Legal experts will meet next week to hammer out the details of how a ‘Hillsborough Law’ might prevent a repeat of the institutional subterfuge and lies which followed the death of 96 Liverpool supporters at Sheffield Wednesday’s ground in 1989.
It took 27 years to establish the degree to which South Yorkshire Police and other public services failed supporters, with the police then involved in a calculated project to deflect blame by besmirching supporters and it is expected that a ‘Hillsborough Law’ will be drafted and tabled later this year to ensure that cannot happen in the future.
A symposium will be held in Liverpool next Wednesday, coordinated by the Liverpool Law School and Jackson Canter solicitors, at which Pete Weatherby QC, who represented many families at the Hillsborough inquests which concluded last year, is among the speakers. It will consider how the experience of disastrous management in the NHS can inform the bill. The Mid Staffs NHS Foundation Trust Public Inquiry led to the introduction of a ‘duty of candour’ across the NHS in 2014 and drafters of the Bill must decide whether statutory or regulatory regimes are the most effective approach to challenging institutional defensiveness.
New Hillsborough film reveals unremitting memories of survivors
The NHS has imposed a regulatory requirements of ‘candour’ and whistleblower protection, though the Bill could make it a criminal act to mislead the general public or media “intentionally or recklessly.” Those who mislead court proceedings or inquiries or fail to provide witness statements could also be prosecuted.
Another aim of the ‘Hillsborough Law’ would be to re-balance inquests, to prevent those struggling to cope with the financial might of public bodies by providing legal funding for bereaved families at inquests where police are involved. “We must call time on the uneven playing field at inquests where public bodies spend public money like water on hiring the best lawyers when ordinary families have to scratch around for whatever they can get,” MP Andy Burnham, who will push the Hillsborough Law, recently said.
MP Andy Burnham is pushing for the Hillsborough Law to be passed (Getty)
At the Liverpool symposium, there will be at least three workshops that will, respectively, consider: the Bill itself; the success or failure of the ‘duty of candour’ in the NHS context, enshrined in the Health and Social Care Act 2008 and the NHS Standard Contract 2014/2015; and police/public body accountability more generally. Speakers also include Deborah Coles of the respected INQUEST charity and a former NHS Trust chief executive, Alan Yates.
The Bill’s drafters, Weatherby and Jackson Canter’s Elkan Abrahamson, will consider the feedback from the symposium participants in order to develop and improve the Bill in preparation for presentation to Parliament.
Doctors and nurses are still not reporting mistakes because they fear the ‘finger of blame’, MPs warn today.
Despite repeated attempts by ministers to make the NHS more honest, they say staff are unwilling to talk openly about errors.
In a damning report, the Public Administration and Constitutional Affairs Committee warns that measures introduced to improve care and encourage staff to be more honest have not addressed the problems.
Doctors and nurses are still not reporting mistakes because they fear the ‘finger of blame’, MPs warn today
They included installing whistleblowing guardians at all hospitals with whom doctors and nurses could raise their concerns and were brought in following the 2013 report into the Mid Staffordshire scandal that linked hundreds of needless deaths of patients between 1995 and 2000 to a deep-rooted culture of fear.
Tory MP Bernard Jenkin, chairman of the committee, described the failure as unacceptable.
‘There is an acute need for the Government to follow through on its commitment to turn the NHS in England into a learning organisation; an organisation where staff can feel safe to identify mistakes and incidents without fearing the finger of blame,’ he said.
Last year, the Government went further by announcing the launch of the Healthcare Safety Investigation Branch, which will come into force in three months’ time.
It is intended to be an independent body similar to the Air Accident Investigations Branch which will take up the most serious mistakes in hospital.
Crucially, any doctor or nurse who gives evidence to the branch will be protected from legal action, whilst the investigation is underway.
If the body decides they weren’t to blame, and it was the fault of the system, for example, they wont be sued.
But if the doctor or nurse was deemed to be in the wrong they will be referred to their professional watchdog – and could still face legal action.
Today’s report warns that the branch does not have the powers to be fully independent, and therefore carry out proper investigations.
Julie Mellor, Parliamentary and Health Service Ombudsman said: ‘We know from our casework that families who complain to the NHS want lessons to be learnt so that future mistakes are avoided.
Last year, the Government went further by announcing the launch of the Healthcare Safety Investigation Branch, which will come into force in three months’ time
‘The NHS still has a long way to go to provide staff with the relevant skills to carry out fair, high-quality investigations into avoidable harm.
‘The Government and NHS leaders must commit to providing training, national standards and accountability for the NHS, to make it safer for all.’
Previous research has found that up to 12,000 hospital deaths in the UK a year were unavoidable.
A Department of Health spokesman said it was introducing further measures to ensure the NHS becomes an organisation ‘that learns from its mistakes’ and added that it was committed to ‘pursuing legislation’ to strengthen the new HSIB.
Doctors, staff and patients criticise Care Quality Commission and call for radical change in health service regulation
NHS whistleblowers face being “fired, gagged and blacklisted” while disclosures go uninvestigated owing to the healthcare regulator’s lack of powers and resources, a group of doctors, staff and patients has warned.The Care Quality Commission (CQC) was criticised for being “low value” by the group, which has called for radical change in how the health service is regulated.
In a letter to the Times, the group, which has exposed huge failings, said the CQC had failed to detect poor care and governance since it replaced the Healthcare Commission in 2009. It cited an example where an inspection of a foundation trust cost £273,900 but failed to spot hundreds of uninvestigated deaths.
“The CQC protests that it has no powers to investigate individual cases,” the group said. “Many patients, bereaved relatives and whistleblowers are deeply frustrated that disclosures to the CQC have not resulted in change. On the contrary, if NHS staff whistleblow, they may still be fired, gagged and blacklisted.”
Julie Bailey, whose mother was a victim of the problems at the trust, signed the letter with 13 other whistleblowers.
They include Dr Stephen Bolsin, who revealed failings at Bristol Royal infirmary’s paediatric cardiac unit, and Baby P whistleblower Kim Holt. Holt told the Times: “It’s very frustrating because I feel like the CQC have got all the information. They know what’s happening.
“They sit and listen and nod their heads and say, ‘That’s dreadful,’ but then they don’t do anything about it. [Whistleblowers] that I sat alongside in meetings at CQC have since lost their jobs.”
Sir Mike Richards, the chief inspector of hospitals, said: “The CQC takes concerns raised by staff extremely seriously and we act where appropriate, whether carrying out or bringing forward an inspection, raising concerns with the provider, or alerting another organisation, including the police.”
David Loughton, CEO at Royal Wolverhampton NHS Trust, kept his job
He used taxpayers’ money to fight staff who raise concerns about safety
Dr Raj Mattu was sacked after he exposed that two patients had died
Their deaths had been a result of dangerously overcrowded bays
The NHS was accused of a whitewash this evening after a hospital boss who spent £10million suppressing whistleblowers was cleared by an official report.
David Loughton, who earned £260,000 last year, has been allowed to keep his job despite using taxpayers’ money to fight staff who raised serious concerns about patient safety.
The review into how Mr Loughton’s hospital trust is being run would only go as far as saying that he had ‘an impulsive and honest style’. It appears he will now face no disciplinary action and no sanctions will be taken against him.
David Loughton is the chief executive at The Royal Wolverhampton NHS Trust
Whistleblowers who were forced out of their jobs by Mr Loughton were not even interviewed for the report, and only found out the review had been published when contacted by the Mail.
In a further twist, it has emerged that the consultancy firm chosen by the NHS to do the review has been paid £78,837 by Mr Loughton’s trust for other jobs this year.
Deloitte was paid £45,444 for the review by watchdog NHS Improvement.
Mr Loughton, 62, chief executive at The Royal Wolverhampton NHS Trust, is renowned for fighting whistleblowers through the courts.
They include leading heart surgeon Dr Raj Mattu, who was vilified and sacked after he exposed that two patients had died in dangerously overcrowded bays in a hospital at another trust run by Mr Loughton.
Dr Mattu was cleared at a tribunal and in February was awarded £1.2million damages.
Manager Sandra Haynes Kirkbright was also suspended after raising concerns that Mr Loughton’s Woverhampton trust had mis-recorded deaths, making it look like fewer patients had died needlessly.
An investigation into her case condemned the trust for its ‘significantly flawed’ and ‘unfair’ treatment.
It described an account of how Mr Loughton made sure Mrs Haynes Kirkbright was ‘out of the way’ before a visit from hospital inspectors, telling staff to ‘kick this into the long grass’.
After the report into her case was published in May, NHS watchdogs ordered a review into the management of Mr Loughton’s hospital trust.
But the results of that review were only quietly published on the trust’s website earlier this week. And it emerged that Deloitte was instructed to focus on the hospital as it is now, rather than considering previous whistleblowing cases.
As a result, the report’s authors did not contact Dr Mattu, Mrs Haynes Kirkbright or former board members who have criticised the management. They did not check what they were told by Mr Loughton and his employees, writing in the review: ‘We have assumed that the information provided to us and management’s representations are complete, accurate and reliable.’
Describing Mr Loughton, the report stated: ‘The chief executive is a strong character with an impulsive style and can attract controversy from time to time. However, he is strongly supported.’ It added: ‘Any past behavioural challenges have tempered in recent years.’
