Correspondence with parliament: The Department of Health & Social Care’s obfuscation about the investigation of whistleblowers’ concerns

By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, 29 August 2018

The government continues to duck and dive when pressed to ensure that whistleblowers’ concerns are properly handled and investigated.

The scope of a forthcoming CQC consultation event which originally included review of CQC’s whistleblowing processes and policy, has now contracted.

This followed a request to the DHSC to clarify its position on the investigation of whistleblowers’ concerns in time for the CQC’s consultation event.

Alongside this, judging from her routinely published data, the National Guardian still does not track whether whistleblowers’ concerns are addressed.

But that does not stop her from claiming that Freedom To Speak Up guardians have prevented “untold harm” and saved lives.

The correspondence with parliament regarding these issues over the last year can be found here.

This is the latest exchange of letters with the Chair of Health and Social Care Committee about these matters:

BY EMAIL

Dr Sarah Wollaston

Chair of Health and Social Care Committee

 

28 August 2019

 

Dear Dr Wollaston

 

UK government does not track whether whistleblowers’ concerns are addressed but claims lives are being saved

 

Thank you for your letter yesterday replying to my enquiry of 9 August 2019, both copied below, and your offer to seek an update on whether the NHS National Freedom To Speak Up Guardian will in future track whether whistleblowers’ concerns are addressed.

 

I would be grateful if you would do so.

 

You will recall that I asked the Committee to consider this issue last September.

 

The situation now is very serious, because not only is the National Guardian continuing to fail to track whether whistleblowers’ concerns are addressed, but she recently made unjustified claims that NHS Freedom To Speak Up Guardians were preventing “untold harm” and saving lives even though she still has no safe oversight of whether whistleblowers’ concerns are addressed.

 

This is correspondence with the National Guardian and her Office which revealed the lack of substantiating evidence for her claims about lives saved:

 

https://minhalexander.com/2019/08/25/the-low-fact-national-guardians-office/

 

Professor Sir Brian Jarman, an internationally acknowledged expert on mortality in healthcare made these observations about the lack of adequate evidence:

 

Screenshot 2019-08-29 at 09.19.31

In addition to the concerns about the actions and omissions of the National Guardian’s Office, the Department of Health and Social Care maintains its silence on whether it will ensure that the Care Quality Commission has and uses clear powers to investigate individual whistleblowers’ concerns.

 

 

I was invited to attend a CQC event next month which included review of CQC’s policy and processes for handling whistleblowing, and sent relevant policy and guidance documents.

 

 

However, after I asked the DHSC to clarify its position on investigation of individual whistleblowers’ concerns in time for this consultation event, the CQC advised me and other whistleblowers that the scope of the event would be much narrower than originally advised in CQC’s invitation letter. Indeed, CQC told us emphatically:

 

“Therefore the event on the 2nd…will definitely not touch on our current guidance and your concerns about its current limitations.”

 

 

I am concerned that the DHSC is continuing to control the narrative in an unhelpful way, and undermining any work to resolve the most fundamental flaw in Health & Social Care whistleblowing governance: the failure to reliably investigate individual whistleblowers’ concerns.

 

 

I hope that parliament will seek the clarity that is needed on this vital issue, in the interests of safeguarding the public.

 

 

It is an issue replicated across sectors, and reflects the un-rectified, central failure of UK whistleblowing law to compel investigation.

 

Yours sincerely,

 

Dr Minh Alexander

 

Cc Health and Social Care Committee

Meg Hillier

Barbara Keeley

Laura Pidcock

Anne Marie Trevelyan

Matt Hancock Secretary of State for Health

Caroline Dinenage Minister of State for Care

 

 

 

YOUR LETTER

 

“27 August 2019
Dear Dr Alexander
Thank you for your email of 9 August regarding the tracking of whether whistleblowers’ concerns are addressed.
Naturally, Dr Hughes, the National Guardian, shares my firm belief that matters raised by whistleblowers should be addressed appropriately. I understand that the National Guardian’s Office expects that organisations that receive whistleblowers’ concerns should have appropriate mechanisms for tracking them. The NGO’s office also considers that whistleblowers should receive feedback on what happens as a result of them raising an issue. That means not only being updated of the outcome of their report at the conclusion of the process, but also updates on how the matter is being progressed.
I note your view that the UK Government—and specifically the National Guardian’s office—should itself track whether whistleblowers’ concerns have been addressed. I do not have a further update on this issue from the National Guardian but I am happy to request one.
Yours sincerely,
Dr Sarah Wollaston MP
Chair of the Committee”

 

RELATED ITEMS
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Without a fit for purpose legal framework as a starting point, the same failures will repeat ad nauseam.

Engineered failure to investigate NHS whistleblowers’ concerns

BS FreedomToSpeakUpometer

The Low Fact National Guardian’s Office

 By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, 25 August 2019

 

 

Summary: The NHS National Guardian’s Office could produce no robust evidence for a major recent claim that: Patient’s lives have been saved and untold harm has been prevented because Freedom to Speak Up Guardians have supported workers”

 

 

 The Freedom To Speak Up project is based on government duplicity, spin and half truths.

It had no evidence base.

Robert Francis, the government’s frontman, later spun this as heroic pioneering, but even this was not true:

Screenshot 2019-07-28 at 08.10.10

In fact the model is a hand-me-down from the corridors of Whitehall.

It is clear the National Guardian is keen to generate Good News stories, as her newsletters are full of smiling photos.

Her compact with local trust Speak Up Guardians includes promoting their purported successes, although the evidence so far suggests that caution is needed in accepting the National Guardian’s examples of success.

One of her latest projects is to collect a 100 stories of self-reported success. The instructions for submission encourage NHS Trust Guardians to recruit the help of local trust spin doctors:

 

“Involve your communications team before you make a submission to discuss how you can develop these case studies. They can help you tell these stories by filming short videos; commissioning animated GIFs for social media; shooting high-quality photos; or drafting media releases for the local and regional press. The National Guardian’s Office may get in touch about adapting the case studies for short social media videos, annual reports, news stories and other communications.”

 

 

Of course, the message communicated in seeking Good News stories is that Bad News is not welcome. Surreal coming from a whistleblowing agency

The government’s smoke and mirrors also continue in a lack of rigourous monitoring and evaluation.

The National Guardian does not even collect data on whether NHS whistleblowers’ concerns are addressed.

And yet the National Guardian, a senior doctor trained in the proper evaluation of evidence, makes extraordinary claims of success in the absence of clear evidence.

On 16 July 2019 her office tweeted a claim by her that the Freedom To Speak Up project had prevented untold harm and saved lives:

National Guardian tweet prevented untold harm saved lives

 

Customarily, to reach such conclusions about healthcare interventions and to promulgate them, doctors conduct scientifically rigourous research and have their work peer reviewed prior to publication.

Indeed, the GMC expects all doctors to work in an evidence-based manner:

“provide effective treatments based on the best available evidence”

(Good Medical Practice, Professionalism in Action, 16.b)

To my knowledge, the National Guardian has not produced any evidence that the establishment of the Freedom To Speak Up project, as opposed to other factors, has been specifically responsible for reducing harm and deaths in the NHS.

The evaluation research on the Freedom To Speak Up project commissioned so far by the government avoids core questions such as this. It is designed to faff around at inconsequential edges.

The National Guardian maintains it is a success that staff are raising concerns through Speak Up Guardians, but this is not necessarily a good sign. It can indicate in some cases that there is a difficulty with the line of management and perhaps with the management culture generally.

The tweeted claim of 16 July about lives saved was queried and supporting evidence was requested.

This request was ignored twice. Accordingly, a request for substantiating evidence was formally made by correspondence.

After a chaser, this was the reply from the National Guardian’s Office on 9 August 2019:

 

“Dear Mr Alexander,

Thank you again for contacting the National Guardian’s Office.

The data we have collected over the last two years from FTSU Guardians in trusts and foundations trusts documents the number of cases that FTSU Guardians handled that include elements that indicate a risk to patient safety or the quality of care.  Our report for 2017/18 shows that FTSU Guardians handled 7,087 cases, 32% of which were reported as including an element of risk to patient safety or the quality of care.  We are finalising our report for 2018/19 but our figures so far indicate that FTSU Guardians handled nearly 12,000 cases and nearly 30% of these were reported as involving an element related to patient safety / quality of care.

I hope this information is helpful for you.

Kind regards,

Ellie Staite

Correspondence Officer

National Guardian’s Office

151 Buckingham Palace Road

London”

 

This was also extraordinary, but upon checking, it was confirmed to be the ‘evidence’ for the claim about lives saved.

Low Fact Milk.png

So it appears the National Guardian, a senior doctor, has claimed from self-reported data by NHS trusts that patient safety concerns are raised with Speak Up Guardians, that “untold harm” and deaths have been prevented.

The full correspondence is provided in the appendix below.

It is tragi-comical that this is the level of evidence relied upon to make claims that lives are being saved.

But it does go to the political nature of the National Guardian’s Office.

It is a very expensive firewall, that will pump out cheery messages whilst core NHS services crumble around us.

 

RELATED ITEMS

 Replacing the Public Interest Disclosure Act (PIDA)

 What is needed is a serious, professional whistleblowing agency established under an umbrella of strong, safe whistleblowing law and direct supervision by parliament, not governments.

The first essential step is the urgent replacement of seriously inadequate UK whistleblowing law.

A portrait of ineffectiveness: Internal whistleblowing champions in their own words

 

Matt Hancock FTSU bubble with strapline.jpeg

 

 APPENDIX

 Correspondence with the National Guardian about the claim that Freedom To Speak Up Guardians have prevented untold harm and saved lives

 On Fri, 9 Aug 2019 at 16:25, National Guardian’s Office <REDACTED> wrote:

Dear Mr Alexander,

I can confirm that the email below is in response to your original email of 23rd July.

Kind regards,

Ellie Staite

Correspondence Officer

National Guardian’s Office

151 Buckingham Palace Road

London

SW1W 9SZ

 From: Ian Alexander <REDACTED>

Subject: Re:

Date: 9 August 2019 at 16:21:30 BST

To: National Guardian’s Office <REDACTED>

Dear Ms Staite,

In the interests of clarity, can you advise if your letter of today’s date is in response to, and therefore the answer to, my query of 23rd July addressed to Dr Hughes.

Many thanks,

Ian Alexander

 

On Fri, 9 Aug 2019 at 15:37, National Guardian’s Office <REDACTED> wrote:

Dear Mr Alexander,

Thank you again for contacting the National Guardian’s Office..

The data we have collected over the last two years from FTSU Guardians in trusts and foundations trusts documents the number of cases that FTSU Guardians handled that include elements that indicate a risk to patient safety or the quality of care.  Our report for 2017/18 shows that FTSU Guardians handled 7,087 cases, 32% of which were reported as including an element of risk to patient safety or the quality of care.  We are finalising our report for 2018/19 but our figures so far indicate that FTSU Guardians handled nearly 12,000 cases and nearly 30% of these were reported as involving an element related to patient safety / quality of care.

I hope this information is helpful for you.

Kind regards,

Ellie Staite

Correspondence Officer

National Guardian’s Office

151 Buckingham Palace Road

London

SW1W 9SZ

From: Ian Alexander <REDACTED>

Subject: Re:

Date: 2 August 2019 at 11:18:55 BST

To: Henrietta Hughes <REDACTED>

Dear Dr Hughes,

I refer to my letter of 23td July copied below for your convenience.

I received a reply by return from your office advising me that I would receive a substantive response within twenty working days.

Given the importance of this issue, and your overarching responsibility to your public office, I was surprised to receive such a casual brush off and indeed made a further, as yet unanswered, enquiry regarding civil service response targets.

