Comments - Page 8
"He (Walsall CEO) said: “We saw a big increase in activity in key departments in a short space of time and we didn’t respond to that well enough as it was happening. I would accept that."
“We have also had a culture in the trust of seeking to soldier on in the face of increasing pressure. If we are going to continue to deliver a service we need to be able to deliver it well, if we can’t we need to say so and set out what we are going to do about it."
“This report is an example of us attempting to tackle that culture.”
Sadly this statement by the Walsall CEO is characteristic of the disingenuity which is now essential to putting a brave face on failure in the NHS. The report is not an example of "us attempting to tackle that culture". Walsall requested the review on the instruction of TDA at a time when it was clear they were going into special measures. Otherwise there would have been no review.
They did not “see a big increase in activity” in maternity as though it was a surprise. The expansion of births from 3,500 to 5,000 was a conscious policy. It resulted in 1500 x maternity tariff accruing annually. It is clear that there was no responsible planning in terms of medical or nurse staffing, support or fabric. The same goes for midwifery numbers as pointed out in the CQC inspectors report. So, it was not a matter of poor response to the expansion of birth numbers but lack of planning for it which was the board’s responsibility.
The board failed, probably in an attempt to contain costs, and as a result, as the report makes clear, allowed the neonatal unit to operate with unsafe staffing levels. It cannot be that the board and senior clinicians failed to recognise this as a serious problem. If the directors had listened to frontline staff (who would have been ready to tell them and perhaps did) they would have understood perfectly well that the situation was unsustainable and unsafe.
It would be so refreshing to hear a CEO admit, "We took on 1500 extra births, didn't plan for or risk-assess them properly and put babies at risk." Until we get that level of candour we should understand that this is all spin to protect what is left of an organisations credibility.
I agree by the way with RCPCH report’s view of frontline staff. They are largely of sterling quality, highly motivated, enthusiastic and compassionate. They are what came between Walsall babies and disaster.
Hi Mike Waites. No mention of the Francis Guardian, a claimed bulwark against staff reticence to raise concerns. Have they got one? Did you speak to her?
HSIB expert advisory group, PACAC and now the heir apparent all recognise that independence is essential for this important new body. Only the politicians and civil servants demur. Why would that be? Discuss.
Sad that Anon at 6.23pm has to make a valid point (if it is valid) anonymously. I personally have never posted any comment without putting my name to it. Until Sandra was rescued by the Verita report yesterday she was also a self-styled whistleblower draining resources by sitting at home. Most staff who raise concerns and are retaliated against never get to tribunal. Of those who do with a whistleblower claim only 3% succeed. Most NHS whistleblowers whose stories have been given a high profile in the media are self-styled for this very reason. Until, as the Health Committee has recommended, the NHS is stopped from putting concern raisers through unfair disciplinaries (Kangaroo courts as Narinder Kapur calls them)and or PIDA is reformed to protect proactively that will not change. It is inconceivable that any reasonable person (and most self-styled whistleblowers are eminently reasonable having had long and blameless careers) would hazard financial security, personal and family health and happiness to pursue what they know to be false through the tribunals. All money spent on this is wasteful but bound to continue until the victimisation of whistleblowers is stopped. Minh Alexander knows this perfectly well.
A trust spokesman said: “The trust acknowledges the findings of the report, none of which are related to any issues around patient safety or patient care or patient experience.
The Trust spent £200,000 to keep the whistleblower at home and has yet to resolve this. TDA have spent about the same on this investigation. Countless hours have been spent by staff from the CEO down on this one issue when early acknowledgement of the problem and a bit of Learning not Blaming would have obviated the loss. All this money and other resource could have been put into patient care. Any drain on an NHS Trust's finances these days has a potential effect on patient care.
NHS employee raises concerns about malpractice. Ends up suspended for 4 years. Her concerns have, to this day, not been properly investigated. But she has been investigated twice by defective processes and found to have "a case to answer".
Sir Robert Francis described this phenomenon in his Public Inquiry report:
“A greater priority is instinctively given by managers to issues surrounding the behaviour of the complainant, rather than the implications for patient safety raised by his complaint.”
