By Dr Minh Alexander retired consultant psychiatrist 31 January 2026
This is a brief update for whistleblowers.
A citizen has done a public service by publicly establishing some accountability with regards to the troubling private company WhistleblowersUK, company number 09347927.
They successfully lodged a complaint to the Parliamentary Standards Commissioner about the fact that Tessa Munt MP had not registered her role as a director of the company.
The document provides a useful baseline in that Ms Munt has now committed to the public record her understanding of the nature of the company, which she presently characterises as “not for profit”.
She has stated that she is “deeply” and “truly sorry” for errors in not registering interests.
One matter jarred somewhat. The Commissioner determined that the failure to register was “inadvertent” and decided there was misapplication of the rules.
I reminded him that I wrote to him in early 2025 about a related but separate matter, in which I informed him that Tessa Munt had not registered her role as WhistleblowersUK’s Vice Chair, and that I had not received any response when I wrote to her about this.
I have now furnished him with the TWO unanswered emails that I sent Ms Munt on this matter and asked him if her failure to register her interest could really be “inadvertent”.
RELATED ITEMS
WhistleblowersUK is an entity which has an interest in establishing a US-type financial model of bounty hunting, to replace the mainstream of current UK whistleblowing law and practice. Many whistleblowers are very concerned about this,and see the move as part of private industry’s attempts to monetise what should be the public interest. There are fears that this will distort governance, waste public money and lead to exploitation and unfairness to whistleblowers and sectors which are not lucrative from the bounty hunting industry’s perspective.
There were also concerns about lobbying and access to parliament through a now defunct APPG, administrated by WhistleblowersUK, which received funding from US bounty hunting law firms. There is concern that another similar APPG will be established.
WhistleblowersUK charges whistleblowers for its services and seeks to recover a percentage of their settlements and awards. WhistleblowersUK’s documents have been revealed by a number of whistleblowers who have had dealings with the company.
By Dr Minh Alexander retired consultant psychiatrist 31 January 2026
Summary
I briefly report on the case of Dr Tim Noble who has been sacked by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust under a classic route of broken down relationships, sometimes applied to whistleblowers when no wrongdoing can be proven or manufactured. Shortly after Dr Noble’s dismissal, the trust published external reviews by the private company TheValueCircle on culture and leadership which concede shortcomings in whistleblowing practice but make ineffective recommendations with respect to this. These review reports also omit important governance failings, including the trust’s use of medical disciplinary procedures which is highly germane in Dr Noble’s case, where an excessively prolonged suspension was used and much criticised. The leadership review omitted other data which is unflattering to the trust and which suggests carelessness and/or cover ups, and the culture review instead emphasised that staff were proud of the trust’s services.
Dr Noble’s case
There has been a high profile dispute at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust in which the medical director Tim Noble, a respiratory physician, was subjected to prolonged suspension of over a year.
Dr Noble has been backed by the British Medical Association which has maintained that he was persecuted for raising concerns in the public interest, chiefly about bullying and harassment at the trust.
In other words, the route of dismissal known technically as “Some Other Substantial Reason” or SOSR, applied when there is no misconduct or incapability issue.
The NHS has abused this means of dismissal in some whistleblower cases and also more generally. Some idea of the NHS usage of this category of dismissal can be found here.
The regulator the Care Quality Commission noted in an inspection report of 28 March 2024 that there were issues with trust leadership and staff confidence in raising concerns:
“Not all staff felt leaders were visible. Staff in areas where there were greater pressures, due to challenges recruiting staff, financial restraints, and patient demand, felt less supported by the senior leadership.”
“However, during our discussions with staff groups not everyone felt respected supported and valued. We had received several whistleblowing concerns where employees felt a lack of respect, listening and ‘compassionate leadership’ from the trust. Staff in areas where there were greater pressures, due to challenges recruiting staff, financial restraints, and patient demand, felt less supported and listened to by the senior leadership.”
CQC criticised incomplete recording of staff concerns and noted staff concerns about the safety of the internal whistleblowing process:
“However, as the trust’s process encouraged staff to approach the FTSU [Freedom To Speak Up] partners rather than the guardian in the first instance, the report did not include the details of concerns raised directly to the partners. The trust did not have a process to capture these concerns centrally. This meant the Board were not fully sighted on the numbers of concerns raised by staff through the trust’s FTSU process. Following the inspection, the trust informed us they were undertaking further work to triangulate themes from concerns raised through different routes.
During the inspection most staff said they were aware of how to contact FTSU. However, we received several enquiries from staff who shared their negative opinion of speaking up, as such there was further work needed to ensure all staff felt safe to speak up.”
Two just published external reviews
This week, Doncaster and Bassetlaw published two external reviews, respectively on culture and leadership.