Today Dr Mattu said: ‘They have taken at face value everything management has said. I have great experience of Mr Loughton and he ruthlessly attacks anyone who dissents. He has persecuted whistleblowers. This has been a disgraceful waste of taxpayers’ money.’
Dr Raj Mattu, from Warwick, was vilified and sacked after he exposed that two patients had died in dangerously overcrowded bays in a hospital at another trust run by Mr Loughton
Dr Mattu, right, pictured with his wife Sangita. The stress of 200 false allegations against the heart surgeon left him too sick to work
Mrs Haynes Kirkbright said: ‘I was not consulted at all on this report. I didn’t know a thing about it until the Mail told me.’
Professor David Ferry was outed last year by Mr Loughton’s hospital after he anonymously revealed in the Mail that 55 cancer patients were needlessly put through the agony of chemotherapy.
This evening, he said: ‘They have whitewashed everything. I told them about Dr Mattu, about Sandra, about my case, but they said this is about the future, not the past. They have rewritten history their way, whatever the facts are.’
Mr Loughton, an NHS chief executive for 28 years, was awarded a pay rise of about £35,000 last year.
He joined Royal Wolverhampton in 2014 after 14 years at Coventry’s Walsgrave Hospital.
Mr Loughton said: ‘We are pleased with the review’s conclusions. Our number one priority is always patient care. Having an open and transparent culture is one of the ways in which we can ensure we remain committed to providing the best care we possibly can.
‘We are always seeking ways in which we can improve and we will take on board the recommendations the review makes.’
A trust spokesman said NHS Improvement commissioned Deloitte to do the review and ‘in line with many other organisations we have used the services of Deloitte’.
NHS Improvement said: ‘Deloitte were appointed following a formal and thorough tendering and evaluation process.’
Deloitte declined to comment.
HEART SURGEON’S CAREER WAS RUINED
Dr Raj Mattu was accused of fraud, sexual impropriety and assault after revealing that two patients had died in dangerously overcrowded bays at Walsgrave Hospital in Coventry.
The University Hospitals Coventry and Warwickshire NHS Trust – which was then run by Mr Loughton – submitted 200 false allegations against the leading heart surgeon , according to his lawyer. The stress eventually left him too sick to work.
In a case that ran for 15 years and cost more than £10million of taxpayers’ money, bosses attacked his reputation in a witch-hunt to silence him and stop other potential whistleblowers from speaking out.
Dr Mattu, 57, who is married to Sangeeta, 46, was finally vindicated in February when it emerged that he had been paid £1.22million in damages by the trust after he won an employment tribunal two years earlier.
While at Walsgrave Hospital, he and other doctors at the trust raised concerns that five patients at a time were being put in bays meant for four.
After two patients died in these bays, he spoke out again – only to see Mr Loughton appearing on BBC TV in September 2001 denying the deaths were due to overcrowding.
As a result, he went public and spoke to BBC News about his concerns. In February 2002, he was suspended from his £70,000-a-year job and escorted off the premises, accused of intimidating a junior doctor. Dr Mattu was reinstated in 2010 before being dismissed again a year later.
In April 2014, a tribunal cleared him of wrongdoing and ruled he was unfairly dismissed and targeted by hospital managers because he blew the whistle.
This evening, he said: ‘I’m not employed and I’m still trying to salvage my career and rebuild my life. David Loughton is still in his job. Nothing has changed.’
Sandra Haynes Kirkbright has faced ruin since being suspended in 2012 by the trust to which Mr Loughton had moved.
The hospital administrator, 52, blew the whistle after she was hired by Royal Wolverhampton Hospitals NHS Trust to oversee record keeping at the trust.
She said that when she arrived, others at the trust were ‘breaking every rule in the book’ and deaths had been recorded in a way that made it look like fewer people were dying needlessly.
Mrs Haynes-Kirkbright also said the trust had fraudulently made money by charging for treatments it had not performed – all of which is denied by the trust. She was later suspended on allegations of bullying, which she says are untrue.
Mrs Haynes Kirkbright spoke out about her concerns in the Daily Mail two years ago.
This evening, she said: ‘I’m still suspended four and a half years later but I want to go back to work. I’ve been in limbo.’
Dr Stephen Frost, who called for inquest in Dr David Kelly, sacked by MoD
Allegedly prescribed maimed veteran six times normal dose of morphine
But soldier denies he had higher dose – which was left out of army report
Dr Frost claims he was sacked for blowing whistle on MoD drugs racket
Dr Stephen Frost is accusing the Ministry of Defence of wrongful dismissal after he was sacked from the medical corpse
A Ministry of Defence medical official denied ‘deliberately suppressing’ crucial facts in a report which led to the dismissal of an Army whistleblower, a tribunal has heard.
Dr Stephen Frost – who led calls for an inquest into the death or weapons expert Dr David Kelly – was sacked after a maimed Afghanistan war veteran was wrongly prescribed morphine six times his normal dose.
The 69-year-old, who neither prescribed nor dispensed the tablets, was fired by the Ministry of Defence for allegedly not telling the soldier that he had been issued with the wrong tablets and was at risk of overdosing.
But an employment tribunal heard that the serviceman – whose left leg was blown off by an IED – insisted he had never been given 60mg tablets of powerful morphine sulphate.
He claimed he had only ever been given the correct strength of 10mg pills and Dr Frost said he did not show withdrawal symptoms – indicating he had never taken the higher dose.
The hearing in Manchester was told that if he had taken the wrong dosage he would have consumed 120 mgs of morphine every day for 16 days.
Dr Frost believes he was dismissed by text while on holiday for blowing the whistle on a drugs rackets at an Army base.
He has testified that he believed the soldier may have illegally sold the wrongly administered stronger pills on the black market and told colleagues there should have been a police investigation.
In a dramatic twist, Samantha Cotgrave, the former deputy clinical director of Army Primary Health Care Services (North), admitted that the soldier’s insistence he had not been given 60 mg were not in her interim report into the incident.
Dr Stephen Frost (pictured, left with solicitor Helen Clifford) led calls for an inquest into the death or weapons expert Dr David Kelly (right) and claims he was sacked for blowing the whistle on a drugs racket
She also admitted that she had failed to record a meeting between Dr Frost and the soldier outside a pharmacy where the patient was shown a distinctive orange 60mg tablet – as opposed to a brown 10mg one – and had told the doctor he had never seen one before.
John Hendy QC, for Dr Frost, accused Mrs Cotgrave of ‘having a closed mind’ and had deliberately suppressed the details in her report which was submitted to senior officers at Weeton Barracks, near Blackpool.
He told her: ‘You deliberately suppressed the fact that the patient had categorically denied receiving 60mg tablets. It did not fit in with the picture you were trying to paint.’
Mrs Cotgrave replied: ‘It was not intentional. I was not trying to paint a picture. There was overwhelming evidence that there had been a dispensing error.
‘The only tablets he could have had were 60mg because they were the only ones dispensed on that date.’
John Hendy QC, for Dr Frost, accused Mrs Cotgrave of ‘having a closed mind’ and had deliberately suppressed the details in her report which was submitted to senior officers at Weeton Barracks (pictured), near Blackpool.
But Mr Hendy challenged her: ‘Because you were convinced, you were prepared to leave out evidence to the contrary.’
Mrs Cotgrave said that her report was attached to all the witness statements so that the three senior officers could make a final decision.
Mr Hendy said: ‘So it was up to the decision makers to extract this from all the statements?’
Mrs Cotgrave replied: ‘It was not intentionally excluded. It was not my intention. I was not trying to portray a picture.’
She agreed that her report included a reference to Dr Frost not being ‘sure enough’ that an error had been made and pointing out that he was not the patient’s lead clinician.
Dr Frost, from Colwyn Bay in North Wales, claims he was dismissed because he had uncovered a potentially criminal appropriation of morphine at the military base.
He says that senior officers then tried to smear him by labelling him a conspiracy theorist and a Russian sympathiser when he challenged his dismissal.
An NHS worker who says she faces being fired for whistleblowing is going on hunger strike outside the Department of Health.
Jade Taylor, 46, has set up camp in Whitehall with placards, bags, and bottles of water. She has vowed to stay as long as she could – until she gets a meeting with Health Secretary Jeremy Hunt.
Taylor, who leads a community team in a mental health trust, started speaking up about her concerns over patient and staff safety after the mistreatment of her parents at Mid Staffordshire NHS Foundation Trust.
Their deaths prompted her to complain about a ‘plethora of concerns’ in her own trust, Berkshire Healthcare NHS Foundation, including allegations of bullying and the mistreatment of whistleblowers.
She started her hunger strike at 7pm on Monday before taking up her post in Whitehall yesterday.
‘The trust I work for are saying that I have lost trust and confidence in them,’ she said, speaking outside the DoH last night. ‘I am not accepting that.
‘I want them to properly investigate my concerns. I refuse to resign and I’m not going anywhere.’
Two years later her mother Maureen, who suffered from Alzheimer’s disease, was seen at Stafford Hospital’s A&E and was admitted to stay overnight.In 2006 Taylor’s 67-year-old stepfather Andrew Panayiotes received care at the now-defunct Mid Staffs trust. He died after contracting an infection following surgery to remove a tumour.