As I have still not received any meaningful explanation for your extraordinarily important claim, I confess to being a little uneasy that such a claim, made over two weeks ago still lies on the public record unevidenced.

I would be glad if you could correct that, and publish the evidence on which you made such an important claim without further delay.

Thank you,

Ian Alexander

To: Henrietta Hughes <REDACTED>
Sent: Tue, 23 Jul 2019 11:56

Dear Dr Hughes,

Attached is a screen shot quoting your response to the APPG report. It also shows my request that this claim be evidenced. To date there has been no response. Accordingly I now bring it to your attention in case your comms team have not done so.

Thank you,

ID Alexander

 

 

 

More consultation on the regulatory response to whistleblowing in Health & Social Care (But government is keeping shtum on investigation of whistleblowers’ concerns)

 By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist 22 August 2019

Last year the Health and Social Care watchdog the Care Quality Commission acknowledged that it had still not got whistleblowing governance right.

It agreed to consult again by the end of the year. I advised that this should be an open process.

To give due credit, Ted Baker Chief Inspector of Hospitals also agreed to revisit a request for audit of CQC’s handling of whistleblower confidentiality, despite Peter Wyman CQC Chair having arbitrarily dismissed the need for audit, after breaches.

CQC board minutes subsequently showed that CQC reviewed a series of cases and concluded that there had been no recent confidentiality breaches.

However, the general consultation on whistleblowing did not materialise.

CQC board papers from July this year revealed that CQC pressed on with internal review  of its whistleblowing process.

The CQC has now sent out, at short notice, invitations to a national event on 2 September 2019 which includes consultation on how its whistleblowing process might be improved:

We are also reviewing our policies and procedures as they relate to how we manage information from people who work in the services we regulate and how we communicate and use the information shared. We have listened and heard that we have not always been successful at managing information shared with us. As a result of this, and in line with our commitment to consult on how we can make improvements, we are bringing together people who can help us to determine what good looks like.”

The Department of Health and Social Care, GMC, NMC, NHS England/ Improvement and the National Guardian will be represented.

Some whistleblowers have been invited, but I do not know how many in total.

There also does not appear to be clear open access to the consultation process by correspondence, and I am not aware that the consultation has been advertised.

There is no agenda for the 2 September workshop yet, but the event is scheduled for a five hour slot.

It is led by Professor Ursula Gallagher CQC Deputy Deputy Chief Inspector for Primary Medical Services and Integrated Care, who is the CQC lead on whistleblowing.

I have asked for sight of the policies about which the CQC is consulting. I am advised that these are the two relevant policies:

  1. Published 2013 guidance for providers on whistleblowing governance

Whistleblowing Guidance for providers who are registered with the Care Quality Commission

  1. Internal CQC guidance for its inspectors produced in June 2019, and currently in use

Guidance: Handling concerns raised by workers of providers registered with CQC

The 2019 internal guidance document replaces a document produced last year:

Handling concerns raised by workers of providers registered with CQC

Apart from a different title and a curious new section on RIPA powers, the 2019 CQC guidance for its inspectors looks much the same as the 2018 guidance.

 

The new section in 2019 CQC guidance on whistleblowing for its staff:

10. The Regulation of Investigatory Powers Act 2000 (RIPA)  “CQC does not routinely as a matter of policy currently undertake or authorise providers or members of the public to undertake either directed covert surveillance or Covert Human Intelligence Sources (CHIS).

 

In addition, the Regulation of Investigatory Powers Act 2000 (RIPA) places restrictions upon the use of surveillance and covert intelligence sources by public bodies. Under RIPA, the Care Quality Commission does not have the power to undertake intrusive covert surveillance or to authorise providers or the public to undertake intrusive covert surveillance. This prohibits CQC from authorising the use of hidden cameras and listening devices in residential premises.

 

Therefore, CQC currently does not ask people to create recordings on its behalf. For further information about RIPA and covert activity including intrusive surveillance, directed surveillance or CHIS please visit the RIPA intranet page and RIPA awareness video in ED.”

 

Inevitably, the CQC guidance to its staff toes the government line: UK whistleblowing law is protective, the National Guardian is leading culture change, blah blah blah…

The key issue that is unspoken in these documents is the fact that the CQC declines to actually investigate whistleblowers’ concerns.

The government continues to avoid answering questions about whether CQC should do so under its current regulations, or whether new regulations will be drafted to ensure that CQC has clear powers to do so.

I have asked the DHSC to clarify its position in time for the event on 2 September 2019, but the correspondence fencing bout may well continue. The latest correspondence with the Department is copied below in the appendix.

The event on 2 September 2019 will be an expensive affair, and whilst CQC’s recent staff guidance documents are an improvement on past versions which were technically very rudimentary, little will be achieved until whistleblowers’ concerns are appropriately investigated.

If any Health or Social Care whistleblower who has not so far been invited to contribute wishes to send in comments on how CQC can improve its handling of whistleblowing, I would suggest sending written contributions to CQC FAO Professor Ursula Gallagaher.

UPDATE 24 AUGUST 2019

Some whistleblowers who have expressed interest in contributing to the consultation have received conflicting information about its scope. For clarity, this is the original correspondence from the CQC, sent on 14 August 2019:

CQC Ursula Gallagher invitation to event 2 September 2019

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Whistleblowers in Their Own Words: What’s wrong with UK whistleblowing law and how it needs to change

 

APPENDIX

Most recent correspondence with the Department of Health and Social Care about whether CQC will investigate whistleblowers’ concerns:

 

From: “Benjamin, Jennifer” <REDACTED>

Subject: RE: Will the government ensure that the Care Quality Commission investigates individual whistleblowers’ concerns?

Date: 16 August 2019 at 14:48:57 BST

To: Minh Alexander <REDACTED >

Cc: Caroline Dinenage <REDACTED>

Dear Minh

Thank you for your email.  Just to confirm that your email to Alan has been picked up in his absence and we will be able to provide you with a response.

Jennifer

 

Jennifer Benjamin

Deputy Director – Quality, Patient Safety & Investigations

Department of Health and Social Care

Email: REDACTED

 

From: Minh Alexander <REDACTED >

Sent: 15 August 2019 11:03

To: Benjamin, Jennifer <REDACTED>

Cc: Caroline Dinenage <REDACTED>

Subject: Will the government ensure that the Care Quality Commission investigates individual whistleblowers’ concerns?

Hi Jennifer,

I received an out of office message from Alan’s account, advising that he is away until the 5th September.

Are you able to help with my enquiry in his absence?

BW

Minh

From: Minh Alexander <REDACTED>

Subject: Will the government ensure that the Care Quality Commission investigates individual whistleblowers’ concerns?

Date: 15 August 2019 at 09:25:57 BST

To: Alan Addison

Cc: Jennifer Benjamin <REDACTED> Barbara Keeley <REDACTED> Caroline Dinenage <REDACTED> Laura Pidcock <REDACTED>

BY EMAIL

Alan Addison

Ministerial Correspondence

Department of Health and Social Care

15 August 2019

Dear Mr Addison,

Will the government ensure that the Care Quality Commission investigates individual whistleblowers’ concerns?

Since I last wrote on 9 August I have been invited by the Care Quality Commission to a consultation event on 2 September 2019, led by Ursula Gallagher Deputy Chief Inspector PMS and Integrated Care London, which includes reviewing how CQC manages whistleblowing by the staff of provider organisations:

“We are also reviewing our policies and procedures as they relate to how we manage information from people who work in the services we regulate and how we communicate and use the information shared. We have listened and heard that we have not always been successful at managing information shared with us. As a result of this, and in line with our commitment to consult on how we can make improvements, we are bringing together people who can help us to determine what good looks like.”

I also understand that the DHSC will be represented at this event.

In advance of the event, I have asked for sight of the relevant policy and procedural documents that are being consulted upon.

However, it would be surreal for this event to take place without a clear answer from the DHSC on its position on whether the CQC should investigate whistleblowers’ concerns.

I would therefore be very grateful if you could expedite your answer to the questions posed in my letter of 9 August below, before the event on 2 September, which are the subject of matters first put to the Department in December 2018.

Yours sincerely,

Dr Minh Alexander

Cc Caroline Dinenage Minister for Care

Jennifer Benjamin DHSC Deputy Director, Quality, CQC & Investigation

Barbara Keeley Shadow Minister for Mental Health and Social Care

 

From: Minh Alexander <REDACTED>

Subject: Your recent correspondence to the Department of Health and Social Care

Date: 9 August 2019 at 17:07:49 BST

To: Alan Addison <REDACTED>

Cc: Jennifer Benjamin <REDACTED> Caroline Dinenage <REDACTED>

BY EMAIL

Alan Addison

Ministerial Correspondence

9 August 2019

Dear Mr Addison,

Will the government ensure that the Care Quality Commission investigates individual whistleblowers’ concerns?

Thank you for your email regarding my query, first put to the Department eight months ago.

I asked if the Department would:

  1. Confirm that CQC has the powers to investigate, and should investigate, individual whistleblowers’ concerns

 or

  1. Amend CQC’s regulations to make it unequivocally clear that CQC should investigate individual whistleblowers’ concerns.

I am unsure from your reply today whether the Department considers that CQC has the power to investigate individual whistleblowers’ concerns.

With regard to your comment:

“The CQC has the power to respond where a matter of concern raises any issues about patient safety or quality of care and will intervene in its capacity as a regulator.  If, in the course of that action, it has concerns about the how a provider has responded to a whistleblower’s concerns, it can take regulatory action.  A provider’s systems and processes in place to respond to complaints are assessed on inspection as part of the CQC’s ‘well-led’ key lines of enquiry.”

the CQC does ‘intervene’ sometimes in response to whistleblowers, largely superficially, and its actions are usually short of actual investigation. It tells whistleblowers it has no power to investigate.

Please can you clarify if your above advice means that the CQC has the power to investigate individual whistleblowers’ concerns about patient safety and or quality of care, and not just the way in which the provider responded to their concerns.

If what you are saying is that CQC has no powers to investigate individual whistleblowers’ primary, presenting concerns, as opposed to how their concerns were handled, please can you advise if the Department will amend CQC’s regulations to ensure that CQC has clear powers to investigate individual whistleblowers’ concerns about patient safety and or quality of care.

Yours sincerely,

Dr Minh Alexander

Cc Caroline Dinenage Minister for Care

Jennifer Benjamin DHSC Deputy Director, Quality, CQC & Investigation

 

From: Department of Health and Social Care

Subject: Your email to Caroline Dinenage

Date: 9 August 2019 at 16:30:20 BST

To: “Alexander, Minh” <REDACTED>

Our ref: DE-1185271

Dear Dr Alexander,

Thank you for your further correspondence of 1 August about the Care Quality Commission (CQC).  I have again been asked to reply.

I was sorry to read that you were unhappy with my reply of 1 August (our ref: DE-1169259).  I should clarify that it was a response to your correspondence of 5 March, 12 March and 28 May to Caroline Dinenage and 23 April to Matt Hancock.

I note your continuing concerns about the role of the CQC.

The CQC treats whistleblowing concerns as it would any other concern, and will use the information as part of its assessment of a provider.

The CQC has the power to respond where a matter of concern raises any issues about patient safety or quality of care and will intervene in its capacity as a regulator.  If, in the course of that action, it has concerns about the how a provider has responded to a whistleblower’s concerns, it can take regulatory action.  A provider’s systems and processes in place to respond to complaints are assessed on inspection as part of the CQC’s ‘well-led’ key lines of enquiry.

