229 comments By David Drew
November has seen a rash of reports of the avoidable deaths of CYP due to poor NHS care and subsequent cover-up. These are depressing reminders of an NHS culture that persists. The common theme is longstanding resistance to the truth about these children's deaths by provider trusts, the failure of any regulator to ensure fair play, and an outcome secured after many years as a result of determined mothers and journalistic support. It turns out that the only way to get a decisive investigation of these "heritage" cases is on the say-so of the Health Secretary.
Four years ago I wrote an open letter to Jim Mackee, then CEO at NHSI:
"NHS Regulators allow Trusts to bury their fatal mistakes: An open letter to Jim Mackey at NHS Improvement."
RCPCH, commissioned to investigate the cases I reported did not investigate any, taking the trusts word on them. They were not given, nor did they ask for any of my documentation. They showed no interest in speaking to me. And were well paid for the report they produced. All consistent with Kirkup.
Finally, where are the UHMBT FTSUGs in all this? They were the solution (under the so-called NGO, although God knows who they guard) Sir Robert Francis proposed almost 6 years ago. An unevidenced solution Jeremy Hunt swallowed hook, line, and sinker. A solution rejected by all NHS Whistleblowers who had suffered at the hands of senior management in such dysfunctional organisations.
"They claimed Mr Herlekar was also redoing some of the wrongly performed operations without escalating concerns.."
Someone has to ask what the patients were told. What kind of informed consent was obtained? The problem with this kind of culture is that patients are kept in the dark. Unable to understand exactly what has happened to them or why, they are unable to raise a meaningful complaint about shoddy or negligent treatment.
We are still waiting for the report on Mr Peter Duffy's mistreatment by UHMBT under Dame Jackie after he raised concerns about patient harm and the competence of his urology consultant colleagues. And now there is clearly need for another inquiry to unravel this can of worms. Leadership is clearly out if its depth and in denial. Patients harmed. Duty of Candour? Concerns ignored. Staff threatened & bullied. Lessons from James Titcombe, Peter Duffy, Sue Allison, Russell. Dunkeld not learned. Claims that they have been learned. Pretence. Spin. Lies.
"A DHSC spokeswoman said: “We profoundly regret any distress caused to Ms Ocloo by our lies and deliberate withholding of vital information.""
Followed by a humble and sincere apology. Then back to business as usual.
And do these inhuman bureaucrats not understand that such barefaced insincerity further compounds this mother's suffering? This is all so typical of many NHS complaints where bereaved families spend years trying to establish the truth only to be rewarded with frustration and a burning sense of injustice. Shame.
Hi Anonymous at 14:11. You're funny. Call me by my given name as though we are friends. But you have no name. No identity. Read Roger Klines comment. That is the context of my own comments. Vexatious whistleblowing has nothing to do with this case. You introduced that. It muddies the water. And you are the one who always asked for clarity.
Confusion here at 8:59 and 9:59. Hard to see why the expression of such opinions has to be made anonymously. Qualifying disclosures are covered in PIDA 1998. The requirement they be made in good faith was removed in 2013. Employees should be grateful when staff raise concerns about serious wrongdoing. Motive is largely immaterial. The whistleblower is protected under law. No employer (or "independent" review mostly) is going to come out and admit a whistleblower has been victimised. That is an admission of law breaking. That is the single greatest difficulty facing sraff who raise concerns.
More to this than meets the eye. The natural instinct of NHSE will be to manage this situation so that no-one's reputation suffers. As usual. Perhaps Stephen Dunn should be appointed to investigate. One good turn deserves another. With the current state of regulation the NHS is going to be saddled with its widespread bullying culture for the foreseeable future.
"Some 81 per cent of respondents were in agreement that the period had had a “detrimental impact on the health and well-being of staff”".
It would be well worth looking at the 19% of respondents (and their organisations) who failed to recognise the impact of the pandemic on staff wellbeing. Including almost 700 who have died. I imagine that might well be a marker of the failure of management and leadership under discussion.
"Research warns pandemic threatens to expose “deficits in skill and confidence of middle managers”"
May I suggest, Annabelle, that this is a wrong perspective. "Promises to expose" is more accurate. Such weaknesses, combined with command and control, are at the heart of problematic NHS cultures that "prevent collaboration, drown out dissenting voices and ultimately undermine compassion and inclusivity.” And patient care and staff morale. This is a good thing. It is a diagnosis which now demands a treatment. The pandemic is not the first or only stress to expose these failings which are in fact widely recognised. Endemic failure in patient care as at Mid Staffs, applications for foundation status, PFI, general underfunding, etc all had the same diagnostic effect. And the same casualties. This report offers one more opportunity to learn from past failings. I will not be holding my breath.
Grateful to Oliver's Mum, Paula for pointing me to this response from North Bristol NHS Trust chief executive Andrea Young: “The staff who cared for Oliver did their very best in managing his complex needs as his health was deteriorating.
“They made decisions, as they do on a daily basis, to weigh up all the risks and sought to give him the best possible treatment."
As with the CCG statement this is not hopeful for learning and improvement as it does not recognise any failing in Oliver's care.
