any review of regulatory performance, the communication petered out. This is unfortunate as the deadline for submission of evidence is this Sunday, 14 August.

No doubt it was a well-meaning approach, by someone who had not yet discovered that the CQC has developed a habit of writing frosty letters to me via its Director of Legal Services.

However, there is a startling contrast between the frenetic publication of CQC’s review of trusts’ performance in handling deaths, compared to the opacity and silence over the purported (and more important) review of oversight processes. The message is one of double standards: “No stakeholder scrutiny please, we’re too important”.

This unwillingness by the DH, and its arm lengths bodies such as CQC, to properly account for their failures to protect patients is typical of a longstanding pattern of behaviour. Major reports by which criticised the DH’s role in creating a culture of fear and compliance, instead of a genuine focus on quality and patient safety, were suppressed by the DH in 2008 and only released in 2010 by FOI. [5] [6] [7]

It is most unlikely that the whole truth will be allowed to emerge about the NHS’ continued mishandling and subterfuges about patient deaths.

A review of CQC inspection reports on English mental health trusts raises serious questions of systematic evasiveness by CQC about patient deaths. [8]

Only one of the new look CQC inspection reports published so far on mental health trusts gave the numbers of deaths of patients under the Mental Health Act. The rest of the reports carefully side-stepped this critical data, even in instances where CQC admitted that some trusts were noted to be at elevated risk of deaths and or suicides under the Mental Health Act. At Mersey Care, a CQC report of October 2015 claimed that although the trust had an elevated risk in terms of the number of suicides under the Mental Health Act, the figures were not given because the numbers of deaths were low and could lead to identification. [9] Yet there are plenty of occasions when CQC reports have referred to very small numbers of other types of incidents, for example: a serious injury sustained by a detained Southern Health patient after climbing onto a roof that was too easily accessed. Perhaps the real issue is government reluctance to reveal the scale of Article 2 Right to Life legal claims to which it is potentially exposed, with liability being most obvious in the deaths of patients detained by the State.

The Mazars report did not spare CQC’s blushes on Mental Health Act deaths. Mazars’ investigation found that Southern Health reported 27 deaths of patients under the Mental Health Act to CQC. However, CQC managed to mislay 9 of these, and told Mazars that there had only been 18 deaths of Southern Health patients under the Mental Health Act.

There is generally arbitrary variation of the way in which deaths data was presented from one CQC report to another. The time periods sampled varied for no given reason. CQC showed displayed Goldfish grade organisational memory in that the time periods sampled were short (mostly around a year or so, distributed variably in time prior to the inspection visits), and there was very little evidence of benchmarking against past deaths. Consequently, there was almost no longitudinal perspective on the degree to which organisations were repeating the same failings. CQC sometimes gave a breakdown of the types of deaths, but sometimes not. Suicide is sometimes not mentioned at all, which is rather surreal when a regulator is reporting on mental health service safety.

The July 2015 CQC inspection report on Kent and Medway, from an inspection chaired by no less than Paul Lelliot CQC’s Deputy Chief Inspector and CQC lead for mental health, did not mention deaths at all. [10] This is rather extraordinary as Kent and Medway have received at least 13 coroner’s warning Reports to Prevent Future Deaths, including 4 reports in 2014.

Similarly, the numbers of deaths were not reported at all by the CQC inspection report on Nottinghamshire Healthcare, of July 2014. [11] Instead, there was only a

brief claim that the number of Nottinghamshire Healthcare’s deaths was in the expected range. Paul Lelliot also chaired this inspection.

At the very troubled and “Inadequate” Norfolk and Suffolk, which has seen very harsh staffing cuts in recent years, CQC’s latest inspection report of February 2015 [12] also contrived not to give the numbers of any deaths whatsoever, despite the fact that the local media has been filled with frequent reports of campaigners’ concerns about increased numbers of deaths and trust inquests. In this context, a question arises of whether is this failure by CQC to report the number of Norfolk and Suffolk deaths was a politicised decision.

There were other CQC reports that did not give the numbers of deaths, and some that gave conflicting numbers of deaths, with no attempt by CQC to reconcile the conflicts.

Importantly, CQC only described reported deaths. There was no evidence that CQC checked on whether reporting was accurate and reliable. In some trusts, CQC stated that no deaths had been reported at all, but gave no indication that inspectors had dug deeper to verify the number of deaths. I have told CQC many times that not all deaths and serious incidents are reported. Mazars also gave ample evidence of that not all deaths are reported: there were a total of 10,306 deaths at Southern Health between 2011 to 2015, but only 195 were reported as serious incidents requiring investigation (SIRIs). Some of the trusts with zero reported deaths were rated “Good” by CQC. CQC did not describe any attempts to cross check directly with coroners. There is evidence that CQC relied on some trusts to tell them how many coroners’ warning reports had been received: “The trust told us about four subsequent coroners’ rulings (regulation 28 rulings)”. In this particular instance, this information was incorrect and there had been two additional coroners’ warning reports.