The CQC does not have the legal powers to intervene in, or investigate, an individual employment matter or how an individual is treated after raising a patient safety or quality issue.

I hope this reply is helpful.

Yours sincerely,

Alan Addison

Ministerial Correspondence and Public Enquiries

Department of Health and Social Care

 

From: Minh Alexander <REDACTED>

Subject: Your recent correspondence to the Department of Health and Social Care

Date: 1 August 2019 at 15:57:55 BST

To: Alan Addison <REDACTED>

Cc: Jennifer Benjamin <REDACTED> Caroline Dinenage <REDACTED>

 

BY EMAIL

Alan Addison

Ministerial Correspondence

1 August 2019

Dear Mr Addison,

Will the government ensure that the Care Quality Commission investigates individual whistleblowers’ concerns?

Thank you for your letter below.

Unfortunately, it is unclear to me to which of my letters you are replying.

Please could you clarify this.

If your letter is not a reply to my letter to Caroline Dinenage of 25 May 2019 about CQC investigation of whistleblowers’ concerns and related reminder letters of 19 June 2019 and 3 July 2019, none of which have been met with replies, please could the Department ensure a swift substantive response.

If your letter today is a reply to my above mentioned correspondence to Caroline Dinenage, it does not address the key issue that I have raised of whether the DHSC will either

  1. Confirm that CQC has the powers to investigate, and should investigate, individual whistleblowers’ concerns

or

  1. Amend CQC’s regulations to make it unequivocally clear that CQC should investigate individual whistleblowers’ concerns.

You will appreciate that this is a critical national patient safety issue.

CQC has avoided investigation of individual whistleblowers’ concerns since its inception 10 years ago, but with an admission to me last October that it might have been wrong to do so.

Your own Departmental lead for whistleblowing policy later advised me that CQC should be investigating individual whistleblowers’ concerns.

I first raised the issue with the Department eight months ago.

Please can the Department finally address this issue.

Yours sincerely,

Dr Minh Alexander

cc Caroline Dinenage Minister for Care

Jennifer Benjamin DHSC Deputy Director, Quality, CQC & Investigation

 

 

 

 

 

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

By Dr Minh Alexander NHS whistleblower and former NHS consultant psychiatrist, 21 August 2019

 

Carl Beech is the individual at the heart of the bizarre VIP paedophile saga, whose false allegations have left some agencies red-faced and the public purse lighter by several million.

Beech was convicted of child sex offences earlier this year, in relation to possession of indecent images. It was reported that he initially tried to blame his son:

“he was prosecuted and initially pleaded not guilty, and in a police interview, sought to blame his teenage son.”

In July he was additionally convicted of perverting the course of justice and fraud, with regards to his false allegations about violent child sex abuse by various VIPs.

Beech was jailed for eighteen years.

These were the judge’s sentencing remarks:

Regina v Beech 26 July 2019

Beech was first interviewed by the police as a witness in December 2012 regarding the false allegations of sex abuse.

Possibly lending credence to his disclosures was the fact that he held a responsible job as a CQC inspector.

The CQC had been very quiet about this part of the story.

The regulator declined to answer any questions earlier this year, claiming that to do so might prejudice the second criminal trial against Beech.

But after his conviction in July, CQC had to answer re-submitted questions.

The CQC’ s FOI response refers to Beech’s “suspension”. It is not clear if he is still a CQC employee.

The CQC has disclosed that Beech was active and taking part in CQC inspections over a four year period, between 7 March 2012 and 11 October 2016.

He took part in 128 inspections of NHS hospital trusts, mental health and ambulance trusts, GP surgeries, private hospital providers, residential care homes and community care facilities.

This is the full list disclosed by the CQC:

CQC inspections involving Carl Beech

Beech inspected NHS trusts in the South West on fourteen occasions as follows:

CQC NHS Trust inspections involving Carl Beech

 

Beech’s public facing role meant he was a potential risk to the public, particularly to vulnerable groups. CQC indicated:

 “…we have reviewed all records to identify any risks from the inspections and CQC activities that he was involved in and we have no information of concern about his conduct on any inspection. All of the providers have been notified of his involvement in the inspection of their services.”

 The CQC maintained that it follows best practice when recruiting, and that after appointment, it continues to conduct three yearly enhanced disclosure and barring checks on workers who are in eligible roles.

It indicated that it has no intention of reviewing its process.

It is possible for some highly deviant offenders to successfully con others and few safeguards are insurmountable when someone lies determinedly.

Excessive bureaucracy in response to scandals, such as the glorified paper chase imposed on busy doctors after the Shipman killings, mostly has the effect of wasting resource but without real effectiveness in identifying the seriously psychopathic.

It is also easy to criticise with hindsight.

It is possible that CQC could not have reasonably identified that Beech was a fraudster and a risk to others.

But Beech did work for CQC for at least four years.

And we know from the Whorlton Hall scandal that despite the government hype about replacement of CQC’s chief officers and purported reform after failures, CQC continued to suppress its whistleblowers. Compounding its misdeeds, CQC recently tried to hide this fact.

CQC only gave reassurance in its FOI response that there were no concerns in relation to Beech’s conduct on inspections, based on its paper review.

This circumvents the question of whether other concerns were raised about him.

I have asked the regulator to clarify if any concerns were raised about Beech by its staff or other parties.

As we know from the Whorlton Hall scandal and other matters, relying upon CQC’s assessment of its own performance is far from safe.

We also know that CQC is very ready to gloss over its misdeeds, as illustrated by its recent indication to Private Eye that it has no intention to investigate why it rated Newbus Grange, a sister unit to Whorlton Hall as ‘Outstanding’ in February this year, just before physical abuse at the facility became public knowledge in April.

We also know from CQC’s 2018 staff survey that only 42% of CQC staff replied affirmatively regarding the item:

“I think it is safe to challenge the way things are done in CQC”              

CQC  2018 staff survey safe to challenge the way things are done in CQC

 

I have sent the data on Carl Beech’s activities at CQC to Health and Social Care Committee and Barbara Keeley, Shadow Minister for Mental Health and Social Care.

UPDATE 21 AUGUST 2019:

The CQC has given the following additional information on Carl Beech’s employment status:

“Carl Beech was suspended on 9 November 2016 following media reports and subsequent confirmation by the individual (on 8 November) that he was being investigated by Northumbria Police for fraud and perverting the course of justice.

A disciplinary investigation was then commenced on 8 February 2017 in relation to failure notify CQC of arrest by Gloucestershire police in relation to indecent images of children on 2 December 2016.

The disciplinary investigation concluded on 27 June 2017. The outcome was dismissal for gross misconduct with immediate effect.”

UPDATE 28 AUGUST 2018:

CQC has today denied that there is any evidence in its records that it received any concerns about Carl Beech:

“Dear Dr Alexander

We write in response to your correspondence of the 21 August in which you made the following request for information:

“May I clarify whether any concerns were raised about him at all, by colleagues or other parties, whether or not this related to his conduct on inspections?”

We have conducted a search and can confirm that no information is held indicating any concerns were raised about Carl Beech by colleagues or any other parties.

Yours sincerely

The Information Access team”

 

Private Eye 1501, 26 July 2019, on CQC’s ‘Outstanding Failures’:

Screenshot 2019-08-21 at 05.47.06

 

RELATED ITEMS

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

Darlington care home worker admits abuse of Newbus Grange patients

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CQC Whorlton Hall Cover Up: More CQC responses & culpability

 

 

 

 

 

Go Whistle: An Unaccountable APPG

By Dr Minh Alexander NHS Whistleblower and former consultant psychiatrist 17 August 2019

The Whistleblowing APPG is compromised by its history, its associations and its sponsorship.

 

 

Previous blog posts about the APPG:

Whistleblowing v Bounty hunting. A new whistleblowing APPG with sponsorship from bounty hunters

Whistleblowing APPG: Whistleblowers UK and questions about funding by Constantine Cannon LLP

 

 

Money is arguably at the APPG’s heart, the opposite to what drives genuine whistleblowers who risk all in the public interest.

The APPG backscratches with those who would make money from whistleblowers, with a few carefully chosen, sharp elbowed celebrity whistleblowers, often those interested in money, and with those who are not even whistleblowers but seemingly happy to be represented as whistleblowers.

In July, the APPG launched its first report, a rambling and poorly evidenced affair, which when read with an experienced eye was focussed on opening up the UK market for the APPG’s main sponsor, US bounty hunting lawyers Constantine Cannon.

 

The APPG report’s key recommendations were:

 

  1. To designate all UK citizens as potential whistleblowers qualifying for protection (mirroring the US model of deputising all who report fraud/ financial misconduct against the government, in order to get a cut of money recovered)

 

  1. To establish an Office for the Whistleblower, mirroring the US Office of the Whistleblower, which deals with financial misconduct and recovers money for the US government, rewarding only a few whistleblowers whose disclosures lead to the biggest bonanzas.

 

The US bounty hunting model is in fact ruthlessly exploitative, and operates as a type of Hunger Games that it is more interested in the protection of property than people, and leaves many genuine whistleblowers in the cold.

The APPG’s influential members orchestrated an inevitable news splash  about creating an ‘independent’ Office to protect whistleblowers.

It seems not many journalists could bear to trudge through the APPG report, or else they would have discovered a landmine laid for whistleblowers in the small print: the APPG proposed that the ‘independent’ Office should be under government control and located in either the Home Office or the Ministry of Justice:

Page 47 The new Office for the Whistleblower could be accommodated within the Home Office or the Ministry of Justice”

That is, two of the most oppressive and worst possible government departments to entrust with a tender new whistleblowing agency.

It was a deeply cynical proposal by the seasoned politicians on the APPG.

 

 

The Ministry of Justice victimises its own whistleblowers

To illustrate the preposterousness of locating a Whistleblowing Office in the Ministry of Justice, this is the recent case of Kathryn Hopkins, Ministry of Justice whistleblower who raised justified concerns about the ineffectiveness of the national Sex Offender Treatment Programme, but was ignored for several years:

“Fears about sex crime treatment were ignored”

During Kathryn Hopkins’ Employment Tribunal case  the MoJ even tried to deny that she had made disclosures to a nominated whistleblowing officer, but the Tribunal chose to believe the whistleblower:

97.The respondent does not accept that the claimant said the following to Ms Lloyd, which comprise the protected disclosures 6g-6l:

97.1. That there had never been any robust evidence that the SOPT worked and that oft-repeated claims of efficacy had been made based on little or no evidence. [PID 6g]

97.2. That the research should have been published immediately after the peer review in 2012. [PID 6h]

 97.3. That sexual offences committed since February 2012 may have been prevented if the SOTP had been halted in February 2012. [PID 6i]

97.4. That NOMS and CSAAP were covering up the research by subjecting it to continuing and invalid criticism. [PID 6j]

97.5. That the claimant was being bullied in order to stop her from pursuing the publication of the research. [PID 6k]

97.6. That there was a serious breach of research ethics by reason of the endless running and re-running of the research results which was done in order to try and reverse or minimise the findings which was part of the cover-up. [PID l]

Nevertheless, we find on the balance of probabilities that the claimant did make these extra observations to Ms Lloyd. They are consistent with what she was repeatedly saying to everyone. Although Ms Lloyd does not specifically remember the claimant saying those things, the claimant does remember. Given the overwhelming amount of detail with which the claimant was more familiar than Ms Lloyd, we think on balance the claimant’s memory is more likely to be reliable on this point.”

 

 

There is a lot of concern in the small, specialist world of whistleblowing governance about the direction of this APPG.

