Surgeon: ‘How many more children like Kayden must die?’

By Sarah Bloch-Budzier 30 March 2017


Kayden’s grandmother: “I wanted to strangle somebody”

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”.

Kayden Bancroft was 20 months old when he died at Royal Manchester Children’s Hospital

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.”

Basem Khalil
Mr Khalil warned of “ballooning” waiting lists

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.”

Whistleblowers out in cold: Struggling to find work, isolated and shunned, the terrible price medics sacked for exposing NHS failures are STILL paying

  • 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’

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

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.


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.’


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’.


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.’


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.


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.’


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.’


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.’


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.’


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.’


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.


Whistleblower dentist wins legal claim against Shropshire NHS trust after ‘witch hunt’

Shropshire Star  February 26, 2017

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.

Mr Paul Dowsing, who specialised in treating mainly young patients, was consultant orthodontist at Telford’s Princess Royal Hospital.

He claimed detriment and constructive unfair dismissal against Shrewsbury and Telford Hospitals NHS Trust at a previous Birmingham Employment Tribunal after complaining that he was put under pressure to resign after making whistle blowing allegations against the hospital.

He alleged the hospital “covered up” failures to meet patient treatment targets within 18 weeks – at one stage involving 176 patients – and kept a “hidden” surgery waiting list of patients.

Mr Dowsing complained that the “waiting patients” could have been lost for ever considering that some dental could take up to three years.

Mr Dowsing, of Burton-on-Trent, also alleged the hospital “stopped the clock” for patients when they had been seen for assessment, rather than when their treatment had commenced. There was also an allegation that a hospital staff member incorrectly ordered £10,000 worth of stock.

The trust opposed Mr Dowsing’s legal claims and accused him of bringing patients from his Manor Practice at Burton to the hospital for out-of-hours treatment as private patients. The hospital complained this was a breach of contract and twice suspended him for a total of nearly 21 months.

An investigation was carried out. Mr Dowsing complained he became the victim of a witch hunt.

The tribunal hearing had been listed for 12 days and Judge Ron Broughton said he would make a decision at a later date.

Mr Broughton has now announced that Mr Dowsing was subjected to detriment and unfairly constructively dismissed as a result of making whistle blowing disclosures.

But he also said that Mr Dowsing’s own conduct had been “potentially both culpable and contributory”.

Mr Broughton said in his report: “He appears to have been held in high regard by many and to have had an almost impossible workload due to demand, the time-critical nature of some of the treatments, understaffing and financial constraints.”

A tribunal spokesman said an undisclosed award had since been made.


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.

It’s ruined my career’: accounts of bullying in the NHS

The Guardian 26 October 2016 

Midwives, nurses, doctors, managers and other healthcare professionals speak out about the bullying they suffered and the effect on their health and wellbeing

Long corridor in cold blue
‘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.’ Photograph: atbaei/Getty Images

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


ARI surgeons under investigation cleared by watchdog

The Press and Journal

26 September 2016 by Stephen Walsh

The 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

Boss of scandal-hit hospital with 287 unexplained deaths apologises for suffering patients endured @Jeremy_Hunt @theresa_may

 The Mirror

18 SEP 2016

Libby McManus has issued the apology after taking over from former hospital chief executive, Julie Lowe


North Middlesex Hospital, Edmonton
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 McManusLibby 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.

Main entrance to North Middlesex Hospital in EdmontonNorth 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.

The Numerophobic CQC

To: “Behan, David” , Health Committee

From: Minh Alexander
Subject: CQC’s reporting of coroners’ Reports to Prevent Future Deaths
Date: 9 September 2016 at 09:01:46 BST


 To David Behan Chief Executive Care Quality Commission, 9 September 2016

Dear Mr Behan,

 CQC’s reporting of coroners’ Reports to Prevent Future Deaths

I write to inform you of an irregularity regarding information about coroners’ Reports to Prevention Future Deaths.