However, Taylor says her mother was discharged inappropriately on her own the next day, which caused considerable distress. She was 66 years old.
‘Because of these experiences – whistleblowing was a real issue in Stafford – because of that I’m not going to give up on raising my concerns.’
She says she raised issues with trust bosses and the Care Quality Commission over bullying, patient and staff safety, the ‘culture’ and the treatment of whistleblowers.
However she claims they weren’t dealt with properly, and she was ‘overloaded and bullied’ as a result.
Now Taylor claims trust bosses have called a meeting to consider her future this week. She isn’t attending the meeting, but will be represented by the Royal College of Nursing.She has been off work sick for about a year, due to stress and a mild heart condition.
Berkshire Healthcare NHS Foundation Trust said: ‘We are unable to comment directly about Jade’s case as it is ongoing and we respect her right to confidentiality.
‘However, we take concerns about patient safety and quality of care extremely seriously and have a strong culture of encouraging and supporting our staff to speak up.
‘To date, all whistleblowing cases raised with us have been thoroughly investigated to the full satisfaction of our regulators, and where necessary we have implemented improvements to address any lessons learned.’
Whistleblowing chief says NHS needs a ‘happier environment’ to improve
Henrietta Hughes says grumpy doctors and nurses make atmosphere toxic
Believes happier attitudes would improve care and end bullying culture
The NHS needs a happier environment to improve levels of care and end a culture of bullying, its new whistleblowing chief has said.
According to Henrietta Hughes, grumpy doctors and nurses contribute to a ‘toxic environment’ that harms patients and prevents staff from speaking out.
Speaking in her first interview as ‘National Guardian for speaking-up’, Dr Hughes, a GP, urged ‘every single person’ in the health service to be more positive at work.
According to whistleblower and GP Henrietta Hughes, grumpy doctors and nurses contribute to a ‘toxic environment’ that harms patients and prevents staff from speaking out (file image)
She said the NHS needed a greater dose of the ‘trust and joy and love’ hormone oxytocin.
‘If you think about that scene in Love Actually where everybody is meeting at the airport, that’s the oxytocin feeling,’ Dr Hughes told The Times.
‘So wouldn’t it be better if oxytocin was the predominant neurotransmitter in the NHS?’
Her role as a National Guardian was created as a result of Sir Robert Francis’ report into the ‘horrific’ victimisation of staff who drew attention to poor levels of care, which called for an end to the health service’s climate of fear.
On top of the national guardian, local whistleblowing guardians will also be appointed at every hospital.
Dr Hughes said her role was ‘to create a really positive culture in the NHS so that all staff feel safe to speak up.’
She also raised her concerns that medics are too afraid to come forward, saying: ‘Staff are seeing things which could potentially be a risk to patient safety and they don’t feel safe to speak up about it. That’s a really worry.’
She added: ‘If you bring a positive attitude to work with you then you start seeing all those benefits of working well as a team.’
‘If you come to work feeling distrustful, you’re going to transfer that emotion on to the way you deal with your patients.’
Dr Hughes said her role was ‘to create a really positive culture in the NHS so that all staff feel safe to speak up’
The problem is one that must be tackled by every member of staff in the NHS, Dr Hughes warned.
She said: ‘It’s about every single person seeing this as their responsibility…If you’re a consultant and you’re responsible for ensuring the safe care of your patients, then it’s your duty to have good relationships with your colleagues.
‘And if you’re struggling with that, do something about it.
‘At the farthest extreme, if you’ve got someone who’s responsible for the safer surgical checklist and they don’t see it as something they need to be involved in, you could end up having the wrong leg taken off.’
Although critics have argued that her role will be mainly ineffective without official investigatory powers, Dr Hughes was adamant that most NHS workers were keen to raise standards.
She said: ‘I’m really hoping to work in partnership as a supportive and developmental arm rather than something which is seen as punitive.’
The ‘two big barriers’ still preventing staff from whistleblowing are fear of victimisation and the expectation that nothing would be done, Dr Hughes warned.
She said she wanted the NHS brand to ‘carry with it the confidence for patients and the public that if something has been identified as a problem, the organisation is doing something about it.’
Kim Holt from the whistleblowers’ organisation Patients First told The Times: ‘It’s all fine and well going with a positive attitude but if you’re subjected to relentless attack and hostility nobody is going to be happy and positive and smiling.
‘It would be lovely to think that the world was full of people who all behaved in an appropriate way, but there are people who have been allowed to continue with negative behaviour in the workplace and that needs to be rooted out.’
Arguing that Dr Hughes focus on positivity was ‘a bit utopian’, Dr Holt added: ‘It needs to be backed up by your manager and by your organisation. When the workforce sees that they are supported for speaking out rather than driven out, that’s what makes the difference.’
Anthea Mowat from the British Medical Association told The Times: ‘Everyone in the NHS, especially those in managerial and leadership positions, must lead by example to make this a reality.’
Richard von Abendorff Patient Safety Campaigner and Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, 31 August 2016
‘Just culture’ is a term for principles of respectful governance, with fair and proportionate accountability and a focus on learning. Politicians and senior NHS officials say they want just culture  but so far, it has been elusive in the NHS. Why so?
The literature often focuses on how just culture should apply to the NHS frontline and provider organisations, and less so on commissioners, watchdogs and politicians.  This distracts from the root causes of unjust culture.
In his statement of 6 February 2013 about the MidStaffs Public Inquiry, Robert Francis noted failure at all levels of the NHS:
“Regrettably there was a failure of the NHS system at every level to
detect and take the action patients and the public were entitled to expect.” 
The Public Administration Select Committee noted last year that culture comes from the top:
“Throughout the past five years, the recurring theme of our findings and recommendations reflects the importance of effective leadership in creating effective organisations. Our work has shown that it is the positive or negative attitudes and behaviour in the people and the culture of an organisation which determines success or failure..….the same issues will keep arising until there is a comprehensive determination to address the attitudes and behaviour of all the most senior Ministers and officials.” 
The deficit of just culture in the NHS can be traced to the top. Numerous NHS inquiries into healthcare failures have shown the contribution of poor leadership by politicians and senior officials in creating a culture of fear and reputation management, and wilful blindness to harm and risk to patients.
The deficit of just culture in the NHS can be traced to the top. Numerous NHS inquiries into healthcare failures have shown the contribution of poor leadership by politicians and senior officials in creating a culture of fear and reputation management, and wilful blindness to harm and risk to patients.
The Department of Health suppressed 3 major reports on NHS culture and quality improvement in 2008, which were critical of the Department’s leadership of the NHS.    They were not released until 2010, and only via a Freedom of Information request. It appears that the Department of Health did not wish to reveal findings that:
* The NHS had a culture of “fear and compliance” and “shame and blame”
* Managers in the NHS “look up, not out” (that is, NHS managers manage to please those above in the hierarchy, as opposed to prioritising the interests of patients and families)
* Patients and families were not central to those at the top of the NHS, and were little mentioned – “We were struck by the virtual absence of the mention of patients and families”
* That there was “an absence of an improvement imperative within the Department of Health and the NHS”
At the Midstaffs Public Inquiry, evidence was given by several senior officials about negative political interference in the NHS, and a driving imperative not to “embarrass the Minister”. 
In another matter, a leaked email by a civil servant revealed collusive practices to prevent a whistleblower, Raj Mattu, from gaining access to a Minister.  Similar ruses to ensure political deniability are common and continue. NHS whistleblowers often appeal to the Secretary of State and Department of Health as a final port of call when they have exhausted attempts to raise safety concerns with regulators. However, the typical response of the Department of Health is to dismissively claim that it does not get involved in ‘employment issues’ and to refer anxious and frustrated whistleblowers back to the regulators who have failed them.
Similar stonewalling is experienced by NHS complainants, despite official lip service to the immense value of feedback provided by complainants. Years of repeated reports about failure of NHS complaints governance have not resulted in improvement, and the number of complaints has actually increased.  Families find out time and again that loved ones died or suffered preventable harm because the NHS failed to properly learn from previous incidents or to mitigate known risks, and sometimes families do not get answers at all.
Complainants and whistleblowers alike are often badly mistreated if they raise concerns about NHS failure.  Politicians have decades of evidence of such malpractice, but it has never been effectively discouraged. The truth is that the NHS is not allowed to learn, because of the political pressure to suppress matters that may embarrass Ministers, and to avoid exposure of the fact that the NHS has long been under-funded. Indeed, there is evidence that wide-spread gagging of NHS staff continues despite headlines in 2013 that Jeremy Hunt supposedly banned gags. He did not. He simply asked NHS trusts to do better, but omitted to ensure effective oversight. 
Just culture requires that politicians and senior officials should also be held accountable for care failures that arise from poor stewardship of the NHS, and systemic failings. Staff struggling in a seriously underfunded, understaffed service that is in perpetual crisis can be expected to make mistakes. Politicians and senior officials who produce policy that makes unrealistic and unachievable demands, and
creates oppressive and exploitative working conditions for NHS staff are guilty of disrespect. Such tensions have been highlighted by the junior doctors contract row. However, as Lucian Leape et al have noted, this form of disrespect is often normalised in health services.  When disrespect is evident, or justice is not seen to be done, this will naturally intimidate staff and deter them from speaking up.