In the last two months I have written to the APPG to:

 

  1. Ask for information about contributions from a new APPG sponsor, NAVEX Global

 

  1. Ask for clarification about anomalous statements about the APPG secretariat’s (Whistleblowers UK) charitable status and services sold by the secretariat

 

  1. Raise concern about a serious factual error in the APPG’s report which may harmfully mislead NHS workers

 

  1. Ask for substantiating evidence regarding some of the APPG’s report recommendations.

 

I have not received a substantive response about the sponsorship by NAVEX Global, and no response at all regarding the other matters.

I have now asked the Registrar of Members’ Interests if they could establish whether the support provided by NAVEX Global reaches the threshold for declaration in the APPG register, because the APPG has not so far declared any details in the official register.

 

APPGs of course have no official status whatsoever.

But they comprise peers and elected officials, so one would hope for a modicum of transparency and accountability. Absence of such is revealing.

This is my correspondence with the APPG and the Registrar:

Correspondence with Whistleblowing APPG and Registrar of Members Interests July and August 2019

 

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Bundles of $100 dollars

A portrait of ineffectiveness: Internal whistleblowing champions in their own words

By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist 28 July 2019

 Summary: The model of internal, nominated whistleblowing officers was spawned in the corridors of Whitehall by Sir Humphrey and enforced by Francis Urquhart. It is huge joke on unsuspecting plebs, who must of course be kept in their place.

It led to the English network of Freedom To Speak Up Guardians who were employed by NHS Trusts and the Scottish whistleblowing Champions, who were directors of Health Boards.

FOI data revealed that despite Robert Francis’ promises that Guardians would provide ‘independent’ advocacy for NHS whistleblowers, hardly any Freedom To Speak Up Champions were escalating matters to the National Guardian.

Similarly, FOI data reveals that Scottish Whistleblowing Champions are escalating very few matters to either the Scottish Health Minister or NHS Scotland.

Feedback from Scottish Whistleblowing Champions raises additional doubts about the effectiveness of the role.

There are examples from other sectors of failure of internal whistleblowing mechanisms, including the recent case of Kathryn Hopkins Ministry of Justice whistleblower. The MoJ denied in legal proceedings that the whistleblower had even made protected disclosures to the Department’s internal nominated officer. However, the Court made a finding of fact that she did.

 

The Civil Service Code 2006 introduced a model of internal nominated officers with whom concerns could be raised:

16. If you have a concern, you should start by talking to your line manager or someone else in your line management chain. If for any reason you would find this difficult, you should raise the matter with your department’s nominated officers who have been appointed to advise staff on the Code.’

The recent case of Ministry of Justice (MoJ) whistleblower Kathryn Hopkins illustrates the ineffectiveness of the model: she made public interest disclosures to an internal MoJ nominated officer, but the MoJ later denied this in Court.

The Employment Tribunal had to consider whether the whistleblowing officer had colluded or had been intimidated into supporting the MoJ’s false narrative.

The Tribunal chose to believe the whistleblower.

97.The respondent does not accept that the claimant said the following to Ms Lloyd, which comprise the protected disclosures 6g-6l:

97.1. That there had never been any robust evidence that the SOPT worked and that oft-repeated claims of efficacy had been made based on little or no evidence. [PID 6g]

97.2. That the research should have been published immediately after the peer review in 2012. [PID 6h]

97.3. That sexual offences committed since February 2012 may have been prevented if the SOTP had been halted in February 2012. [PID 6i]  

97.4. That NOMS and CSAAP were covering up the research by subjecting it to continuing and invalid criticism. [PID 6j]

97.5. That the claimant was being bullied in order to stop her from pursuing the publication of the research. [PID 6k]

97.6. That there was a serious breach of research ethics by reason of the endless running and re-running of the research results which was done in order to try and reverse or minimise the findings which was part of the cover-up. [PID l]  

Nevertheless, we find on the balance of probabilities that the claimant did make these extra observations to Ms Lloyd. They are consistent with what she was repeatedly saying to everyone. Although Ms Lloyd does not specifically remember the claimant saying those things, the claimant does remember. Given the overwhelming amount of detail with which the claimant was more familiar than Ms Lloyd, we think on balance the claimant’s memory is more likely to be reliable on this point.”

However, although Hopkins was judged to have made genuine, vital public interest disclosures about the ineffectiveness of the national Sex Offender Treatment Programme, and to have suffered reprisal in consequence, she lost her case because her claim was judged to be have been filed out of time. Such is the weakness of current UK whistleblowing law and governance.

Her case was covered by the Times:

Fears about sex crime treatment were ignored

Richard Ford, The Times, 17 June 2019

A whistleblower who said that a sex offender treatment programme made some criminals more dangerous was treated unfairly by the Ministry of Justice, an employment judge has ruled.

Kathryn Hopkins’s research highlighted flaws in the programme in 2012 but it was not stopped until five years later. She has estimated that about 180 more crimes will have been committed by sex offenders who were treated in that time than had they not been.

Ms Hopkins had been asked to investigate the effect of the core sex offender treatment programme which had been used by the prison service since 1991. It was aimed at changing the thought processes of men in group sessions and behavioural therapy. Her first results suggested that prisoners on the programme were more likely to reoffend than those who were not.

In 2017 the treatment programme was scrapped and the Ministry of Justice released a report saying that 10 per cent of sex offenders who completed the core sex offender treatment programme (SOTP) committed at least one sexual offence in a follow-up period, compared with 8 per cent of those who had not been treated.

For offences involving explicit images of children the reoffending rate was 4.4 per cent for those who had done the programme, compared with 2.9 per cent in the comparison group.

Ms Hopkins accused the ministry of discrimination at an employment tribunal but lost her case because she had lodged her claim out of time.

Judge Tamara Lewis said in a ruling: “The final report confirmed what the claimant [Ms Hopkins] had been saying all along, ie that there was a higher rate of reoffending by prisoners who had undertaken the SOTP. We can understand the claimant’s frustration that it took five years to publish a report on such an important matter of public policy.”

The tribunal panel said that Ms Hopkins had been unfairly marked down in a performance review in 2014 because she had raised concerns about the SOTP. She was given a “must improve” rating which Judge Lewis said “caused her enormous distress” and prompted her to start a grievance procedure.

Ms Hopkins told the BBC that the ministry had “allowed people to continue attending the course” while knowing “it could be harmful”.

A ministry spokesman said: “Both internal and external experts who reviewed Ms Hopkins’s research judged that it was not of sufficient quality and that the methodology needed to be changed to remove the risk of bias and inaccurate results.”

 

 

Another case which starkly illustrates the uselessness of internal whistleblowing models, when the stakes are high, is that of the head of whistleblowing at Barclays, who Private Eye reported was gagged and left under mysterious circumstances.

Barclays whistleblowing champion Private Eye 1470 18.05.2018

 

Internal whistleblowing champions in the NHS

The Head of HR at the then Department of Business, Innovation and Skills steered the Freedom To Speak Up Review on NHS whistleblowing.

The civil service model of internal whistleblowing officers (which had not been properly evaluated – more of that another time) was parachuted into the NHS as ‘Freedom To Speak Up Guardians’.

Robert Francis, the government’s frontman peddled the myth that it was an innovation.

At the National Guardian’s first national conference in March 2017 he told star-struck Guardians they were “pioneers”.

This false claim was flatteringly repeated by Public Concern at Work (now rebranded as Protect), whose head of legal had taken up a job at the National Guardian’s office:

Screenshot 2019-07-28 at 08.10.10

Evidence of the ineffectiveness of the Freedom To Speak Up project continues to accumulate, despite the frantic spinning coordinated by the National Guardian’s office.

Henrietta Hughes National Guardian has gone as far as claiming that the Freedom To Speak Up project has prevented “untold harm” and saved lives. She has not evidenced this claim and has not so far responded to a request to do so.

Screenshot 2019-07-28 at 12.36.00

NHS whistleblowers continue to be disciplined and dismissed, and the National Guardian does her best to turn a blind eye through both unfairly designed processes and failure to even adhere to her own processes:

The Greasy Freedom To Speak Up Review is Stuck. More Tales of Silence about Silence.

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

Some Freedom To Speak Up guardians have reported that they have been bullied and obstructed:

The Disinterested National Guardian & Robert Francis’ Unworkable Freedom To Speak Up Project

Importantly, and predictably, FOI data showed that Freedom To Speak Up Guardians are not fulfilling a core function as intended – acting independently by escalating matters to the National Guardian.

The National Guardian’s office admitted that it received only 18 whistleblowing disclosures from 18 Freedom to Speak Up guardians in 2017/18, out of many hundreds of guardians in that year:

“We can confirm that out of 85 qualifying disclosures, 18 of these came from NHS trust Freedom to Speak Up Guardians (or Freedom to Speak Up ‘Champions’, ‘Ambassadors’ or equivalent).”

Scotland followed the English model and installed ‘Whistleblowing Champions’ in Scottish NHS Health Boards. The variation being that the posts were restricted to non executive directors and the champions were not intended to be the main interface for staff:

Paul Gray Letter to Health Boards 29.09.2015 about whistleblowing champions

The Whistleblowing Champion would not be expected to:  

  • Be the sole point for staff, or expected to become directly involved in the operation of the whistleblowing policy
  • Investigate cases.”

It had been a recommendation of Robert Francis’ Freedom To Speak Up Review that NHS bodies should designate a NED as a whistleblowing lead on boards. This was interesting because NEDs are not classed as workers under UK whistleblowing law and are not covered by the legislation.

As might be expected, the Scottish model also failed. A Scottish whistleblowing champion came forward with related disclosures:

NHS Tayside whistleblowers’ champion quits claiming ‘serious’ concerns ignored

To test whether Scottish whistleblowing champions had in fact been doing much championing, I asked about the number of disclosures that they had made to the Scottish Health Minister and NHS Scotland. The numbers were so small that they could not be released without risk of identifying individuals.

Scot Gov:

“No whistleblowing champions have approached Ms Freeman to make ‘qualifying disclosures’ as defined under the Public Interest Disclosure Act 1998 (PIDA), since Ms Freeman made her speech on 8 October 2018.”

Prior to 8 October 2018 between 1-5 whistleblowing champions disclosed to Ms Freeman that health board staff concerns are being covered up by a health board, or that health board staff are being unlawfully victimised and subjected to detriment for making public interest disclosures. We are unable to advise you of the exact numbers as this could potentially identify any individual(s) involved in the case(s).”

NHS Scotland:

“Since the role of whistleblowing champion was established in November 2015 between 1-5 whistleblowing champions have made whistleblowing disclosures to the Scottish Government. We are unable to advise you of the exact numbers or the nature of the concerns as this could potentially identify any individual(s) involved in the case(s).”

The Scottish government disclosed feedback from Health Board whistleblowing champions about the role:

Annex to FOI_19_00388 – Role of Whistleblowing Champion

The comments by the whistleblowing champions give an impression of variable and  primarily administrative processes, with dependence on information filtered by executive directors. Some indicated that they cross-checked whether whistleblowers were happy with investigations (NHS Lothian). Others such as NHS Tayside emphasised that they had a hands off role:

“WBC are not expected to be the sole point of contact for staff, be directly involved in the operation of the whistleblowing policy and investigate cases.”

At NHS Grampian, a site of much suppression and multiple whistleblower carnage,  the whistleblower champion noted with doubt, that there had been no recent reports of whistleblowing. They speculated on what this meant, but concluded that they could have no part in directly investigating whistleblowing issues.

Structures which are designed to be inconclusive will not reveal the truth.

The ineffective structures that we have in place at present need to be replaced with properly designed infrastructure that genuinely serves the public interest, and is underpinned by effective new UK whistleblowing law.