 In CQC’s annual Mental Health Act monitoring report for the period 2014/2015, it is reported that:


Between December 2014 and June 2015, we received three ‘Prevention of future death reports’ concerning patients who were receiving mental health services at the time of their death; one report related to a detained patient.” (Page 27)

 I have found by searching information uploaded by the Chief Coroners’ office, that there were at least 92 Reports to Prevent Future Deaths on mental health service patients in the period 2014/2015.

 Additionally, six of the 92 reports related to detained patients.
Five of the 92 reports, which related to informal patients, appeared to have been copied to CQC by coroners. One of the five was sent to you personally. I provide links below to all five original reports.

I would be grateful to understand why CQC did not include all relevant data in its 2014/2015 report, particularly as it advised in its 2013/2014 report that:

 “Coroners Society: In 2014 we developed a memorandum of understanding with the Coroners Society. We now receive information from individual coroners’ reports about any deaths in health and care settings and how these could be prevented in future.” (Page 33)


Yours sincerely,

 Dr Minh Alexander

cc Health Committee

    Chairs of Public Accounts and Public Administration and Constitutional Affairs




    Keith Conradi Chief Investigator HSIB


Five coroners’ Reports to Prevent Future Deaths that were apparently copied to CQC by coroners in 2014/2015:



Whistleblowers being ‘blacklisted by NHS’ as staff records state they were ‘dismissed’ even after being cleared at tribunal

The Telegraph  Camilla Turner
Jennie Fecitt
Jennie Fecitt was dismissed from her post as a senior nurse at a walk-in centre in 2010, after raising concerns about a nurse who had lied about his qualifications CREDIT:JON SUPER FOR THE TELEGRAPH

When Maha Yassaie began to suspect that a colleague was taking money from drug companies to prescribe a certain product and that a GP had obtained controlled drugs to attempt suicide she naturally raised the alarm.

But after reporting these and other concerns about her colleagues the former chief pharmacist at Berkshire West Primary Care Trust was dismissed from her post.

To her dismay Lady Yassaie was told by an internal inquiry that she was “too honest” to work for the NHS.

It should therefore have been a moment of vindication when she was awarded £375,000 compensation after the Department of Health was forced to admit to her that “the investigation and disciplinary processes… were, in some respects, flawed”.

Over the following four years, however, every one of Lady Yassaie’s attempts to find a new job met with failure, despite her experience and qualifications.

It was only when she obtained her staff record from the Department of Health that she discovered that officials had effectively blacklisted her in the eyes of prospective employers, by wrongly stating that she had been dismissed from her previous job.

Lady Yassaie
Lady Yassaie was told by an internal inquiry that she was ‘too honest’ to work for the NHS CREDIT: JULIAN SIMMONDS FOR THE TELEGRAPH

It was a similar story for Jennie Fecitt, who was dismissed from her post as a senior nurse at a walk-in centre in 2010, after raising concerns about a nurse who had lied about his qualifications.

Ms Fecitt went on to win an unfair dismissal case against NHS Manchester, which found she had been bullied and victimised by her colleagues.

But she later discovered that her employment record continued to state her reason for leaving as “Dismissal – Some Other Substantial Reason”.

The plight of the two women is similar to that of dozens of NHS whistleblowers who have been effectively blacklisted by the NHS because of incorrect employment records.

The Telegraph can reveal that despite being cleared by employment tribunals, or receiving formal apologies for their treatment, whistleblowers’ staff records continue to state that they were “dismissed” from their previous job.

Jennie Fecitt
Jennie Fecitt won an unfair dismissal case against NHS Manchester, but she later discovered that her employment record continued to state her reason for leaving as ‘Dismissal – Some Other Substantial Reason’ CREDIT: JON SUPER FOR THE TELEGRAPH

The Department of Health has now been accused of flouting data protection and employment legislation by refusing to amend incorrect records that are preventing doctors and nurses who exposed care scandals from returning to work.

Lawyers have warned the treatment of Ms Fecitt, Lady Yassaie and other NHS whistleblowers is “tantamount to blacklisting”, as prospective employers are unlikely to hire anyone who has been dismissed from a previous role.

