Decaying Reinforced Autoclaved Concrete in our NHS hospital roofs: Disclosed engineers’ reports and suppression

Dr Minh Alexander retired consultant psychiatrist 1 December 2022

This is a post to share engineers’ reports and related documents on NHS buildings that are at risk due to unsafe roofs.

It also feedbacks about NHS trusts which have failed or refused to disclose such information, in a context of minimisation by NHS England.

The NHS has always been underfunded, and building hospitals is a complicated business, with a history of good intentions followed by misfires.

Decades ago, some NHS hospitals were built quickly on the cheap, with central government oversight – the “Best Buy” hospitals, which offered with the slogan “Two for the price of one!”.

East Anglia was the most enthusiastic adopter of the model.

Simple construction techniques included the use of limited-life Reinforced Autoclaved Aerated Concrete (RAAC) beams in roofs.

RAAC roofs were often flat, resulting in later problems with water ingress.

 Reinforced Autoclaved Aerated Concrete  

RAAC was developed in Sweden a century ago.  

It is composed of bubble-filled concrete, without coarse aggregate, which is usually embedded with metal reinforcements.  

The material is lighter, and insulates better, but it is less strong.  

“Compressive strength is significantly lower than traditional concrete at 2-5N/mm², as are related flexural, shear, and tensile strengths. Elasticity and creep are substantially inferior to traditional concrete due to the aerated nature and lack of coarse aggregate, which are reflected in large observed long-term deflections. [Bending]”  

RAAC also does not prevent corrosion of the embedded metal components as effectively as normal concrete.  

“…aerated RAAC’s vulnerability to moisture ingress means any reinforcement lacking sufficient protection becomes ultra liable to corrosion.”  

To compensate for this, in some RAAC beams, the metal elements were coated with bituminous material.   It has been found that this protective coating was not always properly applied.  

Surveys of failing RAAC roofs on school buildings have shown that a lot of the damage has related to water ingress,  resulting in corrosion of metal reinforcements, and loosening of the metal reinforcements from surrounding concrete.  

A worry is that such corrosion may NOT be visible on inspection:  

“Not all defects are visible … panels which appear to be in a good condition may conceal hidden defects which could present a risk to the integrity of the panels,” it said. “The corrosion of reinforcement could lead to large pieces of RAAC falling which presents a risk to occupants.”  

It has also been reported that there are variations in RAAC material, which may create additional unpredictability.    

Problems with RAAC roofs were evident by the 1980s:

“By the 1980s, RAAC roof planks installed in the 1960s had begun to fail. Subsequent case studies revealed significant underlying issues with the RAAC roof planks. The steel reinforcement was often insufficiently covered, allowing corrosion to occur. Many roof planks had a high span to depth ratio, meaning that they did not have the suitable capacity to span between bearing points. Often, the steel reinforcement did not extend throughout the complete length of the product and contained an inadequate number of welded crossbars.”

RAAC beams bend and may disrupt water proofing materials as they warp. Water ingress by this route, or other routes, may pose an added threat to the beams. Some beams were cut to fit particular sites, which would have removed important, extra metal reinforcements located at the ends of the beams and compromised their load bearing capacity. Harsh weather can also pose a threat to RAAC roofs. For example, snowfall can push RAAC roofs to their limit and this has to be factored into the risk management.

Worryingly, in August this year, Collaborative Reporting for Safer Structures UK (CROSS-UK) reported that RAAC beams had been found in the pitched roof a hospital built in the 1990s.

Who knows how many more exist?

And government guidance on identifying RAAC roofs only tells public bodies to look at buildings constructed up to the 1980s:

“RAAC is a lightweight, ‘bubbly’ form of concrete that was commonly used in school and other buildings from the mid-1960s to the mid-1980s.”[my emphasis]

It is thought that the safe life span for RAAC structures is about thirty years.

Some NHS hospitals have RAAC roofs which are known to exceed this 30 year timescale.

Trust board papers by an affected NHS trusts, Queen Elizabeth Hospital King’s Lynn NHSFT (QEHKL), asserted in February 2020 that the life span was even shorter – 25 years.

Consistent with this, QEHKL trust board papers indicate that the problem of the RAAC roofs has been on QEHKL’s risk register since May 2006 – twenty five years after the hospital was built.

An October 2021 report commissioned by NHS Property Services proposed these measures for managing RAAC roofs:


To help prolong the life of RAAC panels, the following rules should be adopted generally. A structural engineer should be consulted if the following cannot be complied with:

  • No additional loads to be applied to any RAAC panels.
  • No new fixings should be installed to the panels
  • No additional penetrations should be formed through the RAAC panels without a review from a structural engineer


The following should be put in place as operational procedures:

  • Where standing water is present on the roof, introduce robust pumping arrangements to discharge excessive quantities of water.
  • Snow build up on the roof should not be allowed to generally exceed 200mm. When removing snow, snow should not be piled in any location to height of greater than 300mm.
  • If snow does build up greater than 300mm, all accommodation below should be closed to access until the snow has been clear and panels re-assessed by a structural engineer.
  • Maintain robust roof permit system to control access to the roof and to inform personnel of restrictions

No roof maintenance should exceed the design loadings of 0.6kN/m2.”

Not all RAAC beams in NHS buildings have been surveyed due to problems of access, which makes risk assessment and management more difficult.

Some trusts have been forced into elaborate risk management arrangements, with frequent checks, physical propping of the roofs and full or partial decanting of some buildings.

Queen Elizabeth Hospital King’s Lynn NHSFT had to evacuate a theatre complex on an emergency basis this July, because of ceiling movement.

Local MP Liz Truss spoke about the problems at King’s Lynn during the recent Tory leadership race, but had reportedly ignored concerns for years.

At some NHS trusts, staff have been issued with guidance on signs of deterioration that should be reported.

But RAAC beams can fail suddenly and with little warning.

The 2018 index case of a school roof collapse, which led to a recent national alert about RAAC, occurred within 24 hours of the first signs:

“There were signs of structural stress on Friday evening and the collapse occurred last evening (Saturday)”

The government has not given the NHS enough money to address these risks promptly, and a replacement programme for the RAAC roofs is not scheduled for completion until 2035.   

In September the Lib Dems shared an FOI request to NHS England which revealed that there were 32 NHS buildings which had RAAC roofs:

 Number of buildings with RAAC roofs
Queen Elizabeth NHS FT4 (Kings Lynn)
West Suffolk NHS Foundation Trust2
James Paget University Hospitals NHS Foundation Trust1
North West Anglia NHS Foundation Trust2 (Hinchingbrooke Hospital) 1 (Stamford Hospital)
Mid and South Essex NHS FT1 (Broomfield)
Airedale NHS Foundation Trust1
Liverpool University NHS FT1 (Aintree)
Mid Cheshire Hospitals NHS FT4 (Leighton)
Blackpool Teaching Hospitals NHS FT2
Countess of Chester NHS FT1
University Hospital Southampton NHS FT1
Frimley Health NHS FT1 (Frimley Park)
Midlands Partnership NHS FT1 (Haywood)
Doncaster and Bassetlaw NHS FT2 (Bassetlaw)
Worcestershire Acute Hospitals NHS Trust1 (Kidderminster)
York Teaching Hospital NHS FT1 (Scarborough)
East Lancashire Hospitals NHS Trust1 (Royal Blackburn)
Northern Care Alliance1 (Royal Oldham) 1 (Salford)
NHS Trust total30
NHS Property Services1 Haverhill
 1 Warren Farm
NHS Property Services total2

NHS England advised on 28 October 2022 that this may not represent the full extent of NHS buildings affected by RAAC issues, and that effectively, no one knows how many more buildings need remediation.

“The safety of our people within our hospitals is of paramount importance to the NHS. On learning of the issues surrounding reinforced autoclaved aerated concrete (RAAC) beams, NHS England wrote out to all organisations in 2019-20, asking them to assess their buildings for RAAC. The result of this was the instigation of the national RAAC programme.  

Proactive steps are being taken to ensure that all RAAC in the NHS is identified and subsequently eradicated; the list above represents our current understanding of RAAC across the NHS.  

At this time, we cannot state that this is the final list of all instances of the material across the NHS however we have a clear process for tracking and mitigating RAAC if/as/when it occurs.” [my emphasis]

Contrasting with this tone of concern, the Eastern Daily Press reported in August 2021 on FOI request which showed that NHS England criticised the CEO of Queen Elizabeth Kings Lynn NHS Foundation Trust for being “sensationalist” about the RAAC risks.   

To obtain more detailed information on the risks, I asked affected NHS trusts and NHS Property Services for engineers’ reports and risk management documents.

Several trusts did not respond at all, or gave limited responses, which may reflect discouraging attitudes by NHS England and the Department of Health.

Others have upheld the public interest and shared information more transparently.

The data reveals a story of chronic anxiety, disruption and sometimes desperate making do.

It also shows that affected NHS trusts are painfully aware of not just the risks to people, but the likely legal, regulatory and health and safety blowback if the roofs collapse.

The data shared, whether in full or only partially, puts to shame NHS England’s unsupportive comments last year about the QEHKL then chief executive’s advocacy for her service.

She has since left the NHS, after forty years.

Local people continue to campaign.

See @save_lynn

And see the Westminster petition to prioritise for a new hospital for King’s Lynn & West Norfolk (now closed):

The information shared by affected trusts – or details of their lack of response – are listed below in the appendix.


York and Scarborough Teaching Hospitals NHS Foundation Trust

This trust provided one of the most detailed and transparent responses.

This gives a helpful comparator to the responses by trusts which were less transparent, showing what will have been omitted by these trusts.

The trust disclosed the following documents:

Structural report 20 December 2021

Workplace risk assessment 23 June 2022

Risk review of affected labs May 2022

RAAC roof weekly checklist form

Action plan June 2022

Poster for staff by Estates, raising awareness of warning signs of structural failure

Blackpool Teaching Hospitals NHS Foundation Trust

This trust also answered transparently and also disclosed the following documents:

Structural report 20 December 2019

Structural report 9 January 2020

Structural report 10 March 2020

Structural report 5 March 2021

Structural report 11 January 2022

The trust gave the following account of its risk management:

“The Trust has made safe the RAAC units in the laundry by providing a fail safe supporting structure. In line with guidance and initial evaluation by the approved structural engineers these are now inspected on an annual basis, The planks are not above patient or public areas, and as they are independently supported no progressive deterioration can be expected. Consequently, no special evacuation plans over and above a standard space evacuation for fire is envisaged, and the area would be re-inspected by engineers in the event of any detectable failure or deterioration of a unit.

The Units on Phase 4 roof are immediately above medical records storage. Each unit is secured between steel supports; therefore no progressive collapse is anticipated. As with the laundry the units are inspected annually, and currently all are in good condition. Additional investigation and evaluation is being undertaken in November. The roof therefore has a low risk score of 2 and consequently no special evacuation plans over and above a standard space evacuation for fire is envisaged, and the area would be re-inspected by engineers in the event of any detectable.”

Queen Elizabeth Kings Lynn NHS Foundation Trust

The trust has had the highest profile with regards to RAAC roof problems.

It was opened in 1980. The site weas mostly constructed with RAAC roofs.

NHS England’s above disparaging comments about the trust’s external comms seems, unsurprisingly, to have dampened the trust’s willingness to reveal details.

The trust has not provided engineers’ reports as requested, with no explanation, and has disclosed only this summary:

“Rolling programme of maintenance and failsafe installation

79% of the hospital buildings have RAAC planks that need monitoring and emergency repairs carried out on a rolling basis. We have a dedicated team of surveyors and technicians who survey the buildings and identify where support props and failsafes are needed to reduce the risk of plank failures in the roof and maximise safety.

In 2021/22, with £20.6m national capital funding we opened new Endoscopy and Outpatient Units to create the necessary theatre and ward decant space for a three-year rolling failsafe programme.

The first year of an £80m three-year programme is currently underway to install failsafes across the first floor of the hospital. The investment maximises safety and does not create additional ward space or capacity.

