When Dr Nigel Sewell read his advance copy of the Commission for Health Improvement's clinical governance review report on Epsom and St Helier trust, he had been employed at St Helier for more than 21 years.
But from that day on, his career as chief executive at the trust was effectively over. His early retirement was announced last week.
The report's summary includes a list, running to almost two pages, of action and urgent action needed to bring services across the trust up to standard. Many problems were not new - poor cleanliness; difficulties with staff recruitment and morale; lingering troubles over the two-year-old merger between Epsom and St Helier hospitals; long trolley waits; high mortality rates.
Many of the trust's deficiencies have already been covered in recent years. HSJ highlighted some of the problems at St Helier in a 'First Person' column last month, written two weeks before the CHI visit, though the hospital was not named at the time.
But what probably sealed the fate of Dr Sewell were some of the comments about his own role.
'Management of the trust is defensive in its attitude and staff morale is low, as communication systems between the executive team and staff are weak.
'CHI found that there was a strong 'us and them' culture at both hospitals. The majority of staff felt they were not valued or supported by the executive team.'
The hospitals, sited at the border of south-west London and Surrey, serve a relatively affluent population, but in environments and with outcomes that are far from ideal. Refurbishment is going on at various trust sites. But there is a limit to how much can be done to upgrade the acute trust's crumbling pre-war building.
Talks about demolishing existing buildings have been rumbling on for over two decades. No public finance initiatives are planned here. Little 'modernisation' seems to have infiltrated.
Unusually, CHI drew attention to the trust's poor performance against the high-level indicators:
mortality rates after emergency surgery and following fractured neck or femur are the 'highest in the comparator group' with high rates in other specialties.
CHI found trolley waits of 18-20 hours in accident and emergency, and patient diaries showed prolonged waiting times in other areas. 'Unacceptable' mixed-sex wards across the trust meant patients' privacy and dignity was often breached, patient notes were not always kept in such a way as to ensure confidentiality and diagnoses were discussed loudly by staff, for others to overhear.
The reviewers concluded that good practice was hindered by 'staff shortages and other constraints - for example the inadequate condition of the current buildings'.
Patients' experiences put it more starkly: 'Nobody answered his bell. He wanted to go to the loo but they had removed the frame.
He then had an accident on the ward but nobody came to help or change him.'
CHI notes that 'cleanliness had been seriously compromised in the past', pointing out that a patients' environment action team visit earlier last year 'recommended that carpeting in some wards be removed. . . to eliminate the strong smell of stale urine'.
CHI paints a picture of staff struggling in difficult circumstances. Though training is good, staff feel unsupported and have no communication with senior management. There is high dependence on agency staff, yet systems to check their registration and training are weak. Calling for action to improve employee relations, CHI points out that the trust has been 'unable to marry the cultures of the two sites' with harmonisation lacking even over rates of pay.
Of 455 formal complaints to the trust last year, a high proportion related to aspects of clinical treatment, staff attitude and appointment delays, while damages cost£21.6m last year. Nevertheless, CHI reports that the trust did not appear to take complaints seriously: staff had limited knowledge of handling them and resolution can take more than three years.
Highlighting weakness across clinical risk policies, CHI cites the need for 'urgent action to implement a trust-wide untoward incident reporting system'. The trust is aware that it does not involve patients and the public in planning services - yet 'does not see remedying this as a priority'.
Problems were found in IT, with different parts of the trust using 'numerous and disparate information systems'. Even the collection of performance data is 'seriously hampered'.
A few elements of good practice were flagged up: strong multidisciplinary working in the renal service, efforts by one elderly care ward sister to involve patients in the service. But even in the cautious language of CHI, this was a damning report. Dr Sewell, with statutory responsibility for clinical governance, had to go.
What CHI said: the main findings Defensive leadership and poor communication.
Increasing number and cost of complaints.
Staff do not feel safe raising concerns.
Major problems with recruitment and staff shortages.
Different departments operate different patient administration systems.
Poor reporting of incidents and near misses: a director for clinical risk management and a clinical risk manager have been appointed.
Cleanliness should be improved.