And a Deputy High Court Judge has called for a change in legislation to give whistleblowers specific protection against blacklisting, describing it a “real gap in the law”.

Blacklisting via the electronic staff record is a way of keeping whistleblowers out of the NHSJennie Fecitt

Under data protection legislation, the Department of Health is responsible for ensuring that the electronic staff records it holds – which are available to all prospective NHS employers – are kept up to date.

Legal experts said that refusing to amend staff records is a potential breach of employment regulations, as they contain inaccurate information and could be seen as an act of “post-termination victimisation”.

A senior NHS director has admitted that, in many cases, the  records are not updated, even after a dismissal has been overturned, adding that this is the main reason why whistleblowers find themselves barred from future employment.

A former NHS human resources director told The Telegraph that staff records were being used to blacklist whistleblowers.

She said that anyone whose record states they have been dismissed from a previous role “would find it very hard to get work”.

“As an HR director, you think ‘I need to know what the risk is’. If there are disciplinary issues or dismissal, then it suggests there is a risk for that candidate,” she said. “If there is a second candidate who is good, you would go for another candidate.”

Staff at work in a hospital
Sir Robert Francis warned of a culture of ‘fear, bullying and ostracisation’ within the NHS (file photo) CREDIT: GETTY IMAGES

Ms Fecitt, who went on to become the director of the whistleblowing organisation Patients First, said that many of her 200 members have reported problems with their staff records, and believe these are preventing them from finding work in the NHS.

She said she has seen the staff records being used to disadvantage whistleblowers in a number of ways, such as marking “gardening leave” as “sick leave”, or using a comments section to elaborate on the trust’s version of the reason for dismissal.

“Blacklisting via the electronic staff record is a way of keeping whistleblowers out of the NHS,” she said.

A group of four whistleblowers, all of whom have obtained their staff records through subject access requests, are now in talks with lawyers about taking possible legal action over the issue.

Jeremy Hunt
Jeremy Hunt, the Health Secretary CREDIT: REUTERS

Jahad Rahman, a partner at Rahman Lowe Solicitors and specialist in employment law, said that employers do not have to give references, but if they do, they are legally obliged to give accurate statements.

“If the record is inaccurate, that is potentially a breach of employment law,” he said.

Mr Rahman added that the Department of Health’s refusal to change staff records is “probably deliberate”, saying: “I don’t think it is an administrative error; that would be absurd in my opinion.”

He said that numerous staff records that incorrectly state “dismissal” for whistleblowers “indicates that there is an internal policy, whether written or not, to disadvantage those that complain about wrongdoing within the NHS”.

Doctors and nurses shouldn’t be afraid to express concern about patient safety, and they should not be disadvantaged for doing soJahad Rahman, Rahman Lowe Solicitors

“The NHS don’t like it, they want to silence you once you’ve blown the whistle. Legislation is meant to protect and encourage people to come forward,” Mr Rahman said.

“Doctors and nurses shouldn’t be afraid to express concern about patient safety, and they should not be disadvantaged for doing so. Sometimes the trusts think they are above the law, but they should be held to account.

Neil Churchill, NHS England director for improving patient experience, acknowledged that prospective employers would “have concerns” about hiring someone who had been dismissed from a previous NHS role, adding that it would “act as a bar” to re-employment.

“If someone has won an employment tribunal case then that should be corrected [on their records] without us having to intervene. That should be something that happens automatically,” he said.

Concerns were raised about the electronic staff records by senior NHS officials when they were introduced a decade ago.

Anne Gadsden, the then Information Governance Officer at North Cumbria Acute Hospitals NHS Trust, warned that staff were being forced to agree to the new system despite their reservations.

In her letter, seen by The Telegraph, she wrote: “Our staff have concerns about the fact that there will be a central ‘Data Warehouse’ somewhere in the heart of England, holding all the staff information. Worries about security, access etc.

“The Finance Director of my organisation has said that staff are not allowed to opt out, and if they do, they can no longer be employees of the trust (Yep, he’s happy to threaten).”