UHB remains as dogged by cultural problems as ever. One of UHB’s governors has recently revealed that he is being investigated by UHB for publicly engaging with discussion on a recent scandal about use of funds for recruiting overseas doctors:
The more recent culture review at Doncaster and Bassetlaw was reportedly based on twenty confidential interviews of senior staff (“Chair, CEO, Executive and Non-Executive members of the Board, and wider system partners”), surveys, walkabouts engaging 150 plus staff and listening groups with 67 staff.
The trust noted that about 10% of staff participated.
The authors say that their report was commissioned by the trust. The trust’s website states: “We commissioned the independent review to provide another safe and confidential place for colleagues to share their experiences openly”, and adds that the reviews were commissioned in “mid-2025”.
In the context of major allegations and disputes, NHS England usually has a hand in these matters, albeit this is not yet admitted in the current situation.
The report’s executive summary emphasised staff’s pride in care provided by the trust, acknowledged a “top down” dynamic, some disconnect between staff and senior management and noted improvements were needed. But I found the language somewhat euphemistic and the summary did not fully reflect the negative findings listed in the body of the report. These in fact showed:
* 27% staff did not feel respected by their immediate manager/local leader
* 46% staff did not feel respected by the trust as their employer
* 26% staff did not feel their work was valued by their immediate manager/ local leader
* 45% staff did not feel their work was valued by the trust
* 28% staff did not feel the trust was an employer which cared about their well being
* 47% staff did not feel their immediate manager/ local leader cared about their well being
Lending support to Dr Noble’s reported concerns,
* 49% staff had felt bullied or harassed in the workplace
Staff indicated that 62% of the bullying and harassment came from managers, whether from “senior management in the trust”, “senior managers in your own teams” and/or “immediate line manager/local leader”.
And very seriously,
* 54% staff did not feel confident that the trust would listen and consider their feedback
The review authors reported there were mixed views about internal whistleblowing process: “Some staff felt confident if they needed to use the FTSU route, that their concerns would be taken seriously and considered in an appropriately confidential manner. However, others felt a similar feeling to raising concerns of any kind to the Trust and doubted the process’ effectiveness. A small number of staff and some staff representatives expressed concerns regarding the perceived confidentiality of the FTSU process.”
Interestingly, reviewers noted “We were made aware that the Trust Executive team have commissioned a peer review of FTSU.”
In my view, the reviewers made largely anodyne recommendations. On whistleblowing governance they recommended:
“6.7 The review team recommends that the Trust ensures the FTSU process meets its intended purpose, assessing the effectiveness of that process, ensuring feedback is given to those raising concerns and the importance of confidentiality is understood by all.”
This is hardly going to change any abusive practices.
Nor will it assuage staff fears, when the workforce have just witnessed one of the most senior trust officers being bundled out of the door under SOSR, after a prolonged suspension.
It is necessary to acknowledge serious issues before there can be real change.
The Well Led review was also undertaken by TheValueCircle. It relied on some of the same evidence used in the culture review, as well as observation of meetings and also document review.
There were a slew of observations about trust process with some criticisms about failures to follow up and mitigate corporate risks, consistency in ensuring stated trust values, issues about communication and non executive challenge. Below average staff engagement was noted. Concerns from governors about access to some board sub-committee meetings and whether governors were heard was also raised.
Although governors’ concerns were mentioned, I found no mention of the major rupture behind the suspension of an executive director, and yet the mission includes “To identify the dynamics of the board”. Instead, the reviewers appeared to erase the fact that there had been a rupture and reported as if a member of the board was not currently suspended. They referred only to “respectful” and well chaired ongoing meetings.
Similar comments were made about whistleblowing governance as in the culture review, with the added detail that the trust had worked with the General Medical Council on whistleblowing matters, implying that at least some doctors were fearful:
“We acknowledge that the Trust has worked with the General Medical Council to strengthen perceptions of psychological safety in speaking up and to improve medical colleagues’ confidence in the process. However, listening groups identified that some colleagues still lacked confidence. In addition, some staff reported they were unsure how to access the FTSU service.”
Of note, despite the controversial and excessively long suspension of the medical director, I could find no comment by the reviewers about the trust’s application of formal NHS medical disciplinary process under MHPS (Maintaining High Professional Standards).
This seems to be a serious omission in the trust’s favour and potentially a point of criticism about impartiality of the review, or at best, its effectiveness.
The only reference that I found in the Well Led review report on trust disciplinary process was the inclusion of the policy “ORP/EMP 2– Disciplinary Procedure” in the list of documents reviewed.
Neither was disciplinary culture discussed in TheValueCircle’s culture review report, as far as I could see.
These seem to be inexplicable omissions given the high level of bullying and harassment flagged by staff.
Especially as staff reported that 62% of the bullying and harassment came from managers.
Neither could I find discussion of compliance with CQC Regulation 5 Fit and Proper Persons in the Well Led review report. This may be a limitation of the NHS England template for these types of reviews.
On general search, I also found past CQC fines against the trust for breach of candour and several serious and relevant coroners’ findings in 2025, that were not reflected in TheValueCircle’s well led review report. I list these at the end of this post. I would have hoped that these should have been considered under the banner “Is there a culture of high quality, sustainable care?”