Evacuation plan in the event of RAAC failure

We have robust plans in place in the event of RAAC failure and these are tested regularly. This includes the East of England RAAC response plan and a smart evacuation system (which is recommended by NHS England in the East of England for implementation across all acute and community providers in the region). There is also an overarching Trust-wide evacuation plan which covers all eventualities.

Appropriate training has taken place and several exercises have been undertaken to test our response to a RAAC emergency. Learnings from these exercises have been used to further strengthen our plans.”

Although the trust has withheld engineers’ reports, there is a continuous summarised narrative in “Significant Risk” reports in the trust board papers.

Risk has been graded at 20 since 2019 (Likely catastrophic harm).

The Board papers also show that the RAAC roofs have been an open item on the trust risk register since May 2006:

The trust has benchmarked with other affected trusts and concluded that it was more badly affected than comparators such as Hinchingbrooke Hospital and James Paget Hospital:

In April 2022 the trust reported:

“We believe we are the most propped hospital in the country with 1,528 steel and timber support props in 56 areas of the hospital – almost three times more props than beds.”

By October 2022 the number of props had mushroomed:

Roof at crumbling hospital serving PM Liz Truss’s constituents is being held up by 2,500 props

There was a deeply concerning incident in July of this year when theatres had to be evacuated after movement was noticed in the ceiling above a theatre complex.

A hospital spokesperson, understandably, commented:

“This demonstrates once again that our hospital is unfit for purpose and the need for an urgent announcement about the desperately needed funding for a new QEH, recognising the impact on patient and staff experience and the operational running of our hospital.”

It beggars belief that a hospital that is incredibly stressed by COVID19 and all the other ills that beset the NHS, has to also juggle emergency evacuations of critical areas because of unpredictably failing infrastructure.

Frimley Health NHS Foundation Trust

Frimley claimed that it could not disclose the requested material because it is intended for future publication.

It has not answered questions about the purported future publication.

The construction of the Frimley site, under the “Best Buy” scheme, was originally monitored by the Department of Health.

Countess of Chester

The trust has failed to respond at all despite chasers.

Mid and South Essex NHS Foundation

Has not responded at all despite reminders.

Northern Care Alliance NHS Foundation Trust

The trust disclosed engineer’s reports:

Structural report Salford June 2022

Structural report Oldham July 2022 

In terms of documents on risk management, the trust stated on 21 October 2022:

“The Trust do not have an over-arching documented plan or protocol available. Work is still on-going to develop these kind of plans.”

Worcestershire Acute Hospitals NHS Trust

The trust has disclosed an engineer’s report:

Structural report August 2021

It gave this account of risk management:

“We can confirm that in line with the following report points, we undertook the following actions:

6.2- the first floor of A block was cordoned off
6.3- immediate mitigation of temporary steel props to underside of ceiling 6.5- we are currently undertaking a programme of works to replace the roof

This work has been funded by the National RAAC Replacement scheme and is regularly monitored by them.”

North West Anglia NHS Foundation Trust

The roof at Hinchingbrooke Hospital, run by the trust, is a well known example of the RAAC roof problems.

The trust has issued a blanket refusal to disclose any engineers’ reports on spurious grounds of “commercial interest”:

“Following a detailed review of both your initial and subsequent request, North West Anglia NHS Foundation Trust (the Trust) is withholding the engineers’ reports. It is the Trust’s view that this information is exempt under Section 43 (Trade secrets and prejudice to commercial interests).”

The trust has disclosed the following documents:

Datix Risk Assessment updated 24 Nov 2022 by Paul Denton Assoc Director of Governance and Risk

Risk action plan updated 26 October 2022

Emergency evacuation plan

Importantly, it is noted in these documents that not all the RAAC beams have been surveyed yet due to access problems.

The trust has identified the following as risks:

A published trust business case of July 2021 on affected main theatres gives additional information.

East Lancashire Hospitals NHS Trust

The trust has refused to disclose engineers’ reports claiming a spurious exemption of third party information:

“The full report is third party data therefore the Trust cannot disclose.”

The trust has disclosed only a fragment from a report, with no indication of date.

The trust has disclosed partial material from Quarter (3) 2022/23 which shows that there are between 300 to 500 RAAC panels in its buildings and 25% have yet to be surveyed.

The trust reported on 22 November 2022 that the affected areas have decanted and mothballed:

“The affected areas have been decanted and it has now become a restricted access construction site. Programme of works to remove the roof panels has commenced. There is no risk to patients, staff or the general public.”

Southampton University Hospital NHS Trust

The trust has not provided a response despite being reminded.

Midlands Partnership NHS Foundation Trust

The trust disclosed these engineer’s reports:

Structural report 28 January 2020

Stuctural report 17 December 2021

It advised on 27 October 2022 that props had been required and that the affected area had been decanted:

“Following a survey in February issues in three locations resulted in acro props being installed. Due to this the services were unable to safely access the day case unit, orthotics and out of hours nursing. Services were temporarily stood down and have now been fully decanted. The section of the Hospital with RAAC planks is now locked off and access managed and restricted to facilities and estates for the purposes of surveying and monitoring whilst the Trust works through the business case process for the replacement of the building.”

West Suffolk NHS Foundation Trust

The trust has disclosed an engineer’s report and details of risk mitigation:

Structural report March 2021

Risk mitigation details

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

The trust has disclosed an engineer’s report and a diagram of RAAC panels surveyed:

Structural report 22 October 2021

Diagram of RAAC panels surveyed

Liverpool University Hospitals NHS Foundation Trust

The trust disclosed only an extract from an engineer’s report:

Extract from report by Curtins engineers

The trust gave this strange response to the request for details of risk management:

In accordance with Regulation 12(4)(a) of the EIR, we can confirm that the Trust does not record/collate the above information.”

James Paget University Hospital NHS Foundation Trust

The trust has not responded at all despite being reminded.

Mid Cheshire Hospitals NHS Foundation Trust

The trust refused to disclose any information at all, pleading that it would require too much work to collate the documents:

In order to comply with your request it would require an extensive manual review and cross reference of a vast number of reports, plans and protocols. In addition, some of this information is not held in a document format and would require additional work to collate it.”

If true, this is not reassuring evidence that it is on top of matters.

Mid Cheshire has now delayed its response to a request for internal review until 5 January 2023.

Could that be political water treading, pending an NHS England communication of some sort?

NHS Property Services

NHS Property Services did not answer at all despite being reminded.

However, a report on a property that it manages, Warren Farm Health Centre, which has an RAAC roof is in the public domain:

WARREN FARM HEALTH CENTRE Monitoring and Remedial Strategy

Why has the National Guardian’s Office given conflicting information about quality assurance of its case records and protection of whistleblowers’ confidentiality?

Dr Minh Alexander retired consultant psychiatrist 29 November 2022

The National Freedom To Speak Guardian’s Office (NGO) was not designed to help whistleblowers and patients but to help the government control the narrative about quality issues in the NHS.

It has no powers and what narrow remit it has, has been implemented in a mean and cynical way to deprive whistleblowers of any real support.

For example, its exclusion criteria are designed to abandon whistleblowers at the height of their conflict with employers – it tells whistleblowers who are in a legal dispute with their employers to come back when it is all over. This often takes years.

For example, Dr Jasna Macanovic Portsmouth Hospitals whistleblower was unfairly dismissed in 2018 and filed a claim in the Employment Tribunal that year. Her remedy hearing was only held this month. She originally sought help from the National Guardian but was told to come back after her case had finished.

This is extraordinary cruelty and irresponsibility by the Office, which has been repeatedly meted out to highly distressed whistleblowers.

Through this withholding of help from NHS whistleblowers, the NGO has kicked many patients’ interests into the long grass

Patient safety matters should not wait for years at the National Guardian’s convenience.

For over two years now there have been incidents which call into question the National Guardian’s Office’s respect for whistleblower confidentiality and its diligence in keeping proper whistleblower cases files.

I had cause to challenge the Office twice this year.

Because of the NGO’s evasive and minimal answers, and failure to follow up on anomalies brought to its attention, I made an FOI request in September about its quality assurance processes.

In its responses, the NGO appears to have misled me about the existence of quality assurance processes for its whistleblower case records and protection of whistleblower confidentiality.

Bear in mind that failure to protect a whistleblower’s identity and confidentiality is now a criminal matter in some jurisdictions (for example, some EU countries, Australia, Ireland).

The National Guardian has personally also tried to prevent disclosure of accountability data by her Office through an implausible attempt to apply an exemption under FOIA that relates to prejudice to law enforcement.

The reasoning given is laughable. It claims that internal audits should not be published in case it puts people off audit.

This is also at complete variance to the National Guardian’s written guidance to NHS trusts, which advises regular audit of Freedom To Speak Up arrangements, and that audits should be“shared externally to support improvement elsewhere” !!!

The correspondence below gives the broad details of the National Guardian’s obfuscations.


Jayne Chidgey-Clarke

National Freedom To Speak Up Guardian

Care Quality Commission

28 November 2022

Dear Dr Chidgey-Clarke

Apparently misleading information provided by your Office and apparent lack of audit of case record keeping and confidentiality by your Office

I have received a response from your Office which suggests that it previously misled me by claiming that there had been two audits of the National Guardian’s case record handling and protection of whistleblowers’ confidentiality. It now appear these audits may not have taken place.

Time line of relevant events

On 13 September 2022, because of a number of events of concern, I asked you if your Office held data on audits undertaken about case record handling by your Office.

On 4 October your Office replied:

Our office has had two audits since its inception in 2016, one in 2017/18 and one in 2020/21. We are due to undertake a further audit in the next financial year. Parts of these audits looked at risk management, including secure record management and confidentiality.”

On 7 October 2022 I asked you for copies of these two audits.

On 7 November your Office said it might not disclose the audit reports, and it was considering whether to apply Section 31 FOIA exemption (prejudice to law enforcement processes) on these grounds:

We have determined that the exemption under section 31(1)(g) of FOIA applies as disclosure of the requested information would be likely to prejudice the exercise of the NGO’s statutory functions.” 

FOI response by National Guardian’s Office 7 November 2022   

I was puzzled as your Office has no powers and only one statutory function as far as I am aware. I asked you to clarify which Section 31 categories of law enforcement you claimed applied.

On 15 November 2022 your Office wrote to:

1.   Disclose what it claimed was the 2017/18 audit which included case records and confidentiality

What it disclosed was in fact a fragment from a document. The fragment contained no information about case record handling or confidentiality.

Fragment of document disclosed by National Guadian’s Office 15 November 2022

2.   Refuse disclosure of the 2020/21 audit.

Your Office claimed that this was because Section 31 FOIA law enforcement, category “Health and Safety” applied:

“Internal audits are a way for organisations to test and improve their processes and improve their effectiveness and efficiency in performing their roles. A disclosure that would prejudice the effectiveness of future internal audits would therefore prejudice the future effectiveness and efficiency of the NGO in delivering on its purposes.

These prejudices would be likely to arise where disclosure of internal audit reports resulted in concern about the likely impact of disclosure of similar reports in the future. This would be likely to have the effect of prejudicing the candid and open approach of colleagues in their future interactions with auditors, and prejudicing the candid and open reporting of auditors findings in future reports. These prejudices to the effectiveness of the internal audit process would therefore be likely to prejudice the overall effectiveness and efficiency of the NGO in supporting Guardians in their work for the ultimate purpose of protecting the health and safety of people who speak up and patients.”

Your Office indicated that it had been your decision to apply Section 31 FOIA.

My reading of this is that your Office is implausibly claiming that the publication of audits will lead to your staff not contributing candidly to future audits, and you claim that this will threaten the health and safety of staff who speak up, and of patients.

I rejected this argument in my response to you of 17 November 2022:

Letter to Jane Chidgey-Clark 17 November 2022 re FOI issues

Not least because your Office has issued written advice to NHS trusts, which urges them to regularly audit their Freedom To Speak Up arrangements, and that their audits should be “shared externally to support improvement elsewhere.”

