The conclusions of the first two Commission for Health Improvement investigations into North Lakeland Healthcare trust in Cumbria and Carmarthenshire trust in Wales, both published this week, certainly live up to CHI's claim to be hard-hitting.
Elderly people with mental health problems in Cumbria were refused ordinary food. One was tied to a commode. It was the inevitable result of a culture that was 'unprofessional, countertherapeutic and degrading - even cruel'.
In a separate case at a trust in Wales, mystery still surrounds the chain of events leading to the death of 70-year-old Graham Reeves five weeks after surgeons removed a healthy kidney rather than the diseased one in January.
By June a 'paper' action plan had 'not been implemented at clinical level' and a director of nursing 'does not appear to have a responsibility for quality in nursing'.
In another critical blast, the wrong categories of patients continued to arrive at the doors of accident and emergency at Prince Philip Hospital in Llanelli.
And so it goes on. CHI director of communications Matt Tee said this week that the commission 'did not pull any punches, but would also give a very clear route map back for the organisations.
It's a road to recovery - not just a report saying things are awful.'
CHI says its role is 'developmental, not confrontational'. It certainly does not have the power to remove or replace staff. That is up to the health bodies, and ultimately to health secretary Alan Milburn and his Welsh counterpart Jane Hutt.
But if the reports are supposed to be supportive, it is an uncompromising kind of support.
North Lakeland Healthcare trust provides mental health services and community services across North Cumbria. The investigation provides a vivid and disturbing picture of an environment in which terrible practices went 'unchecked and were even condoned and excused'.
Under orders from Mr Milburn, the investigators looked at three previous reports dating back to 1996 which examined and occasionally upheld allegations including emotional and verbal abuse, and cruel treatment such as tying patients to commodes while they had their breakfast.
Their job was to identify what needed to be considered further, look at arrangements for handling adverse incidents and propose steps needed to improve the quality of care at the trust.
That first 1996 report had failed to uphold allegations of abuse in ward 21 at Garlands Hospital by five student nurse whistleblowers and no disciplinary action was taken. Additional statements made by the nurses were 'lost by the trust and remain so'.
In 1997, ward 21 merged with two other wards to form Kielder House, bringing together patients with severe physical disabilities and mobile older patients with behavioural problems. In December 1998 two bank nurses complained about abuse of patients by staff.
The then director of nursing and quality, David Moorat, headed an investigation, but 'wider issues of abuse in Kielder House and previous instances of abuse were not investigated'.
Other aspects of care gave cause for concern instead. Some staff were given warnings, a healthcare assistant was dismissed and a ward manager resigned.
Then in July 1999 an external review panel made up of the trust, North Cumbria health authority and Northern and Yorkshire regional office looked at the two earlier reports. Its report was published in March, but the 1996 investigation was not referred to the panel and it knew nothing of it until it was mentioned after it had begun work.
CHI's conclusions are stark. 'It seems clear that had the trust responded positively to the student whistleblowers in 1996 it might have prevented further abuse.' The team said the courage of the whistleblowers must be publicly acknowledged.
Most worryingly, when CHI visited the trust in May this year, it reported that it 'could not be confident. . . that abuse and malpractice would be reported, or that the trust would respond effectively to such reports'.
The investigators encountered 'widespread concern' about the responsibility of doctors for the context in which the abuse took place. Associate medical director Dr Chris Hallewell 'was responsible for the patients who were abused in 1996 and 1998'.
He told CHI he was 'made to feel like a visitor on the ward and had not known of the abuse'.
CHI said it was 'of grave concern' that he had not known of its recurrence. 'This reflected an inadequate sense of medical accountability in so senior a figure', said the report, which says CHI is 'deeply disturbed' by Dr Hallewell's lack of awareness given the fact that he has joint responsibility for clinical governance across the trust.He remains in post.
The trust's 'failure to ensure the proper treatment of patients' resulted from an absence of effective corporate management and clinical governance - a whole-systems failure'. Executives and non-executives alike 'were responsible for that failure'.
Acting chief executive Nigel Woodcock told HSJ that a lot of the trust's action plan allowing it to move on was 'going to take some time'.
He says: 'The hardest thing to solve is actually drawing a line in the sand and moving forward.'