In conclusion
We appear to have a classic NHS whistleblowing case of very harsh discipline following reported public interest disclosures and then dismissal on shaky grounds on breakdown of relationships. The latter is usually a last resort when employers are unable to make misconduct or incapability grounds stick. All accompanied by somewhat lacking employer-commissioned reviews which offer partial fig leaves by omission, throw up some vapour trails yet have not answered all the crucial questions.
None of which serves patients’ interests, and likely only leaves remaining staff in anxiety and doubt.
As well as the wasteful dismissal of an expensively trained and developed senior doctor who was not accused of misconduct or incapability, the prolonged suspension of Dr Noble was especially objectionable. Such torturous suspensions are wasteful and almost never justified. They are punitive and very harmful to individuals and their families. They were supposed to be actively tracked and phased out long ago after NAO recommendations in 2003, but harsh discipline and suppression in the NHS is too politically useful and so was retained.
Tim Noble may obviously lodge an Employment Tribunal claim against the trust in respect of his treatment, in which case more details will emerge about the nature of the governance concerns.
RELATED ITEMS
1) It is relevant to note that the CQC issued two fixed penalty notices against Doncaster and Bassetlaw in recent years for failing to comply with the legal Duty of Candour:
“In 2021 CQC completed an investigation of a serious incident at the trust. The fixed penalty notices relate to an incident in July 2018 where a patient, who cannot be named for legal reasons, died after complications during childbirth. These two breaches of duty of candour regulations were:
Failing to notify the family as soon reasonably possible that an incident had occurred
The trust did not provide the family with an account of the incident or offer an appropriate apology to them in a timely manner.”
These governance failings reflect on trust leadership.
2) Doncaster and Bassetlaw has also been issued several coroners’ Prevention of Future Deaths reports last year as follows, some of which raise issues about organisational learning and thus leadership.
In the case of John Bell, the coroner was concerned that no Datix incident report was filed and that six months after his untoward death, no investigation had taken place.
In the case of Marina Raisbeck, the coroner was concerned that the factors which contributed to her death had not been addressed, fifteen months after her death.
Distressingly, in the case of Walter Horton, the coroner concluded that staff did not understand cleanliness or aseptic technique.
In the death of Emily Hewerdine from neglect, the coroner noted fifteen months after her death that the system failings had not been rectified.
In the death of Khadija Kerri, radiological evidence of cervical and rib fractures were not passed on initially and clinical action was not taken to immobilise the fractures for 3 days. Eight months after the patient’s death, the coroner noted that there was no policy on disseminating addendum report findings.
It would seem to me that such governance failings should have been reflected in a report on whether the trust was well led.
NHS England’s expectations for Well Led reviews require:
“Senior leaders can evidence that there are appropriate and effective mechanisms for turning concerns/ incidents into improvement actions based on inquiry about the root causes of what has happened, where constructive challenge is welcome at all levels of the organisation, including the board.”
4) It is worth reminding ourselves that the lamentable architect of the NHS Freedom To Speak Up model, Robert Francis, claimed expansively over ten years ago in his 2015 Freedom to Speak Up report:
“The climate that can be generated by these measures will be one in which injustice to whistleblowers should become very rare indeed, but is redressed when it does occur.”
Neither of the risible claims in this statement is true.
I have spent the last ten years tracking and documenting the failures of Francis’ patently ineffective but government-pleasing policy.
It is clear that there continue to be no end of casualties. Redress for NHS whistleblowers is very patchy and usually only partial and inadequate when achieved. And redress very rarely comes in the form of resolution of the original whistleblowing concerns, which is so important to the majority of whistleblowers. In the NHS this is vital to public safety, which still limps in last.
Realistically, I usually have to advise whistleblowers to prepare themselves for loss, and to make choices about the level and type of losses.
The least risky whistleblowing strategy is NOT to follow the internal policy but to disclose to the media, either anonymously or with guarantee of anonymity. But it is best to take advice and each must make a personal decision.
And until UK policy and law are properly reformed, the situation will sadly not change.
5) At University Hospitals Birmingham, which also commissioned reviews from TheValueCircle after scandal, another whistleblower was severely victimised and the CQC failed to hold trust directors to account under the Fit and Proper Person provisions:
Accordingly, I asked HOLAC if it routinely checks nominees’ qualifications, or had arrangements for third parties to do so.
I also asked that if not, whether this would be corrected, and whether there would be any retrospective review to assess whether there were past cases where qualifications had not been checked. I also asked for documented reasons if there had been a decision not to undertake such a retrospective review.