I did not accept therefore that you genuinely believed there would be prejudice under Section 31 FOAI, as had been claimed.

On 25 November 2022 your Office wrote to say that the 2020/21 audit of record keeping and confidentiality practices which it claimed took place, did NOT take place.

It stated that the 2020/21 audit was about something else:

However, please note that the 2021 audit was not around case handling and the handling of whistleblower confidentiality. The title of the audit is ‘Freedom to Speak Up Guardian role in arms-length bodies and regulators’.

It would therefore appear that your Office made an incorrect claim in its response of 4 October 2022, stating that there had been two audits of its case record keeping and handling of confidentiality, in 2017/18 and 2020/21.

1.    I would very much appreciate an explanation of why I have been given conflicting information about whether your Office’s core processes, of case record keeping and handling of whistleblower confidentiality, have been audited. Please clarify if any such audits have ever been undertaken.

Please disclose the NGO risk register that was audited in 2017/18 as part of your reply, given your Office’s contention that the risk areas managed included record keeping and confidentiality.

I copy this correspondence to Ian Trenholm with respect to the regular accountability meetings that I believe he holds with you, and to Andrew Morris and Robert Francis as members of the National Guardian’s Accountability and Liaison Board.

You will be aware that as result of the recent responses by your Office, I wrote to Andrew asking if the Accountability and Liaison Board should review the National Guardian’s published values and mission, and its operations, to ensure better adherence to Nolan Principles of Accountability and Transparency.

I understand that Andrew gave you a copy of my letter and has forwarded it to Ian Trenholm for investigation of the specific issues.

2.    I ask that the apparent inaccuracy of the 4 October 2022 response by your Office, claiming audits of case records and confidentiality had been undertaken – where none now appear to exist – be added as a matter for investigation.

3.    If it is the case that your Office has NEVER undertaken any audit of its case record keeping and protection of whistleblowers’ confidentiality, despite Dr Campbell’s case and despite the other concerns raised, please advise if you will put this right and put in place an ongoing audit cycle.

Yours sincerely,

Dr Minh Alexander


Ian Trenholm CEO CQC

Andrew Morris Deputy Chair NHS England and Chair of National Guardian’s Accountability and Liaison Board

Robert Francis CQC NED and member of National Guardian’s Accountability and Liaison Board


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Do CQC staff feel safe?

By Dr Minh Alexander retired consultant psychiatrist 27 November 2022


CQC has a history of poor transparency about its staff surveys. In 2015, I asked for sight of CQC’s staff surveys. CQC subsequently announced that it would routinely publish future staff surveys. However, the data is not presented in a complete and accessible way.  A current CQC staffing transparency page displays only results for 2018 and 2019. Results for 2020 appear to be missing from CQC’s website. It is possible that a survey was not even carried out in 2020. Results for the 2021 survey and surveys before 2018 could only be found only by a manual search of archived CQC board papers.

The 2021 CQC people survey shows:

Only 49% of CQC staff think it is safe to challenge the way CQC does things.

Of those who think it is not safe,

– 29% of these staff fear repercussions if they speak up

– 10% of these staff have actually experienced repercussions

The Care Quality Commission demands accountability from others, but CQC itself is often not accountable.

CQC employs over three thousand staff (FTE). The CQC staff surveys are of interest in that they have showed poor speaking up culture.

This is particularly significant in the wake of CQC’s proven persecution of its whistleblower Shyam Kumar, senior surgeon.

In June 2015 I asked for sight of CQC’s staff survey reports (called “people surveys”) and compiled this table from the results provided:

CQC announced in October 2015 that it would publish future people surveys.

Currently only the results for the 2018 and 2019 People Survey are published on CQC’s transparency web page about staff matters.   

CQC people survey results 2018

CQC people survey results 2019

Some CQC “pulse” staff surveys, which are undertaken more frequently, are published but it seems the public dataset is not complete.

I could find no single place on the CQC website where all of CQC’s people survey reports are transparently gathered in one place.

I asked Ian Trenholm CQC CEO on 11 September 2022 if the missing CQC people survey reports from 2020 and 2021 would be published on the relevant CQC transparency web page.

He has still not answered, despite a reminder.

I have asked the Department of Health Permanent Secretary about his expectations of CQC transparency as an arms length body of the Department.

I have also trawled back through CQC’s archived board papers.

But I could find no 2020 CQC people survey report attached to CQC board papers.

It is possible that no survey was even carried out in 2020, as a survey in 2021 references 2019 results as a comparator, and not 2020.

 The 2021 CQC people survey report was located after a manual search of archived board papers.

It is relevant to point out that the Civil Service People survey results are all displayed in one central place, and benchmark reports transparently provide all previous years’ results, to assist interpretation and show trends more clearly. This is a much more accountable approach.

The 2021 CQC people survey showed that less than half (49%) of CQC staff believe “it is safe to challenge the way things are done at CQC”:

Earlier CQC staff surveys, before 2018, also had to be located by a manual search of archived CQC board papers.

The scores on speaking up culture at CQC across the last six years have been poor overall, with less than half of staff feeling safe to challenge the status quo, but with a recent trend of improvement.

YEAR OF SURVEYPercentage of staff replying affirmatively to CQC people survey question “I think it is safe to challenge the way things are done at CQC”

(Agree or Strongly Agree)
2015 report  The question appears either not to have been asked, or alternatively, not reported in the results
2016 report  43%
2017 report  42%
2018 report  42%
2019 report  47%
2020No data published
2021 report  49%

Of interest, the 2021 CQC people survey report gives a more detailed breakdown of the results for this question:

It showed that of the CQC staff who feel that it is NOT safe to challenge the way things are done at CQC,

  • 29% fear repercussions
  • 10% have actually experienced repercussions.

Even amongst those who think that it is safe to challenge things at CQC:

  • 5 percent indicated that they feared repercussion.
  • 15% thought there would be a lack of action by CQC.

Not great statistics for a regulator who polices other organisations’ culture.

Meanwhile, the CQC has wasted more public money by hiring consultants to assist with one of two insider-controlled review of whistleblowing governance and race discrimination.

CQC’s suppression of problems at Tees Esk and Wear Valleys NHS Foundation Trust  

Barry Stanley Wilkinson former CQC inspector gave evidence to parliament that he had raised concerns about CQC suppression of governance issues at TEWV.  

There has been a string of patient deaths and also a homicide since then.

An independent review of the investigation undertaken by Tees Esk and Wear Valley NHS Foundation Trust into the care and treatment of Mr H



Please click and add your signature to this petition to reform UK whistleblowing law – whistleblowers protect us all but weak UK law leaves them wholly exposed, lets abusers off the hook and it is a threat to public safety.

Replace weak UK whistleblowing law and protect whistleblowers and the public


Mr Shyam Kumar, Surgeon and vindicated NHS whistleblower’s case: CQC sacked a whistleblower for disclosures about its poor regulatory performance, and dug for dirt on the whistleblower

Shyam Kumar’s whistleblowing case and the CQC’s inconsistent claims on how it processes feedback data from Specialist Advisors

Serious Case Review into Winterbourne Hospital Abuse

Witness statement of Amanda Pollard CQC whistleblower, to the Mid Staffs Public Inquiry

Resignation letter 26 January 2016 and disclosures by Barry Stanley Wilkinson, CQC whistleblower

Counting the cost of the CQC: Abuse, Whorlton Hall and CQC spin doctors

The spreading CQC Whorlton Hall scandal – emerging allegations at ‘Outstanding’ Newbus Grange. Another CQC deception?

Mr Tristan Reuser’s whistleblowing case: Scandalous employer and regulatory behaviour on FPPR

CQC’s Victimisation of Whistleblowers: Failure to Investigate Concerns

Breach of confidentiality by CQC and complicity in referring a whistleblower to the Disclosure and Barring Service

Whistleblowers Unheard by CQC

More CQC denial about collusion with employers against whistleblowers

Carl Beech, CQC inspector, convicted child sex offender and fraudster: Activities at the CQC

CQC’s Asleep on the Night Shift

CQC case study. Snooping. Briefing. Porkies. And vexatiously applied ‘vexatious’ protocols.

NHS England does not want to know about long COVID in NHS staff

Dr Minh Alexander retired consultant psychiatrist 24 November 2022

Frontline key workers have been dreadfully mistreated by the UK government, as part of its gross mishandling of the pandemic.

Last year Grace Pritchard, a member of the public, did a great public service by sending FOI requests to NHS trusts and universities about staff affected by long COVID.

Shockingly, this revealed that some NHS trusts were not bothering to collate data about long COVID in their staff.

A number of NHS trusts did not even bother to respond to the FOI request.

NHS Resolution holds some of the relevant data because NHS staff are starting to sue employers for COVID injuries.

But NHS Resolution said that it could not run a computer search for this data because long COVID is not assigned a specific injury code in its systems:

Transparency about NHS staff with long COVID injuries and NHS staff personal injury claims for long COVID

The Department of Health and Social Care callously said that it held no central data on NHS staff affected  by long COVID, and crucially, that it had no intentions to collate this data:

The Department of Health holds no data on long COVID in NHS staff and has no intention of collating this data

The DHSC could not say authoritatively if the data was held elsewhere.

To fill in the gaps from Grace Pritchard’s FOI request last year, I have sent a similar request to all the trusts that did not bother to answer Grace’s questions.

I will post the replies below as they come in.

The first reply received has come from West London NHS Trust, which runs Broadmoor hospital:

West London NHS Trust FOI response ref 396) 23 November 2022 long COVID in trust staff

The trust has disclosed 71 cases of long COVID in staff so far.

Of great concern, the trust has indicated that it has NOT been asked by NHS England for information on long COVID in its staff:

5. Has NHS England asked the trust to specifically report data on how Long COVID has affected trust staff?

Response:  No”

The concerted wilful blindness by oversight bodies is a great betrayal of the duty of care to frontline keyworkers.

I have written to Amanda Pritchard NHS England CEO, copied to the parliamentary Health and Social Care Committee, the Office of National Statistics, Health and Safety Executive and the Secretary of State.


Amanda Pritchard

CEO NHS England 

24 November 2022

Dear Ms Pritchard,

Collation of data on long COVID injuries in NHS staff

I am writing to raise a concern that NHS England does not appear to be collating data on long COVID injuries suffered by NHS staff.

Please see below an FOI response from West London NHS Trust which records 71 staff affected by long COVID, and which indicates that the trust has not been asked by NHS England to report specific data on long COVID injuries amongst staff.

No central public body seems to be tracking the level of COVID injury amongst NHS staff.

ONS collates long COVID data by occupation, which allows a rough estimate, but it does not publish data by employer.

Some NHS Trusts are collecting data about long COVID in their staff.

However, other NHS trusts responded to an FOI request by a member of the public last year, saying that they did not hold the data.

NHS Resolution holds data on personal injury claims by NHS staff affected by long COVID, but says it has no specific code for long COVID and therefore cannot run a computer analysis.

Transparency about NHS staff with long COVID injuries and NHS staff personal injury claims for long COVID

The DHSC says it holds no central data and has no intention of collating the data.

The Department of Health holds no data on long COVID in NHS staff and has no intention of collating this data

As a matter of basic duty of care, surely the NHS should be actively tracking this data?

Please advise what action, if any, NHS England will take to track long COVID amongst NHS staff and to learn from the data.

With best wishes,

Cc Health and Social Care Committee

     Sir Ian Diamond, National Statistician and Permanent Secretary, Office of National Statistics

     Sarah Albon CEO Health and Safety Executive

     Baroness Healther Hallett, UK COVID public inquiry

     Steve Barclay Secretary of State for Health and Social Care

     Helen Vernon CEO NHS Resolution

CQC whistleblower Mr Shyam Kumar’s forthcoming interview & CQC CEO’s silence

Dr Minh Alexander 18 November 2022

This is a brief post to raise awareness that an interview of Mr Shyam Kumar about his whistleblowing experience at the Care Quality Commission will take place on 24 November 2022 and will be streamed:

Health chat with Shyam Kumar CQC whistleblower 24 November 2022

Mr Shyam Kumar was appallingly treated by the CQC. An Employment Tribunal made decisive findings that he suffered detriment and was unfairly dismissed explicitly because he made public interest disclosures.