Junior doctor says his career destroyed after whistleblowingPlay!01:38

Earlier this year, the NHS published its first standardised national whistleblowing policy, following Sir Robert Francis’s Freedom To Speak Up review.

Sir Robert warned of a culture of “fear, bullying and ostracisation” within the NHS that punished doctors and nurses who exposed failings.

He said whistleblowers were derided as “snitches, troublemakers and backstabbers”.

However, experts have argued that the new policy did not go far enough.

John Bowers QC, who is one of the UK’s foremost experts on employment law, said that a lack of specific protection against blacklisting of whistleblowers is a “real gap in the law”.

I was a highly experienced, highly paid manager, I had a fantastic career in the NHS. Now they are simply destroying my futureLady Yassaie

“It is a problem that there is no law that stops blacklisting of whistleblowing claimants,” said Mr Bowers, who is principal of Brasenose College at Oxford University and sits as a Deputy High Court Judge.

“It is particularly serious in the NHS for two reasons. Firstly, because there are more whistleblowers in the NHS than anywhere else, due to the nature of what people deal with. Secondly, although there are lots of different employers, it is effectively one large super employer.

“And if you are blacklisted by one, you are probably not going to get another job. For many things it is effectively a monopoly organisation.”

The Information Commissioner’s Office (ICO) suggested that the Department of Health was falling foul of data protection legislation.

“If someone was dismissed then that would be included, but if it is established that they were dismissed unfairly, a note should then be added to the record,” a spokesman said.  “An individual is entitled to this under the Data Protection Act.”

Maha Yassaie
Lady Yassaie said all her attempts to have her employment record updated have been met with obfuscations and buck-passing CREDIT: JULIAN SIMMONDS FOR THE TELEGRAPH

Lady Yassaie, whose husband is Sir Hossein Yassaie, a technology entrepreneur who was knighted for services to technology, said all her attempts to have her employment record updated have been met with obfuscations and buck-passing, with the Department of Health telling her she would need to take legal action to have it changed.

She said: “I was a highly experienced, highly paid manager, I had a fantastic career in the NHS. Now they are simply destroying my future. I feel so let down, so devastated.

“I am still blacklisted even though I had an apology and cleared my name. God knows how many more people are in my position.”

Ms Fecitt has met with similar obstruction when she tried to get her own record corrected.

It’s like wading through treacle to get records changed to reflect the truthJennie Fecitt

“I’ve seen on a back screen of my form in a comments section it says I am a ‘vexatious whistleblower’ – but the Department of Health deny it exists and will not disclose it,” she said. “Despite repeated requests to change incorrect entries and providing evidence to support why those changes must be made, the Department of Health have so far refused to intervene.

“It’s like wading through treacle to get records changed to reflect the truth.”

The Department of Health insisted that all its staff records are accurate, and that it was acting in line with data protection laws.

It said every NHS organisation has a Freedom To Speak up Guardian and that ministers are in the process of strengthening legislation that prevents discrimination against whistle-blowers.

“We want to make the NHS the safest healthcare system in the world and will support staff to speak up when things go wrong, without fear of reprisal,” a spokesman said. “That’s why, as well as working with individuals to ensure that their electronic staff records are accurate and up to date.”

The spokesman said Lady Yassaie’s case “has been investigated and the department believes the matter has now been concluded appropriately”. He added that Ms Fecitt’s case “was the subject of an employment tribunal and subsequent appeals, which concluded in 2011.

UK law fails to protect whistleblowers

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.


CQC Deaths Review: All Fur Coat…

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

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

[3] Labour’s ‘denial machine’ over hospital death rates. Telegraph 14 July 2013

[4] CQC scoping paper for deaths review

[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

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

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

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







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

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







Boss of failing NHS trust claims she never saw email alerts over patient safety

Mail on line  31 JUL 2016

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

North Middlesex Hospital
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.

Ambulances outside the A&E department of the North Middlesex Hospital in EdmontonThe 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.