Bizarrely, the November 2015 CQC inspection report on Lancashire Care NHS Foundation restricted itself to looking at Coroners’ warning reports from only 6 months in 2013:

“Every six months, the Ministry of Justice publishes a summary of recommendations that had been made by coroners with the intention of learning lessons from the cause of death to help prevent deaths. There were no concerns raised regarding the trust in the most recent report (April 2013 – September 2013).” [13]

In fact, Lancashire Care had 5 coroners’ warning Reports to Prevent Future Deaths from December 2013 up to the time of CQC’s report. A very serious question arises about why CQC chose to ignore this evidence and to exclude it from its inspection report.

CQC performed the same worrying manoeuvre in its February 2015 inspection report of the extremely troubled Norfolk and Suffolk. The CQC report claimed that

“In the latest report covering the period from October 2012 to March 2013 there were no concerns regarding the trust raised by the coroner.”

Firstly, this was wrong as there was a coroner’s warning report issued on

28 March 2013 on the death of a patient detained under the Mental Health Act. Moreover, there were another 6 coroners’ warning reports after that, up to the time of CQC’s inspection report. In total, Norfolk and Suffolk have had at least 22 coroner’s warning reports, which is one of the highest if not the highest numbers of coroners’ warning reports nationally.

The same dodgy dance steps were followed at Avon and Wiltshire Partnership, when the CQC July 2015 inspection reported claimed:

“In the latest report covering the period from October 2012 to March 2013 one concern regarding the trust was raised relating to the death of a patient at Fromeside” [14]

In fact, from September 2013 to the time of CQC’s inspection report, there were at least 8 further coroners’ warning reports. Avon and Wiltshire Partnership has had at least 17 coroners’ warning reports in total, and some have described the most serious failures of care. These the highly publicised case of a 2014 suicide-infanticide in which the trust was criticised by the coroner in October 2015 for not making adequate contingency plans for a very high risk pregnancy, in a patient with known psychotic illness. [15] [16]

At Greater Manchester West, CQC’s inspection report of June 2016 [17] mentioned only one coroner’s warning report in January 2016, when in fact between September 2013 and December 2015, there were 8 other warning reports issued.

At Devon Partnership, CQC’s inspection report of January 2016 [18] did not mention coroners’ warning reports at all, despite the fact that the trust has had at least 19 warning reports, with 4 issued between July 2014 and October 2015.

CQC’s January 2016 inspection report of SLAM [19] was equally silent on coroners’ warning reports, when there had been a total of at least 19 warning reports, with 8 issued between August 2013 and July 2015.

At troubled Sussex Partnership, CQC’s inspection report of May 2015 [20] also did not mention coroners’ warning reports at all, despite the fact that there had been a total of 11 reports up to the time of CQC’s inspection report, with 8 reports issued between August 2013 and April 2015. This inspection was chaired by Paul Lelliot.

There were other examples of CQC selective omission of coroner’s warning reports from inspection reports.

The only CQC report that gave detailed data on deaths and their handling was the post Mazars inspection report on Southern Health. The superficial Pre-Mazars

inspection report on Southern Health of February 2015 mentioned ‘death(s)’ only six times. [21] The post-Mazars inspection report of April 2016 mentioned ‘death(s)’ 94 times. [22] Ironically, CQC states in this latest report that the trust should “give a more transparent breakdown of deaths” in its annual report. It is a pity that CQC does not devote the same thoroughness to trusts where there has been less publicity about deaths, and does not follow its own advice about transparency regarding the pattern of deaths.

The overall superficiality, passivity, frank inaccuracy and lack of standardisation by CQC means that the deaths data presented by CQC reports is not robust, sometimes seriously misleading, and that it is difficult to track the performance of individual trusts or to compare trusts. Politically however, the moveable measurement goal posts keep CQC’s options open, and make it easier to stretch a rating to fit when required. Jeremy Hunt’s vision of a “single version of the truth” by an authoritative and trusted regulator is yet more tarnished tinsel.

They really should all toddle off to M&S for some items of intimate apparel.