The ET rejected the CQC’s unpleasant dissembling during the ET process, which shockingly and falsely tried to cast him as a troublemaker and bully all through proceedings.

The details of the case and key documents can be found here:

Mr Shyam Kumar, Surgeon and vindicated NHS whistleblower’s case: CQC sacked a whistleblower for disclosures about its poor regulatory performance, and dug for dirt on the whistleblower

On 11 September 2022 I asked Ian Trenholm, CQC’s CEO several questions about CQC’s and his own actions with regard to Mr Kumar’s case, and CQC’s whistleblowing governance.

Despite an indication from Trenholm’s Office that there would be a response, none has been issued, This is despite reminders.

These are just a few of the unanswered questions that I put to Ian Trenholm:

“8. Would you like to comment on the fact that only 47% of CQC staff replied affirmatively in the 2019 CQC staff survey to survey question number 62:  “62. I think it is safe to challenge the way things are done in CQC”

For context:

The Civil Service all organisation median for this question in 2019 was 50%. /file/876879/Civil_Service_People_Survey_2009_to_2019_Median_Benchmark_Scores__final.pdf

In 2019, the NHS staff survey revealed that 71.7% of staff who participated stated that they would feel secure to raise a concern about unsafe clinical care.

Would you also like to comment on why only CQC staff surveys for 2018 and 2019 are published on this CQC webpage:

Were there no CQC staff surveys in 2020 and 2021, or is it that the survey was done in those years but the results were not published?

If CQC did carry out staff surveys in 2020 and 2021, will it now publish the results on this webpage?

Thank you.

Yours sincerely,


Dr Minh Alexander

Cc Ian Dilks CQC Chair, CQC press office”

Of concern, the CQC has been allowed to control an investigation into its own behaviour in Shyam Kumar’s case and a “selected” number of other cases of NHS trust whistleblowers.

There is no transparency about how the NHS trust cases have been selected – which gives rise to a concern that the selection is in CQC’s favour.

Of immense concern, the investigation terms of reference did NOT include any examination of CQC’s general whistleblowing governance. This is incomprehensible given: 

  1. CQC’s recurrent history of victimising its own whistleblowers
  2. CQC’s appalling behaviour in Mr Kumar’s case

Surely when something so serious has happened, such as a regulatory cover up, it should be automatic to review the whole system which gave rise to it?

The exclusion of any examination of CQC’s general whistleblowing governance from the investigation is a slap in the face for CQC staff. Indeed, it is intimidatory, and possibly intended to be so.

But it is not so surprising given that CQC seems not to have accounted for its workforce relations in recent years.

Also, CQC recently unlawfully evaded an FOI request about its whistleblowing governance and failed to disclose internal reports by its own Freedom To Speak Up Guardian:

CQC’s unlawful evasion of an FOI request about its whistleblowing governance

What is going on at CQC that requires such obfuscation?

No matter how much CQC tries to spin and manipulate its investigation to its advantage, a strong stink is still present.


Please click and add your signature to this petition to reform UK whistleblowing law – whistleblowers protect us all but weak UK law leaves them wholly exposed, lets abusers off the hook and it is a threat to public safety.

Replace weak UK whistleblowing law and protect whistleblowers and the public


Ian Trenholm CQC CEO was previously CEO of NHS Blood and Transplant 2014-2018. There have been several recent media revelations of bullying and Race discrimination at NHS Blood and Transplant, some of which reportedly took place when Trenholm was CEO.

Leaked report shows ‘long-standing’ bullying and discrimination within national agency

CQC’s unlawful evasion of an FOI request about its whistleblowing governance

Mr Shyam Kumar, Surgeon and vindicated NHS whistleblower’s case: CQC sacked a whistleblower for disclosures about its poor regulatory performance, and dug for dirt on the whistleblower

Shyam Kumar’s whistleblowing case and the CQC’s inconsistent claims on how it processes feedback data from Specialist Advisors

Serious Case Review into Winterbourne Hospital Abuse

Witness statement of Amanda Pollard CQC whistleblower, to the Mid Staffs Public Inquiry

Resignation letter 26 January 2016 and disclosures by Barry Stanley Wilkinson, CQC whistleblower

Counting the cost of the CQC: Abuse, Whorlton Hall and CQC spin doctors

The spreading CQC Whorlton Hall scandal emerging allegations at ‘Outstanding’ Newbus Grange. Another CQC deception?

Mr Tristan Reuser’s whistleblowing case: Scandalous employer and regulatory behaviour on FPPR

CQC’s Victimisation of Whistleblowers: Failure to Investigate Concerns

Breach of confidentiality by CQC and complicity in referring a whistleblower to the Disclosure and Barring Service

Whistleblowers Unheard by CQC

More CQC denial about collusion with employers against whistleblowers

Carl Beech, CQC inspector, convicted child sex offender and fraudster: Activities at the CQC CQC’s Asleep on the Night Shift

CQC case study. Snooping. Briefing. Porkies. And vexatiously applied ‘vexatious’ protocols.

The Department of Health holds no data on long COVID in NHS staff and has no intention of collating this data

Dr Minh Alexander retired consultant psychiatrist 12 November 2022

The UK is not good to its public servants.

ONS has just compiled basic data on armed forces veterans for the first time. It was astonishing that there were previously no such no official figures.

Frontline NHS staff injured by COVID19 whilst trying to keep services afloat despite government mismanagement of the pandemic, have been treated with disdain by the government..

NHS Resolution holds some of the central data on NHS staff long COVID cases, but says the data is not specifically coded to allow a computer search and analysis. See:

Transparency about NHS staff with long COVID injuries and NHS staff personal injury claims for long COVID

I asked the Department of Health and Social Care if it knew of any central data, and whether it held central data on long COVID-affected NHS staff.

The answer was ‘No’ and ‘No’.

Asked whether it intended to collate this data in future, the answer was also ‘No’.

The DHSC suggested I try ONS, but ONS only holds long COVID data by occupational group, and not by employer.

In the midst of an epic NHS workforce shortage, the DHSC knows of no central data about staff who have left the NHS due to long COVID:

“The numbers of NHS staff to date who have left their employment due to long covid

DHSC does not hold this information. Standard publications of information by NHS Digital does not record this level of detail and we are not aware of any specific NHS collections known to DHSC.”

This is the DHSC FOI response:

Department of Health and Social Care FOI response 11 Nov 2022 Long COVID in NHS staff Ref FOI-1422015

The government’s treatment of key workers on the COVID frontlines is beyond words.

Will the unions campaign hard enough to ensure that COVID injured NHS staff are better treated and NHS staff are better protected from transmissible diseases?

It is not only a matter of justice but of public health. Unprotected workers are part of the engine of transmission and infection.

I have sent the DHSC’s FOI response to the COVID public inquiry.

CQC’s unlawful evasion of an FOI request about its whistleblowing governance

By Dr Minh Alexander retired consultant psychiatrist 8 November 2022

The Care Quality Commission has a long history of politicisation, arbitrary regulatory behaviour and poor conduct towards whistleblowers, both its own and those from regulated bodies.

On 26 October 2022 CQC announced cursory terms of reference for a review into its whistleblowing governance.

These extraordinarily omitted to explore CQC’s general handling of internal whistleblowing matters.

The ToR only focussed on a single internal CQC whistleblowing case and and examination of CQC’s conduct towards whistleblowers from regulated bodies:

“In relation to

(1)  the protected disclosures made to the CQC by Mr Kumar; and

(2) a sample of whistleblowing concerns received by the CQC related to NHS Trusts, the size and date range of which is to be agreed:

The Review will:

(3) consider how CQC used these disclosures in its regulation of the relevant NHS Trusts and whether appropriate action was taken, taking account of all relevant factors including whether ethnicity played any part in the management of those disclosures; and

(4) make recommendations for improvement.

(5) Should the reviewer consider, during the course of the review, that these Terms of Reference require amendment, they will make a written proposal to that effect to the CQC Board for their consideration.”

This represents a defiant lack of apology to CQC’s workforce about its poor behaviour and it fails to ensure psychological safety for any current or future CQC whistleblowers.

It is possible of course that the above omission contains an implied threat to CQC’s workforce, and is a message that silence is preferred.

On 7 September 2022 Martin Morton social care whistleblower and former Social Services manager asked the CQC about its whistleblowing governance, via the What Do They Know website.

Included in his FOI request was a request for disclosure of the CQC’s own Freedom To Speak Up Guardian’s reports.

It was poor that CQC had not already published these reports. NHS trusts routinely publish these types of reports by their Freedom To Speak Up Guardians. That is to say, instead of being an exemplar as a regulator should, CQC is a governance laggard.

The CQC acknowledged the Morton FOI request and initially indicated that it would provide a response by 5 October 2022, the statutory deadline.

But CQC then changed course and stated to Martin Morton, on 6 October 2022, that it had encountered unspecified difficulties:

Unfortunately, we are not currently able to respond to your request due to an unforeseen delay in processing your request.”

This was not a lawful response.

By 4 November 2022, as he had still not heard, Martin Morton prompted the CQC with the admonition that he would refer the matter to the ICO if necessary.

Faced with this, on 7 November 2022, the power-abusing CQC finally responded. This is the CQC’s response:

CQC FOI response to Martin Morton 7 November 2022 Whistleblowing governance and Freedom To Speak Up Guardian reports Ref CQC IAT 2223 0450

The response shows that in the course of five years, only 131 speaking up cases were raised with CQC’s own Freedom To Speak Up Guardian.

This is a small number of Speaking Up cases for a large organisation (over three thousand FTE workers), if compared to the reporting rate at NHS trusts.

Moreover in 2021/22, there was a sharp fall in CQC’s speaking up cases.

Is this because CQC’s victimisation of yet another of its own whistleblowers became public?

The CQC denies that any of the 131 speaking up cases featured detriment.

Most remarkably, in its FOI response of 7 November 2022, CQC continued to evade the request for copies of reports by its own, internal Freedom To Speak Up Guardian.

Instead of disclosing its own Freedom To Speak Up Guardian’s reports, CQC bizarrely pointed Martin Morton to published reports by the National Guardian.

What could CQC be hiding?

What content in the internal Freedom To Speak Up Guardian reports is CQC so reluctant to disclose?

This shabby organisational behaviour, whilst a review into CQC’s whistleblowing governance is underway, is hardly reassuring evidence of genuine remorse and learning.

Martin Morton continues to pursue the disclosure of the CQC Freedom To Speak Up Guardian reports.

In other news, CQC has tried to apply a patently invalid FOIA exemption to an FOI request by another whistleblower, but it retreated when challenged.

More coming soon about that misdemeanour.


Please click and add your signature to this petition to reform UK whistleblowing law – whistleblowers protect us all but weak UK law leaves them wholly exposed, lets abusers off the hook and it is a threat to public safety.

Replace weak UK whistleblowing law and protect whistleblowers and the public


Mr Shyam Kumar, Surgeon and vindicated NHS whistleblower’s case: CQC sacked a whistleblower for disclosures about its poor regulatory performance, and dug for dirt on the whistleblower

Shyam Kumar’s whistleblowing case and the CQC’s inconsistent claims on how it processes feedback data from Specialist Advisors

Serious Case Review into Winterbourne Hospital Abuse

Witness statement of Amanda Pollard CQC whistleblower, to the Mid Staffs Public Inquiry

Resignation letter 26 January 2016 and disclosures by Barry Stanley Wilkinson, CQC whistleblower

Counting the cost of the CQC: Abuse, Whorlton Hall and CQC spin doctors

The spreading CQC Whorlton Hall scandal – emerging allegations at ‘Outstanding’ Newbus Grange. Another CQC deception?