Main entrance to North Middlesex Hospital in EdmontonA 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


Southern Health NHS Trust ‘paid millions’ to Katrina Percy’s associates

Southern Health NHS Foundation Trust chief executive Katrina PercyChief executive Katrina Percy has come under pressure to resign

A troubled NHS trust has paid millions of pounds to companies owned by previous associates of its embattled chief executive, BBC News has learned.

One firm received more than £5m despite winning a contract valued at less than £300,000, while another was paid more than £500,000 without bidding at all.

Both are owned by former acquaintances of Southern Health NHS Trust’s chief executive Katrina Percy.

The trust said it took its financial responsibilities “very seriously”.

‘Failure of leadership’

The BBC has also learned Southern Health has access to the services of former Labour spin doctor Alastair Campbell, after it hired Portland Communications to help with its ongoing problems.

Mental health trust Southern Health has been under intense scrutiny since an NHS England-commissioned report in December found it failed to investigate the unexpected deaths of hundreds of patients.

A failure of leadership and governance at the trust was blamed for the problems, a conclusion a subsequent CQC report in April agreed with.

In light of the criticisms, Katrina Percy, the only chief executive the trust has ever had, has faced widespread calls to resign but has refused to do so.

Chris MartinImage copyrightTALENT WORKS
Image captionChris Martin’s website contained a commendation from Katrina Percy


2006 – Management consultant Chris Martin and Katrina Percy start working together during her capacity as chief operating officer at Surrey and Sussex Hospitals

2009 – Ms Percy becomes chief executive of Hampshire Community Health Care and Mr Martin follows her, providing coaching and leadership support

2010 – Mr Martin starts a firm of organisational psychologists called Talent Works Ltd, whose website says they are “experts in culture and behaviour change”

2010 – In December, Southern Health advertises for management development support. The tender has a value of £288,000, and the contract is to last three years, with an option for a one year extension

2011 – Ms Percy joins Southern Health as chief executive and the work is awarded to Talent Works Ltd

2014 – The initial three year contract ends and the firm is paid £5.365m – an over-spend approaching 2,000%. The trust chooses to exercise its option for a one-year extension

Now she is facing fresh questions about two former associates, Chris Martin and Paul Gray, whose companies were paid by Southern Health.

Roy Lilley, former chairman of an NHS trust and now a health policy expert, said the overspend on Mr Martin’s company was “extraordinary”.

He said: “It really doesn’t look good, and it casts a deep shadow over the people involved and the way in which the trust has been run by the board.”

A former governor at Southern Health, John Green, who has a background in running quality management programmes, said he queried the work that Talent Works was doing at the trust.

“I was fobbed off,” Mr Green said.

“I didn’t get any information for well over a year. I believe the spending of public money in the NHS is nothing as accountable to the public as it should be.”

Southern Health logo
The trust confirmed Ms Percy had worked with the men before

Paul Gray worked with Ms Percy as director of strategy at Hampshire Community Health Care and his firms made money from the trust without having to bid for a contract.

In July 2009, he set up consultancy firm Consilium Strategy Consulting Ltd and in 2014 he formed a second company, Consilium Partners Ltd. Together they have been paid at least £602,000 by Southern Health since 2011.

In a statement, Southern Health said it had “tested the market to ensure value for money in 2011. There has been no increase in rates since this benchmarking exercise took place”.

‘Not unusual’

Regarding Talent Works, the trust said: “We fully accept that the original contract for Talent Works was for a sum far less than the eventual spend, however it was made clear in the tender documentation that there would be scope for additional work to be provided.

“The trust’s audit committee were aware of the contract overspend but were satisfied that the market rates had been tested and that for a number of reasons, it was in the best interests of the trust for their work to continue.”

It added that it was “not unusual” both men had worked with Ms Percy “given the specialist services they provide to the NHS”.