Severe NHS cuts of all forms continue despite the obvious safety concerns of the workforce. Senior establishment figures in the Health community are united in voicing increasingly urgent concerns about NHS under-funding.   Yet key recommendations of the MidStaffs Public Inquiry are being jettisoned one by one. Jeremy Hunt has made much of ‘intelligent transparency’ and has said that he wanted the CQC to be ‘chief whistleblower’. However, CQC’s inspection reports present safety data in an inconsistent and incomplete way, which makes it hard to track the effects of government policy on patient safety.   CQC has also been criticised for failing to regulate the Duty of Candour properly.  Moreover, CQC has failed woefully on implementing Regulation 5 Fit and Proper Persons.   Not one manager whose fitness to lead has been seriously called into question has been removed by CQC. NHS England asked NICE to stop its safe staffing work, and NHS Improvement has been criticised for dismantling NICE’s previous work on safe staffing.   NHS Improvement has castigated trusts for spending on staffing, even where trusts were responding to CQC requirements to increase staffing levels to safeguard patient care.  Waiting time standards have also effectively been cast off.    Most recently, the leak of a DH risk assessment raised questions of whether the Secretary of State had unsafely ploughed on with the 7 day NHS initiative, despite even the concerns of his own officials.  Since the leak, the DH has not produced evidence that it has any means of mitigating the risks identified by civil servants. The Chair of Health Committee entered the fray with strongly worded criticism:
“Cannot keep piling ever greater responsibilities onto an overstretched service without realistic resource and workforce to cope”.
“Expect problems when thin evidence is used to bolster an under resourced political objective instead of policy following the evidence.” 
In just culture, accountability is acknowledged as an important part of creating psychological safety, and recklessness is considered a matter for sanction. The following are listed by Stedman as blameworthy acts that merit sanction:
· Reckless behaviour
· Disruptive behaviour
· Working significantly outside your capability
· Disrespectful behaviour
· Knowingly violating standards
· Failure to learn over time
· Failure to work as a team
· Covering up 
How then do the Secretary of State, the Department of Health and the Department of Health’s arms length bodies measure up against this sort of ruler? We contend that they do not measure up at all well, based on the evidence.
After the publication of the MidStaffs Public Inquiry, Jeremy Hunt wrote to NHS providers to say that he wanted lasting change to create a more open, compassionate and safer NHS, and not just “short term noise”.  But it seems from the escalating stream of news about NHS staff shortages, increasing rationing, service closures and repetition of the same clinical failures that although Mr Hunt loudly banged the patient safety drum, patients have in reality not been protected.
Professor Brian Jarman rightly described the NHS as a denial machine.  It remains so. Until there is mature political leadership of the NHS, based on evidence, diligent governance and just culture as opposed to hot air about just culture, this will continue.
 From a blame culture to a learning culture. Speech by Jeremy Hunt, 10 March 2016
Pauline Lewin accused Phil Morley of bullying after she was suspended
Mrs Lewin’s complaint was ruled out due to insufficient evidence
Her actions were the catalyst to unseat Mr Morley from his position
She was too traumatised to return to work until a settlement was reached
Now she has received £257,000 in damages which includes holiday pay
An NHS whistleblower, whose 40-year career came to an end when she accused a hospital chief executive of bullying, has been awarded a payout of more than £250,000.
Pauline Lewin accused the former boss of Hull and East Yorkshire Hospitals NHS Trust, Phil Morley, of bullying after she was suspended for using the wrong guidelines on a redundancy settlement.
Mrs Lewin, who was a director of estates and facilities at the time, lodged an official complaint but it was ruled that there was insufficient evidence.
However sources say her actions were the catalyst to unseat Mr Morley as his departure from the trust came in April 2014 – just weeks before the CQC uncovered a ‘culture of bullying’ at his hospitals.
Mrs Lewin revealed she was too traumatised to return to work until a settlement was reached – and she retired in July 2015.
Now she has received £257,000 in damages which include holiday pay, salary, a contractual payment over the severance of her contract and a non-contractual payment of £120,000.
Speaking about the payout, Trust chairman Mike Ramsden said: ‘We felt, overall, that the right thing to do was to draw a line under some of the difficult problems of the past.
‘Sometimes, payments taking into account enhancements and entitlements and that can be a lot of money over a period of time. It’s not all one cheque, it’s ongoing and we are mindful of our responsibility over the use of taxpayers’ money.
‘None of us want to see an offer made at all – we want to recruit staff who will do a great job and stay with us but, occasionally, this happens.’
Mrs Lewin was on the Department of Health’s Estates Policy Advisory Committee and was the Northern and Yorkshire representative on the National Council for HEFMA – the professional body for estates and facilities management within the NHS.
However she was suspended by Mr Morley in July 2013 after she was accused of breaching new guidelines over a redundancy offer to a member of staff – although evidence showed the guidelines were only issued after her suspension.
While Mrs Lewin was too traumatised to go back to work she was supported by Hull MP and former Health Secretary Alan Johnson and health union Unison.
A former key ally of Mr Morley, chief of workforce and organisational development Jayne Adamson, also received a pay-off of more than £115K following her redundancy.
Jayne was in charge of the 8,000-plus staff at Hull Royal Infirmary and Castle Hill Hospital.
Sources say her actions were the catalyst to unseat Mr Morley as his departure from the trust came in April 2014 – just weeks before the CQC uncovered a ‘culture of bullying’ at his hospitals
A series of investigations began early in 2014 just before Mr Morley’s departure – and weeks before a Care Quality Commission (CQC) report uncovered a ‘culture of bullying’ at both hospitals.
A KPMG report revealed Jayne had been awarded £8K ‘relocation expenses’ by the trust when she took up her post in Hull in 2011 – eight months after Mr Morley took over as chief executive.
But she never moved house – and was later forced to pay the back the money.
Mrs Adamson was made redundant at the end of 2014 following the arrival of new senior staff members.
The trust’s annual report shows Mrs Adamson received a salary of £34,944, £10,337 in lieu of annual leave and £70,000 in compulsory redundancy.
The trust paid out £1.2m in exit packages after staff quit their jobs – and Mrs Adamson was one of 18 compulsory redundancies.
The annual report states: ‘Following a board restructure, the post of chief of infrastructure and development no longer exists.’
Freedom of Information was requested by Fiona Bell @Unity_portal to Mersey Care NHS Foundation Trust regarding compromise agreements. The response was a staggering 443. This is the number of staff who have been paid not to take matters forward. Many would been whistleblowers raising of concerns – some serious which had resulted in dismissal.
What is a settlement agreement?
Settlement agreements (previously known as compromise agreements) are legally binding agreements, which are normally used to settle disputes on the termination of employment.
Once you sign a settlement or compromise agreement, you will not be able to pursue any potential claims that you may have against your employer. Settlement agreements often contain a full and final settlement clause under which you agree to accept a cash lump sum payment in return for giving up any claims arising from your employment or its termination.
Further to your Freedom of Information request in respect of compromise agreements, please find a reply below.
Please can you advise me in regards to the last 5 years?
How many compromise agreements has the trust entered into with staff or former staff?
COMPROMISE AGREEMENTS WITH STAFF/FORMER STAFF
443 (including 441 MARS)
How many of these compromise agreements require staff members not to discuss the existence of the compromise agreement itself?
The total amount of 443 staff members (including 441 MARS) are required not to discuss the existence of the compromise agreement itself.
How many of these compromise agreements contain non-disparagement clauses that require staff members not to criticise the employees of the trust?
As above, the 443 staff members (including 441 MARS).
If you are unhappy with the way your request for information has been handled, you can request a review by writing to:
Information Governance Manager
Mersey Care NHS Foundation Trust
This represents vast sums of monies which has been paid for by the taxpayer which should have been used for patient care in the NHS. Instead this has been used to ‘shut up’ staff and ultimately destroy their careers. The cost will not only be the sum paid to individual staff but will include vast sums spent on legal fees. The cost is of course far higher if loss of valuable staff member from the workforce is considered.
By Dr Minh Alexander, NHS whistleblower and former consultant psychiatrist, 29 July 2016
In the six years of its much-criticised life, CQC has been part of the NHS denial machine. Its decisions have been exposed as overtly politicised on some occasions , and suspected as such on others. Its ratings are questioned for their methodology, and because people think they can be arbitrary, and either unfairly severe or unduly lenient. CQC has sometimes failed to detect – or report – gross safety failings such as those at Southern Health NHS Foundation Trust. 
In November 2014 the CQC assumed a legal duty under Regulation 5 Fit and Proper Persons (FPPR) to assure that trusts appointed Fit and Proper directors and that existing directors continued to be Fit and Proper Persons. Under FPPR, directors who have been guilty of – or privy to – serious misconduct and mismanagement, may be removed. 
In December 2014 other NHS whistleblowers and I took part in a teleconference with Mike Richards CQC Chief Inspector – who was going to chair CQC’s FPPR panel – and his entourage to find out how CQC intended to run FPPR. This was not encouraging as the Chief Inspector made comments such as CQC action would depend on the “level” of whistleblower reprisal. Before a single shot had been fired, he asserted that it would not pass in the “Court of Public Opinion” if too many managers were removed under FPPR.