North Cumbria HA is currently consulting on proposals to reconfigure acute, community and mental health services in the area. Many heads have rolled already.
Previous chair Mary Styth was dismissed by the health secretary in March and former chief executive Alan Place was dismissed in October. Director of personnel Catherine McCreadle has been dismissed and a number of managers have been given warnings. Director of nursing and quality David Moorat - one of those who received a warning - has since retired.
In Wales, problems may have begun with the terms of reference. CHI can be asked to carry out an investigation by government or by outside bodies, and in this case it was Jane Hutt who ordered it in. The report says the kidney incident was the 'immediate trigger'.
CHI examined the trust's clinical governance and makes recommendations 'in selected clinical areas'. The politicians did not ask CHI to look at the critical incident itself.
Neither of the two previous reports or summaries were made available to the public. CHI told HSJ that the local coroner had ordered this 'for legal reasons'.
The inquest has yet to be completed. Hence there is a long list of things the investigation wasn't briefed to explore.
Difficulties in Carmarthen began with the trust's creation.
The merger of Carmarthen and District trust and Llanelli/ Dinefwr trust in April 1999 had been 'difficult '. Interviewees pointed to an 'historic lack of strategic leadership' from Dyfed Powys HA.
But the two hospitals in the area - the Prince Philip and West Wales General in Carmarthen - were not talking to each other.
'They are still very much operating as two hospitals rather then one trust', says a CHI spokesman.
Staff at Prince Philip had 'responded rapidly' to the kidney incident. A 'comprehensive action plan had been drawn up'.
But the flaw was that it had not so far been put into practice.
CHI recognises 'clinical governance was at an earlier stage of development in Wales than in England', and there were 'several concerns' about the management of nursing staff.
The new nursing structure 'operates separately from the general and clinical management of the trust' and 'unusually' the nursing budget was centrally held - arrangements that 'could allow people to absolve themselves of responsibility for decision-making'.
Despite noting the 'high proportion' of the nursing budget spent on agency staff, none of the trust's three assistant directors of nursing could shed any light on the matter. And despite concerns about the effect of 'the number of locums. . . on continuity of care and staff morale, ' the report does not look into how many were actually employed.
The CHI report also expresses concern that the trust's own action plan did not include the suggestion to provide an extra nurse on duty to hand over patients to the operating theatre.
Additionally, the trust 'should consider introducing a system of hole-punching x-rays 'L' and 'R' as a routine measure', the team suggests. It also says it examined the trust's 'independently validated' audit of all main theatre patients treated by the urological team at Prince Philip and 'was satisfied' there were no issues of concern.
CHI, which says that it 'will in time set standards on how to undertake high-quality investigations', does not inform us why 'a number of staff are subject to disciplinary proceedings, on special leave or undertaking restricted practice'.
According to CHI's Mr Tee, the Welsh health minister asked the commission to decide whether the Prince Philip was 'a reasonably well-functioning hospital in which something tragic had happened or a hospital that was not functioning properly in which things could potentially happen again'.
He adds: 'I think we are closer to the former'.
As HSJ went to press, chief executive Mike Jones and the rest of the board is still in place, as is head of nursing John Power. A spokeswoman for Mr Jones told HSJ he would not be commenting until the launch of the report yesterday.
North Lakeland Healthcare: what should happen next The board must include strong representation of members with knowledge of and interest in mental health services and have access to high-level, credible advice.
All members must understand and commit to effective corporate management and clinical governance. It should also develop an effective quality-improvement strategy.
Board business conducted in private session must be reduced to a minimum to demonstrate openness. It should publicly acknowledge the courage of the whistleblowers.
The trust should review its corporate values and establish an explicit statement that will underpin all its policies and decisions.
Carmarthenshire: key recommendations The trust board and the HA should review the role and function of the accident and emergency department at Prince Philip Hospital and designate and resource it appropriately.
Chief executive Mike Jones should appoint a human resources director at executive board level.
The board should require director of nursing John Power - reporting to the chief executive - to review the decision to align the nursing structure outside clinical directorates and general management arrangements.
Mr Power should also be ordered to develop a financial strategy to devolve financial resources to the clinical directorate level with effect from 1 April.
The trust board should, through the medical director, Dr Peter Thomas, and the director of nursing, review the trust-wide strategy for clinical governance.
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