NHS chief accused of telling colleagues to ‘keep your mouths shut’ after a surgeon made an incision on the wrong hand because he ‘did not know his right from his left’

  • 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 

Rachel Sansbury allegedly told staff who raised concerns about incidents going unreported not to ‘open that can of worms’ at Lancashire Teaching Hospital NHS Foundation Trust

Rachel Sansbury allegedly told staff who raised concerns about incidents going unreported not to ‘open that can of worms’ at Lancashire Teaching Hospital NHS Foundation Trust

An NHS chief silenced whistleblowers and told a colleague to keep quiet after a surgeon made an incision on the wrong hand because he ‘did not know his right from his left’.

Rachel Sansbury allegedly told staff who raised concerns about incidents going unreported not to ‘open that can of worms’ at Lancashire Teaching Hospital NHS Foundation Trust.

Sansbury warned colleagues they should ‘keep their mouths shut about any issues’ as she feared the department would lose its ‘gold standard’, the Nursing and Midwifery Council heard today.

Michael Collis, for the NMC, said: ‘This case relates to a period of time when the registrant was working as the head of nursing for the surgical division at Lancashire Teaching Hospital NHS Foundation Trust.

‘The registrant started in that role at some point in 2009. As part of her role, she had responsibility for clinical governance processes and ensuring compliance with trust and national guidelines.

‘These six charges relate to comments allegedly made to three separate individuals working in the clinical governance team for whom the registrant was the line manager.

‘In essence, relate to comments allegedly made that these three colleagues should not raise complaints or issues and that they change conclusions to prevent damage being caused to the clinical governance team or the surgical division as a whole.’

Mr Collis said two of the charges related to a meeting in October 2012.

‘Gail Gardiner [Colleague A] and Sarah Fay [Colleague B] were present in this meeting.

‘The purpose of this meeting was to determine whether or not Ms Fay wanted to proceed with bullying allegations made against another colleague.

‘During that meeting, however, the registrant berated Ms Gardiner and Ms Fay for the impact that raising concerns was having on the governance team.

‘She pointed out it was being noticed within the department and that they had worked hard to get a gold standard and it was being destroyed.

‘The registrant told these two individuals not to raise concerns outside the clinical governance team and that they should keep their mouths shut about any issues.

‘Charge 3 relates to allegations made by Ms Fay that on occasions she was instructed by the registrant to change the conclusions of investigations in order to make them sound more favourable.

Sansbury, who is present and represented at the hearing, denies all charges

Sansbury, who is present and represented at the hearing, denies all charges

‘Ms Fay resisted this request and submitted the investigations as she had worded them.

‘Charge 4 relates to an incident again involving Ms Fay and the registrant.. Ms Fay informed the registrant that she was receiving reports regarding staff failing to report incidents or under-reporting them.

‘When presented with that information, the registrant responded with “don’t open that can of worms as you don’t know what will come out,” or words to that effect.’

The hearing was told Anita Lowe [Colleague C] also worked with the clinical governance team.

‘It came to the attention of the registrant and the clinical governance team that a surgeon had made an incision on the wrong finger of a patient.

‘Ms Lowe accompanied the registrant to the theatres to address this emerging situation.

‘The surgeon, the registrant and general manager went into a private room and had conversations.

‘When the registrant came out, she informed Ms Lowe that the surgeon did not know his right from his left and had been diagnosed with dyspraxia.

‘The registrant told Ms Lowe not to tell anyone about this and stated “if you tell anyone he would be stopped from working and waiting lists would increase” or words to that effect.

‘As charge 6 makes clear, it is the NMC’s case that all these incidents were dishonest in the fact that they were efforts by the registrant to encourage her colleagues to conceal or misrepresent information that may have been damaging to the clinical governance team or the surgical team as a whole.’

Sansbury is charged with telling a colleague not to raise concerns outside the clinical governance team, telling colleagues to keep their mouths shut about any issues so as not to lose the department’s gold standard, asking a colleague to change the conclusions of investigations, telling a colleague ‘don’t open that can of worms’ in relation to failure to report incidents and telling a colleague not to tell anyone that a surgeon was diagnosed as dyspraxic.

Sansbury, who is present and represented at the hearing, denies all charges.