 

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This is a study by Greenwich University on a highly selected sample of whistleblowers who contacted the PCaW helpline, but it does nevertheless shed very useful light on high levels detriment that are quickly accrued during the internal stage of whistleblowing.

Whistleblowing in Whitehall: Civil Servants’ Complaints about Breaches of the Civil Service Code since 2014

Speak Up Guardians: A Whiter Shade Of (Corporate) Pale

 

 

 

 

CQC Whorlton Hall Cover Up: More CQC responses & culpability

 By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, 26 June 2019

 

Summary: The CQC suppressed a critical 2015 inspection report  on Whorlton Hall which effectively described institutional abuse in the form of wide ranging, serious care failures.

CQC has now admitted via FOIA that it has a legal duty to publish an inspection report on every inspection, and that it has no policy which allows it to discard an entire inspection report. CQC has also admitted that where there is a concern about insufficient evidence to back up regulatory findings, normal procedure is for the same inspector to go back. In contrast, at Whorlton Hall the CQC sent a different team in several months later, which delivered an unrecognisably upbeat portrait of the service.

The CQC is suspiciously evading a question about whether CQC board members were involved in the decision not to publish the 2015 Whorlton Hall inspection report.

It also refused to disclose, on questionable grounds, the detailed evidence relied upon for the conclusion of the whitewash 2016 CQC inspection report that no unofficial seclusion was taking place at Whorlton Hall. A question arises about the sufficiency of this ‘evidence’.

Similarly, CQC refused to disclose on questionable grounds why its whitewash 2016 report was silent about the lack of an organisational rapid tranquillisation (forced medication) policy at Whorlton Hall, a serious failing, which was described in the suppressed 2015 inspection report but later conveniently omitted.

The stench grows stronger. The CQC is dangerous and needs to be abolished. In the meantime, parliament is duty bound to stop the DHSC/ CQC charade of an faux independent investigation controlled by the CQC. It should ensure a much more robust, wider investigation of whether the CQC is fit for purpose, as Barbara Keeley MP has called for.

 

On 22 May 2019 BBC Panorama broadcast an undercover investigation which revealed abuse of highly vulnerable adults at Whorlton Hall, a facility which used to be run by the company Castlebeck, which ran the notorious Winterbourne View.

Panorama also exposed gross abuse at Winterbourne View in 2011, where CQC was implicated in the poor care and had ignored whistleblowers.

Whorlton Hall was taken over by Danshell when Castlebeck ran into difficulties, and was the company responsible for Whorlton Hall when CQC last inspected and rated it ‘Good’.

After the Panorama broadcast about Whorlton Hall, Barry Stanley-Wilkinson a former CQC inspector came forward and accused the regulator of covering up abusive practices at Whorlton Hall four years ago.

Screenshot 2019-06-26 at 07.47.36

CQC initially scoffed at these claims. Although it was forced to admit that there was an unpublished 2015 report, CQC flatly denied that the suppressed 2015 report contained any evidence of abusive practices.

Screenshot 2019-06-26 at 08.49.38

 

Barry Stanley-Wilkinson accused the CQC of trying to discredit him with this denial:

Screenshot 2019-06-26 at 08.50.31

 

On 10 Jun CQC was forced by the Joint Committee on Human Rights, to publish the hitherto suppressed 2015 report  and this confirmed Barry Stanley-Wilkinson’s claims:

Suppressed draft 2015 CQC inspection report by Barry Stanley-Wilkinson and team 

 The report registered concerns about unofficial use of seclusion, administration of rapid tranquillisation (forced medication) without any organisational policy and the discovery of a care plan which stated that staff should ignore a patient’s allegations against staff.

The suppressed 2015 report described other serious problems such as understaffing, failure to carry out required observations on patients, very serious failures of risk management and care that was so poor and unskilled that it resulted in needless incidents and physical restraint.

On 28 May 2019 I asked CQC the following questions through a request under the Freedom of Information Act:

 

1) Please provide the relevant policy/ procedural document(s) which govern any decisions not to publish draft CQC inspection reports and the seniority of the CQC personnel involved in such decisions.

2) Please advise of the circumstances in which a draft CQC report might not be published in its entirety, as opposed to just edited. 

3) Please advise how exceptional it is for CQC inspection reports not to be published and whether CQC can provide figures for the number of inspection reports that have not been published since CQC’s inception. Can CQC provide a rough proportion, to its best knowledge, of the inspection reports that have not been published if a precise figure cannot be given.

4) Please advise of the seniority of the most senior CQC personnel involved in the decision not to publish the draft report arising from the August 2015 inspection on Whorlton Hall. If a CQC board member(s) was involved in the decision not to publish, please disclose who they were.

5) As far as I can see, CQC’s June 2016 inspection report on Whorlton Hall fails to address the issue of rapid tranquillisation (forced medication).

This is despite the fact that the same report notes that there were 188 episodes of physical restraint in the six month period prior to CQC’s inspection visit:

https://www.cqc.org.uk/sites/default/files/new_reports/AAAF5065.pdf

“In the six months prior to our visit, there had been 188 episodes of restraint.”

In contrast, in two later 2017 inspection reports CQC addressed the issue of rapid tranquillisation. CQC noted failure by Whorlton Hall to monitor  physical health following use of rapid tranquillisation.

Incongruously, CQC seemed to be visiting Whorlton Hall quite frequently for an establishment that it had designated as ‘Good’, which might suggest ambivalence:

– August 2015

– March 2016

– August 2016

– November 2016

– September 2017

– March 2018

CQC inspection reports on Whorlton Hall claimed that that the provider had no designated seclusion rooms and that seclusion had not taken place in other rooms. However, Panorama’s findings may question CQC’s conclusions about the absence of illicit use of seclusion.

CQC’s inspection reports remark that there was no evidence in case notes of illicit seclusion in non-designated areas. Abusers are not likely to create a record of their illicit activities.

Mr Barry Stanley Wilkinson former CQC lead inspector has made a statement that the draft CQC inspection report on Whorlton Hall from the 2015 inspection, which was never published, described unsafe and abusive practices:

https://www.linkedin.com/feed/update/urn:li:activity:6538773786865483777

“For those that watched the BBC news last night will have seen my interview. CQC have said  in a statement that my report contained “no concerns regarding abusive practice”. This is to discredit me. 

This is not true the report detailed how there was seclusion taking place without any policies or protocols in place, rapid tranquilisation was available without any policies in place, it was written in a care plan if people raised allegations of abuse they were to be ignored, it was also written that where patients raised concerns about the attitudes and behaviours of staff they did not feel listened too. It was written an external agency also made allegations about staff attitudes and behaviours. It also included information from another Government Department that stated the place was like something from the 1990’s it was so institutionalised. 

They say the report went through a rigorous peer review! That peer review advised a change of ratings to inadequate for “effective”. 

CQC have not detailed the provider at the time complained about us an an inspection team and meetings were had without my presence. The next I was told was it had been agreed the report would not be published. I was told it was down to the evidence. In a 9 year career I have never not had a report published.”

Can CQC please confirm if the unpublished CQC draft report from the August 2015 inspection of Whorlton Hall did indeed detail concerns about: 

– the use of rapid tranquillisation outwith policies

– the use of seclusion outwith policies and protocols

– a care plan which stated that allegations of abuse should be ignored. 

6) Mr Barry Stanley-Wilkinson has stated that he believes that the CQC destroyed the draft inspection report from the August 2015 inspection visit on Whorlton Hall. 

https://www.linkedin.com/feed/update/urn:li:activity:6537063313275142144/

“the report was deleted and never published”

Please confirm if this is the case. If not, please disclose a copy of the report.

 

 

After the CQC published the suppressed 2015 inspection report, I amended my request as follows:

 

Further to my request of 28 May below, CQC’s publication yesterday of various previously unpublished drafts of the 2015 CQC inspection report on Whorlton Hall, the facility previously run by Danshell now owned by Cygnet, has addressed some of my original questions.

 Obviously, I would be grateful if you would address the remaining questions.

I would also be glad if you could address two additional questions as follows. 

Mr Barry Stanley-Wilkinson’s 14 December 2015 draft inspection report, after peer review and other preparation, concluded that Whorlton Hall staff had been using seclusion unofficially in a room not badged as a seclusion room. This was through removing and isolating patients in a low stimulus room, under physical restraint, if they were merely “distressed”, when seclusion should only be used as the last resort for managing significant of significant harm to others.

https://www.cqc.org.uk/sites/default/files/20151214%20Draft%20NOT%20FOR%20PUBLICATION%20-%20Report%20ready%20for%20IM%20review.pdf

 The subsequent 16 December 2015 draft of the Whorlton Hall inspection report, with annotations by an Inspection Manager, raised questions about Barry Stanley-Wilkinson’s conclusion that Whorlton Hall staff were using seclusion unofficially.

The inspection manager wanted to know if Whorlton Hall staff released restraint, or prevented patients from leaving the room:

https://www.cqc.org.uk/sites/default/files/20151216%20Draft%20NOT%20FOR%20PUBLICATION%20-%20Draft%20report%20post%20IM%20review.pdf

Six months later in June 2016, CQC published an inspection report which simply asserted that CQC was satisfied that seclusion was not taking place at Whorlton Hall:

 “The hospital did not have a seclusion room. Following discussions with staff and review of care records we were satisfied that seclusion was not taking place in any other rooms.”

https://www.cqc.org.uk/sites/default/files/20160617%20Published%20report%20on%20Whorlton%20Hall.pdf 

1. In regards to the above, please can CQC provide the detailed evidence for its conclusion, in its June 2016 report, that the removal and isolation of distressed patients under physical restraint to a low stimulus room did not constitute seclusion.

 It is now clear, despite CQC’s recent denial that Mr Stanley-Wilkinson’s unpublished inspection report described any abusive practices, that his report did describe the administration of rapid tranquillisation (forced medication) by nursing staff in the absence of any organisational policy and guidance. His 2015 unpublished report states:

“The organisation did not have a policy relating to rapid tranquilisation. This meant nurses administered drugs without any organisational guidance on the appropriate use.” 

2. Please can CQC advise why its published report of June 2016 appears to be silent about the use of and presence or absence of policies about rapid tranquillisation at Whorlton Hall?”

 

 

The CQC’s response to these questions in summary

The CQC responded yesterday via two emails, as set out below in the appendix.

In short, the CQC admits that:

  1. It has a legal duty to publish a report for every inspection report
  2. It does not have a policy or procedural document which governs decisions NOT to publish a draft report
  3. Normal CQC procedure when there is insufficient evidence to support a regulatory judgment or conclude a rating is for the inspector to go back in, or for more information to be obtained by using other regulatory powers.

In other words, not the fishy events that unfolded at Whorlton Hall with CQC sending in a replacement inspection team, several months later.

The CQC claims in a heavily qualified manner that it is “so far” unable to say how often it has binned entire inspection reports, as it did the 2015 Whorlton Hall report.

We have so far been unable to establish how often we have had circumstances where a draft report has not gone on to be published at all. This would be outside of our normal process and we have not identified a way in which we could track this from the management data that we hold. It is therefore our view that we do not hold the requested information.”

The last sentence of this paragraph is particularly suspicious. It is not a clear denial that CQC holds the requested data, only a slippery statement of CQC’s “view”.

Neither does the CQC give straight answer to whether CQC board members were involved in the decision not to publish the suppressed 2015 report. It side steps the question in the following manner:

We have not identified any records which indicate that members of the CQC Board or Executive Team were involved in the decision not to publish the draft report.” [my emphasis]

 As the deputy chief inspector Paul Lelliott has been shown to be implicated by internal CQC correspondence sent to the Joint Committee of Human Rights, it is highly unlikely that no board members were involved. If so, Lelliott will know who they are, and CQC has no need to rely on records. This latest CQC evasion almost certainly confirms that CQC board members were involved and aware of the suppression, whether or not they were the apparent decision makers.