Mr Tristan Reuser’s whistleblowing case: Scandalous employer and regulatory behaviour on FPPR

CQC’s Victimisation of Whistleblowers: Failure to Investigate Concerns

Breach of confidentiality by CQC and complicity in referring a whistleblower to the Disclosure and Barring Service

Whistleblowers Unheard by CQC

More CQC denial about collusion with employers against whistleblowers

Carl Beech, CQC inspector, convicted child sex offender and fraudster: Activities at the CQC

CQC’s Asleep on the Night Shift

CQC case study. Snooping. Briefing. Porkies. And vexatiously applied ‘vexatious’ protocols.

North East Ambulance Service breached its obligations under FOIA, wrongly withheld data on staff suicides and appears to be under-reporting bullying incidents and serious incidents

By Dr Minh Alexander 19 October 2022

Summary: North East Ambulance Service (NEAS) has like other ambulance services been under chronic, major pressure. Like other ambulance trusts, it has poor workforce metrics. Like other ambulance trusts, it has had staff suicides. Of concern, NEAS tried to obfuscate about these suicides when asked about them via FOI. There are other questions about NEAS’ reliability in reporting. NEAS appears to have under-reported bullying in another FOI response, and there are questions about the fact that it appears to be an extreme outlier in reporting a lower number of serious incidents than other ambulance trusts. Moreover, NHS England is in control of the investigation into NEAS’s deaths scandal, but the terms of reference for the investigation reportedly ignore possible manipulation of coronial reporting processes. They have been described by a “source close to the investigation” as a “white wash”. A properly independent judge led inquiry is needed given the serious questions of probity and alleged criminal breaches of coronial law.


North East Ambulance Service NHS Foundation Trust (NEAS) is, like other ambulance trusts, a highly stressed and neglected organisation.

NEAS is currently under the microscope after whistleblowers disclosed that it had been altering staff statements for coroners’ inquests and failing to report deaths to the coroner.

NHS England has been criticised for not acting upon the NEAS whistleblowers’ disclosures, yet NHSE has been left in charge of an investigation into these matters.

That serious conflict of interest was of itself appalling, but it has since emerged through a Health Service Journal report 0f 13 October 2022 that the terms of reference for NHS England’s investigation omit a vital area, and represent an attempt by NHS England to “whitewash” the matter.

“Mr Calvert said the AuditOne review was made aware of “numerous cases” and “not just the five” being examined by the new inquiry. Another source close to the investigation, who asked to remain anonymous, echoed the concerns about the limited number of cases being examined, and added: “What’s missing is an analysis of attempts to conceal facts from coroners, there’s nothing in the terms of reference about this. 

The families want a full independent inquiry, this is going to be a whitewash.” [My emphasis]

Moreover, the person whom NHS England appointed to lead its investigation is an NHS insider, Marianne Griffiths former CEO of University Hospitals Sussex NHS Foundation Trust.

When a contentious whistleblowing matter arose at her trust, she and her board were improperly protected by the then National Guardian, Henrietta Hughes:

A Study in Delay: The National Guardian & Brighton and Sussex University Hospitals NHS Trust

There is a serious question over whether this obfuscation of organisational failings and poor culture at Sussex contributed to later failures of whistleblowing governance, which affected maternity safety:

A Study in Delay II : The National Guardian, maternity safety & University Hospitals Sussex NHS Foundation Trust

NEAS staff suicides

Information about staff suicides at NEAS from several sources led to the submission of an FOI request to NEAS about this.

NEAS responded on 12 October 2022, and initially tried to evade disclosure of this information. NEAS answered as follows:

How many NEAS trust staff have died by suicide or suspected suicide since 1 April 2016?

The Trust would confirm that it is the coroner who decides whether a death was suicide.”

(NEAS FOI disclosure ref. 22.271)

NEAS was challenged about the fact that its FOI response had not met the legal obligations under FOIA to:

  1. Confirm whether or not it held the requested information
  2. Indicate which legal exemption it relied on if it held the information,  but did not want to disclose it.

On 18 October 2022  NEAS responded again, disclosing that there had been three staff suicides or suspected staff suicides since 2020:

NEAS denied that it held data before 2020.

In addition to the tragedy of ambulance trust staff’s working conditions, a very serious issue arising from this FOI matter is that NEAS initially attempted to evade the question about staff suicides.

This surely shows continuing organisational failure and secrecy?

For context this is an FOI disclosed by NEAS in 2018 about staff sickness related to mental health issues:

NEAS FOI Ref.FOI.18.009 staff mental health absence

It has been reported that NEAS in fact established a mental health advisor post as part of Occupational Health services, following staff suicides. NEAS have been asked to confirm if this is correct, and to provide details about these issues.

Has NEAS issued a false FOI disclosure about levels of bullying?

In another area, NEAS’ reporting is also in doubt.

I have seen an FOI response by NEAS of 28 September 2022 which reports tiny numbers of reports of staff-staff bullying in recent years:

2019 < 5 cases

2020 6 cases

2021 < 5 cases

This is the relevant extract from NEAS’ FOI disclosure:

This data is strange because it does not match up with NHS Staff Survey data.

The most recent NHS staff survey on NEAS showed that:

a) 15.7% of NEAS staff reported being bullied by a manager in the previous twelve months

Scaling this up, based on an NEAS workforce of approximately 2,700 staff gives an estimate of 424 staff who experienced bullying by a manager in the previous twelve months.

b) 19.4% of NEAS staff reported being bullied by a colleague in the previous twelve months:

Scaling this up, based on an NEAS workforce of approximately 2,700 staff gives an estimate of 524 staff who experienced bullying by a colleague in the previous twelve months.

c) 43.5% of NEAS staff reported the last incident of bullying and harassment that they experienced was reported:

Therefore, the total recorded incidents of reported bullying at NEAS that year should have been something like 43.5% of the hundreds staff who experienced bullying, and not the tiny single figures reported in NEAS’ FOI disclosure of 28 September 2022.

Questions arise of whether NEAS made a false statement under FOIA about its recorded incidents of bullying, or whether there is something terribly wrong with NEAS’ systems for recording and tracking the serious workforce issue of bullying.

Both options are disturbing.

NEAS claimed in its annual report of July 2022 that it planned to investigate the numbers of bullying incidents,

“In addition to the activities that have already commenced we have identified actions that will be progressed over the next 12 months, including….. Investigating the data around bullying and harassment in more detail and triangulate with free text comments, Freedom to Speak Up Guardian, grievances and exit interviews to get a more detailed picture.”

Is it really plausible that NEAS was unaware that its FOI release of 28 September was a gross misrepresentation of its levels of reported bullying?

Is NEAS under-reporting serious incidents?

Someone has drawn my attention to a suspiciously low number of serious incidents reported by NEAS.

NEAS reported that there were only 6 serious incidents in 2021-2022:

In contrast other ambulance trusts reported many times this number of serious incidents:

North West Ambulance Service: 86 serious incidents

Yorkshire Ambulance Service: 71 serious incident

East Midlands Ambulance Service: 38 serious incidents

West Midlands Ambulance Service: 204 serious incidents

South Central Ambulance Service – 2021/22 Quality Account not yet published

East of England Ambulance Service: 161 serious incidents   

South East Coast Ambulance Service: 67 serious incidents

London Ambulance Service: possibly 81 serious incidents based on feedback, but not found in the trust quality account

South Western Ambulance Service: 74 serious incidents

NEAS has been asked about its apparent outlier status on serious incident reporting.

Public inquiry in light of allegations of criminal breaches

The charade about NEAS’ governance will likely continue, given HSJ’s revelations about the deeply flawed terms of reference for Marianne Griffiths’ investigation of NEAS.

An NHS insider investigation seems a seriously inadequate response to matters which raise Article 2 and alleged criminal breachs of coronial law.

In light of ongoing evidence that NEAS may be obfuscating, given the Article 2 issues and given the extremely serious issues of alleged criminal breaches of coronial law, a fully independent judge led inquiry with statutory powers is needed.


Please click and add your signature to this petition to reform UK whistleblowing
law – whistleblowers protect us all but weak UK law leaves them wholly exposed,
lets abusers off the hook and it is a threat to public safety.

Replace weak UK whistleblowing law and protect whistleblowers and the public


Henrietta Hughes former National Freedom To Speak Up Guardian, South Central Ambulance Service, out of touch “extreme positivity” and failures to act on staff concerns

North East Ambulance Service settlement agreements, ambulance service leavers, bullying and understaffing

Auditors concluded North East Ambulance Service failed to act on legal advice to ensure it complied with coronial legislation to disclose evidence, and vilified staff who followed the law

Paul Calvert North East Ambulance Service Whistleblower says NHS internal Freedom To Speak Up mechanism is “entirely ineffective, being used to cover up and delay matters”

Staff suicides at West Midlands Ambulance Service NHS Foundation Trust

Professional regulators fail to protect frontline health and care staff from rogue employers: The HCPC and NHS ambulance trusts

The National Guardian’s Office does not put a blue light on for ambulance staff

Was the CQC wilfully blind to organisational failures by East Kent Hospitals NHS Foundation Trust on maternity safety?

Dr Minh Alexander retired consultant psychiatrist 17 October 2022

My condolences to all affected East Kent families.
The Kirkup investigation into maternity failures at East Kent Hospitals University NHS Foundation Trust is due to report on Wednesday 19 October 2022.
A Telegraph investigation has today added to the general concerns about NHS maternity care. It has revealed that some NHS trusts have been wrongly classifying neonatal deaths as stillbirths, with the alleged aim of covering up and avoiding an inquest.
Mark Tattersall Consultant Obstetrician has whistleblown on this practice. He has made past disclosures about patient safety and his evidence on this is held by parliament.
There have been concerns at East Kent maternity services for around a decade, in the context of generally poor trust governance and the CQC placing the trust into special measures in 2014.

The trust came under increased scrutiny as a result of an avoidable death of baby Harry Richford on 9 November 2017.  Harry’s mother was a healthy young woman, her pregnancy had been uneventful, and Harry’s death was shocking and unexpected. Harry died due to poor care, which centred around the poor supervision of a locum doctor whom the trust rostered for out of hours duties without checking his competence. The family’s search for the truth and media investigations led to increasing awareness that other families had been affected and that EKHUFT had repeatedly failed to refer cases to the coroner.  Systemic failings were confirmed after the commencement of local Healthcare Safety Investigation Branch maternity investigations in 2018. The government ordered the Kirkup investigation as the scale of the failures emerged.

In this post I share documents provided by Harry Richford’s family via @DerekRKENT to explain a key concern – regulatory failure to keep other babies and mothers safe. The documents give an audit trail of failures by EKHUFT to learn, and denial by the Care Quality Commission (CQC) of these systemic risks to the public.
EKHUFT became an embarrassment to the authorities in 2014 when it had to be placed in special measures because of poor governance and unsafe care. Thereafter, CQC reported improvement. Despite evidence of continuing organisational failure and harm, CQC claimed to the Richfords in 2018 there was no breach of EKHUFT’s organisational legal duty under CQC Regulation 12 to provide safe care related to Harry’s death. Two years later, CQC reversed and prosecuted the trust, the first prosecution of its kind.

CQC’s denial that Harry Richford’s death was linked to systemic failings was disproved by the trust’s internal investigation, five expert reports and the coroner’s findings, all of which identified organisational related failings by EKHUFT. CQC denied organisational failure even though EKHUFT failed to refer Harry’s death to the coroner. It was also despite the fact that the trust reported to external authorities that Harry’s death was “expected”, even though EKHUFT had identified that the death was linked to care failings. CQC also claimed it had never seen a highly critical Royal College of Obstetricians and Gynaecologists (RCOG) report on EKHUFT which was carried out before Harry’s death. The RCOG identified many examples of previous poor care, organisational failings and risks, including those which specifically led to Harry’s death. CQC claimed it had not reviewed the report until 2019, despite CQC being aware of a related action plan before that, and despite the fact that the RCOG report was commissioned with the involvement of the CCG and NHS England, who have joint working arrangements with the CQC.