The reply to my FOI request was that it would not be in the public interest to disclose how nominees’ qualifications are checked, with the following convoluted argument:
“The information that you have requested in question 1 falls within section 37(1)(b) of the Freedom of Information Act, which relates to the conferral of honours and dignities. A peerage is a dignity for the purposes of the Act. Section 37 is a qualified exemption which is subject to a public interest test. In favour of disclosing information, there is a strong public interest in knowing that the appointments process is accountable and transparent, and in maintaining public confidence in the peerage appointments system. In favour of maintaining the exemption, there is a strong public interest in limiting the level of detail about exactly what checks are carried out by the Commission, to ensure individuals are not able to tailor the information they provide once nominated. It would set a dangerous precedent to start providing precise detail of the checks conducted, which could allow individuals to selectively decide what information might be presented to both the Commission and the nominating Party.
Taking all of the relevant factors into consideration, including the fact that the Commission already places a great deal of information about its working practices and the checks it carries out in the public domain to reassure the public that these are sufficiently rigorous, I consider that the balance of the public interest lies in maintaining the section 37(1)(b) exemption in respect to confirming whether the Commission verifies individuals’ qualifications.”
I think this response would probably make even Sir Humphrey blush.
The rest of the world presents a curriculum vitae to prospective employers, which is checked, and educational qualifications are duly verified with the relevant institutions.
Straightforward, no?
But it seems that the arcane HOLAC is concerned that letting us know about its procedure for verifying qualifications will somehow give nominees some nebulous, nefarious advantage.
Or maybe they simply have no checking procedure and are too mortified, as very important individuals, to admit this to impertinent plebs.
Perhaps very important people are content to accept recommendations from other very important people. PLU to PLU.
With respect to the rest of the FOI request, it is maintained that:
“I have established that HOLAC does not hold any information in scope of questions 2,3 and 4 of your request”.
That is to say, there is no intention to correct any possible omission in HOLAC’s verification procedure nor to retrospectively review for any other naughty peers with non-existent qualifications. And there is no written record of the latter decision not to review.
All told, a very unsatisfactory and unaccountable position after such a major scandal.
This serf will now withdraw to her wattle and daub hut to appeal to the ICO and dispute HOLAC’s application of the public interest test.
Feudalism being what it is, the chances of success may be slim, but I was pleasantly surprised on a past occasion so we shall see.
Internal review request
Prior to appealing to the ICO, I have taken the preliminary step of requesting an internal review of the FOI response, which I have directed to Baroness Deech Chair of HOLAC:
FAO Baroness Deech
Chair House of Lords Appointments Commission
12 January 2026
Dear Baroness Deech,
Request for FOI internal review and query about governance on verification of nominees’ qualifications
I was concerned by the Sunday Times report about Ann Limb’s qualifications – or lack of – and asked for information via FOIA about HOLAC’s process, if any, for verifying nominees’ qualifications.
I received the attached FOI response which I take to mean that:
1) HOLAC does not wish to disclose the details of any verification process on grounds that it may somehow given undue advantage to nominees.
Indeed, the FOI response states: “It would set a dangerous precedent to start providing precise detail of the checks conducted, which could allow individuals to selectively decide what information might be presented to both the Commission and the nominating Party.”
I confess I do not understand this argument as past qualifications are something one possesses or does not, and that is the point of verification – to establish the truth of claimed qualifications.
What I am merely seeking is confirmation of whether or not HOLAC has within its process a means of checking that nominees have not fraudulently manufactured qualifications on their CV which they never earned. I do not see how providing confirmation of a process could prejudice the selection of nominees.
I would be very grateful if you could consider my query on this aspect to be a request for internal review under FOIA for disclosure of whether HOLAC has a procedure for verification of nominees’ qualifications, and for broad details of any procedure.
For example, does HOLAC (or a third party) routinely contact universities to establish that nominees hold the degrees that they claim to hold?
2) I further understand HOLAC does not intend to make any changes to its procedure – whatever it may be – or to retrospectively review for any cases where nominees’ qualifications may not have been verified. Also, there is no record of a decision not to retrospectively review for any cases where nominees’ qualifications may not have been verified.
If my understanding is correct, may I ask if this is the right approach in light of the seriousness of the Ann Limb matter?
HOLAC says that its purpose is to ensure the highest standards of propriety. Would not wider learning be important after such an incident?
Dr Minh Alexander retired consultant psychiatrist 6 January 2026
This is a post-script to my last post on the still unfolding breast cancer surgery scandal at County Durham and Darlington NHS Foundation Trust (CDDFT).
An independent investigation (the “Aubrey Report”) reported major governance failures by trust executives and failures to act on red flags over many years. These included concerns from multiple sources, including staff whistleblowers.
A missing element to the whole picture was any apparent contribution by the regulator, the Care Quality Commission (CQC), to the identification of the failures.
Accordingly, I asked the CQC via FOIA for information on public interest disclosures by trust staff about the breast cancer surgery service and other information. This is because the CQC is a ‘prescribed person’ under UK whistleblowing law, which is responsible for receiving concerns from the staff of regulated health and social care providers.
It seemed inconceivable that at least some staff who had been so concerned for so long would not have sought help from the key regulator responsible for overseeing health services.