CQC looks set to throw a less senior manager under the bus as the nominal decision maker, but conveniently declines to say who they were, using the current faux independent investigation, controlled by CQC, as a pretext:

We do hold some information which indicates who made the decision not to publish the draft report, but pending the findings of the independent investigation we cannot say that this information is conclusive. In any case, we will not release information at this time that would be likely to lead to the identification of this person. We are concerned that making this information public (especially in advance of the full circumstances of that decision being investigated and reported upon) would be likely to expose that person to potential harassment. We consider that this person has a reasonable expectation that this information will not be disclosed publicly at this time. We therefore consider that the exemption from disclosure under section 40(2) of FOIA (“personal information”) is engaged.”

Shades of the Morecambe Bay affair perhaps, when the CQC board insinuated that some of their managers covered up, without naming them but clearly fingering them. That led to litigation, settlement and the CQC being forced to issue a grovelling apology:

https://www.cqc.org.uk/news/stories/cqc-settles-case-former-deputy-chief-executive-jill-finney

“CQC settles case with former deputy chief executive Jill Finney

Published:

9 December 2014

Following the settlement of a case brought by former deputy chief executive Jill Finney, CQC’s chief executive David Behan said:

“In January 2014 the Care Quality Commission’s former deputy chief executive, Jill Finney, instigated legal action against CQC. This was following CQC’s publication of the Grant Thornton report into CQC’s regulatory oversight of University Hospitals of Morecambe Bay NHS Foundation Trust in June 2013. Ms Finney’s legal claim was based on two key elements: a libel action in respect of the Grant Thornton report; and a claim for damage to Ms Finney’s reputation resulting from the manner in which her name was released into the public domain. The total damages sought were £1.5m.

“Parties to high value litigation are encouraged to consider confidential mediation at an early stage before legal costs escalate for both sides. As a result of successful mediation, CQC has this afternoon issued a statement jointly agreed with Ms Finney. In addition, CQC has paid Ms Finney £60,000 in damages reflective of those matters set out in the statement, specifically the manner in which her name was released. This represents a full and final settlement with Ms Finney over all aspects of her claim. CQC has also made a contribution to Ms Finney’s legal costs.”

The parties have agreed the following statement.

“The CQC has settled the proceedings brought against it by Jill Finney, its former Deputy Chief Executive.  The proceedings arose from the publication on 19 June 2013 of a report into the CQC’s regulation of the University Hospital Morecambe Bay NHS Foundation Trust (UHMB), produced by Grant Thornton LLP. The CQC had previously committed itself to publishing Grant Thornton’s report, which came to the conclusion that Ms Finney may have been party to a “cover up” of a report into the CQC’s regulation and oversight of UHMB, something she and others have always emphatically denied.

“From the interview stage, Ms Finney and others were highly critical of Grant Thornton’s fairness and processes including their interviewing, note-taking and record-keeping techniques.  She complains that she was not even given advance notice of the allegations to be levelled at her in the interview.

“The CQC deeply regrets its decision, taken on legal advice, to withhold the names of individuals in the report, as promised to Ms Finney and others.  It then had to reverse that decision after names, including Ms Finney’s, appeared in the media as a result of speculation by journalists. The consequences for Ms Finney were aggravated by the fact that some of the national media wrongly portrayed the internal report as being about maternity deaths at UHMB. Further, due to confusion caused by an IT failure, the CQC failed to inform Ms Finney that her name had been released until 18 hours later, by which time she had been summarily dismissed from her then employment.

“The CQC accepts that Ms Finney was thereby disadvantaged in protecting her reputation and giving her public defence to an allegation which she has always denied; in addition, she suffered considerable distress. The CQC wishes to take this opportunity to apologise to her and is happy to repeat what its Chief Executive Mr Behan wrote to her at the time of her departure in February 2013: ‘you have been a rock of stability in CQC leading with passion, energy and dedication. You have given much, and people have testified to this.’”

Lastly, CQC refuses to answer the request for the detailed evidence underlying its whitewash 2016 report’s conclusion that no illicit seclusion was taking place at Whorlton Hall, despite Barry Stanley-Wilkinson’s clear report of such activities in his suppressed 2015 inspection report.

Laughably, the CQC is so desperate to avoid this question, which goes to the heart of its cover up at Whorlton Hall, that it claims this question does not constitute an FOI request:

Answering these questions would require analysis and interpretation of information held by CQC, to decide which evidence within our records was the basis for specific decisions or omissions. We therefore do not consider these to be requests for recorded information subject to the Freedom of Information Act 2000.”

Similarly, on the same basis, the CQC refuses to answer why the whitewash 2016 was completely silent about the lack of any organisational rapid tranquillisation policy at Whorlton Hall despite Barry Stanley Wilkinson rightly identifying this as a serious matter in 2015.

The stench has only got a whole lot stronger.

The CQC is riddled with almost a decade of rotten culture and engrained misdeeds. Its senior leaders for the main part cannot tell wrong from right, and it seems they do not even want to. CQC was created as a tame regulator by Labour, in response to the embarrassment of MidStaffs and other disasters.

Under a longer stretch of Tory rule, in the dark shadow of austerity and the need to disguise the ferocious attack on civil society, CQC has fungated. It has done so whilst cynically spinning about squeaky clean reform under David Behan 2012-2018.

Robert Francis, a CQC NED even wrote me a patronising letter telling me that CQC was going straight under Behan’s leadership and…wait for it…that CQC’s critics should be careful not play into the hands of those who profit from vulnerability.

 

From Robert Francis 16 January 2017, after being sent a copy of the report

‘What’s Wrong with the CQC’ by the Centre for Welfare Reform:

“Dear Dr Alexander

I must apologise for not replying before now to your earlier request for a meeting but I have of course followed your correspondence with Dr Hughes.  As you may be aware I am in full time practice as a barrister and have a limited amount of time to devote to the aftermath of Mid Stafford, the FTSU review  and subsequent developments.and the contribution I can make in my spare time is therefore limited.  I have noted that you are in dialogue with Dr Hughes and it seems to me that pursuing that is likely to be more fruitful for you than a meeting with me,  Your views are well known to me, and I respect them even if I do not always agree with them.

Thank you for alerting me to the Burton essay giving his view of CQC’s performance in the regulation of adult social care.  I do not accept that it is a fair characterisation of its work.  In particular my own experience of observing the inspection of a care home is very different from that he describes.  The same applies to his view of the function of the Board.   Of course nothing is t perfect and the organisation recognises this: under the leadership of David Behan, it is constantly – and openly –  striving to improve the way it regulates the sector.  I note that Mr Burton gives no credit to CQC for the way in which it speaks truth to power in the State of Care Report  in relation to the dangers caused by the under funding of the sector and its concern that the sector is approaching a tipping point, a view based on  evidence gathered in the course of its work.  I do think those who criticise CQC in the way Mr Burton does should be wary if getting what they ask for.  No regulator is popular with those it regulates. and it is not difficult to pick holes in the work it does. However I believe that to do away with national regulator as he suggests would play into the hands of those who would exploit vulnerable service users for their own profit.

Yours sincerely

Robert Francis”

 

We have already seen one CQC NED trying, not terribly convincingly, to put blue water between himself and CQC. One wonders what it will take for Francis to stop his vain defence of the putrid CQC.

Behan of course has since shown his true colours by skipping off to the board of the care home giant HC-One. As a HC-One NED he shamelessly advocated for radical policy changes to compulsorily impoverish the public in order to fund their future care in old age. On 10 May 2019 the Financial Times reported on HC-One’s tax avoidance – zero corporation tax paid since 2011 – and the fact that it has paid £48.5m in dividends whilst crying that the care sector was in danger of financial crisis due to underfunding.

CQC is not only unfit for purpose, but dangerous.

It is parliament’s duty to put a stop to the pointless faux investigation on Whorlton Hall that CQC and DHSC have offered up as a sop, and ensure a much wider, more robust investigation, free from government interference.

Barbara Keeley Shadow Minister for Mental Health and Social Care, JCHR, and Public Accounts Committee have all tried to hold CQC to account over the years, but the sticking point is Health and Social Care Committee and its until recently Tory Chair. Health and Social Care Committee has the lead responsibility for CQC but has done little to truly probe, challenge and follow up.

 

Appendix: Full CQC response  FOI 25 June 2019

Our Ref: CQC IAT 1920 0148

 Dear Dr Alexander

I write in response to your correspondence of the 28 May in which you made a request for information.

We will respond to each part of your request in turn.

“FOI request re Non-publication of CQC inspection reports and Whorlton Hall

1) Please provide the relevant policy/ procedural document(s) which govern any decisions not to publish draft CQC inspection reports and the seniority of the CQC personnel involved in such decisions.”

We have a legal obligation to publish a report for every regulatory inspection we carry out. We do not have a specific policy or procedural document which governs decisions not to publish a draft report.

We have a process for quality assurance of reports which means that we will often produce several versions of a draft report. In circumstances where we have insufficient evidence to support a judgement or conclude a rating, our usual process would be for the Inspector to return to the service or use our other powers to obtain more information from the provider and amend the report accordingly on the basis of this further evidence.

However, the documents relating to this quality assurance process do not include instructions or guidance on making a decision to not publish a draft report. Therefore we do not hold the requested information.

“2) Please advise of the circumstances in which a draft CQC report might not be published in its entirety, as opposed to just edited.”

For the reasons set out above, we do not hold this information.

“3) Please advise how exceptional it is for CQC inspection reports not to be published and whether CQC can provide figures for the number of inspection reports that have not been published since CQC’s inception. Can CQC provide a rough proportion, to its best knowledge, of the inspection reports that have not been published if a precise figure cannot be given.”

We have a legal obligation to publish a report for every regulatory inspection we carry out. The report of the March 2016 inspection stated that it covered the main findings of the August 2015 inspection. 

We have so far been unable to establish how often we have had circumstances where a draft report has not gone on to be published at all. This would be outside of our normal process and we have not identified a way in which we could track this from the management data that we hold. It is therefore our view that we do not hold the requested information.

“4) Please advise of the seniority of the most senior CQC personnel involved in the decision not to publish the draft report arising from the August 2015 inspection on Whorlton Hall. If a CQC board member(s) was involved in the decision not to publish, please disclose who they were.”

We have not identified any records which indicate that members of the CQC Board or Executive Team were involved in the decision not to publish the draft report. We have commissioned two independent reviews of our regulation of Whorlton Hall [www.cqc.org.uk/news/stories/update-independent-review-regulation-whorlton-hall] both of which are expected to look in detail at the decision making process that resulted in this draft report not being published.

We do hold some information which indicates who made the decision not to publish the draft report, but pending the findings of the independent investigation we cannot say that this information is conclusive. In any case, we will not release information at this time that would be likely to lead to the identification of this person. We are concerned that making this information public (especially in advance of the full circumstances of that decision being investigated and reported upon) would be likely to expose that person to potential harassment. We consider that this person has a reasonable expectation that this information will not be disclosed publicly at this time. We therefore consider that the exemption from disclosure under section 40(2) of FOIA (“personal information”) is engaged.

I hope that you have found this response helpful. If you are not satisfied with our handling of your request, then you may request an internal review.

Please clearly indicate that you wish for a review to be conducted and state the reason(s) for requesting the review.”