The Chief Inspector subsequently demonstrated impressive reluctance to remove seriously erring NHS managers. To my knowledge and others’, not a single director has been removed under FPPR. CQC has in a handful of cases triggered investigations – but allowed trusts to commission and direct these investigations. At Southport and Ormskirk where at BME doctors complained of unfairness and mistreatment, and 30 consultants
had written to complain of a bullying culture, CQC rubber-stamped such an FPPR investigation as sound.  This was followed only three months later by suspension of the CEO and 3 other managers. CQC also rejected an FPPR referral on Southern Health NHS Foundation Trust, only for this to be seriously questioned by the revelations of the Mazars report that hundreds of unexpected trust deaths had not been investigated.   The outcome of a re-referral is awaited, whilst more revelations came today from the BBC about millions paid by the trust to the Chief Executive’s former associates. 
An FOI request in May 2015 confirmed that CQC had received referrals on 65 NHS managers, including 14 individuals reported to have suppressed whistleblowers, but it did not take action to remove any of these 65 managers.   
An update FOI request was made in May this year, but CQC has refused to provide this data on grounds of cost, even though it had already announced plans to review its use of FPPR. When asked, CQC failed to say what data it would be prepared to provide within the cost limits.
Also interesting is the fact that trusts may appeal against CQC’s decisions on FPPR, but in response to an enquiry, CQC’s Chief Executive David Behan stated that referrers may not.  However, I am told that in at least one case, CQC has undertaken a review in response to a referrer’s objections. So much then for equitable and consistent decision -making.
CQC’s performance on FPPR has not gone unnoticed. Health Committee has noted the concerns reported to it for the next accountability hearing with CQC. After the recycling of Paula Vasco-Knight at St. George’s, with Monitor’s involvement by allowing her into their interim pool, CQC was caught very, very short when she was suspended over financial allegations. Soon after that CQC admitted that there were legitimate concerns over its handling of FPPR, and that questions had been asked about why CQC was only tick boxing trusts’ FPPR process, when it should also have been looking at the soundness of FPPR decisions. CQC announced that it would review itself with regard to FPPR.  This will most likely take the path of past CQC internal reviews. For example, that relating to CQC’s poor response to Homerton maternity risks and whistleblowers’ warnings, which implausibly found no serious error. 
The recent parliamentary debate on the Liverpool Community Health NHS Trust scandal exposed the active complicity of regulators in recycling some poor NHS managers, even to the extent of misleading an MP about what they had done. 
It is worth taking the microscope to CQC’s lamentable role in the Vasco-Knight business. Paula Vasco-Knight was Chief Executive of a trust, South Devon Healthcare NHS Foundation Trust, which was severely criticised for harming two whistleblowers who raised concerns about nepotism by Paula Vasco-Knight. She resigned from that trust in 2014 after a damning Employment Tribunal judgment against the trust    but within months she had been recycled by the NHS. Controversially, she worked on an interim basis for another trust at a cost to the public purse £248K.  By September 2015, she was hired as interim Chief Operating Officer by St. George’s University Hospitals NHS Foundation Trust. The trust informed me that in appointing her, “references were taken from Monitor, which had provided support for the Monitor FPPT process”. Monitor informed me: “The business referees put forward, from whom references had been sought and obtained, all held senior roles in the NHS trusts that Paula Vasco-Knight had recently worked for, including East Lancashire Hospitals NHS Trust”.
In October 2015 I made an FPPR referral on Paula Vasco-Knight to CQC, and received a curt acknowledgement which effectively said “Don’t call us, we’ll call you”.  But months passed and there was no call. I made an enquiry at the end of February 2016 about progress, which was acknowledged by CQC, but no still substantive response followed. In the meantime, on 25 April, St. Georges disclosed a letter from Mike Richards to the trust dated 16 February 2016, closing down the FPPR process on Paula Vasco-Knight.  As you can imagine, I was very concerned that CQC appeared to have avoided giving me a straight answer about what it had done, during which time St. George’s announced on 22 April that Ms Vasco-Knight had been promoted to interim Chief Executive. Clare Sardari, one of the South Devon whistleblowers wrote an open
letter on 26 April to St. George’s governors, protesting the appointment of Paula Vasco-Knight to Chief Executive. 
The house of cards soon tumbled when on 3 May St. George’s announced that it had suspended her “…the acting chief executive of St George’s was suspended from her role on Friday because of serious allegations being made against her relating to a previous employment. Suspension is required in such circumstances but it is a neutral act….The allegations are financial in nature and relate to her work at a previous employer”.  On 20 May the Health Service Journal reported that CQC had indicated that it was looking into “whether St George’s had carried out its duty under the fit and proper person regulations” (CQC email 19 May). 
I was therefore somewhat perplexed when St. Georges advised on 27 July that it had in fact terminated Paula Vasco-Knight’s agency contract on the day it suspended her – or it seems in plain English, sacked her.  Why then did St Georges continue to refer only to suspending her? On 5 May the trust reportedly stated: “As a result of serious allegations being made against her, Dr Paula Vasco-Knight has been suspended from her role as acting chief executive at St Georges University Hospitals NHS Foundation Trust”.  Why did CQC say it was looking into her appointment, in terms of compliance with FPPR, when it has in the past insisted that it can only apply FPPR to current directors? (I had specifically asked CQC in 2015 if it would run a disclosure and barring scheme for ex NHS directors who might return to the NHS, but CQC indicated that it had no intention or remit to do so).
So, did CQC claim on 19 May that it was conducting a review of FPPR in relation Paula Vasco-Knight’s appointment on 20 May, over 2 weeks after her contract with St George’s had been terminated, simply to spin an impression that CQC was doing “something”?
And why does CQC say one thing about the limit of its jurisdiction on FPPR, but then do the opposite?
The whiff of arbitrariness has not been dispelled, and is a most unfortunate quality in a regulator.
I hope Health Committee looks very closely at all this, and insists on more robust governance than the usual CQC “lessons NOT learned” internal review. Patients’ lives depend on competent, honest NHS management and regulation.
 Labour’s cover up on failing hospitals: Ministers tried to silence watchdog on eve of general election. Sophie Borland, Daily Mail, 3 October 2013
Rapid response by Dr Peter Wlimshurst BMJ 18 July 2016
Quis custodiet ipsos custodes I have considerable doubts whether the GMC’s proposed changes to fitness to practise procedures as outlined by Anna Rowland will benefit either patients or doctors. I am surprised by the GMC’s claim that the proposals have received positive feedback from patients. The GMC Patient Leaders Roundtable scheduled for 21 June 2016, at which some of these issues were tabled for discussion, was cancelled by the GMC at one day’s notice “due to unforeseen circumstances” and has not been rescheduled.
I have considerable concerns about the GMC’s plans to pass responsibility for some procedures to employers for two reasons.
1. There are many examples of employers concealing or failing to take prompt action in response to poor clinical care and dishonesty by doctors either to protect the reputation of their institutions or to prevent patients becoming aware of events that might cause the trust to pay compensation. In some cases it took years before miscreant doctors (e.g. A K Banerjee and C Handler) were removed from the medical register.[2,3] In the latter case, the Medical Director of the trust involved in the cover up was a GMC member. It is clear that in many cases the interests of institutions are placed before patient welfare.
2. Institutions have misused disciplinary procedures, including GMC procedures, to silence those who raise concerns. Some trusts employed private detectives to spy on whistleblowers. Others secretly searched through the computers, the desks and even the waste bins of whistleblowers to find something incriminating to use against them. A secret audit of a consultant’s practise by an external clinician has been used. When all those turn up blank, trusts have suspended whistleblowers on fictitious charges. From working with Patients First I know that such spurious suspensions allow trusts to claim that doctors have become deskilled, so that they can no longer be employed or revalidated.
In some cases trusts have made complaints to the GMC about whistleblowing doctors and after a year or more the GMC has dropped the case when the trust failed to provide any evidence. In other cases, trusts have offered to withdraw allegations made to the GMC provided that the whistleblower agreed to withdraw concerns that they had made about patient safety.
There are valid concerned about doctors who died during GMC investigations. Some of those deaths were the result of allegations made by trusts as a result of the types of institutional misconduct described above.
1. Rowland A. GMC review of procedures is complete. BMJ 2016;354:i3654. [See also rapid responsehttp://www.bmj.com/content/353/bmj.i1925/rr ]
2. Wilmshurst P. Poor governance in the award of honours anddegrees in British medicine: an extreme example of a systemic problem. BMJ 2016;352:h6952.
3. Wilmshurst P. No doctor should be untouchable. BMJ 2013;346:f2338.
4. Dyer C. Whistleblower who was excluded from work for five years wins apology from employer. BMJ 2008;336:63.
Competing interests: I was reported to the GMC and investigated for disparagement after I reported the concerns of a national committee that I chaired about misconduct in research.
Some of our concerns were later found proved (i.e. that the research did not have ethics approval and patients did not give informed consent), but the GMC said that they were unable to investigate our allegations that some data had been falsified because the institution refused to allow the GMC sight of the data. The GMC did not use its legal powers to compel disclosure (though the GMC has threatened whistleblowers with High Court injunctions forcing them to disclose documents). I am a member of the steering committee of Patients First, which has collected details of the experiences of whistleblowers. I have supported a number of doctors whose employers made spurious complaints to the GMC.