For all its shortcomings this is a very useful report describing the dark side of NHS culture. Hierarchy in which the CEO can determine a whistleblowers fate. Arbitrary, slipshod disciplinary investigations; the Health Committee advised 3 years ago that staff raising concerns should not be put through disciplinary procedures. (There can be little doubt that if the Trust had ever got Sandra into a disciplinary hearing she would have been dismissed by SOSR). Blatant unfairness which the report acknowledges. A CEO whose response to the fact that 37% of his staff would have difficulties with raising concerns is that his organisation is no worse than any other. The depressing thing is that many of us who have suffered in similar ways after raising serious concerns in good faith understand that this culture is widespread in the NHS.
There is a huge overlap in the problems faced by NHS complainants like James Titcombe and NHS whistleblowers like Minh Alexander (1:25 pm).
"The Kirkup report and the response by the government (Learning not Blaming) said the professional regulator would deal with accountability." James Titcombe.
Sir Robert Francis in his Freedom to Speak Up report said pretty much the same thing about CQC. Using regulation 5, the Fit and Proper Person Requirement, CQC would be able to hold to account the senior managers who had victimised NHS whistleblowers in the vicious ways he so graphically described. Paula Vasco-Knight was one of those CEOs. The evidence that shows this is in the public domain. Nevertheless CQC, ignoring the evidence presented to it in October 2015, allowed St Georges to approve her as a fit and proper person to hold an NHS director post. More recently her appointment as interim CEO means that she continues to satisfy this requirement.
Up to the present time not one director, to the best of my knowledge, has been found unfit. CQC has ignored damning evidence from employment tribunals in other cases. It is reasonable to conclude that CQC may not be a fit and proper organisation to carry responsibility for regulation 5.
This is not about blame. It is about accountability. It is not about errors or mistakes. It is about wilful misconduct. In a just culture we dispense with blame. In a just culture we hold people accountable. In a just culture we have a fair system for distinguishing between error and wilful misconduct.
Well done to James Titcombe and Minh Alexander for your continued striving to achieve a just NHS culture. This is not down to a vindictive streak in their natures. Believe me, I know them both. It is due to a passionately held belief that only truth and accountability where there has been wrong doing will change the dark side of NHS culture that Francis exposed and is now widely acknowledged.
NHS Guardians are in. We have Francis Guardians for each Trust, overseen by a National Guardian at CQC. Now we have Safe Working Guardians being appointed to each Trust. Last week in HSJ Ann Clwyd MP, in the face of no progress following her review in 2013, called for an independent commissioner for NHS Complaints, effectively a Guardian for those who think they are entitled to the truth when their own or a relatives NHS care has gone wrong.
A guardian is someone who defends or protects or defends something or someone. This begs the question with respect to NHS Guardians: "defend or protect from who?"
NHS whistleblowers need protection from victimising managers. Junior doctors need protection from managers who have to staff emergency services. Unless you have been there it is hard to imagine how hot it can become before 5 pm. when there is no SHO or registrar for the night. Patients and relatives need protection from the managers who are behind the "deny, delay, defend" culture they meet when they raise concerns.
The need for all these Guardians is a policy of despair, an admission of failure. It reflects the deeply ingrained culture of blame, bullying and victimisation seen in the worst Trusts. Inquiry after inquiry, review after review, report after report and yet although some Trusts are improving all too many are unchanged or getting worse. Guardian is a Department of Health initiated or approved role and unlikely to make much difference to culture in the long term. We need to look much deeper with the help of organisational psychologists and others to find a real solution. Caveat: Lawyers are unlikely to help.
.Andrew Vincent: Has Paula acknowledged her "mistakes" publicly or to the St George's appointment committee? Has she apologised to her old Trust or the whistleblowers she damaged. If she has there could possibly be room for reconciliation and rehabilitation. I have reported Paula's appointment to Sir Mike Richards at CQC under FPPR and made these very points. That was in October 2015. I am still waiting for a response. I can only see in this a perpetuation of the NHS culture of secrecy, hierarchy and inequity that Francis, Hunt, Wollaston and the whole Department of Health claim they want brought to an end. The truth is that they are all quite happy with the culture as it is. It is after all largely of their making.
The appointment of Paula Vasco-Knight as interim CEO at St Georges is astonishing. When she ultimately resigned her previous CEO post Sarah Wollaston (constituency MP and chair of the Health Select committee) tweeted, “Paula Vasco-Knight has resigned from South Devon Foundation Trust. This was necessary but overdue & so overshadowed her prior achievements.” The tribunal in which she gave evidence (as an unreliable witness) demonstrated that she had been involved in nepotism and the mistreatment of 2 whistleblowers who reported her for this. In 2014 Sir Robert Francis told the Health Select Committee that any CEO found supressing a whistleblower should be dismissed. The case of Paula Vasco-Knight demonstrates that with CQC administering the Fit and Proper Person Requirement an NHS director can get away with pretty much anything and continue with their careers. Compare that to the NHS whistleblowers who are sacked and blacklisted as described in Sir Robert's Freedom to Speak Up report. The government has belatedly started a half-hearted programme to get some of these back into work but as yet without success. This is a shameful inequity.