 Our Ref: CQC IAT 1920 0213

Dear Dr Alexander

 I write in response to your correspondence of the 11 June in which you stated:

“1. In regards to the above, please can CQC provide the detailed evidence for its conclusion, in its June 2016 report, that the removal and isolation of distressed patients under physical restraint to a low stimulus room did not constitute seclusion.

2.Please can CQC advise why its published report of June 2016 appears to be silent about the use of and presence or absence of policies about rapid tranquillisation at Whorlton Hall?”

 Answering these questions would require analysis and interpretation of information held by CQC, to decide which evidence within our records was the basis for specific decisions or omissions. We therefore do not consider these to be requests for recorded information subject to the Freedom of Information Act 2000.

CQC has announced an independent investigation into our regulation of Whorlton Hall between 2015 and 2019, which will include recommendations for how our regulation of similar services can be improved, in the context of a raised level of risk of abuse and harm. You can find more information here: 

www.cqc.org.uk/news/stories/update-independent-review-regulation-whorlton-hall

Our expectation is that these investigations will review and publicly report on the decision making process.

 I hope that you have found this response helpful. If you are not satisfied with our handling of your request, then you may request an internal review.”

 

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

By Dr Minh Alexander, NHS whistleblower and former consultant psychiatrist, 20 June 2019

 

 Summary: Newbus Grange is another former Castlebeck-Danshell learning disability facility, which CQC inexplicably gave a pass despite staff convictions for abuse against patients and other matters.

The former deputy manager of Newbus became the manager of Whorlton Hall in 2017.

Following recent exposure of serious abuse against patients at Whorlton Hall by BBC Panorama, the police arrested ten members of staff.

A CQC cover up about Whorlton Hall has been exposed by Barry Stanley-Wilkinson, CQC whistleblower and former lead inspector.

According to Darlington, Hartlepool and Stockton on Tees CCGs’ minutes of May 2019 there is also emerging serious Safeguarding concern about alleged physical abuse at ‘Outstanding’ Newbus Grange.

The CQC is a dangerous organisation which needs to be abolished. Barbara Keeley Shadow Minister for Mental Health and Social Care has called for a properly independent inquiry into whether it is fit for purpose.

 

In 2011 the Winterbourne View scandal was unmasked by BBC Panorama and CQC was forced to review all the properties owned by Castlebeck, the company which ran Winterbourne View.

CQC was forced to concede in July 2011 that there were  serious systemic issues across the whole chain, but it claimed that Newbus Grange was fine:

“Newbus Grange is compliant with essential standards. We have not requested any follow up action.”

This was despite a Newbus Grange worker being jailed for eight months in February 2010 for an assault on a highly vulnerable patient, whilst observed to be laughing:

Ex-soldier jailed for attack on disabled man

Not long after CQC gave Newbus Grange the all clear, Castlebeck itself suspended some Newbus Grange staff over allegations of abuse and drug misuse.

Darlington-based care provider, Castlebeck, sacks and suspends staff in mistreatment probe

In 2014 a Newbus Grange worker was convicted of theft from the patients:

Care home worker escapes jail after stealing more than £3,000 from vulnerable residents

And yet CQC still awarded Newbus Grange a rating of ‘Outstanding’.

The CQC considered that Newbus Grange was outstandingly well-led.

Newbus Grange Outstanding

 

Newbus Grange’s deputy manager Chris Shield won an award:

Chris Shield Nurse of the Year cached web page

 

By April 2017 he was promoted to manager of Whorlton Hall:

Chris Shield tweet by recognition PR about promotion

 

We know now that the CQC covered up a 2015 inspection report by Barry Stanley-Wilkinson on Whorlton Hall  which detailed wide-ranging and serious care failures which effectively amounted to institutional abuse. For example, Barry Stanley-Wilkinson and colleagues considered that staff at Whorlton Hall were so lacking in therapeutic skills that this provoked needless incidents and a high level of physical restraint:

“Staff demonstrated little understanding of autism, communication needs or recognised best practice. This contributed to a limited understanding of individual needs. As a result, there were high levels of restraint and restrictive practice to manage difficult and complex behaviour.”

We also now know that the matter went as far up as Paul Lelliott the CQC Deputy Chief Inspector and CQC lead for mental health. Given the political ramifications of ex-Castlebeck facilities and all things whistleblower-related, I think it is almost certain that the matter went all the way up the CQC chain of command.

Barry Stanley-Wilkinson had an unhappy experience of whistleblowing to the CQC, as evident from 2016 internal correspondence.

Most seriously, published papers of Darlington, Hartlepool and Stockton on Tees CCGs of 22 May 2019 report that there is a serious emerging Safeguarding concern about physical abuse at Newbus Grange: 

“111.8 Ms Golightly advised of an emerging concern at Newbus Grange, a Danshell / Cynet property, with serious safeguarding concerns relating to physical abuse.”

 This is not surprising. CQC’s sins were always going to find them. But such outcomes are beyond tragedy for the patients and families who are harmed and terrorised by CQC’s unforgivable, despicable derelictions of duty.

Barbara Keeley Shadow Minister for Mental Health and Social Care has called for a properly independent inquiry into whether CQC is fit for purpose.

 

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

By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist 14 June 2019

 

Summary A dismal spectacle of self-preservation, sly deflection and scapegoating of subordinates unfolded when CQC directors, Paul Lelliott Deputy Chief Inspector and Ian Trenholm Chief Executive appeared in front of the Joint Human Rights Committee on 12 June 2019.

They had been hauled in to answer questions about CQC’s suppression of a 2015 inspection report. The report described wide ranging and serious care failings that effectively amounted to institutional abuse, serious risks and allegations of mistreatment at Whorlton Hall, where BBC Panorama recently exposed serious abuse by staff. 

Although the CQC refused to hand over crucial documents, the Committee had in its possession internal CQC correspondence with Barry Stanley-Wilkinson CQC whistleblower. This put Lelliott in the thick of things in 2016, just before a whitewash alternative CQC report was published June 2016. The correspondence also revealed other allegations of bullying and suppression by CQC managers.

It was clear from the Committee hearing this week that the last thing that the CQC intends to do is to take responsibility. Instead, there is yet another disingenuous proposal to review inspection methodology, when the issue is not incompetence but cover up.

It takes time and money to service a denial machine.

A quick search reveals that CQC hires at least twenty seven comms and ‘engagement’ staff. This must be gratifying for its executive escape artists.

Of special note, it seems that CQC hired a PR bod to assist Andrea Sutcliffe former CQC Chief Inspector with managing the news on social care failings and BBC Panorama exposures.

Also noteworthy is the fact the former Department of Health’s chief spin doctor for the whitewash Freedom To Speak Up Review, on NHS whistleblowing, is now CQC’s Head of Provider Engagement.

The CQC is too riddled with years of misdeeds to be reformed. Only abolition and a clean slate will do now.

 

 

Background

 There are many, many disturbing things surrounding the Whorlton Hall affair.

Questions arise about the fact that in May 2016 a CQC operations manager joined Danshell,  the company which ran the facility, as a Director of Operations.

Questions also arise about the general extent of regulatory capture given that last year, CQC’s previous chief executive walked straight through the revolving door onto the board of care home giant HC-One.

Just after Behan’s arrival at HC-One was announced, he gave evidence to parliament urging that more cash for care should be generated through various taxes and compulsory levies:

Screenshot 2019-06-14 at 09.17.37.png

 

However on the subject of tax,  the Financial Times reported that HC-One itself has been avoiding tax.

The company complained of social care sector underfunding, paid zero corporation tax since 2011 but had paid at least £48.5m in dividends. The FT considered that more payments had probably been hidden by its complex structure, which made the flow of money hard to trace:

Britain’s biggest care home operator has paid out more than £48.5m in dividends in the past two years despite warning that local authority funding cuts have brought the sector to the brink of a financial crisis.” 

“HC-One appears to have declared a loss every year except one since its creation in 2011. It has paid no UK corporation tax in that time, and instead received net tax credits of £6.5m since a reorganisation in 2014.”

“Tracing the flow of money is difficult as HC-One has a complex corporate structure, with 50 companies, six of which are registered offshore either in the Cayman Islands or Jersey and a further five in the UK as foreign entities. This means investors and executives are likely to have received much greater sums as only one of its subsidiaries files consolidated accounts — the top UK company, FC Skyfall Upper Midco Limited.”

 

 

Whorlton Hall needed to fit the CQC narrative

Whorlton Hall was a former Castlebeck facility. Castlebeck was the company which ran Winterbourne View, where vulnerable people were severely abused whilst CQC turned a blind eye to desperate whistleblowers:

BBC Timeline: Winterbourne View abuse scandal

Danshell took over Castlebeck when the company ran into financial difficulties after the Winterbourne View scandal. Danshell was the company running Whorlton Hall in 2015, when care failings were discovered by Barry Stanley-Wilkinson’s team, but suppressed by senior CQC managers.

The CQC took a monumental pasting over its gross failures at Winterbourne View.  CQC would have been hypervigilant and very actively managing all news about ex-Castlebeck properties such as Whorlton Hall. It carried out review of the Castlebeck estate after Winterbourne View and was forced to admit there were serious systemic issues.

But by 2016, a politically useful landscape of 100% ‘Good’ ratings had been established across all of Danshell’s estate, and thus the spectre of Castlebeck was seemingly finally banished. Thus a typical heart-warming yarn was spun of improvement under CQC’s regulatory influence.

It follows that the likes of Barry Stanley-Wilkinson, who described care failures in plain English, would be a threat to the narratives that CQC wished to weave.

 

CQC’s fixers and schmoozers

From a quick and dirty search of information in the public domain, there are at least twenty seven CQC staff, besides the legal team, whose primary role is to protect the organisation and ensure correct messaging.

A list is provided in the appendix of individuals whose details appear in the public domain as CQC comms and engagement staff.

Stunningly, there is an individual who it appears was explicitly hired as Andrea Sutcliffe former Chief Inspector of Social Care’s personal flak handler on the social care crisis and BBC Panorama’s coverage of care scandals:

Screenshot 2019-06-14 at 06.44.54

Whistleblowers will also be interested to know that the Department of Health’s chief spin doctor for the whitewash Freedom To Speak Up Review is now engaging for a living at the CQC.

Screenshot 2019-06-14 at 08.35.25

The suffering, neglect and injustice implied by the contents of the suppressed 2015 inspection report on Whorlton Hall is a matter of deep shame.

One line in the 2015 report told Lelliott et al everything they needed to know about Whorlton Hall:

“Patients did not have a discharge plan in place, and senior managers recognised this as an area for development.”

 There are online reviews by apparent former Danshell workers, dating from 2016, which allege abusive employment and care practices. Are we to believe that CQC’s well paid intelligence gathering teams did not pick these up?

The parasitic model of regulation – running interference for government, infested with private interests and generating a self-serving industry of itself rather than serving the vulnerable, needs to be swept away.