Mirror 18 JUL 2016 BY ANDREW GREGORY , SIMON KEEGAN
Scottish National Party MP Philippa Whitford warned that “what comes back from whistleblowers I meet is they are concerned that the person who has been appointed is an NHS manager.”
Jeremy Hunt has been warned patients face a “risk of harm” because his new NHS whistleblowing tsar is not “independent” enough.
Dr Henrietta Hughes was given the top job to prevent another Mid Staffs scandal – where up to 1,400 patients died – earlier this month.
The Health Secretary has been told patients may suffer if she cannot persuade medics to raise the alarm with her over safety issues.
But Mr Hunt, who pledged to protect whistleblowers, has been told medics “feel a concern that she comes from the NHS corporate culture that has failed them for many years”.
That means they may be less likely to feel safe raising concerns about NHS safety issues with her office – thereby putting patients at risk. Dr Hughes, set to take up her new role in October, is Medical Director for NHS England North Central and East London, which oversees 12 NHS trusts in the capital.
Speaking in the House of Commons last week, Scottish National Party MP Philippa Whitford warned that “what comes back from whistleblowers I meet is they are concerned that the person who has been appointed is an NHS manager.”
She added: “We have to have someone who is utterly outside the system.”
London GP Dr Henrietta Hughes The first person appointed to the role of National Guardian, Dame Eileen Sills, quit before she began in March, nine weeks after the Daily Mirror revealed she would be part-time.
We told earlier this month how health watchdog the Care Quality Commission had sparked yet more anger by appointing another part-timer, Dr Hughes, as her replacement.
Dr Hughes will do a four-day week, and will keep two NHS jobs as a GP and GP appraiser. She will step down as Medical Director for NHS England North Central and East London.
But critics fear the fact that Dr Hughes has held a senior role at NHS England could deter medics from raising the alarm about patient safety.
The Daily Mirror can also reveal today (MON) that the panel of health chiefs who appointed Dr Hughes included representatives from NHS England.
Dr Whitford, a surgeon who is the SNP ’s Westminster health spokesperson,
added: “The feedback that I have had from whistleblowers is that they see the new replacement National Guardian as someone who is in an NHS manager role, and they feel that that is not sufficiently independent for the National Guardian for whistleblowers.”
In a letter to Mr Hunt, one of Britain’s leading NHS whistleblowers said she shared Dr Whitford’s concerns about Dr Hughes.
Dr Minh Alexander said “whistleblowers naturally feel a concern that she comes from the NHS corporate culture that has failed them for many years”.
The former consultant psychiatrist, who was forced to quit after she exposed abuse at a mental health trust in Cambridgeshire, added: “Whilst I do not suggest any such impropriety by Dr Hughes, perception and trust are all in creating a safe environment for staff to speak up.
“Effective NHS whistleblowing governance is a key component in preventing further Bristols, Mid Staffs and Liverpools, but we are a very long way off from safe culture and systems.
“As long as staff remain too frightened to speak out, patients will be at risk of harm.”
Dr Hughes could not be reached for comment at the weekend.
But in a statement issued when she was appointed earlier this month, she 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.
“It requires a great deal of courage, honesty, and selflessness to ‘blow the whistle’. People should never feel that they are at risk of punishment when advocating better and safer care for patients.”
In a statement hailing her appointment, also issued earlier this month, Mr Hunt said: “The appointment of Dr Henrietta Hughes as National Guardian is an important step in our ambition to create a more open and honest culture in the NHS.
“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.”
The job of National Guardian was a key demand originally made in February 2015 by Sir Robert Francis. He had previously led the inquiry into the Mid Staffs scandal.
Mr Hunt eventually confirmed five months later, in July 2015, that he would act on the recommendation, but then palmed off the creation of the post to the Care Quality Commission.
The CQC has since faced criticism for twice appointing a part-timer to the role.
Mr Hunt, who sparked surprise when he kept his job last week following a reshuffle by new PM Theresa May, faces criticism for putting the CQC in charge of the job in the first place.
In her letter to Mr Hunt last week, Dr Alexander said: “I am afraid that whistleblowers do not find that the CQC is truly independent, and in fact usually view CQC as part of the problem.
“Therefore, the majority of whistleblowers do not feel that the Department of Health’s choice of CQC as a host for the National Guardian is appropriate.”
New figures show that 287 deaths were recorded as ‘unexpected’ at the North Middlesex Hospital over a two-year period from 2014-15
North Middlesex Hospital in Edmonton North Middlesex Hospital, where recent deaths are higher than the national average
A scandal-hit NHS trust faces a new probe into whether it is to blame for the deaths of nearly 300 patients, the Sunday People can reveal.
New figures show that 287 deaths were recorded as “unexpected” at the North Middlesex Hospital over a two-year period from 2014-2015.
Many of those were vulnerable elderly people who needed support to ensure they drank and ate properly.
The deaths are contained in official Department of Health figures and show the hospital’s death rate is higher than the national average.
It was the collection of such data by Imperial College London that helped expose the high death rates at Stafford Hospital. It had as many as 1,200 additional deaths between 2005 and 2009.
Ambulances outside the A&E department of the North Middlesex Hospital in Edmonton
Last week, Care Quality Commission inspectors found more failings in the North London hospital’s A&E department after two visits in a month.
In February the Sunday People exposed the dreadful care in the hospital’s A&E after a Tannoy announcement told 100 people waiting to see a doctor to go home and come back in the morning unless they were dying.
In their latest visit, CQC inspectors learned that a patient had lain dead in A&E for four hours after staff failed to monitor him.
They also found a lack of consultants and nurses seeing patients who arrived by ambulance. And an untrained receptionist was deciding which patients saw A&E doctors.
On elderly wards, inspectors found evidence that patients were probably being deprived of food and fluids.
John JamesProfessor Sir Brian JarmanProfessor Brian Jarman helped expose the high death rates at Stafford Hospital
Records showing how much a patient drank or ate were not kept, and routine medical checks were not performed.
Patients were also getting the wrong drugs. Inspectors also found evidence of abuse of patients by staff. Many of those who died at Stafford were elderly people starved of fluids and food.
The CQC singled out failures to give fluids and food on North Middlesex’s Charles Coward ward when it failed its care of the elderly unit in 2014.
Professor Brian Jarman, who helped expose the high death rates at Stafford Hospital, said: “What is going on at North Middlesex is very worrying.”
Last January, an NHS whistleblower visited Charles Coward ward and wrote to Trust chief Julie Lowe, Health Secretary Jeremy Hunt and CQC chairman David Prior. She raised concerns about patient safety but they were apparently ignored.
Prof Jarman, of Imperial College London, said the death figures were reminiscent of Stafford and urged the CQC to mount an urgent inspection of the hospital.
He said: “They need to quickly find out what is going wrong to prevent more deaths. It is two years since the last inspection and the hospital doesn’t seem to be improving.”
Shadow Health Secretary Diane Abbott said: “These figures are a scandal. Since the closure of nearby Chase Farm hospital’s A&E unit, North Middlesex has failed to cope.”
Sunday People page 5 – February 21st 2016
Last year three patients died as a result of A&E blunders at the North Middlesex. Concern over the safety of A&E patients has led to ambulance crews being told not to use it at night.
North Middlesex Hospital was failed by CQC inspectors in 2014. Just days before, local MP David Burrowes nearly died from a burst appendix after he was left on a trolley in A&E for 12 hours.
A spokesman for the North Middlesex said: “We are working with the CQC to make sure we improve.”
But hospital boss Lowe is on leave. Another NHS manager has taken over.
The Department of Health said: “Recent incidences of poor care at North Middlesex are unacceptable. The situation must change and quickly.”
The Medical Director for NHS England’s North Central and East London region and practising GP, Dr Henrietta Hughes has been appointed as the new National Guardian for speaking up freely and safely within the NHS.
Dr Hughes is a practising GP with over twenty years of experience across primary, secondary and community healthcare. She has been Medical Director for NHS England’s North Central and East London region since April 2013, in which she provides system leadership across 12 clinical commissioning groups and 12 NHS trusts, and she is the Responsible Officer for nearly 3,000 GPs.
Dr Hughes’s selection for appointment was made by a panel consisting of representatives of CQC, NHS England and NHS Improvement, as co-sponsors for the National Guardian’s Office, as well as the Patients Association and Sir Robert Francis QC, whose independent review from February 2015 into ‘whistleblowing’ across the NHS instigated the creation of the National Guardian role.
As the National Guardian, Dr Hughes will help to lead a cultural change within NHS trusts and NHS foundation trusts, so that healthcare staff feel confident and supported to raise concerns about patient care at all times.
This will include leading, advising and supporting the growing network of ‘Freedom to Speak Up’ Guardians within NHS trusts who are responsible for developing a culture of openness within their hospitals. Also, as the National Guardian, she will share and advise on good practice in responding to staff concerns, and provide challenge and support for the system so that it has a truly safe and open culture.
Dr Hughes is expected to take up the role in October 2016. She will be supported by a small office of staff, which is already in operation with an interim team.
Commenting on the appointment, David Behan, Chief Executive of the Care Quality Commission, said: “I am very pleased that Henrietta has accepted the position of National Guardian.