Ms Davies and Mr Stanton are exceptional people. For seven long years they kept the faith. They encountered the all too common delay deny defend response of the NHS complaints system. But now they are vindicated.
The truth is that there must be many parents like them who know something went wrong with their child's care but, lacking the resourcefulness, the resilience, the obstinacy to pursue the truth that Kate's parents showed, they let it pass. This case shows why an apology and a promise that lessons have been learned is empty. It is also uncertain whether the Medical Examiner role would have picked this up despite any commitment to listening to relatives. It will be years if ever before HSIB can guarantee competent transparent investigations of such deaths. The best defence against this kind of cover up lies in the professional responsibility of frontline staff to speak the truth. The staff survey shows we are still, as Kate’s parents found, some way from that. Meanwhile the suffering, the trauma of loss and the re-traumatisation of prolonged struggle against an inhuman system, will continue.
“A voice is heard in Ramah, weeping and loud lamentation. It is Rachel, weeping for her children and refusing to be comforted because they are no more.” Jeremiah the Prophet.
Well done Shaun Lintern at Health Service Journal for exposing this fiasco. Well done the whistleblowers who know they are at risk for speaking out. Well done PCSU for saying enough is enough.
But where is PACAC? Where is Parliament? This from the Health Committee's report Complaints and Raising Concerns January 2015:
88. The accountability of the Ombudsman is important, especially since decisions cannot be challenged save through judicial review. The Ombudsman is accountable to the House through PASC, which is given the task of examining reports of the Parliamentary Commissioner for Administration and the Health Service Commissioner for England: that Committee has undertaken to follow up issues raised in Ombudsman reports, including on issues relating to the health service.
It cannot be that the committee is unaware of these developments. As so often happens it is the people and the press that have to force change on matters which have a major bearing on safe patient care.
In 2008 Sir Ian Kennedy, in an interview for this journal, told Charlotte Santry that Bullying was the main threat facing the NHS. A bullying culture is, as you say, immoral, antisocial and inefficient. I say, more to the point, it harms patients and staff. Three questions force themselves upon us. Where has this immoral, harmful culture come from? Why have NHS leaders including various Secretaries of State, the Department of Health, CQC, NHS England and, amongst others, the NHS Confederation tolerated the intolerable year after year? And last, what is to be done?
I do not believe you have given a satisfactory answer to any of these questions. I would be surprised if anyone has contacted you and admitted, "Yes, I looked in the mirror and I saw a bully staring out at me". Nor is it likely that NHS Employers will make any impression on the problem. They haven’t so far. I am not sure they understand it well enough to prescribe a remedy.
On a personal note: In 2009 I wrote to my then CEO describing institutionalised bullying at our Trust. The nursing staff in particular were suffering merciless bullying. There was an outright denial of this (despite the staff survey). I was described as a toxic individual by senior management and within a year I was dismissed. The 2014 staff survey showed the Trust to be in the worst 20% for bullying and harassment. In 2015 the Trust went into special measures. The CQC report noted "heavy handed senior management amounting to a bullying culture". Although I have received regular reports from staff confirming this it is inconceivable that any of them will openly report it.
The victimisation of NHS whistleblowers as reported by Francis in his Freedom to Speak Up Report is the sharp end of the NHS bullying culture. Sarah Wollaston, chair of the Health Select Committee, used exactly the same phrase as you have to describe it, "a stain on the NHS". In the Freedom to Speak Up report Senior Management are the bullies and the whistleblowers are the victims.
More than a year on no whistleblower has heard an apology, received redress or been helped back into work. No Senior Manager has been held accountable for the bullying. This was not minor bullying. It was not name calling. It was the ruin of distinguished careers, finances, mental and physical health as Francis described in some detail. The bullies have won. All you leaders have allowed them to win.
I expect someone else will be writing a similar blog to yours after the next staff survey. It may differ in some details but I anticipate the same overall thrust. Immorality. Inefficiency. Misery.