Implausibly, the CQC denied that it had received any whistleblowing disclosures from CDDFT staff about the breast cancer surgery service. There is some wiggle room in that CQC advised it was unable to manually review the records within the FOIA cost limits and relied only on searching for key words. But even so, it is still remarkable that a key word search yielded nothing.
It should be noted that CQC is now aggregating provider staff whistleblowing disclosures with concerns from other sources, which inflates numbers and contributes to its claims of Section 12 cost exemptions under FOIA.
I further asked the CQC to confine its search to trust staff disclosures to the local CQC inspection team in the last five years. It denied that these were recorded any differently. CQC advised that it had received 520 concerns about CDDFT in the last five years and claimed that it would still exceed FOI cost limits for these to be manually reviewed for staff disclosures relating to breast surgery.
I am almost certain the CQC will have received disclosures about CDDFT breast surgery services at some point, given the level of concern and the very long period of time over which the problems occurred. We may receive confirmation in due course that such staff disclosures were made, especially if any of the staff who made disclosures about the breast cancer surgery service learn that CQC has denied receiving them/ avoided answering.
But in swerving the questions about staff whistleblowing at CDDFT, the CQC lays itself open to criticism of general negligence in tracking whistleblowing activity in NHS organisations – a vital governance task. If it has really stopped differentiating the various sources of concerns, as it now claims, it must have no grip. I will write to the latest CQC CEO about this. Alternatively, the CQC may eventually decide that it can tell us about whistleblowing at CDDFT after all.
CQC evaded a question about whether it had been alerted to the breast cancer surgery issues by other regulators:
“3. Please disclose if since 2012 the CQC has been alerted by other regulators such as Monitor, NHS Improvement or NHS England of any pf the problems in the breast cancer surgery services at CDDFT? If so, please give dates and relevant details.
We do not keep a central record of information that can easily answer this point.”
Although CQC did not clearly say whether it had specifically inspected breast cancer surgery in the years concerned, the CQC disclosed that it re-inspected the trust’s surgery services in October 2025, and has taken enforcement action.
“6. Has the CQC inspected the trust since 2019? Does the CQC have anyplans to inspect CDDFT in the next year?”
The trust’s surgical services were recently inspected by the Care Quality Commission. We carried out an inspection of surgery services in October, and due to concerns found, we have taken enforcement action against the trust to ensure the safety of people using services.”
As far as I can see, the report from this inspection has not yet been published on CQC’s website.
I asked CQC about data held on serious incidents relating to CDDFT’s breast cancer surgery service. CQC advised that data is held for only three years and not in a form which allows analysis of incidents specific to the breast cancer surgery service: “we cannot break it down to identify incidents specifically about breast cancer surgery services”.
This would obscure detection and monitoring of any patterns.
Regarding whether CQC has reviewed itself in the light of the Aubrey report, and has identified any lessons to learn from the breast surgery scandal, CQC replied thus:
“5. Please disclose if CQC has assessed whether it has any lessons to learnarising from events at CDDFT and the findings of the Royal College ofSurgeons invited review and the Aubrey report into breast cancer surgeryat CDDFT. If so, has the CQC conducted any internal review of itsinspection process at CDDFT or does it plan to do so?
Following reasonable searches, no recorded information has been located with which we can answer this specific part of your request.”
Dr Minh Alexander retired consultant psychiatrist 26 November 2025
Introduction
This is a brief report on the continuing failure of the wasteful Freedom To Speak Up model, which is being retained by the NHS despite abolition of the National Freedom To Speak Up Guardian’s Office.
An external review of failings in breast cancer care, the “Aubrey Report”, has this week been published by County Durham and Darlington NHS Foundation Trust (CDDFT).
About the author of the Aubrey Report Mary Aubrey the author is described in the report as Director and Specialist Expert Advisor in Governance. Her LinkedIn entry describes her as a part time NHS director “Providing specialist advice and support on progressing the NHS Trust to moving to excellence and exiting RSP 4 in 2026”. She is also listed on the website of the private company Quality Governance Solutions 15267661 where she is described as a CQC associate. A search shows that she has acted for CQC as an executive reviewer in past CQC inspections. For example, during the 2019 inspection of Royal Berkshire NHS Foundation Trust.
Care Failings
The Aubrey report found multiple failings spread over a long period of time, which resulted in poor care, summarised as follows:
“Patient harm due to outdated clinical practices and unnecessary procedures:
Patients experienced avoidable harm, including delayed diagnoses, unnecessary mastectomies and axillary clearance, and benign procedures that were not clinically indicated. These failures resulted in significant physical, emotional and psychological consequences for patients and staff”
“A lack of documented breast reconstruction planning in at least six cases highlights missed opportunities for shared decision making. Additionally, technical errors, including incorrect skin marking leading to repeat surgery, underscore preventable harm and resource inefficiencies.”