“The need for the NHS to have a positive reporting culture, which encourages and supports its staff to raise concerns about care without fear of reprimand has been stressed time and time again and now must become common practice.
“Leading the healthcare system on this journey alongside the Freedom to Speak Up Guardians within NHS trusts will be a core aim of the National Guardian and her office, so that ultimately, patients can get the safe, high-quality and compassionate care they deserve.
“The role requires strong leadership, trust and a clear understanding of the NHS and the challenges its staff face in raising concerns. I am confident Henrietta will bring all of these qualities in abundance as the National Guardian and I look forward to working with her in this capacity.”
Dr Henrietta Hughes, incoming National Guardian for the NHS 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.
“It requires a great deal of courage, honesty, and selflessness to ‘blow the whistle’. People should never feel that they are at risk of punishment when advocating better and safer care for patients.
“As a practising GP and with my experience in the NHS, both on the frontline and at leadership levels, I understand the challenges that lie ahead.
“Together with my office, the growing network of Freedom to Speak Up Guardians in NHS trusts, our national partners, and anyone else who has an interest in supporting and protecting staff who wish to speak up, I look forward to driving forward this agenda of openness.
“I want staff to always feel listened to regardless of where they work within the NHS, so that we can see real improvements in patient safety and staff experience. This is a real opportunity to work towards making that a reality.”
Health Secretary, Jeremy Hunt said: “The appointment of Dr Henrietta Hughes as National Guardian is an important step in our ambition to create a more open and honest culture in the NHS.
“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.”
Sir Robert Francis, CQC board member and author of the ‘Freedom to Speak Up’ review, said: “No service can be effective without listening to and acting on the concerns raised by its staff, let alone one which employs such skilled and dedicated people as the NHS. They are the lifeblood of the service, and the lifeline for their patients.
“However, the evidence clearly shows that many staff are fearful of speaking up. It is important that every part of the NHS develops a culture in which it is entirely normal to raise issues about safety, quality and effectiveness of the service, for those issues to be addressed and for those who raise them to be protected from any adverse consequences arising out of their disclosures.
“I believe that the National Guardian, her office and the network of Freedom to Speak Up Guardians all have an invaluable role to play in supporting these changes.
“I would like to congratulate Henrietta for her appointment as National Guardian. She displays a genuine commitment to want to make a real difference to the lives of NHS staff and their patients. With her leadership, I am confident that she and her office can make great strides in achieving that.”
Ruth May, Executive Director of Nursing at NHS Improvement, said: “I would like to welcome Dr Henrietta Hughes as the new National Guardian. Her extensive clinical experience and expertise means she has the know-how to encourage the growth of the Freedom to Speak up Guardian’s network. Alongside the guardians, I am sure she will provide the leadership to ensure that a culture of openness within NHS trusts flourishes.
“Whistleblowers can play a crucial role in making sure that the NHS delivers the highest standard of care to patients day in, day out. If we all continue to do our part to safeguard the freedom to speak out, NHS staff will feel more confident to share vital information that can prevent the risks of harm to patients.
“I look forward to working closely with Dr Hughes, and our partners, to help NHS staff feel free and safe to speak out.” Professor Jane Cummings, Chief Nursing Officer of NHS England, said: “I welcome the appointment of Dr Henrietta Hughes as the new National Guardian and look forward to working with her. The experience she brings to this role will be key in delivering an open and transparent health service. Providing all staff with the confidence and means to speak up is an essential part of providing high quality care to all.”
Katherine Murphy, Chief Executive of the Patients Association, said: “The Patients Association endorses Henrietta’s vision for NHS where staff feel valued and supported and where patients are treated safely and with dignity. Through our national helpline we not only hear from patients but also increasingly professionals working within services who feel they have nowhere else to turn. We welcome Henrietta’s appointment to this important national role and look forward to working closely with her to help deliver her vision.”
For media enquiries about the Care Quality Commission, please call the press office on 020 7448 9401 during office hours.
Also, follow the team on Twitter for the latest national announcements: @CQCPressOffice.
Journalists wishing to speak to the press office outside of office hours can find out how to contact the team here:www.cqc.org.uk/media . (Please note: the duty press officer is unable to advise members of the public on health or social care matters).
For general enquiries, please call 03000 61 61 61.
2. Biography: Dr Henrietta Hughes is Medical Director for North Central and East London at NHS England and a practising GP. Her role at NHS England is a commissioning and assurance role as Responsible Officer for nearly 3,000 GPs, with 12 clinical commissioning groups and 12 acute, specialist and mental health providers. She is the clinical lead for mental health for London region in NHS England. Prior to that, Dr Hughes was the Acting Medical Director in the North Central London Cluster, the Associate Editor of the Journal of Family Planning and Reproductive Healthcare, and the Lead Appraiser at Camden Primary Care Trust. She has experience in hospital and community roles as well as in primary care. Dr Hughes is passionate about improving the quality of care for people in England by disseminating good practice, improving the skills and reflection of staff and by managing variation in quality. She has experience of working with individuals and organisations in difficulty and brings a formative, learning and reflective approach which helps to create a sense of calm and purpose to support staff morale and bring improvement. She has published articles on a wide range of health related issues and written chapters in two books.
3. Dr Henrietta Hughes will serve as National Guardian for four days a week, primarily from the office in London and she will continue to work as a GP and GP appraiser. Her salary as National Guardian will be £105,040 per annum. She replaces Dame Eileen Sills who stood down as National Guardian in March 2016.
4. The need for an independent National Guardian for the NHS was highlighted in Sir Robert Francis’s ‘Freedom to Speak Up’ review in February 2015, which found that patients could be put at risk of harm because vital information about mistakes and concerns was not being raised by NHS staff routinely. The review found that reporting systems were either insufficient or not used or because healthcare professionals did not feel able to speak up. The creation of the National Guardian was one of the key recommendations from this; an arrangement which the Secretary of State for Health confirmed in July 2015. For further information about Sir Robert Francis’s Freedom to Speak Up review, please visit: https://www.gov.uk/government/publications/sir-robert-francis-freedom-to-speak-up-review
Inspectors with the Care Quality Commission (CQC) rated the hospital’s urgent and emergency care services as “inadequate”.
Staff at the hospital told inspectors they were worried about patient safety because of the competency of middle-grade doctors. These doctors were often left in charge of the emergency department overnight – with no consultant presence in the department after 11pm,inspectors were told.
The hospital’s chief executive, Julie Lowe, is believed to have secretly quit following the findings.
Staff have said Ms Lowe is on “leave” but a source inside the hospital claimed she was, in fact, ousted by NHS chiefs appalled at her leadership.
Inspectors also found vital equipment, including a portable resuscitation trolley, was often missing or broken.
Walk-in patients were seen by a receptionist, who judged if they were suitable for the urgent care centre or needed to go to the main emergency department, according to the CQC’s report.
The unit logged 22 serious incidents in the past year, the BBC reported, including the failure to discover the dead patient.
When we inspected we found that patients were waiting for a long time to be seen, without being assessed by a doctor in the first placeSir Mike Richards
Others included a patient being left sitting on a bedpan for more than an hour, the broadcaster reported.
In August 2014, David Burrowes, MP for Enfield Southgate, told the Mail on Sunday how, despite arriving with a burst appendix, he was left on a trolley “curled up in pain” for 12 hours in the “chaotic” A&E before being treated.
The MP said he was “dismayed but not surprised” by the report.
“Whilst I recognise that the hospital has now turned the corner with new clinical leadership and consultants and doctors, it has taken far too long to respond to the siren calls made for over two years,” he added. “It is hugely disappointing that the CQC has found that the A&E has got worse since 2014.”
He said his constituents had been let down and said assurances of support must be “urgently delivered”.
The report added: “Members of staff told us there was a culture of not calling consultants out at night. They said that middle grade doctors seemed to assume that it was acceptable to leave patients in ED (emergency department) overnight, thus treating it as if it were a hospital ward.”
Meanwhile nurses told inspectors they spent a “substantial amount of time supporting and advising more junior doctors”.
In recent weeks it has emerged that the General Medical Councilissued preliminary warnings to North Middlesex Hospital leaders because of a lack of training for junior doctors.
Sir Mike Richards, CQC’s chief inspector of hospitals, said: “People going to the emergency department at the North Middlesex University Hospital NHS Trust are entitled to a service that provides safe, effective, compassionate and high quality care. When we inspected we found that patients were waiting for a long time to be seen, without being assessed by a doctor in the first place.
“North Middlesex University Hospital is one of the busiest A&E departments in London – so it is worrying that we found that there were not enough experienced doctors on call to deal with demand. We have strongly encouraged the trust to engage with other organisations across the local health and social care system to resolve this challenging issue.”
He added that a new leadership team was in place and the trust has called on consultants from within the hospital to provide routine daily support to A&E.
“The evidence from our latest inspection last week is that North Middlesex’s emergency department has turned a corner, but there is still much more that needs to be done. We will be watching their progress very closely,” he added.
North Middlesex University Hospital said it would receive support in making further improvements in A&E from the Royal Free London NHS Foundation Trust.
“Chief executive Julie Lowe is currently on leave,” the hospital added in a statement.