The hearing continues.


Former nurse blasts Morecambe Bay health trust’s whistleblowing policy


Lancaster Guardian    Nick Lakin   22 July 2016

Russell DunkeldRussell 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.

Firm appointed for New Cross Hospital whistleblower probe

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 HospitalWolverhampton’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.

NHS in new part-time health service whistleblowing tsar row as second person appointed

Mirror  8 JUL 2016

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

Dr Henrietta Hughes
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 sillsDame 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 SillsDame 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 HuntJeremy 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.”

A Word in Your Shelford-Like, Mr Behan

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

[2] Hunt humiliated as NHS Whistleblowing Tsar quits

[2] No one believes Jeremy Hunt on patient safety and whistleblowers – not even his own appointees

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

[5] Letter from Rebecca Lloyd-Jones CQC Director of Legal Services 24 May 2016

[6] Speak Up for a Health NHS. Social Partnership Forum 2010

[7] FOI disclosure from Guy’s and St. Thomas’ NHS Foundation Trust 11 April 2016

[8] FOI disclosure from Guy’s and St. Thomas’ NHS Foundation Trust 21 March 2016

[9] Shelford Group website

[10] Shelford Group Trust rated ‘Good’ across the board. Health Service Journal 13 June 2016

[11] Joint letter by David Behan and Sir Robert Francis to NHS trusts about appointment of new National Guardian 7 July 2016

Report condemns hospital in baby death cover-up: Parents speak of ‘vindication’ as senior staff who plotted to delete evidence of medical blunders in care of their son are blasted by health chiefs

  • 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

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

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


Jenny and Allyn Condon with their baby son Raffi

Nothing can replace a lost child, but Jenny and Allyn Condon were finally able to celebrate again earlier this year with the birth of a boy, Raffi.

Jenny, who has suffered many miscarriages, gave birth to him ten weeks early at Southmead Hospital in Bristol after intensive monitoring by doctors. Their son is now four-and-a-half months old and doing well.

‘Raffi is a lovely, laughy baby – all smiles,’ said Allyn. Jenny said his birth, which came almost exactly a year after Ben was born, had brought back painful memories. She added: ‘I found myself reliving every moment, watching everything constantly, and expecting something to go wrong.’

Last night, Ben’s father Allyn, 41, said: ‘This report vindicates what my wife Jenny and I have been saying all along. We would like to thank the MoS, because without its coverage, it is unlikely this external investigation would have taken place.’

After Ben died last April, at eight weeks old, the couple were first told he had succumbed to a cold-like viral infection. But two months later, doctors revealed he had also contracted a more virulent bacterial infection, which could have been prevented with timely antibiotics. They incorrectly told them this infection, pseudomonas, was only identified after Ben died.

Unhappy with the care Ben received, the couple scoured his medical notes. At a meeting last July, they put it to doctors that staff had missed chances to spot the infection and treat him.

The meeting was openly recorded by both sides. During a break, the Condons left the room and the NHS representatives forgot they were being recorded. Neonatologist Dr Paul Mannix candidly told intensive care consultant Dr Margrid Schindler: ‘Margrid, they are absolutely right… these are not misinformed bolshy parents.’ Dr Schindler responded: ‘They’ve got a point.’

She then realised their own recorder was still taping and asked manager Julie Vass if there was ‘any possibility of taking off’ the last section ‘because that could get us into difficulty’. Mrs Vass agreed.

But moments later, Dr Mannix spotted the Condons’ own iPhone was recording too, so they left both machines running. Covering the microphone, Dr Mannix then said he ‘struggled to see’ why Ben did not get antibiotics three days before he died.

Dr Schindler was heading Ben’s child death review at the time while Dr Mannix, who works elsewhere, had been acting as the Condons’ representative. When the couple returned he alerted them to ‘extra stuff’ on their tape.

Trust chief executive Robert Woolley said: ‘We accept the report’s findings in full. We are saddened we missed too many opportunities to proactively engage with Ben’s parents. We apologise to them unreservedly.’


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