A local media report gives a devastating report of one patient who was left bed bound after sepsis:
“This has been totally devastating. It has ruined my life, without a doubt,” says Moira, who is in her 60s….I never thought this would be the case at this age. I have had a very busy life and career, but now I am dependent on the care of others.”
“She says she is completely bedbound unless hoisted into a chair by her carers.”
The patient describes a traumatic encounter with a surgeon:
“This surgeon was in his suit and put surgical gloves on – and without warning from him, and without any kind of anaesthetic, cut open my wound.”
“He began taking out handfuls of blood clots from my breast and putting them into a surgical bowl.
“While it wasn’t painful, it was uncomfortable and felt very concerning. Blood was pooling underneath me and down my left-hand side, which the nurses cleaned after the surgeon left the room.
“From the faces of the nurses who were present, I could tell this wasn’t normal.
“I didn’t know what to do, as I wanted my breast to get better, but the faces of the nurses told me everything I needed to know. They didn’t say anything about what he had done.
Related governance failings including whistleblowing failures
The Aubrey report also noted a failure of the legal, organisational duty of candour:
“Despite clear evidence of harm, including unnecessary axillary clearance, mastectomies, excessive surgery due to poor diagnostics, and benign procedures that were not clinically indicated, the Executive Medical Director and former Executive Director of Nursing delayed the initiation of Duty 12 of 232 of Candour. Action was only taken in February 2025, a nine-month gap that represented a significant breach of statutory obligations.”
According to his LinkedIn entry, the Executive Medical Director was in post from 2017 up to November 2025. The former Executive Director of Nursing according to his LinkedIn entry was in post 2015 to December 2024 and is now a NED at York and Scarborough Teaching Hospitals NHS Foundation Trust.
Mary Aubrey concluded that there were repeated missed opportunities to identify and correct the patient harm, with multiple red flags and warnings from different sources, including from senior personnel, which the trust board failed to act upon.
For example:
“Despite multiple early warnings from 2012 to 2025 including internal audits, external reviews, national surveys, and benchmarking data, effective action was not taken until 2025. This prolonged delay reflects deep-rooted leadership and governance failures, where Executive Directors, Care Group Triumvirate and Specialty leaders repeatedly failed to intervene, challenge poor practice, or implement improvement recommendations.”
“Concerns raised in 2017. 2018, 2019, 2021, 2023, and 2024 were either ignored or subject to delayed action, despite clear red flags. Service and Care Group leaders did not act on, or escalate warnings from colleagues across pathology, radiology, booking, MDT coordination, medical records, operational management and clinical nursing.”
These listed whistleblowing episodes all fall firmly within the period when the NHS Freedom To Speak Up arrangements should have been embedded. They were introduced in 2015 and it is reasonable to expect that by 2017, all trusts should have had compliant structures and informed boards. It was certainly what the central propaganda claimed. But there may have been issues of capacity, as a CQC report of 2019 stated:
“On our last inspection we raised concerns about the capacity of the Freedom to Speak Up Guardian (FTSUG). While two champions had been recruited and working hours increased there was still work to do to increase capacity and raise the profile of the role within the trust.”
Aubrey noted dysfunctional culture within trust breast surgery services with issues of bedside manner, rudeness within teams, insularity and resistance to feedback and change.
For example: “Cultural and behavioural issues, including poor communication, lack of psychological safety, and unprofessional conduct from some consultants, contributed to staff distress, high turnover, and reluctance to raise concerns.”
The RCS invited review noted problems with multidisciplinary decision making, challenge and leadership.
Moreover, Trust staff showed fear during Aubrey’s investigation and asked for anonymity.
Their fears proved justified when Trust executives tried to identify them. Aubrey wrote:
“Staff repeatedly expressed to the Reviewer their desire to remain anonymous, particularly where roles were unique and individuals could be easily identified. Attempts by some Executive Directors to identify contributors not only breached this understanding but also reflected a leadership approach perceived to prioritise control over accountability. This incident highlights broader cultural challenges within the Trust, where psychological safety appears compromised and staff remain apprehensive about potential retaliation or scrutiny when raising concerns.”
It is a measure of dysfunction that trust executives felt free to attempt to identify staff in plain view of an external investigator.
Clearly, whether or not the trust Freedom To Speak Up Guardian service was adequately resourced, it had no chance if the trust executives had no respect for staff confidentiality.
Unsurprisingly, the Aubrey report concludes that whistleblowing governance at the trust was flawed. There is possibly an implication that Freedom To Speak Up procedures – “formal mechanisms” – failed:
“As outlined above, staff reported feeling discouraged by managers from whistleblowing due to apprehension about retaliation, including warnings from managers that speaking up could adversely affect their careers. This culture of deterrence contributed to the persistence of harmful practices and undermined efforts to strengthen safety, transparency, and accountability within the service. Concerns were not escalated and the Trust Board did not have effective systems to detect and address suppression of concerns within the areas affected. While the Trust’s staff survey scores for ‘Raising Concerns’ are in line with national averages, qualitative feedback from interviews and helpline data suggests that formal mechanisms were not always experienced as psychologically safe or effective by staff” [my emphasis]
There was specific criticism of Non-Executive directors who should challenge, and who often hold “champion” roles for FTSU arrangements:
“The cultural factors outlined above combined with staff apprehension around whistleblowing and limited scrutiny from Non-Executive Directors, including the former Trust Chairs during their tenure. and assurance committees created conditions in which unsafe practices were able to persist unchallenged and without accountability.”