This is a tragically sad story. A few comments:
"Another midwife told investigators: “Back then if the baby looked well then you presumed that the baby was well.”"
“Back then” was not the Stone Age but 2009. This bears an uncanny resemblance to the professed ignorance that a low body temperature was a possible marker of infection by the FGH midwives in the case of Joshua Titcombe. These claims sound hollow to anyone who has spent any time looking after the new-born.
"Sarah Bloomfield, nursing director at the trust, said: “[Kate’s parents] should not have had to fight so long to get a clear picture of events surrounding their daughter’s death."
This states the obvious. The frequently stated obvious. Given the non-existence of operational policies, the sanctioned alteration of clinical records, the lies about training status, the poor records etc. it is no surprise that it was difficult to get at the truth here. But that is typical of the secrecy and fear culture that prevails in poorly led units.
"Trust chief executive Simon Wright said: “To reassure us, our patients and communities that there were no wider cultural problems in 2009, we are using our incident reporting system and reviewing any other deaths from that period..."
Given this account of incompetence and cover-up a fully independent investigation of any baby death or seriously injury following birth over the last ten years in this unit should be commissioned. The babies involved and their parents deserve this.
It is encouraging to see that the PHSO has in this case grasped the nettle and declared unequivocally that Kate's death was avoidable.
It is not clear from the article but may be from the full report whether any clinician or manager had raised concerns about the operation of this unit. And if so how these concerns were dealt with. It would be a sad reflection on the Trust if every professional involved was complicit in allowing such dreadful failure. Ed Snowdon’s maxim applies. “I saw something wrong. I spoke about it.” That’s all it takes.
Thank you senior NHS manager at 7 January, 2016 8:58 pm. I very much appreciate that comment. It is true that there are many like you, professional, decent and committed to changing NHS culture. It is time for you all to act and secure a just culture in which the treatment of whistleblowers described by Francis can never happen again. I do not see this happening in my lifetime. Nor do I see the National Guardian role helping. But my best wishes to you and all like-minded managers. Patients are depending on you.
"I have no doubt that we can make the changes together that are needed to deliver a new culture of transparency and openness.” Dame Eileen.
Such naive optimism. Two days a week and no powers. And Dame Eileen promises to deliver culture change. The descriptions of strands of NHS culture contained in the Freedom to Speak report suggest this will be a much tougher nut to crack than she imagines. The truth is that the Departent of Health and many senior NHS managers do not want genuine culture change. That would involve a redistribution of power, a democratisation. The end or at least an attenuation of hierarchy. The whole Guardian system which must be costing millions will accomplish little other than giving an appearance of something being done.
Dear Anonymous at 4:02 pm. Although I am the doctor who instigated this investigation I have great sympathy with that. It is extremely difficult to pursue a sensible conversation with someone who cannot even attach a name to such an anodyne comment. Send me your contact details through Shaun and maybe we can have a constructive dialogue.
Sir Robert Francis told us in meetings about his Freedom to Speak Up Review that FPPR would be sufficient to hold to account CEOs who victimised whistleblowers. He reiterated this in the report which testified to widespread victimisation of NHS staff for no other reason than that they spoke up for patients. Oddly, as FPPR passes its 1st birthday, not one of these senior members has been identified or held to account. Surely this mismatch should set alarm bells ringing. Today's report on Mrs James was the 2nd attempt to "clear" her. The first was rejected by CQC as neither independent nor robust. In refusing to even consider my evidenced complaint that this 2nd investigation suffered the same failings CQC have supported the old culture. CEOs are largely untouchable and whistleblowers are troublemakers who deserve dismissal and public vilification. Sadly CQC has a history of treating its own whistleblowers badly and its whistleblowing governance is under criticism. The office of National Guardian, a half-hearted solution to whistleblower victimisation proposed by Francis, is to be located within CQC. Problem solved then.
"The statement added: “Since Connor’s death, Southern Health Foundation Trust have consistently tried to duck responsibility, focusing more on their reputation than the intense pain and distress they caused (and continue to cause us)"
This is the wider issue for the NHS. Trusts simply do not want to admit when they are negligent and patients die. There is no evidence that regulation 20, the statutory organisational duty of candour introduced 27 November 2015 will make any difference to this. Families will have to continue fighting for the truth. And suffering the secondary trauma that involves.
Well balanced article considering paucity of evidence. It should be possible to reconstruct what actually happened. Until then suspend judgement. This tragedy happened only months before regulation 20 became statute. Would it have made any difference?