Another dreadful example of a mother having to struggle for years to get an acknowledgement that her child died as a result of NHS failure. Once again a clearcut account of reputational defence by bullying, dishonesty, and publicly-funded legal support. And even now that defence continues:
"A spokesman from Bristol, North Somerset and South Gloucestershire CCG said: “It remains a deep source of regret to us that the McGowan family’s experience of LeDeR was so poor." Is that intended to be an apology? This is a fake apology and likely to cause yet more anger and frustration. Rob Behrens has recently had a public consultation on a new NHS complaints framework. Neither he nor Ian Trenholm at CQC appear to have any standard for what constitutes an acceptable apology. He needs to sort this out. Genuine apologies heal. This kind of wickedness further inflames hurt.
Crass sandwich anyone? Or a commemorative bodge?
Thank you Alison at 12:53. Good coverage. And you are right. It would be unreasonable to hold a CEO who had been in post for 3 weeks responsible for the death of a baby in her hospital due to inadequate care. I don't think anyone has done that. The problem for Susan Acott lies elsewhere. She was CEO during the protracted period when this family, Derek Richford, Harry's grandfather, in particular, was struggling, against significant resistance, to get the truth about Harry's death.
Not only that, there was evidence of victim-blaming which is a well recognised problem in the NHS complaints system. In a letter addressed to North Thanet MP Roger Gale, on 7 June 2019, Susan Acott wrote: "We all fully appreciate and sympathise with Derek Richford. But. Trying to undermine the reputation of the entire hospital and deny it resources doesn't help or improve the situation for future parents and our existing staff however."
Parents and grandparents should not have to fight for the truth over years when, as a result of negligent care, they lose a baby they they have loved and longed for. Nor should they be subject to these false counter-allegations. A criminal prosecution will enable insight to be gained into the inhumane systems that allows this to happen. We should all be grateful for the dogged persistence shown by Derek Richford who refused to take no for an answer.
Thanks anon at 15:14. I do accept much of what you say. Though that would be easier if I knew who you are. But. If it is too much work , too costly, too high a bar and too often not in the public interest for CQC to prosecute breaches of reg 20, there is either something wrong with the statute or the regulator itself. I do agree however that £2.5K is a derisory fine. And even worse it is paid by the Trust (ie taxpayer) and not those responsible for putting families through profound and unnecessary distress.
Lazy police work allows criminals to go free and continue to harm others. We correctly criticise the police for their failure. It is a given that crime is wrong. No need to go there. Anon at 13:13 fails to recognise the regulators responsibility to police the organisational duty of candour. This can be done as part of its work during inspections or following reports of breaches. My own experience is that CQC takes no notice of the latter. Huge sums of taxpayer money is poured into CQC and they have a responsibility to detect and deal with statutory breaches. At least more often than once in 6 years.
Regulation 20 came onto the statute book in November 2014. Six years later and this is the first time CQC has prosecuted an identified breech. It is hard to believe that they do not know of hundreds or thousands of similar if not worse examples.
Good comment from Shaun Lintern on the wider significance of this story this evening. "Personally if hospitals did less of the lying and obfuscation with patients and families there would be less legal action. Many families do it as the only way to obtain facts and apologies."
Organisational duty of candour was introduced because of a widespread recognition that trusts do not tell patients and their families the truth about adverse incidents. In CQCs hands it has had little measurable effect on combating this problem.
Hi Anon at 0933. Witch hunt? Outdated? No. Let's see a bit more colourful language. The scandalous mistreatment of NHS Whistleblowers merits it. BTW do you want to get rid of "stone age", "antediluvian" and other terms which refer to events long ago but retain a strong metaphorical force?
We could be forgiven for anticipating the arrival (with further delays and redactions no doubt) of Ms Outram's "independent" review with a degree of cynicism.
December 2018: Mr Hancock was busy tweeting his congratulations to Mr Dunn on his CBE for "services to health and patient safety". Mr Dunn "humbly" acknowledges.
April 2019: Mr Hancock tweets on whistleblower protection: "I’m determined to end the injustice of making NHS staff choose between the job they love & speaking the truth to keep patients safe"
December 2019: Mr Hancock refuses to meet consultants from the NHS trust in his own constituency. They wanted to talk to him about bullying, intimidation and yes, management preventing them from raising concerns about "patient safety". Three requests. All refused. Even though the trust had used methods to identify the whistleblower in the Susan Warby case that look to be more at home in a totalitarian state.
This whole story illustrates the way in which senior NHS leaders and politicians exercise control. Their own position is defended. Patient safety goes out of the window. Ethical professionalism is trampled underfoot.
More than 5 years ago on receiving the Francis FTSU report Mr Hunt committed to changing this pernicious culture. And here we are, with it operating in plain sight, with not even a slap in the wrist.
Only weeks on from the publication of First Do No Harm (IMMDS Review). The boss of the principle healthcare regulator thinks patients are so safe under his surveillance that there is no obvious need for Cumberlege's recommended patient safety commissioner. He needs to be reminded of the reports view of current system failings:
“We have found that the healthcare system – in which I include the NHS, private providers, the regulators and professional bodies, pharmaceutical and device manufacturers, and policymakers – is disjointed, siloed, unresponsive and defensive”.
Regulatory failure in the Ian Paterson case, the emerging long-term scandals at East Kent and SATH, and the PHSO consultation on the not-fit-for-purpose NHS complaints system should raise concerns that little progress is being made on keeping patients safe. As I understand the role the PSC would be likely to listen to patients, co-ordinate intelligence and act decisively and promptly to protect patients and ensure learning in a way other organisations currently do not. Small wonder Mr Trenholm is expressing uncertainty. As Rob Behrens has also done in HSJ. Is that what First Do No Harm means by "unresponsive and defensive?"