[1] Mazars December 2015 report on Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015

https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/12/mazars-rep.pdf

[2] Written statement by Jeremy Hunt Secretary of State 17 December 2015 on Southern Health

https://www.parliament.uk/business/publications/written-questions-answers-statements/written-statement/Commons/2015-12-17/HCWS421/

[3] 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

[4] CQC scoping paper for deaths review

http://www.cqc.org.uk/sites/default/files/20160624%20Investigating_deaths_across_mental_health_acute_and_community_setting_Scoping_Paper.pdf

[5] When managers rule, patients may suffer and they’re the ones that matter. Prof Brian Jarman BMJ Editorial 19 December 2012 BMJ 2012;345:e8239

http://www.ajustnhs.com/wp-content/uploads/2012/06/Brian-Jarman-BMJ-Dec-2012.pdf

[6] Institute of Health Improvement 2008 report, Achieving the Vision of Excellence in Quality: Recommendations for the English NHS System of Quality Improvement

https://www.dropbox.com/home?preview=IHI+report+achieving+the+vision+of+excellence+in+quality+(2).pdf

[7] Joint Commission International 2008 report, Quality Oversight in England – Findings, Observations and Recommendations for a New Model

https://www.dropbox.com/s/dpnhg605fhrsq52/JCI%20report%20Quality%20oversight%20in%20England.pdf?dl=0

[8] The main data collated on data about deaths in CQC mental health trust inspection reports can be found uploaded here:

https://www.dropbox.com/home?preview=CQC+data+on+deaths+in+inspection+reports+.xlsx

[9] http://www.cqc.org.uk/sites/default/files/new_reports/AAAD5292.pdf

[10] https://www.cqc.org.uk/sites/default/files/new_reports/AAAC9675.pdf

[11] http://www.cqc.org.uk/sites/default/files/new_reports/AAAA1862.pdf

[12] http://www.cqc.org.uk/sites/default/files/new_reports/AAAA3470.pdf

[13] http://www.cqc.org.uk/sites/default/files/new_reports/AAAD1977.pdf

[14] http://www.cqc.org.uk/sites/default/files/new_reports/AAAC0116.pdf

[15] Bristol mother Charlotte Bevan and missing baby CCTV issued. BBC 3 December 2014

http://www.bbc.co.uk/news/uk-england-bristol-30316699

[16] Coroner’s Report to Prevent Future Death in the case of Charlotte Bevan, 27 October 2015

https://www.judiciary.gov.uk/publications/charlotte-bevan/

[17] http://www.cqc.org.uk/sites/default/files/new_reports/AAAF1696.pdf

[18] http://www.cqc.org.uk/sites/default/files/new_reports/AAAD7774.pdf

[19] http://www.cqc.org.uk/sites/default/files/new_reports/AAAE6494.pdf

[20] https://www.cqc.org.uk/sites/default/files/new_reports/AAAC1746.pdf

[21] http://www.cqc.org.uk/sites/default/files/new_reports/AAAB9266.pdf

[22] http://www.cqc.org.uk/sites/default/files/new_reports/AAAF4191.pdf

Mail on line  31 JUL 2016
BY MARTYN HALLE

North Middlesex Hospital, which has almost 300 unexplained deaths, was subject to a damning Care Quality Commission report triggered by a story in the Sunday People

The People has fresh questions for North Middlesex Hospital

The boss of a failing NHS trust with almost 300 unexplained deaths has claimed she knew nothing of a series of emails warning about the safety of patients.

Libby McManus, the ­interim chief executive of North Middlesex Hospital, insisted she was unaware of the existence of the messages.

The emails were sent to Ms McManus’ predecessor Julie Lowe – who ignored them – the Care Quality Commission and Health Secretary Jeremy Hunt.

Ms McManus, who took over the top job three weeks ago, denied knowing anything about them when the Edmonton-based trust met this week. She also refused to say why the hospital failed to act on a damning CQC report .

The CQC probe was ­triggered by a Sunday People story which told how A&E was so packed one night that a tannoy announcement told patients to go home and come back in the morning “unless you are dying”.

Miss McManus refused to confirm whether Ms Lowe had formally left the trust or the whereabouts of Nursing Director Paul Reeves who also saw the warning emails.

The hospital is at the centre of a storm
The hospital’s official line on Ms Lowe is that she is on leave. But the trust’s £201,000 medical director, Dr Stanley Okolu, has departed, following the A&E scandal in February.

But she did agree to investigate and meet a People journalist to discuss the situation.

Experts have likened the situation at the North London hospital to the Mid Staffs scandal where as many as 1,200 patients died over five year period.

When the CQC visited in May it found A&E being run by junior doctors and nurses and discovered a patient had died on a trolley after not being checked for four hours.