It is almost always the case that such summarised details do not convey the depth of suffering of individuals and their families who are at the butt end of such failures of whistleblowing governance. To be at the mercy of trust executives whose goal is “control”, above all else, can be a life-changing nightmare that may extend for years.
In short, Aubrey’s report sets out a fairly typical and familiar anatomy of an NHS scandal.
This “Good” rating is from 2019. One would have hoped that with all the concerns about the breast service and poor trust governance that the trust should have been inspected more recently.
But was CQC even aware of the breast service failings? The trust’s breast service lost training status as early as 2012 and the Aubrey report rightly concludes that the loss of training status was a red flag:
“The Breast Surgery Services was flagged for failing to meet the standards required for safe and effective medical education, and for not providing a supportive training environment which are both essential for surgical trainees. This led to the withdrawal of training accreditation in 2012. The loss of surgical trainees was a direct result of GMC action and serves as a fundamental indicator of breakdowns in supervision and clinical governance.”
“The loss of trainee status in the Breast Surgery Services represents a significant red flag for the organisation”
But as far as I can see, CQC did not specifically inspect the breast service in 2019. Or if it did, it raised no specific concerns.
Moreover, the CQC inspection report of 2019 claimed generally “It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.”
General ineffectiveness of the Freedom To Speak Up model and questions about the Fit and Proper Person Framework
In conclusion, this affair only reinforces concerns that the government’s Freedom To Speak Up project has been a wasteful, deflective propaganda exercise that has done very little to help NHS patients and staff.
At least the lead propagandist’s Office, the National Guardian’s Office has been disbanded. But the decision to continue wasting scarce public funds by continuing with a local model of Freedom To Speak Up Guardians is a classic but disappointing NHS fudge.
There has been little transparency about how the latter will work, only a few cryptic comments in a NGO’s newsletter and a brief NHSE update about how some central functions will transfer to NHS England. I have asked NHS England via FOI for more precise details.
I have also written to Jim Mackey NHSE CEO to ask if and how the findings of the Aubrey report will be used by NHS England with respect to new NHS Fit and Proper Person arrangements following the Kark review. This is with respect to general findings of executive failure to act upon red flags and safety indicators, the failure of organisational duty of candour and the reported attempts by trust executives to breach anonymity of staff reporting concerns to an investigator. It is unclear to me if the FPP framework and related database/ disbarring mechanism have been finalised six years after completion of the Kark Review on Fit and Proper Persons in the NHS, but I have asked NHSE for a completion date if not.
My wonderful husband Ian has died. I am not back at work at full strength and cannot respond to requests as much as usual, but will aim to post from time to time. All my very best.
RELATED ITEMS
CDDFT has as per NHS standard operating policy, announced a cultural reset. The trust also reports early progress in rectifying the safety issues.
This is considered to be a weighty indicator of the eventual ruling of the international court on the genocide case against Israel.
At present, the UN Commission considers there is a duty on all states parties to the genocide convention to do all they can to actively halt the Gaza genocide and restrain Israel. This includes the tool of economic pressure.
Concerns have been raised about NHS bodies purchasing supplies from Israeli companies.
A particular issue is that Kings are involved and the Chair of Kings is no other than David Behan the former regulatory chief of the Care Quality Commission. Who one might hope should take extra care to ensure a high level of legal and ethical compliance. Cough.
Campaigners, including trust staff, remain very concerned.
I have been sent this flyer for anyone with an interest in these matters:
All best wishes and see you when I see you.
A reported exchange between campaigners and Behan at Kings:
The issues are set out in detail in that report. The issues relevant to mental health crisis services can be summarised as follows.
Mental health beds have been relentlessly cut despite protests by patients, families, professionals and Royal Colleges.
Politicians and senior NHS leaders have claimed that there has been investment in community services to compensate for bed loss, and policy has been devised to reduce access to beds.
The introduction of a gatekeeping function by community-based mental health crisis resolution teams has been key, and has in some instances inappropriately and unsafely blocked access to inpatient care.
The services offered by crisis teams have been flourished by politicians and senior NHS leaders as part of the justification for cutting mental health beds, but crisis teams are neither sufficiently resourced nor safe. NHS crisis services currently lack crucial elements needed for fidelity to a recommended model of safe and sufficiently intensive care.
An aspect of these safety failures has been failure of risk assessment and management. The failures are reflected in repeated coroners’ Prevention of Future Deaths reports.