“In her absence, Libby McManus, currently at the Royal Free London NHS Foundation Trust and previously the interim chief executive at Chelsea and Westminster Hospital NHS Foundation Trust, has agreed to take on the role of interim chief executive at North Middlesex from Thursday July 7, with David Sloman, chief executive of the Royal Free, taking on the role of accountable officer on an interim basis.”
Dr Cathy Cale, the North Middlesex University Hospital medical director, said: “We are extremely sorry for the current problems in A&E and for the long waiting times for some patients.
“We are committed to getting back to the standards that we and our patients expect and, working with our health partners, are taking all the necessary steps to address the concerns raised, particularly the shortage of doctors which lies at the heart of it.”
In a joint statement, Niall Dickson, chief executive of the General Medical Council (GMC), and Professor Ian Cumming, chief executive of Health Education England (HEE), said: “Significant concerns have been raised about the care provided in the emergency department at North Middlesex University Hospital Trust and about the lack of proper support for and supervision of doctors in training.
“We are pleased to see that a number of key improvements have already been made and a programme of further measures is being put in place over the next few weeks.”
Accepting “there is more to be done” to cope with pressure, they added:
“In the meantime the GMC and HEE – the two organisations responsible for postgraduate medical training – have placed conditions on the continuation of medical training posts in the emergency department and the situation will be closely monitored with daily rigorous checks.
“We have made it clear that we will not hesitate to act if we consider patients or staff are being put in unsafe situations.”
An independent report on New Cross Hospital’s botched investigation into a whistleblower’s claims cost the NHS nearly £180,000, it can be revealed.
A report on New Cross Hospital’s handling of a whistlebower’s claims cost the NHS nearly £180,000.
Investigative consultants Verita were called in to look at New Cross bosses’ handling of Sandra Haynes-Kirkbright’s allegations relating to an alleged cover up over mortality rates.
A Freedom of Information request by the Express & Star reveals the firm was paid £134,879 for producing the report, with a further £42,688 spent on legal fees.
The total figure of £177,567 has been branded a ‘scandalous waste of taxpayers’ money’ by a prominent city councillor, while Walsall Manor Hospital whistleblower Dr David Drew said he was appalled that such vast sums had been ‘squandered’ rather than being spent on patient care.
Verita’s inquiry led to calls for the trust’s chief executive David Loughton to stand down over his treatment of Mrs Haynes-Kirkbright.
It found that the Royal Wolverhampton NHS Trust’s investigation into claims of malpractice was ‘significantly flawed’ and criticised Mr Loughton for being ‘dismissive’ of the allegations.
The report was completed in March 2015 but publication was delayed for more than a year while the NHS Trust Development Authority engaged legal advice on issues regarding publication.
Councillor Milkinder Jaspal, chair of Wolverhampton council’s health and scrutiny panel, said: “This is a report that should never have been required in the first place.
“If the trust had done its job and investigated these claims properly we wouldn’t be left with this scandalous waste of taxpayers money. This is money the NHS can ill afford in the current climate.”
Mrs Haynes-Kirkbright claimed she had been head-hunted to ‘fix’ mortality rates and alleged she was suspended after she refused to take part in a cover-up.
She has been suspended on full pay from her £54,000-a-year role since 2012 and still has an internal disciplinary charge hanging over her.
Dr David Drew said: “This is just the latest example of David Loughton being involved in a situation that leads to the NHS squandering huge sums of money.”
NHS Improvement spokeswoman Rebecca Salari, said: “Due to its complex nature, the review process took longer than anticipated. However, it has produced a number of important findings and identified some additional governance issues that require dedicated and focused consideration.”
An employment tribunal ruled Dr Kevin Beatt was wrongly sacked by Croydon Health Services NHS Trust
The legal saga of a whisteblower doctor sacked by Croydon’s NHS trust after voicing fears about patient safety has taken a fresh twist.
Kevin Beatt, former consultant cardiologist at Croydon University Hospital, has been granted leave to appeal a High Court ruling that he must face a fresh employment tribunal.
A 2014 tribunal ruled he had been unfairly dismissed from his job in 2012 after raising concerns about patient safety and staff bullying in the hospital’s cardiac catheter unit, which he ran, following the death of a patient.
Croydon Health Services NHS Trust, which runs the hospital, hired a £5,000-a-day QC to fight the ruling.
It insists it fired Dr Beatt for making “unsubstantiated and unproven allegations of an unsafe service” and successfully appealed to the Employment Appeals Tribunal, which in January ruled the original tribunal decision had not been “properly reasoned”.
But Dr Beatt’s legal team have now won permission to take the fight to the Court of Appeal.
He said: “With all the expense involved, it’s just about the most ridiculous decision that can be made when actually what could have happened and what’s happened in other cases is the court has just sought clarification of the judgment, which would have been a very reasonable way to do it, or for them to go back and contest one issue.
“We decided that in order to avoid that process we would appeal to the Court of Appeal, where three judges will hear it.”
The hearing is not expected to be heard until April, meaning the legal battle is likely to enter into a fifth year.
The trust has spent hundreds of thousands of pounds on legal fees contesting the case and will be forced to pay Dr Beatt a large compensation package if it loses.
Dr Beatt, a respected specialist who led the hospital’s well-regarded department for interventional heart procedures from 2007, argued he should have been afforded protected whistleblower status when he made a catalogue of complaints about staffing shortages, “appalling” equipment and workplace bullying, including at the inquest into the death of a patient during a routine operation.
But instead he lost his job in a case he claimed provided a damning demonstration of the trust’s attempts to cover up failings.
The trust argues Dr Beatt’s allegations amounted to gross misconduct, but 2014 employment tribunal ruled there was “no consistent evidence” of wrongdoing by the cardiologist and concluded the trust had “failed to carry out a fair process”.
Dr Beatt, who is effectively unable to work in the NHS while the legal fight is ongoing, said: “Because [the trust] maintains [it] was right it makes it very difficult for me to get a job.
“What they should be doing is saying they were wrong and the service was unsafe and they should just admit it, but they won’t do that.”
A spokeswoman for Croydon Health Services said: “We are aware of the appeal. We will not comment further at this stage.”
The Mirror 12 JUN 2016 BY MARTYN HALLE , DAN WARBURTON
The Care Quality Commission says there not enough medical staff at the North Middlesex Hospital unit and ordered urgent improvements
North Middlesex Hospital A&E struggled to cope with patients
An A&E unit exposed by the Sunday People for ordering patients to go home unless they were dying has been criticised by watchdogs.
Staff at the North Middlesex Hospital faced criticism after stricken patients were turned away despite waiting up to seven hours on hospital trolleys .
In February a shocking message was broadcast over the loudspeaker system in an alarming new low for the over-stretched NHS .
Patients were told: “We would ask anyone who doesn’t have a life-threatening illness to go home and come back in the morning.”
Our revelations in February sparked an urgent probe by the Care Quality Commission (CQC).
The watchdog found the hospital is struggling to provide a safe and effective service on a daily basis and ordered the trust’s embattled chief executive Julie Lowe to make improvements by August 26.
Inspectors found there were delays in the initial assessment of patients, in their assessment by a doctor and in moving them to specialist wards.
It also emerged there were “insufficient middle grade doctors and consultants”.
A&E units must see 95% of patients within four hours
The CQC’s deputy chief inspector of hospitals, Prof Edward Baker, said: “People going to the emergency department at the North Middlesex University Hospital NHS Trust are entitled to a service that is safe, effective and responsive.
“When we inspected we found that patients were not receiving the quality of care that they should have been.
“We have strongly encouraged the trust to engage with other organisations across the local health and social care system to resolve this challenging issue.
“We will continue to monitor the trust closely, and will be returning for further inspections of the hospital to check that the service has improved.”
Read more: Ambulance trust pays private firm to cover for crews after £50m cuts
In February the Sunday People reported how the department struggled to cope with more than 150 patients.
One eyewitness said he saw more than 100 people in the waiting room in addition to dozens in the treatment areas and cubicles.
At one point there were a dozen patients on trolleys lining the wall along the department because all cubicles were full. Many had been on trolleys for hours.
At 11pm a message went on the tannoy saying that the wait to see a doctor was eight hours for adults and six hours in children’s A&E.
The North Middlesex has one of the worst records in the country for meeting national four-hour treatment targets.
Lack of resources in the NHS is hitting A&E departments
It has struggled to meet demand since the Coalition Government allowed the closure of the A&E at Chase Farm Hospital, six miles away, in December 2013.
Earlier this year we revealed paramedics at North Middlesex were forced to wait for hours in A&E with patients because of a trolley shortage.
The hospital saw 68% of A&E patients within four hours in March, the worst performance in London. It rose to 72% last month, but the NHS target is 95%.
Ms Lowe said: “We appreciate the CQC’s acknowledgement of our difficulties and the impact of the shortage of middle-grade and consultant emergency department doctors, which has led them to issue the warning notice.”
Critics see the failure at North Middlesex as a reflection of a national A&E crisis which many blame on a lack of resources from the Government.
Last November we reported how patients at Northumbria Specialist Emergency Care Hospital, in Cramlington, were waiting for hours in corridors.
And in a separate fiasco, so many ambulances were queuing at nearby Barnet Hospital that they had to park on a roundabout in the hospital grounds.
Cliff Mann, President of the Royal College of Emergency Medicine, said: “More and more A&E units are being failed due to a lack of resources.”