It also found evidence of Stafford type abuse and neglect on the wards including care of the elderly wards singled out in 2014 by the CQC and again in warning emails sent to the trust 18 months ago.

The People intends to provide evidence of the warning emails sent to Ms Lowe at the meeting with Ms McManus.

We will also raise the case of tragic toddler Toddler Armagan Denli died of meningitis at the hospital in April 2015.

A family is planning legal action against the hospital
His family – who plan legal action – say they have battled to get the truth about his care for more than a year.

We can now reveal that when the youngster was taken to hospital by ambulance he waited for two hours before seeing a doctor

His heavily pregnant mother was forced to sit with her sick son on her lap for two hours in a cubicle without a trolley bed.

We can also reveal that the doctor who came to see the three year-old was a local GP working in paediatric A&E.

The GP diagnosed chickenpox and Armagan was sent home even though his mother claims he already had the tell-tale purple blotches of meningitis on his body.

Fatma, 26, said: “We have papers showing that GP claims she spoke to a paediatrician about my son, but that paediatrician has denied having such a conversation.”

We can also reveal that when Armagan was rushed back to hospital, critically ill, three hours after being sent home, staff were unable to find a paediatric mask to deliver oxygen; a machine that was meant to be monitoring his vital signs had not been switched on. He died three hours later.

Ms McManus said: “We will look at any evidence you have about Armagan.”

Further read:

Scandal hit hospital faces fresh probe into 300 deaths

Hospital boss secretly quits as patient lay dead in A&E for 4 hours

 CQC report on North Middlesex

Mail on Line  25 July 2016  VICTORIA FINAN FOR MAILONLINE

• Rachel Sansbury is accused of trying to get whistleblowers to keep quiet
• The NHS chief asked staff not to ‘open that can of worms’, NMC heard
• Sansbury allegedly feared her department was going to lose gold standard 

Lancaster Guardian    Nick Lakin   22 July 2016

Russell Dunkeld

A nurse turned whistleblower at the Royal Lancaster Infirmary has called the health trust’s campaign to encourage staff to speak up a “sham”.

Russell Dunkeld, who resigned in 2009 after his concerns that a colleague was hastening the deaths of patients were not investigated, said the trust is “continuing to sanction whistleblowers”.

A Freedom of Information (FOI) request has also revealed that the health trust has spent £92,519 on lawyers in cases where staff have raised public interest concerns.
Mr Dunkeld said that University Hospitals of Morecambe Bay NHS Trust (UHMBT) chief executive Jackie Daniel offered him a job last year talking to staff about whistleblowing as part of the trust’s Freedom to SpeakUp Campaign, launched in July 2015.

But after discovering new information about previous concerns in relation to patient safety and revealing this to the trust, he said his appointment was frozen and he has 
had no proper correspondence since.

Another NHS whistleblower, Dr Minh Alexander, said legal expenditure by NHS bodies in whistleblowing cases was “usually a sign of governance failure”. She said that there may have been “less learning by Morecambe Bay than has been claimed”, since Dr Bill Kirkup’s investigation into baby deaths at Furness General Hospital last year.

Mr Dunkeld said the responses to his inquiries have been evasive and unsatisfactory.

He said: “I pointed out that it would be difficult to convince an onlooker that the action to shelve my post had not been taken as a result of my raising patient safety concerns, and that this would be seen as uniquely ironic in view of the fact that the post was to be part of the Freedom to SpeakUp Campaign!”
Mr Dunkeld said that he has not received a response from the chief executive since March, even when he asked for clarification on whether he was still to be appointed.

He added: “I think it now perfectly obvious that the Morecambe version of Freedom to SpeakUp is a sham, an attempt by the Trust to appear to have conformed to 
new directives whilst continuing to sanction whistleblowers.”

The trust said that different members of staff had tried to contact Mr Dunkeld over the past three months.

Dr Minh Alexander, an NHS whistleblower who was forced out after she exposed suicides at a mental health trust in Cambridgeshire, and who obtained figures on UHMBT’s legal spending, said: “Legal expenditure by NHS bodies in whistleblowing cases is usually a sign of governance failure, in which employers turn staff safety concerns into employment disputes to distract and wear whistleblowers down.
“It’s of great concern that there may have been less learning by Morecambe Bay than has been claimed.

“I hope the governors and regulators look very closely at how the trust is treating its whistleblowers, and ensure that staff and patients are protected.”

The trust spent £264,988 on services from specialist law firm Capsticks LLP in 2015/16, compared to £100,290 in 2014/15 and £1,321.92 in 2013/14.