Most recently, it was found that the coroner’s Prevention of Future Deaths report on Harry Richford was not published as it should have been on the chief coroner’s website, and that NHS England’s and EKHUT’s responses to the coroner are missing.
Will the pending Kirkup report reveal the whole truth about the failures at EKHUT and the failures of oversight bodies?
Of relevance to EKHUFT’s future management, since April 2022 the CEO of EKHUFT has been the former CEO at Homerton, under whose tenure the ‘ Unhappy Midwives’ whistleblowing scandal arose. This related to multiple maternal deaths (usually very rare) and poor maternity care. Another Homerton maternity whistleblower, Pam Linton senior midwife, reported concerns to CQC but later discovered via a Subject Access Request that nothing appeared to have been done about her concerns.

Harry’s family in their own words:
Harry Richford’s family tenaciously investigated the factors contributing to Harry’s death and they have set out a summary of their experiences at this website:

Systemic factors affecting maternity safety

Healthcare safety is an issue of resources, systems and leadership.

In all serious incidents, even if they involve errors or negligence by individuals, an organisation should take responsibility and reflect on whether it may have allowed a serious incident to occur.

For example, through poor staffing and skill mix, poor supervision, lack of drilling for emergencies, lack of quality monitoring, inadequate equipment, inadequate administrative support, poor team processes and dynamics or leadership unconducive to safety culture.

The Ockenden Review on maternity failures at Shrewsbury and Telford emphasised that dedicated focus is important to protecting service quality, and pointed out the importance of focused leadership on quality:

Ockenden page 54:

“PSIRF- Resources and expertise:

4.138 The review team discussed with NHS England that the National Maternity Assessment Tool recommends the following minimum staffing levels for governance teams:

• Maternity governance lead (who is a midwife registered with the NMC)

• Consultant obstetrician governance lead (Minimum 2 PAs90)

• Maternity safety manager (who is a midwife registered with the NMC or relevant transferable skills).

• Maternity clinical incident leads

• Audit midwife – a lead midwife for audit and effectiveness

  • Practice development midwife
  • Clinical educators, to include leading preceptorship programme

Appropriate governance facilitator and administrative support within the maternity department.”

In 2012, the NHS Litigation Authority (now rebranded as NHS Resolution) analysed ten years’ of maternity claims. NHSLA detected patterns in care failings and recommended systems solutions:

“The key risk management themes to emerge from the project are discussed. Namely, the need to: engage with the risk management process at all levels; provide suitable learning and training; ensure appropriate supervision and support; have in place up-to-date protocols and guidance with which staff are familiar; learn lessons from claims.

The report concludes that the most effective way to reduce the financial and human cost of maternity claims is to continue to improve the management of risks associated with maternity care, focusing on preventing incidents involving the management of women in labour, including the interpretation of CTG traces.”

Safe staffing

A critical organisational factor is safe staffing, in both numbers and skill mix.

Under conditions of inadequate staffing in healthcare, staff may make more mistakes and face disciplinary action for what are systems issues. They may report fewer incidents in consequence, fuelling a downwards safety spiral. Hansard recorded such an example at Mid Yorkshire Hospitals in 2016.

Jeremy Hunt former Health Secretary and self-styled ‘champion’ of maternity safety, who made political capital out of appearing to support the patient safety cause, decided not to introduce mandatory NHS safe staffing standards:

Why won’t the government implement safe staffing levels in the NHS?

We continue to see healthcare scandals, many of which are maternity scandals, across the NHS. As well as harm to the public, there is compensation and litigation cost for the public purse, particularly for maternity cases.

Nationally, some maternity outcomes had previously been on an improvement trajectory. Rates of neonatal deaths, infant deaths and stillbirths fell steadily in previous decades. The rate of safety improvement has slowed under recent Conservative governments. ONS data is available up to 2020  and shows the following trajectory, set against government targets for reduction by 2025:

A BBC investigation in 2011 showed significant variation in midwife numbers across the NHS, with the lowest numbers found in the East and South East.

Staffing ratios should of course vary with the health of local populations, but the question is whether less than the minimum is sometimes provided.

In 2020, a survey by the Royal College of Midwives concluded that half of maternity units were understaffed.

The final Ockenden report on Shrewsbury and Telford Hospital NHS Trust, published this year, emphasised the importance of safe staffing:

“In the last year since our first report was published we have seen significant pressures in maternity services in the recruitment and retention of midwives and obstetricians.

“It is absolutely clear that there is an urgent need for a robust and funded maternity-wide workforce plan, starting right now, without delay and continuing over multiple years. This has already been highlighted on a number of occasions but is essential to address the present and future requirements for midwives, obstetricians, anaesthetists, neonatal teams and associated staff working in and around maternity services. Without this maternity services cannot provide safe and effective care for women and babies. In addition, this workforce plan must also focus on significantly reducing the attrition of midwives and doctors since increases in workforce numbers are of limited use if those already within the maternity workforce continue to leave. Only with a robustly funded, well-staffed and trained workforce will we be able to ensure delivery of safe, and compassionate, maternity care locally and across England. ”

Current official guidance on calculating required staffing seems elliptical and coy about setting a minimum standard, reflecting the government’s refusal to legislate for minimum staffing. Guidance refers the reader to other guidance, which leaves the ultimate decision with each local provider.

Midwifery staffing red flags

But NICE midwifery guidance from 2015 does recognise that clinical red flags should  trigger a review of midwifery staffing:

A midwifery red flag event is a warning sign that something may be wrong with midwifery staffing. If a midwifery red flag event occurs, the midwife in charge of the service should be notified. The midwife in charge should determine whether midwifery staffing is the cause, and the action that is needed.

• Delayed or cancelled time-critical activity.

• Missed or delayed care (for example, delay of 60 minutes or more in washing and suturing).

• Missed medication during an admission to hospital or midwifery-led unit (for example, diabetes medication).

• Delay of more than 30 minutes in providing pain relief.

• Delay of 30 minutes or more between presentation and triage.

• Full clinical examination not carried out when presenting in labour.

• Delay of 2 hours or more between admission for induction and beginning of process.

• Delayed recognition of and action on abnormal vital signs (for example, sepsis or urine output).

• Any occasion when 1 midwife is not able to provide continuous one-to-one care and support to a woman during established labour.

• Other midwifery red flags may be agreed locally.”

Based on the still steady stream of maternity care scandals, surely we are currently awash with such red flags?

Seriously unsafe midwifery staffing at East Kent Hospitals University NHS Foundation Trust?

In October 2021 the media reported that CQC had found severe staffing shortage in maternity services at East Kent, following unannounced inspections in July 2021.

Midwives were reportedly forced to work 20 hour days.

This are links to the reports from the July 2021 CQC site visits:

Was the CQC wilfully blind to organisational failings in maternity care at East Kent?

CQC appeared to ignore internal trust findings and external expert findings of organisational failure

At East Kent Hospital University NHS Foundation Trust, the Care Quality Commission bizarrely refused to acknowledge a link between a serious incident – the death of baby Harry Richford seven days after a catastrophic, avoidable birth injury – and evident systems issues.

This was despite the trust’s internal Root Cause Analysis (RCA) report concluding very clearly that there were multiple systems issues:

This leads us to conclude that this incident occurred due to system failures.”

The trust RCA acknowledged that there was inadequate vetting of and supervisory support for the locum junior doctor involved in Harry’s death.

The RCA contained a hint that other staff were concerned about having a locum on call, as one midwife rolled her eyes in front of Harry’s mother upon being told which registrar was on call on the fateful night of Harry’s birth.

This raises many questions about organisational factors. It also linked to an earlier RCOG finding that maternity staff had stopped raising safety concerns because Leads did not act upon them.

Whistleblowing governance at East Kent Hospitals University NHS Foundation Trust
The Royal College of Obstetricians and Gynaecologists (RCOG) was in 2015 commissioned to review governance failures and dysfunctional team relationships in East Kent maternity service.
The College reported that there were issues of poor reporting culture, especially by doctors.
Staff reporting was discouraged by the fact that past concerns were not acted upon.
An FOI request that I submitted to EKHUFT in 2019 revealed that the so called ‘Freedom To Speak Up Guardians” – designated trust employees to whom other employees can whistleblow –  had never escalated any whistleblowing matters to CQC or to the National Guardian.
The BBC has reported that most East Kent staff were too frightened to speak to the media.

This speaks loudly of organisational and senior leadership failure.

The Richfords objected to the trust’s internal RCA investigation.

In response, EKHUFT commissioned two expert reports from a neighbouring NHS trust.These reports concluded that there were some failings. Overall, they were not as critical as later expert reports commissioned by the coroner but organisational failure is implied by:

– A concern that the trust may not have adhered to national guidelines on neonatal resuscitation. (This contradicted the trust internal RCA which concluded that resuscitation guidance was followed).

– A suggestion that EKHUFT should put in place a more robust system of training and drilling to ensure that staff were better equipped to deal with neonatal emergencies and resuscitation.

But CQC denied there was organisational failure by EKHUFT in Harry Richford’s case despite the trust’s RCA findings and these local external reports.

CQC appeared to ignore the probity implications of EKHUFT’s flawed reporting to external authorities about Harry’s death

CQC denied there was organisational failure despite the trust’s flawed decision not to refer Harry’s death to a coroner.

The trust justification for this was recorded in the RCA report. An argument was made that no referral was needed because the cause of death was known (and that it was hypoxia). This is a flawed argument. It failed to acknowledge other relevant criteria requiring a referral to the coroner, such as whether a death could be related to a clinical procedure.

The CQC should have seen the trust’s failure to refer Harry’s death to the coroner as a big red flag about organisational competence, probity and safety culture.

Instead, on 17 August 2018 Emma Carroll then a local CQC inspector (now Inspection Manager) wrote to Harry’s family that three management reviews by CQC had concluded that there had only been errors by individual staff, and that the trust itself was not in breach of regulations:

“We have held three management meetings to discuss the information shared by yourself and the trust, including the RCA, both independent reviews, the trust’s action plan and additional information requested from the trust. We have not received confirmation from the senior coroner as to whether they will be progressing with an investigation. However, I have requested CQC are made an interested party which means we will receive the final Coroner’s report.

After an extensive review, we do not believe there has been a breach in regulation. The concerns raised in this incident are centred on an individual’s decision or error. The criminal offences CQC can prosecute against only apply to registered person failures.”

Derek Richford, Harry’s grandfather, challenged this bizarre position.

The exchange of correspondence between Derek Richford and Emma Carroll on 17 August 2018 can be found here.

Instead of shutting down enquiries about organisational failure, the CQC should have been actively pursuing whether EKHUFT had failed to refer other deaths to the coroner, whether there were common themes between deaths and the level of risk posed to the public by EKHUFT’s systems failure.

The coroner later noted with concern the trust’s outrageous claim that Harry’s death was “expected” and its failure to inform the coroner of Harry’s death:

“Concern 17

The child death notification form was incorrectly completed in that Harry’s death was recorded as ‘expected’. No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry’s death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.”

Normally, arrangements for reviewing child deaths are very formal and involve substantial multiagency scrutiny.    

On a related theme of reporting to external authorities, the coroner also found that EKHUFT’s report about Harry’s death to a national database was inaccurate:

“Concern 18

The MBRRACE form in respect of Harry Richford was inaccurate in a number of important areas. The form is important to provide robust national data to support the delivery of safe, high quality maternal and new born care as well as identifying errors and faults, if any, where there has been a maternal or infant death so that future deaths can be avoided.”

The CQC should have noted that EKHUFT’s MBRRACE submission was inaccurate and that this too was a warning sign.

The coroner noted another serious warning sign about EKHUFT managers’ accountability and transparency:

“Concern 19

Important independent reports do not appear to have been shared within the East Kent Trust’s staff, for instance the HSIB report into Harry’s death appeared during the inquest to be unknown to a number of the staff.”