Barbara Keeley Shadow Minister for Mental Health and Social Care has today written to Ian Trenholm CQC chief executive to challenge continuing evasion:

Barbara Keeley letter to Trenholm 14.06.2019 part 1.jpg

Barbara Keeley letter to Ian Trenholm CQC 14.06.2019 part 2

 

Barbara Keeley letter to Ian Trenholm 14.06.2019 part 3

UPDATE 18 JUNE 2019

Barbara Keeley has now challenged the government’s wholly inadequate plan for the CQC to control an investigation into itself, and has called for a properly independent inquiry:

 

APPENDIX

Currently listed CQC comms and engagement staff:

Anna Jefferson, Head of Media

Laura Conn, Media Manager

Kirstin Hannaford, Senior Media Officer (Hospitals and acute care)

Lauren Haslehurst, Senior Media Officer (Adult social care)

Stephen Clark, Senior Media Officer (General practice, dentistry and other primary care)

Maryellen Clare, Senior Media Officer (Mental Health)

Paul Darigan Social Media Manager

James Hedges Regional Communications Officer

Chris Day Director of Engagement

Louise Grifferty Regional Engagement Manager

Amy Key Head of Provider Engagement

Abigail Walker Provider Engagement Officer

Alan Pickstock Engagement Integration lead

Ayse Sema Senior Engagement and Comms officer

Brian Silk Senior Digital Engagement Advisor

Tom Coales Head of Parliamentary Government and Stakeholder Engagement

Christopher Hares Parliamentary and Stakeholder Engagement Manager

James Bryant Government Engagement Manager

Jill Morrell Head of Public Engagement

Clare Haylock Senior Engagement and Internal Insight Officer

David Fryer Regional Comms manager at CQC

Edward Foster Communications and Engagement Manager

Elizabeth Dobres Communications and Engagement Manager

Farrah Chandra Regional Engagement Officer

Fionnula Robinson Senior Engagement Manager

Holly Daniels Head of Transformation Engagement at Care Quality Commission

Quinten Manby Head of Internal Engagement

 

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Board paper November 2014

Screenshot 2019-06-14 at 10.39.27.png

 

 

 

 

 

 

Did the Royal College of Psychiatrists award fake doctor Zholia Alemi the professional qualification of MRCPsych? A response from Mental Health Tribunal Scotland

By Dr Minh Alexander, NHS whistleblower and former consultant psychiatrist, 1 June 2019

Summary: The Royal College of Psychiatrists has so far refused to confirm if it awarded Zholia Alemi a qualification, the MRCPsych, which would have allowed her to masquerade across the UK as a consultant psychiatrist. Equally, the Mental Health Tribunal Scotland had answered a previous FOI request by a third party somewhat evasively, by failing to say if she was a medical member of the Tribunal. The Tribunal has now confirmed that Alemi was a medical member. It has also advised that Zholia Alemi would have needed to satisfy requirements of either membership (MRCPsych) or fellowship (FRCPsych) of the Royal College of Psychiatrists. However, it stopped short of answering a question about whether she had been verified to be MRCPsych qualified. The Tribunal pointed out that Scottish Ministers are responsible for this.

Zholia Alemi’s case has been widely reported in the media. She tricked the General Medical Council (GMC) into believing that she was a qualified doctor when she came to the UK in the 1995. Despite coming before the GMC over several Fitness To Practice issues of dishonesty, the regulator still failed to thoroughly verify her primary qualification. Had it done so, it would have found it to be fake.

‘Wicked’ will fraud doctor Zholia Alemi jailed

 Fake will doctor lied to NHS bosses

MPTS decision 17 August 2018 on Zholia Alemi re False declaration Section 12 Approval status

The task fell to a resourceful local journalist, Phil Coleman, working for the Cumbrian News and Star, who revealed in November 2018 that she was a bogus doctor:

Doctor who faked will of west Cumbrian widow led life of deception

Clearly the implications of this were enormous, as she had practised as a consultant psychiatrist for years. Many agencies had egg on their faces. The potential legal liability due to negligence cases is huge.

The usual closing of ranks took place.

The Royal College of Psychiatrists, one of the possibly most heavily implicated bodies, clammed up, and refused to officially confirm whether it had awarded her membership.

RCPsych Zholia Alemi MRCpsych correspondence

Unofficially, information leaked out indicating that Alemi had been awarded the MRCPsych.

Gaining Membership is not a question of just sitting an exam, but of passing through a long training process, and being observed in everyday clinical work by trainers.

It is a serious matter if a criminally abusive impostor was not spotted.

I exchanged the following correspondence with the Mental Health Tribunal Scotland this week, which responded in record time today, on a Saturday:

 

“Subject: RE: FOI request for Mental Health Tribunal Scotland

Date: 31 May 2019 at 10:48:40 BST

To:  Minh Alexander  <REDACTED>

Cc: MHTS Presidents Office <REDACTED>

Dear Dr Alexander

Freedom of Information (Scotland) Act 2002 (FOISA)

Thank you for your request for information received on 30 May 2019.  Regarding your request:

Zholia Alemi was appointed as a medical member of MHTS (the Tribunal).  The recruitment and appointment of judicial officers is undertaken by Scottish Ministers.  In making an application to become a medical member, Zholia Alemi would have been required to show that she complied with the requirements for appointment in force at the time,  as set out in Mental Health Tribunal for Scotland (Appointment of Medical Members) Regulations 2004.  Please note that these regulations were applicable at the time of Ms Alemi’s appointment, but have since been amended.  MHTS did not carry out recruitment and I am unable to advise which criteria she claimed to fulfil.  In respect of checking with the Royal College of Psychiatrists, Scottish Ministers may be able to provide further information on the checks undertaken and responses received.

I hope you find this information of assistance.

Yours sincerely

Agnes Ferrie

Tribunals Operations Support

Scottish Courts and Tribunals Service

Tel: 01698 390012

From: Minh Alexander [REDACTED]
Sent: 30 May 2019 11:08
To: Foi
Subject: FOI request for Mental Health Tribunal Scotland

FOI request for Mental Health Tribunal Scotland 30 May 2019

Dear Sir,

In response to an FOI request by R Woods of 19 November 2018, the Mental Health Tribunal Scotland advised that Zholia Alemi sat on 89 hearings:

https://www.whatdotheyknow.com/request/zholia_alemi#incoming-1289378

“Dear R Woods

Thank you for your email of 19 November 2018 requesting the following information:

“Please could you confirm that Zholia Alemi was a medical member of the Mental Health Tribunal for Scotland, and if so: 

In how many hearings (tribunals) did she participate as the medical member? 

And if the Mental Health Tribunal for Scotland has any plans to review the tribunals in which she participated?”

Ms Alemi was a member of the MHTS from 2008 and sat until May 2013. During that time she participated in 89 hearings. Due to the time which has passed since she was last active, all decisions to which she contributed will by now have been reviewed by another tribunal, or the patient discharged from care and treatment.

I trust you will find this information of assistance.

Yours sincerely

Agnes Ferrie 

Tribunals Operations Support 

Scottish Courts and Tribunals Service

18th December 2018”

On 8 January 2019 the Tribunal provided further clarification as follows:

“Dear Mr Woods

Thank you for your email, in which you request clarification of our response to your FOI request of 19 November 2018.

Compulsory Treatment Orders (CTOs) may be made on an interim basis, or for a period as specified in the Mental Health (Care and Treatment) (Scotland) Act 2003. In respect of decisions taken by a panel which included Ms Alemi, the patient will either have been discharged, or the order considered by a different panel. This has occurred in each case either on the expiry of an interim order or on a statutory application to continue an order. No patients will require any additional hearing as a result of her participation.

I trust that this provides sufficient clarification.

Yours sincerely

Agnes Ferrie 

Tribunals Operations Support 

Scottish Courts and Tribunals Service”

The Tribunal does not appear to have answered R Woods’ twice put question about whether Zholia Alemi sat as a medical member of the Tribunal.

Please can the Tribunal answer this question.

Please also answer the following additional questions:

Please can the Tribunal advise if Zholia Alemi applied to be a medical member on the basis that she was:

1) a consultant psychiatrist;

2) that she held the professional qualification of MRCPsych (Membership of the Royal College of Psychiatrists);

If so, 

3) did the Tribunal check with the Royal College of Psychiatrists that she held the MRCPsych qualification?

4) did the Royal College of Psychiatrists confirm that she was indeed MRCPsych qualified?

Yours sincerely,

Dr Minh Alexander”

 

 

This is the crucial section of the legal regulations about medical members that the Mental Health Tribunal Scotland pointed to in its response, which indicated that Alemi would have needed to have demonstrated that she was a member of the Royal College of Psychiatrists:

http://www.legislation.gov.uk/ssi/2004/374/regulation/2/made

Excerpt Mental Health Tribunal Scotland regulations medical members regulations

As the Tribunal has indicated that Scottish Ministers are responsible for verification of prospective medical Tribunal members’ credentials, they will be the next port of call.

Unless of course, the College finds the dignity to provide some clarification in the mean time.

 

 

UPDATE 10 JUNE 2019

I noticed that the GMC had published these details at some point on its website of repeated missed opportunities to detect Alemi’s deception:

https://www.gmc-uk.org/news/news-archive/our-update-on-zholia-alemi/has-there-been-a-complaint-to-us-before-about-zholia-alemi

“Have we ever had a complaint about Zholia Alemi before?

Since we confirmed Zholia Alemi gained registration fraudulently in 1995, we’ve been reviewing all fitness to practise complaints that were raised with us.

In all, we investigated nine complaints during the 23 years that she was on the medical register. And in the majority of these referrals we took action to address the issues raised.

·       From our review it is clear that a concern about Zholia Alemi was raised with us in 1998 when there was a complaint about inappropriate personal comments she made to a patient. We closed this complaint but the matter was handled locally – restrictions and supervision were put in place to address the issue.

·       In 2004 we received a complaint that culminated in Zholia Alemi being given formal advice about the need to demonstrate sensitive communication with families.

·       The next time concerns were raised about Zholia Alemi was in December 2010. This led to her receiving a warning in 2012. From December 2010 until the warning was given in July 2012, we investigated the concerns that had been raised, as well as some new concerns that came to light during the course of that investigation. Matters arising from the warning were later referred to a hearing, which took place in 2017 and at which she was found not impaired by a medical practitioners tribunal. The reason for the length of time between the warning being reopened and the 2017 tribunal was due to the matters under investigation being complex and complicated further by health issues raised by Zholia Alemi.

·       In 2018 she was given a 12-month suspension following a further medical practitioners tribunal. “

 

Importantly, there is also now a quiet admission by the GMC that Zholia Alemi passed successfully through specialist psychiatric training, kitemarked by the Royal College of Psychiatrists:

“Have you established any further information about Zholia Alemi’s work history?

We know that she worked in a range of locations throughout the 20 years from being granted full registration until we suspended her from the medical register in 2017. And that we know she worked as a locum for a significant period of time

We also know that she sat and passed the Member of the Royal College of Psychiatrists exam in 2003. At the time, this was a two-part exam with written and clinical parts. The MRCPysch, as it is known, is awarded to those doctors who have completed at least three years training in psychiatry and who pass the two-part test. The royal college subsequently recommended her for entry to our Specialist Register in 2012 in psychiatry with learning disability. This meant that the royal college was satisfied she had demonstrated the knowledge, skills and experience required to be appointed as a substantive consultant in the NHS.”

This is quite extraordinary, and a reflection of very low expectations, which raises many, many questions about the Safeguarding of mental health and learning disability patients.

I have asked the Royal College of Psychiatrists for more details of Alemi’s pre and post membership specialist training. I would not be at all surprised to be met with more obfuscation and resistance.

Further update 10 June 2019

A letter from the GMC to the National Assembly of Wales of 30 November 2018 reveals extraordinary details of the earlier referrals and prior incidents that slipped through the GMC’s fingers before Alemi’s final unmasking last year as a bogus doctor.

Letter from GMC to National Assembly of Wales 30 November 2018 about Zholia Alemi, bogus doctor

Amongst the catalogue of Alemi’s transgressions are misleading CV details, failures to declare a conviction for careless driving and an ongoing GMC investigation,  working without required Section 12 approval, concerns of earlier dishonesty at St Georges, – attempting to a leave form and pharmacy prescription card for suspected fraudulent reasons and a report to the GMC in 2004 by the Met police that Alemi had allegedly assaulted a police officer.