£159,686 of the 2015/16 was on employment law, and 40 per cent of this was spent in relation to two members of staff who had raised public interest disclosures.

Capsticks LLP have handled a total of four cases in relation to trust compromise agreements for UHMBT.
David Wilkinson, director of workforce and organisational development at UHMBT said staff should not feel anxious about raising concerns, and it is the Freedom to Speak Up Guardian’s role to ensure staff concerns are listened to and dealt with.

He said: “Mr Dunkeld has been in contact with the Trust regarding his experience at UHMBT and the impact this has had, and continues to have, on him.

“His insight into the process would prove useful in ensuring the Trust improves as an organisation as learning through the experience of our employees is the best way of us achieving this.

“Different people within the Trust have tried to engage with Mr Dunkeld over the past three months, and it is disappointing that he has yet to take up these offers as we believe that his insight would help us in developing our approach to Freedom to Speak Up further.

“As with any new scheme, the Freedom to Speak Up Campaign will take time to become fully established and embedded.

“We are also conscious that as this is a new role for the wider NHS, it is a role that continues to develop as it progresses.

“Since the Guardian’s appointment in August 2015, the focus has been on encouraging staff to speak up regarding issues which concern them.

“We are now looking at how we can develop the role here at UHMBT, and continue to be keen to engage with Mr Dunkeld to gain his input and views on how best to embed the Freedom to Speak Up campaign into everything we do at the Trust.

“We actively encourage our staff to raise any matters that concern them, without the fear of any reprimand.

“Our teams across the Trust have worked hard to develop a culture which encourages everyone to raise any concerns and issues, including reporting all incidents and near misses.

“We also have a strong network of support available for staff who do wish to raise concerns, including nearly 200 Respect Champions and Personal, Fair and Diverse Champions whose role is to support and encourage staff who do have concerns.”

In relation to the specific questions surrounding a recent Freedom of Information request regarding the amount spent on legal services, Mr Wilkinson added: “On occasion over the past five years, the Trust has settled matters in dispute with staff via a compromise agreement.

“This process has incurred legal services costs, as detailed in the Freedom of Information request.

“The spend has increased in the past two years as the Trust has sought to consolidate its legal advice through one firm, and because 
of litigation taken against the Trust which necessitated 
legal advice and support 
to resolve.”

In July 215, University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) has become one of the first NHS Trusts in the country to name a Freedom to Speak Up Guardian.

Sir Robert Francis’ report into the culture of raising concerns within the NHS, which was published in February 2015, highlighted the need to have a dedicated individual to ensure staff felt confident in raising a concern.

Heather Bruce, Senior Radiographer at Furness General Hospital was successfully appointed into the role, which will be integral to shaping the Trust’s culture to be one where all staff feel able to challenge any wrongdoing and raise any issues or concerns – knowing that they will be addressed confidentially, swiftly, and in line with good practice.

Express and Star 21 July 2016

Deloitte has been appointed to investigate the management of Royal Wolverhampton Hospitals Trust following the New Cross whistleblower’s report.

Wolverhampton’s New Cross Hospital

The audit firm’s probe was recommended as part of the damning report into which the way chief executive David Loughton treated staff who made allegations about death rates and fraud was laid bare.

An NHS Improvement spokeswoman said: “We can confirm that Deloitte have signed the contract to carry out the governance review at Royal Wolverhampton Hospitals Trust.”

Dates have not yet been confirmed.

The report found Mr Loughton to be ‘dismissive’ of the allegations by Staffordshire whistleblower Sandra Haynes-Kirkbright ahead of a key visit by a health watchdog.

She alleged that she had been hired to ‘fix’ mortality rates, and that she was suspended for refusing to co-operate.

She claimed the trust had fraudulently made money by charging for treatments it had not performed.

The 52-year-old from Stafford also raised concerns that death rates were being made to look better than they were because they were wrongly registered.

Mr Loughton has said he will not resign, and that there is no truth in Mrs Haynes-Kirkbright’s allegations.

After the report was published, Dr David Drew, a whistleblower sacked from Walsall Manor Hospital, said the Chief Executive ‘has to be finished’.

Whistleblowers Professor David Ferry and Dr Raj Mattu were similarly critical of Mr Loughton.

Last month we revealed that the Trust forked out £177,000 on a botched investigation into Mrs Haynes-Kirkbright’s claims.

Figures revealed under freedom of information laws showed Verita was paid £134,879 for producing the report, with £42,688 spent on legal fees.