Alongside the coroner’s above concerns about EKHUFT management’s reliability, it is relevant to note that EKHUFT was one of the trusts which had to repay an insurance discount to NHS Resolution, after it was found to have mis-declared its maternity services to be safer than they really were. The NHSLR spreadsheet which records these events can be foundhere. See Year 1 and Year 2.

CQC’s denial of organisational failings was discredited by the Coroner’s findings

Contrasting with CQC’s denial, the coroner later made in February 2020 a string of recommendations for avoiding future deaths. He made it abundantly clear that he thought there were avoidable organisational factors in Harry’s death, local and national.

The detailed coroner’s conclusions underlying the recommendations for preventing future deaths can be found here.

Three independent expert reports commissioned by the Coroner concluded that there were multiple care failings by EKHUFT and that some of these related to organisational factors. 

Both the medical experts, an obstetrician and a paediatrician, concluded that Harry would have been born alive and in good condition if his care had been appropriate.

At inquest, the trust’s lawyers contended there was no neglect but the coroner rejected this and ruled that a contributory factor in Harry’s death was neglect:

“The cause of death was 1a Hypoxic Ischaemic Brain Encephalopathy. There was a narrative conclusion setting out some seven failures in the care of Harry Richford together with a conclusion that his death was contributed to by neglect.”

Coroners’ findings of neglect
A finding of neglect by a coroner is a very serious matter.
Neglect was defined as follows in the case of
R v HM Coroner of North Humberside and Scunthorpe Ex p Jamieson [1995]
“Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide or procure basic medical attention or shelter or warmth for someone in a dependent position – because of youth, age, illness or incarceration – who cannot provide it for himself. Failure to provide medical attention for a dependent person whose physical condition is such as to show that he obviously needs it may amount to neglect. So it may be if it is the dependent person’s mental condition which obviously calls for medical attention (as it would, for example, if a mental nurse observed that a patient had a propensity to swallow razor blades and failed to report this propensity to a doctor, in a case where the patient had no intention to cause himself injury but did thereafter swallow razor blades with fatal results). In both the cases the crucial consideration will be what the dependent person’s condition whether physical or mental appeared to be”.

Thus, Harry’s case also raised Safeguarding issues, which placed a particularly serious duty on CQC to protect other similarly vulnerable patients.

CQC’s denial of organisational failure was discredited by HSIB’s findings

The HSIB National Investigation team scoped Harry Richford’s case for potential national learning.

The exercise was reported in January 2019 and came to similar conclusions as the coroner’s experts.

The Healthcare Safety Investigation Branch (HSIB) also identified abundant evidence of organisational failures and lack of learning by EKHUFT.

Of note, HSIB identified that the trust had not followed its own policy (Engaging the Temporary Workforce, 2014) on checking the competence of locum staff. This policy recognised that the trust had a duty to proactively mitigate risk when locums are assessed as not being competent, for example by restricting practice or increasing supervision.

The trust had also not followed RCOG guidance on consultant attendance for certain procedures if a trainee has not been signed off as competent:

“The RCOG green-top guideline 2011 and Trust guideline 2015, recommends that a consultant obstetrician should attend in person for a trial of instrumental delivery if the trainee has not been assessed and signed off as competent. The Trust guideline also identifies caesarean section at full dilatation as a procedure the consultant should attend inperson if the trainee has not been signed off for independent practice for the procedure. The locum doctor’s competency was unknown.”

According to the Memorandum of Understanding between HSIB and CQC, it seems likely that HSIB sent CQC a copy of HSIB’s January 2019 scoping report:

“Sharing pre-published HSIB investigation reports and recommendations. To be open and transparent when in receipt of information regarding the safety of services that are registered with CQC and funded by the NHS in England. The information is shared with the CQC in a timely way through the named CQC contact or by a representative delegated by them.”

HSIB began its local maternity investigations in 2018. In February 2020, at the same time as the coroner’s PFD report was issued, HSIB produced a summary report on its local investigations at EKHUFT. In this report, HSIB observed that the same errors kept being made at EKHUFT:

“From December 2018, HSIB engaged frequently with the Trust to present evidence of recurrent patient safety concerns in its maternity services. Despite repeatedly raising these concerns with the Trust, HSIB investigators continued to see the same themes reoccurring and in August 2019, asked the Trust to self-refer themselves to their CCG and the CQC.”

HSIB also wrote to the CQC about the problems at EKHUFT in August 2019.

CQC knew without any doubt by August 2019 that there were organisational failings, linked to ongoing serious harm. By January 2020, a rare maternal death was amongst the EKHUFT incidents investigated by HSIB (page 3 HSIB summary report).

The CQC informed EKHUT on 1 October 2019 that it was commencing a criminal investigation into the circumstances of Harry’s death.

CQC did not announce that it would prosecute EKHUT under CQC Regulation 12 until October 2020.

The reported reason for delay was COVID operational pressures.

A question arises of CQC’s competence in identifying organisational failings and system risks, and or alternatively, its willingness to acknowledge them.

Another question is at what level of seniority in CQC was the original flawed conclusion reached about absence of organisational failings?

Harry’s grandfather Derek Richford objected to the CQC’s 17 August 2018 denial of organisational failure. He copied his objection to Ted Baker, then Deputy Chief Inspector of Hospitals.

Ted Baker responded more sympathetically to the Richfords in September 2018, but he maintained that the threshold for applying CQC regulation 12 was not met.

In December 2018,Ted Baker wrote again to offer the family a meeting in January 2019.

CQC claimed it had never seen the report of a 2015 RCOG review on EKHUFT maternity failings

The Richford’s meeting with CQC took place in early 2019, when the family made the CQC aware of a 2015 Royal College of Obstetricians and Gynaecologists (RCOG) report on EKHUFT maternity services.  This report had been unearthed by Derek Richford via FOI, after the document had been mentioned in trust board papers.

Importantly, the RCOG report revealed that there had been previous concerns about the supervision of junior doctors, consultant availability and the general management of the labour ward at EKHUFT:

In other words, there were systems issues aplenty.

There were numerous examples of poor care and the RCOG described some clinical practices as “dangerous”, such as the poorly supervised use of Syntocinon.

The RCOG found evidence of poor whistleblowing and reporting practice. Consultants’ poor practice tended not to be challenged, or was omitted from incident action plans. Staff stopped raising concerns because they were not acted upon:

“Safety issues relating to practice were not reported as no action would be taken by the Leads.”

Indeed, the RCOG report was commissioned because of concerns about poor governance and team dysfunction in the EKHUFT maternity service:

In other words, organisational failures and systemic risks, as opposed to CQC’s narrative of isolated errors by individuals.

Specifically, the RCOG found evidence of patient harm related to locum doctors’ omissions, whilst working out of hours:

“The locum registrar did not review the patient overnight despite this woman’s details being on the handover sheet.” (Case 6 page 16)

The RCOG was concerned that safety could be affected by middle grade locum cover at night (page 34 and 35).

This proved to be an accurate concern in the light of the later harm to Harry Richford.

Even EKHUFT’s medical director observed, in terms, in a statement of 17 December 2019 to the coroner that Harry’s death was part of a chain of persistent failure and lack of organisational learning linking back to the RCOG report:

 “The analysis of the root cause of Harry Richford’s death led to actions similar to some of those in the RCOG review, CQC reports of 2014-2016 and the HSIB recommendations, indicating a failure to sufficiently embed learning.”

Shockingly, it was reported that the CQC had never, until 2019, reviewed the 2015 RCOG report despite knowing of its existence.

A post by the Health Service Journal on 23 January 2020 reported:

But what is perhaps even more shocking is that the Care Quality Commission did not see the report for nearly three years after it was written in February 2016. The CQC confirmed although it saw an action plan based on the report, its records indicate it did not see the report itself until January 2019.”

The RCOG report was mentioned in a trust board paper of April 2016, entitled “CQC IMPROVEMENT PLAN”.

Surprisingly, the trust stated in this document:

“Review report is clear – the Trust does not have an unsafe maternity service but there is improvement work to do around how the service is run in some areas.”

(Board papers indicated that in the corporate risk register later that year, maternity risk is rated as “extreme”).

It also stated:

“The MBRRACE-UK report has been published and shows the Trust to have a 10% lower average mortality rate for its comparator group. The RCOG report was received on the 18th February. Actions will need to be incorporated into the improvement plan. The deadline for embedding the new maternity dashboard has slipped and will be in place for the end of March 16.”

The comment about favourable MBRRACE-UK ranking is interesting in the light of the coroner’s finding that EKHUFT made an inaccurate submission to MBRRACE-UK about Harry’s death, and in light of today’s revelations in the Telegraph about possible manipulation of NHS deaths reporting.

Why did CQC claim that EKHUFT maternity services had improved and why did it deny that there were organisational failures?

EKHUFT’s response to the RCOG report is published via an undated entry on the trust’s website. It reads as a post hoc communication, drafted in the fallout from Harry Richford’s case.

EKHUFT’s response cites in its defence the praise that it received from CQC in 2018, at which time the Richfords were struggling to be heard by CQC:

“A further CQC inspection in August 2018 acknowledged that the East Kent maternity service had made great strides to drive learning, improve outcomes and improve innovation through a collaborative and multidisciplinary approach but there were continued concerns in several areas indicating that more improvement work remains to be done.”

One of the Richfords’ many concerns about the trust’s governance was the fact that years after the RCOG report, the trust admitted that it had only fully implemented two of the RCOG recommendations. The facts are revealed by this EKHUFT report of 16 July 2020:

“…it is not possible to evidence all actions from that report as having been completed. 23 recommendations were made by the RCOG. When the available evidence was reviewed the LRC concluded there was sufficient evidence that 2 recommendations had been met, that 11 had been partially met. For some of the recommendations where evidence weas [sic] insufficient…”

Why did CQC not identify this evidence of organisational failure sooner?

Was the imperative to create a positive narrative of improvement more important?

If so, from where did the imperative come?

This is how CQC progressively rated EKHUFT’s maternity service, after putting the trust in special measures in 2014

Trust board papers of October 2016 noted that Philip Dunne Health Minister visited the trust and was pleased to see improvement:

“His visit gave him the opportunity to see for himself the progress that the Trust has made and he was quoted in the post-visit press release as saying:

“I saw first-hand the great strides in improving the quality of care that the Trust is making and the positive effect these changes are having on staff and patients.

“I enjoyed meeting and talking with a wide range of members of staff from across the hospital. It was very clear that everyone is passionate and united in their desire to continue to improve services.”

This brings to mind witness testimony from the Mid Staff Public Inquiry that officials were focused on an imperative of not embarrassing the Minister.

What was CQC and NHS England’s coordination on the critical RCOG report?

The RCOG report was received by the trust in 2016. This was AFTER publication of Bill Kirkup’s 2015 report on maternity care at Morecambe Bay.

A relevant recommendation from Morecambe Bay, which was accepted by the government, was that trusts should be under a duty to disclose external investigations.

The government claimed it would take steps to ensure this was embedded in regulations (page 74 and 75), but that as an interim measure, the CQC would use existing powers to compel disclosure by trusts:

“46. In the meantime, Monitor and the Care Quality Commission will continue to use their respective statutory information-gathering powers to require NHS Trusts and Foundation Trusts to notify them of both the commissioning and the conclusions of relevant external investigations.”

Did the CQC actually make any changes to its procedures, following the government’s promises in 2015 that CQC would compel disclosure of external investigations by NHS trusts?

Why did CQC reportedly not ask for a copy of the RCOG report when it first became aware of the report’s existence?

Why did CQC appear to accept the trust’s action plan as a reliable interpretation of the RCOG’s findings and recommendations, instead of insisting on seeing the report itself?

A CCG document of 8 December 2015  revealed that the RCOG report had been jointly arranged by the trust, CCGs and NHS England:

“Maternity services were reported as inadequate within the CQC report given the lack of progress…. The CCGs with NHSE and the trust have commissioned a Royal College review which is underway to support the service to make further improvements.”

What happened to CQC and NHS England’s joint working protocols?