Mrs Haynes-Kirkbright has been suspended on full pay from her £55,000-a-year role as a coder since 2012, and still has a disciplinary hanging over her.

http://collateral.vuelio.uk.com/RemoteStorage/CSCI/Releases/8666/20160706%20North%20Middlesex%20Hospital%20Publsihed%20Report.pdf

Mirror  8 JUL 2016
BY ANDREW GREGORY

The first person given the new role created by Jeremy Hunt dramatically quit earlier this year

Dr Henrietta Hughes is the new part-time health tsar

Health chiefs have sparked fury and disbelief by appointing another part-time NHS whistleblowing tsar to do the country’s top £105,000-a-year job.

The first person given the new role created by Jeremy Hunt dramatically quit earlier this year – before she had even begun – after admitting she couldn’t do the job and her other NHS role.

But now senior officials have stunned whistleblowers by replacing her with yet another person who will only work part-time.

The key post was green lit by the Health Secretary a year ago to prevent another Mid Staffs scandal – where up to 1,400 patients died – by helping brave medics blow the whistle on poor patient care.

But the woman originally appointed to the role, Dame Eileen Sills, dramatically resigned in March – nine weeks after the Daily Mirror exposed how she was only going to do the job part-time.

Dame Eileen Sills quit earlier this year

This week health chiefs have finally appointed her replacement.

But the Daily Mirror can disclose that the new NHS whistleblowing tsar, Dr Henrietta Hughes, will only work four days a week, will not start until October, and will keep her two NHS jobs as both a GP and GP appraiser.

The move has triggered shock and anger among whistleblowers.
Pharmacist Maha Yassaie, who was sacked after blowing the whistle over patient safety concerns, said she was “very disappointed” with the “very ineffective” appointment.

She added: “Another part-time one? That means no time to do the job properly like the previous National Guardian.”

Dame Eileen Sills was also employed on a part-time basis
Mrs Yassaie, sacked as the chief pharmacist for Berkshire Primary Care Trust after making allegations about prescribing practices at the now defunct trust, said it appeared health officials had “not learned from the previous appointment”, adding: “This is just a tick box exercise.”

Dr Kim Holt, a former consultant paediatrician in Tottenham, North London, whose warning that understaffing and poor record-keeping posed a serious risk to patient safety was ignored, said she had “major reservations” about the “part-time” appointment.

And Dr David Drew, a former clinical director of Walsall Manor hospital, who was sacked after voicing concerns about a huge cost-cutting exercise, described the part-time appointment as “a sop to the large number of NHS staff who reported victimisation after they raised concerns of poor care, patient harm, wrongdoing etc”.

He also warned that the Office of the National Guardian was pointless anyway because it had limited powers to intervene in whistleblowing cases.

He added: “This is a bulldog with no teeth with respect to the new incumbent. I have not met a whistleblower who thinks this role has any chance of protecting staff or changing culture.”

Jeremy Hunt has appointed a second part-time tsar
The creation of the National Guardian post was a key demand of Sir Robert Francis who led the Mid Staffs inquiry. He warned patients were at risk of harm because vital information about mistakes and concerns was not routinely being raised by staff.

Mr Hunt eventually confirmed last July he would act on the recommendation but then palmed off the post to health regulator the Care Quality Commission.

A Government source insisted the decision to appoint both Dame Eileen and Dr Hughes on a part-time basis had been taken by the CQC and claimed the Health Secretary could not have intervened to make it full time.

Mr Hunt described the appointment of Dr Hughes as National Guardian was “an important step in our ambition to create a more open and honest culture in the NHS”.

He added: “Dr Hughes will support staff so they can raise concerns without fear of discrimination and ensure the NHS is one of the safest healthcare systems in the world.”

Dr Hughes said: “I am very excited to be appointed as the National Guardian and recognise that supporting and protecting staff across the NHS who wish to speak up is a huge and tremendously important responsibility.”

By Dr Minh Alexander 7 July 2016

David Behan Chief Executive of the much-criticised and “ineffective” [1] Care Quality Commission was the appointing officer for the former National Guardian for whistleblowing, Dame Eileen Sills, and was embarrassed by her resignation less than two months later. [2] [3]

The Dame blustered that she wouldn’t be “dropping any balls” despite combining the National Guardian role, on a seconded two day basis, with her substantive role of Chief Nurse at Guy’s. [4] But within two weeks of this assertion she was gone, citing unmanageable workload.

CQC continued whistling in the dark and insisted in spite of the resignation fiasco that Eileen Sills’ appointment had been robust and entirely appropriate. [5]

A look at Guy’s record on whistleblowing governance suggested otherwise. The trust was unable to demonstrate that it had put in place the systematic whistleblowing monitoring arrangements set out in NHS good practice guidance introduced in 2010. [6] The trust could not produce analysed data on whistleblowing events, and stated:

“Where information has been collected it exists in different reports some of which are confidential in nature and therefore not publically available”

The trust reportedly set up a Speaking Up scheme in 2015 after publication of Robert Francis’ Freedom to Speak Up Review report, but upon enquiry trust documents did not suggest that there was a great deal of substance to this, and the trust advised in April this year that it had not yet audited the effectiveness of its Speaking Up initiative. [7]

Guy’s also disclosed via FOI that over a five year period, it had entered into 50 compromise agreements with staff, all featuring non-disparagement clauses. [8] The trust appeared to admit that it had super-gagged all 50 staff with clauses that made the existence of the compromise agreements secret, but its reply was ambiguously worded, and Guy’s has since failed to reply to a request for confirmation. Very significantly, Guy’s admitted that it had settled with whistleblowers. The trust couldn’t get it sums right, and indicated that there were either two or four. It hasn’t clarified that discrepancy either. Lastly, the trust still has to answer a question first put to it last year – has it suspended, disciplined or sacked any staff after they raised concerns? Some might conclude that Guy’s silence speaks for itself.

Nevertheless, why does Guy’s behave unaccountably, and why did Mr Behan think that the Chief Nurse of a super-gagging trust, who was the trust whistleblowing lead, was a suitable National Guardian? Did he ensure due diligence – or perhaps more likely, did he not bother because the appointment was more about PR than substance?

Whilst those questions remain unanswered, what is known is that Guy’s is a member of the Shelford Group of ten teaching hospitals. The exclusive club members modestly describe themselves thus: “ Shelford Group comprises ten leading NHS multi-specialty academic healthcare organisations. We are dedicated to excellence in clinical research, education and patient care. We aspire to demonstrate system-wide leadership for the benefit of patients and the prosperity of our country.” [9]

The Group was established to network with Important People: “The group was formed in 2011 to benchmark and share best practice in key service areas across the membership through working groups, and constructively engage with Government, Parliament and industry to represent the interests of large tertiary centres and the wider National Health Service.”

The behaviour of some of the other Shelford group members in response to questions about their use of gags certainly suggests that they are disinclined to account to the public.

Central Manchester took the approach of simply ignoring FOI requests for months. The trust Chair, in fairness, apologised when informed of this failure. Newcastle disclosed 22 super-gags and when questioned about this, insisted that super-gags had been mutually agreed – but then fell silent when asked if it was the trust who had proposed the super-gags. Kings College admitted to 29 super-gags but claimed that it was too difficult to identify whether any whistleblowers had been gagged. Sheffield which has had multiple whistleblowers, disclosed a whopping 228 compromise agreements, and claimed that only one came with a super-gag that was unrelated to whistleblowing. Imperial and Addenbrookes, also had difficulty with the maths and both under-declared their numbers of compromise agreements. Addenbrookes revised the number of its compromise agreements from 1 to 29, all with super-gags. Like King’s, Addenbrookes refused to say how many super-gags applied to whistleblowing cases. Imperial revised the number of its compromise agreements from 9 to 125, the majority of which are thought to contain super-gags, because Imperial advised that super-gags were “standard” in its agreements. Oxford, chaired by data governance Tsar Dame Fiona Caldicott, was the worst and tried a flat refusal on grounds of cost. The trust eventually admitted that it had used gags but has resisted disclosing how many were implemented. Only UCH and Birmingham were straightforward in their responses, and neither of these trusts reported super-gagging their staff.

In total, the Shelford Group have accounted for at least 572 compromise agreements, 266 super-gags and 281 non-disparagement clauses in the last five years. Without independent verification it is hard to know how close this is to the real numbers. On that matter, CQC have advised that it has no specific methodology for inspecting compromise agreements and no intention to systematically review providers’ compromise agreements.

CQC, whose Chief Inspector of Hospitals is himself a Guy’s man, has recently favourably rated three members of the Shelford group – Guy’s and Sheffield were declared ‘Good’, and Newcastle was declared ‘Outstanding’. The usual fanfares were tooted in the Health Service Journal, for example “Shelford Group Trust rated ‘Good’ across the board”. [10] But to what extent are these CQC ratings the product of Important People relating more sympathetically to other Important People who have a similar world view?