For example:

“2.2 We commit to working together proactively to share information and intelligence about the quality of care in order to spot potential problems early, and manage risk. To do this we seek to explore ways of sharing data where there is a shared interest or common benefit.”

Did a risk summit of some sort take place about EKHUFT maternity services, as is common practice?

How could CQC plausibly claim that there were no systems issues if its fellow regulator, NHSE, had instigated an RCOG governance review based on CQC’s own inspection findings of systems failures?

Why did CQC change its mind about prosecution under Regulation 12 and why has CQC not applied Regulation 12 more consistently?

Eventually, under the glare of public scrutiny, and after the revelations by the Healthcare Safety Investigation Branch of other maternity deaths and  serious management failures at EKHUFT, CQC announced two years later in July 2020, that it would prosecute EKHUFT under Regulation 12. This was for the harm caused to Harry and his mother, Sarah Richford.

What changed between 2018 and 2020? The facts of Harry’s case did not change. And CQC Regulation 12 did not change.

I asked CQC to comment on its various actions and omissions,. I also asked CQC about why it informs bereaved families such as the Richfords that it cannot investigate their concerns, when the discharge of CQC Regulation 12 appears to require investigation by the CQC.

CQC has to date only acknowledged my enquiry and indicated that it would respond.

It does seem very arbitrary as to how the CQC responds to harmed patients and families.

What happens to families who are no less seriously harmed than the Richfords, but who may be less articulate and cannot navigate CQC’s obstacle course?

Reservations about the usefulness of fining public bodies aside, why had CQC not taken a similar approach to other gross and proven NHS care failures?

Has CQC obscured the real levels of unmet need and harm, and how much will Kirkup’s report reveal?

A September 2022 BBC analysis of CQC reports shows that maternity service failings are widespread, with 7% of units rated by CQC as “posing a high risk of avoidable harm”.

Given what we know about CQC’s identification of systems risks, is the real figure higher?

Kirkup’s investigation of maternity services at EKHUFT is due to report on 19 October 2022.

Will he identify all relevant failings, regulatory, corporate and individual?

I was concerned that in a previous investigation, into the death of baby Elizabeth Dixon, Kirkup placed much emphasis on failings and dishonesty by individual practitioners.

His notable comment that there had been “a twenty year cover up” generated many headlines.

But did he do justice to Elizabeth’s parents through a thorough examination of controlling minds and corporate accountability? Should he have undertaken a more searching exploration of the powerful senior management of a favoured NHS trust, Frimley Health NHS Foundation Trust?

Frimley Health NHS Foundation Trust knew about the Dixons’ concerns for years before Kirkup investigated, and had plenty of chances to put the matter right.

Let us hope for better this time round, and that the CQC’s serious failure to help prevent deaths is fairly reflected in Kirkup report. And that the role of other oversight bodies is also fully explored.

It is relevant to note that Tracey Fletcher took up post as EKHUFT chief executive in April 2022. She was previously CEO at the Homerton, where a contentious maternity whistleblowing matter arose.   

NHS England’s then medical director for London, Henrietta Hughes – later the National Guardian for whistleblowing – was a party in NHS England’s handling of the Homerton scandal.

And so the wheels turn.

The curious non-publication of Harry Richford’s PFD report, and NHS England’s and EKHUFT’s missing responses to the coroner
The public bodies which received a copy of Harry Richford’s PFD – the coroner’s report to Prevent Future Deaths on matters arising from Harry’s inquest – were legally obliged to respond to the coroner’s concerns about mitigating risk of future of deaths.
A troubling discovery in the course of checking organisational responses to the coroner was that I found Harry Richford’s PFD was not published by the chief coroner, as it should have been.
It is not known if the PFD was originally published, and then removed at some point. If anyone clearly recalls seeing it on the website, I would be grateful to know.
A worker at the chief coroner’s office kindly checked and agreed with me that as of 11 October 2022, the Richford PFD was missing from the website, and so the organisational responses were also missing:

“We have a system to allocate reference numbers to reports. I’ve checked the website and Harry Richford (2020-0117) report has not been published but 0116 and 0118 have been. I checked our system and found a response from DHSC, I will upload these shortly on our website.”

The PFD and the government response have since been uploaded here.
The ministerial response noted the trust’s unacceptable and misleading claim that Harry’s death was “expected” and its failure to refer his death to the coroner.
The DHSC should hold progress reports by CQC and NHSE on improvement work at EKHUFT, if this ministerial commitment was honoured:
“I expect to be regularly updated.”
However, neither the chief coroner nor the local coroner have so far been able to locate NHS England’s response or the trust’s response.
At this late stage, this seems an unusual anomaly.
I will post the NHS England and trust responses below when I eventually obtain them. Or if it transpires that NHS England and or the trust failed to respond to the coroner, I will confirm this.


The above failures are part of a familiar pattern of government failure.

Both the CQC and Jeremy Hunt as Health Secretary failed to act on whistleblowers concerns at Homerton:

Letter to Jeremy Hunt 16 October 2015 about his role regarding Homerton maternity whistleblowers

There was regulatory failure in the Morecambe Bay scandal, when oversight bodies accepted circular assurance from each other:

The Report of the Morecambe Bay Investigation by Bill Kirkup 2015

The CQC were also found wanting recently in the Shrewsbury and Telford Hospital NHS Trust maternity scandal:

Final Ockdenden review report 2022

This is the CQC’s letter to the Department of Health in response to criticism by the Ockenden review:

Letter from Ian Trenholm CQC CEO to Secretary of State 4 May 2022

These are some of the other East Kent families’ stories that have come into the public domain:

Alisha Pegg and Grace

Rachel Higgs and Archie Batten

Baby Luchii Gavrilescu

Baby Archie Powell

Shelley Russell, Nicholas Edwards and Tallulah-Rai Edwards

Hallie-Rae Leek

These are some related items about HSIB and its maternity investigations:

HSIB whistleblowers and the Secret King’s Fund Fact Lite report

More secret HSIB reports and failures of HSIB maternity investigations

HSIB has sent 152 letters of concern to NHS trusts about maternity safety, including 15 letters to one trust

More Secret Whistleblowing Reports at HSIB, Susan Newton Consulting Limited and implementation of the Kark Review

Kark, Fit and Proper Persons, NHS England, Mason Fitzgerald and the Good Governance Institute

Dr Minh Alexander retired consultant psychiatrist 15 October 2022

In 2018 the government commissioned a review of Fit and Proper Persons in the NHS after a number of scandals and also concerns about the Care Quality Commission’s application of CQC Regulation 5 Fit and Proper Persons:

A review of the Fit and Proper Person Test Commissioned by the Minister of State for Health by Tom Kark QC and Jane Russell (Barrister)

NHS England, despite being one of the targets affected by Kark’s recommendations, was put in control of implementing the recommendations.

Unsurprisingly, NHSE has dragged its feet and been secretive about the work undertaken these past few years, albeit it has attributed some of the delay to lack of government permission. At the last update earlier this week, NHS England advised that the terms of reference for its NEW Kark Steering Group will be finalised at the start of next month.

In the meantime, NHS England itself has illustrated the weakness of current approaches to Fit and Proper Persons in the NHS. Ruth May the Chief Nursing Officer has commissioned work from a private organisation, the Good Governance Institute (GGI).

The GGI states on its website that it employs as a senior consultant, Mason Fitzgerald a director sacked last year by the NHS after a furore about CV inaccuracy.

GGI previously failed to answer a question about this.

Material by the GGI that is in the public domain raises questions about whether the GGI – and indeed possibly Mason Fitzgerald – may be undertaking other work with NHSE and Integrated Care Systems.

I have asked NHS England to review it systems, approach to contracts and its relationship with the GGI.

This is the relevant letter to Ruth May, with the details, and is copied to Amanda Pritchard NHSE CEO, the NHSE director responsible for the Kark report implementation and Tom Kark QC:


Ruth May 

Chief Nursing Officer

NHS England

15 October 2022

Dear Ruth,

NHSE, the Good Governance Institute’s governance and Mason Fitzgerald, sacked former NHS director

I write to follow up my response to your social media promotion of the GGI’s work on a staff survey conducted by the GGI, for your team:

I am really concerned that senior NHS managers appear either oblivious of, or unconcerned about, the GGI hiring Mason Fitzgerald, an NHS director sacked last year after false CV claims.

The current GGI  website profile for Mason Fitzgerald, described as a GGI ‘senior consultant’, omits to mention anything about his sacking. See attached screenshot and link:

As you may recall, Mason Fitzgerald’s false CV claim was missed by ELFT and the CQC, but emerged after he was almost appointed as CEO of NSFT. Had that appointment process been completed, he would have had power over thousands of extremely vulnerable mental health patients:

The GGI appears to be unaccountable regarding its hiring of Mason Fitzgerald. When I wrote to the Institute in April this year about it hiring him, it failed to respond.

According to the GGI’s material, a number of NHS organisations continue to use its services.

In particular, the GGI published a blog by Mason Fitzgerald on 10 October 2022, in which he stated:

“GGI is currently working with ICSs to review their governance arrangements, and, through our networks and events, we are developing thinking on how ICSs should approach their first end of year review.”

The GGI tweeted this blog on 11 October 2022, tagging in NHS England (see screenshot), raising a question of whether NHS England is a partner in this work and has commissioned the GGI to undertake this project:

According to a response to this tweet by the GGI Chief Executive, the GGI is working with 13 Integrated Care Systems:

Does the NHS therefore still employ Mason Fitzgerald, as a senior consultant, through the GGI?

If so, is it appropriate for an individual sacked by the NHS after false CV claims, to be vetting governance by NHS organisations?

I am especially concerned if NHS England promotes the GGI or contracts with the GGI in the light of its hiring of Mason Fitzgerald, because NHS England is supposed to be implementing the Kark recommendations on tracking impaired or unsuitable NHS managers.

If NHS England had implemented the Kark recommendations in a timely and effective way, Mason Fitzgerald’s subsequent role at the GGI would have been flagged up if he undertook any work for the NHS through the GGI.

I ask that:

a. NHS England and its officers stop all promotion of the GGI until the issue of the GGI’s employment of Mason Fitzgerald, and the questions arising from this about the GGI’s governance, are further clarified and addressed,

b. NHS England reviews any existing contracts with the GGI based on the evidence, through the GGI’s hiring of Mason Fitzgerald, that the GGI’s choice and deployment of consultants and its governance are in question. Please also review whether Mason Fitzgerald is currently working for NHS England, any ICS or any other NHS body under NHSE’s control, as a GGI senior consultant.

c. NHS England considers in its Kark implementation the specific issue of whether NHS managers sacked by the NHS may resume employment through the back door as consultants, and that NHSE designs Fit and Proper Person systems that are strong enough to detect such a situation.

d. NHS England considers generally in its Kark implementation how it will ensure that consistent Fit and Proper Persons standards apply to contractors and contracted services, in the same way that it currently makes other quality requirements of contractors, through the way NHSE’s contracts are drafted.

I copy this to Amanda Pritchard, Jacqueline Davies NHSE lead director for the Kark implementation and to Tom.

With best wishes,


Dr Minh Alexander

Cc Amanda Pritchard NHS England CEO, Jacqueline Davies NHSE Director of Leadership, Lifelong learning and talent , Tom Kark KC


NHS England and its predecessor bodies have plenty of form on erring senior NHS managers.

Postscripts on Paula. NHS England’s apologia & regulatory reticence

So does the CQC:

Sorry is the hardest word: CQC, Paula Vasco-Knight and Regulation 5 Fit and Proper Persons

CQC downgrades Well Led domain at North Tees and Hartlepool NHS Trust. But no one found lacking on FPPR

Mr Tristan Reuser’s whistleblowing case: Scandalous employer and regulatory
behaviour on FPPR

CQC’s Victimisation of Whistleblowers: Failure to Investigate Concerns

Breach of confidentiality by CQC and complicity in referring a whistleblower to the
Disclosure and Barring Service

Whistleblowers Unheard by CQC

More CQC denial about collusion with employers against whistleblowers