So, CQC be counted on to appoint a National Guardian who will be fair and isn’t there to be just another clubbable, Important Person looking after other Important People? Or will Mr Behan’s new choice of National Guardian announced today, Dr Henrietta Hughes the Medical Director of NHS England North Central and East London region, prove to be part of the clubbable bubble? [11]

[1] Public Accounts Committee Inquiry on CQC, 12th report of session 2015/2016 http://www.publications.parliament.uk/pa/cm201516/cmselect/cmpubacc/501/501.pdf

[2] Hunt humiliated as NHS Whistleblowing Tsar quits http://www.mirror.co.uk/news/uk-news/jeremy-hunt-humiliated-nhs-whistleblower-7513425

[2] No one believes Jeremy Hunt on patient safety and whistleblowers – not even his own appointees https://www.opendemocracy.net/ournhs/minh-alexander/no-one-believes-jeremy-hunt-on-patient-safety-and-whistleblowers-not-even-his-#.VuLP8Vb5NRs.twitter

[4] Minute of a meeting with Eileen Sills 24 Feb 2016

http://twitdoc.com/view.asp?id=254322&sid=5G8I&ext=PDF&lcl=Eileen-Sills-meeting-notes-23-02-2016-.pdf&usr=alexander_minh&doc=303188932&key=key-Ouv41peeWNZ2vhXqJMtl

[5] Letter from Rebecca Lloyd-Jones CQC Director of Legal Services 24 May 2016 https://twitter.com/alexander_minh/status/737159490399801344

[6] Speak Up for a Health NHS. Social Partnership Forum 2010 http://www.pcaw.org.uk/files/SpeakupNHS.pdf

[7] FOI disclosure from Guy’s and St. Thomas’ NHS Foundation Trust 11 April 2016 http://twitdoc.com/view.asp?id=283551&sid=62SF&ext=PDF&lcl=Response-re-audit-of-speak-up-initiative-11-04-2016-FOIA-53771-Alexander-Final-Response.pdf&usr=alexander_minh

[8] FOI disclosure from Guy’s and St. Thomas’ NHS Foundation Trust 21 March 2016 http://twitdoc.com/view.asp?id=283552&sid=62SG&ext=PDF&lcl=Compromise-FOI-response-FOIA-53147-Alexander-Final-Response.pdf&usr=alexander_minh

[9] Shelford Group website http://shelfordgroup.org/

[10] Shelford Group Trust rated ‘Good’ across the board. Health Service Journal 13 June 2016 http://www.hsj.co.uk/7005533.article

[11] Joint letter by David Behan and Sir Robert Francis to NHS trusts about appointment of new National Guardian 7 July 2016 http://www.nhsemployers.org/~/media/Employers/Publications/20160707%20Letter%20from%20Sir%20Robert%20Francis%20and%20David%20Behan%20re%20National%20Guardian%20appointment.pdf

Mail on Line  By STEPHEN ADAMS and CHARLES YATES FOR THE MAIL ON SUNDAY    18 June 2016 | UPDATED: 17:16, 21 June 2016

• Benjamin Condon died at just eight-weeks-old in April last year
• Parents originally told that he had died of a cold-like infection
• But doctors later admitted he could have been given antibiotics
• New report vindicates Mail on Sunday investigation into Ben’s death 

A hospital where senior staff plotted to delete a tape recording in which they admitted appalling errors were made over a baby’s death has been heavily criticised in a damning report.

Bosses at the Bristol Royal Children’s Hospital ‘failed to get a grip of the real issues’ after a consultant and senior manager were caught trying to wipe the recording, said investigators.

The Mail on Sunday exposed the scandal last December, after being alerted to it by the parents of tragic baby Benjamin Condon.

Tragic: Ben Condon died at just eight-weeks-old last April and hospital bosses have been accused of a string of errors in his death

His grieving parents Allyn and Jenny Condon were determined to understand what factors led to their beloved baby son’s death

 

Now, an independent report, commissioned by hospital bosses, has concluded ‘there was a failure’ by management ‘to recognise one of the most serious allegations being made by the parents – why a clinician would want a conversation deleted and why a senior manager would agree to do it’.

It found University Hospitals Bristol NHS Foundation Trust ‘failed to provide Ben’s family with clear answers to a number of questions’ and ‘appeared to lose sight of the fact that this was a grieving family’.

Consultancy firm Verita said it had ‘not seen conclusive evidence to prove or disprove the charge of a conspiracy to cover up what happened to Ben’. But it commented that ‘little the trust did was well directed at disproving’ the existence of a conspiracy.

Manager Julie Vass (left) and Dr Paul Mannix (right) met with Ben’s parents following his death to discuss what happened

Audio conversation between Ben’s parents and staff

 

NEW SON BRINGS JOY TO BEN’S TRAGIC PARENTS

Jenny and Allyn Condon with their baby son Raffi

For further information:

http://thebristolreview.co.uk/news.html