Crisis teams were mandated by The NHS Plan 2000, with a requirement for establishment by 2004.
By 2014 the National Confidential Inquiry into Suicides and Homicides by People with Mental Illness (NCISH) warned that work was needed on the safety of crisis services. Crisis teams accounted for about twice as many suicides as inpatient services (and the running total suggests that they still do).
NCISH also questioned the practice of using crisis teams to facilitate early discharges from hospital. However, the practice has continued, and is in fact required by NHS England guidance on mental health bed management:
“A review of all inpatients individually, to agree on the appropriateness of their continued stay in light of current and predicted levels of activity, and consider whether any of them could be discharged early with increased follow-up by community mental health teams.”
Moreover, NCISH found in 2014 that 43% of suicides under crisis teams were by patients who lived alone.
NCISH advised that providers should be cautious about treating such higher risk patients under crisis resolution/ home treatment teams, and should review their entry criteria for such services.
“CR/HT [Crisis Resolution/Home Treatment] may not be suitable for patients at high risk or those who do not have adequate family or social support: services should review their criteria for its use.”
NCISH advised that more suicide prevention work was needed with regard to crisis teams:
“CR/HT should be a priority setting for suicide prevention in mental health services.”
Failure to improve since NCISH’s 2014 warning
I asked the National Confidential Inquiry about repetition of its 2014 analysis of the social circumstances of people who died by suicide under the care of crisis teams, to see whether NCISH’s advice had been implemented and whether there had been a drop in the proportion of suicides by people who lived alone.
The Inquiry advised that the analysis was repeated in the four following years up to 2018. This showed no reduction in the proportion of patients who were living alone when they died of suicide under crisis service care:
Period
Page of annual report
Proportion of CR/HT suicides in patient who lived alone
In addition, data for the period 2012 to 2022 also suggests that this lack of improvement has persisted. Between 2012 and 2022, 841 patients who lived alone died by suicide under the care of crisis teams:
“Based on this 2012-2022 dataset, there were 1,970 patients under CRHT services in England who died by suicide, of whom 841 (44%) were living alone.”
This is the FOI response by the National Confidential Inquiry.
Taken with the NCISH 2014 data for the period 2002 to 2012, when there were 666 crisis team patients who died by suicide and lived alone, a total so far of 1507 crisis team patients who died by suicide lived alone.
Questions arise about what actions have been taken by NHS England and the Care Quality Commission to ensure learning from the National Confidential Inquiry’s warnings. Also, if no effective action was taken to reduce the risk of suicide by patients under crisis teams, was this due to inefficiency or unwillingness to impede the political drive to cut beds?
2) NHS England’s handling of independent investigations on mental health homicides A report with data on how NHS England fails to ensure learning from mental health homicides. As part of this, NHSE has not shown appropriate accountability and there is opacity on how only a proportion of mental health homicides that are eligible for independent investigation are actually independently investigated. Access to mental health services, including to mental health inpatient treatment, has been a factor in these homicides.
3) The government has announced a cut in the proportion of spending on mental health. This is on top of years of proportionately lower spending on mental health.
“Resident Judge at Southwark Crown Court and Recorder of Westminster until her retirement from the Judiciary in December 2022. In 2022 she was Treasurer of Inner Temple, where she advocated for greater diversity at the Bar.
Deborah will continue in her role as Chair of the Criminal Legal Aid Advisory Board which she has held since July 2023.”
The terms of reference for this statutory inquiry have not yet been published.
There is shortage of complete and reliable official safety data on mental health services and a range of sources have to be examined.
Because of the unsatisfactory data by the NHS, I sorted through hundreds of coroner’s Prevention of Future Deaths reports issued on mental health deaths since April 2019 and these gave a picture of recurring failures, which points to systemic safety issues.
I have produced a report on the mental health bed shortage, the underlying issues and the consequences. The report is lengthy but for those in a hurry, the salient facts and my conclusions are contained in the summary and the conclusions. The supporting evidence in between is indexed, so it is possible to pick out areas that may be more useful to some readers.
The government has announced a small cut in the proportion of spending on mental health. This is on top of years of proportionately lower spending on mental health.
“Resident Judge at Southwark Crown Court and Recorder of Westminster until her retirement from the Judiciary in December 2022. In 2022 she was Treasurer of Inner Temple, where she advocated for greater diversity at the Bar.
Deborah will continue in her role as Chair of the Criminal Legal Aid Advisory Board which she has held since July 2023.”
The terms of reference for this statutory inquiry have not yet been published.
Dr Minh Alexander, retired consultant psychiatrist 23 March 2025
In this post I set out a concern that I raised with the parliamentary Standards Commissioner about misrepresentation about the existence of a Whistleblowing APPG.
This may be related to the fact that its former chair Mary Robinson lost her parliamentary seat in the last general election.
A group of parliamentarians uniting on an issue can only call itself an All Party Parliamentary Group if it is registered and it may not display the crowned portcullis, symbol of parliament, if it is not registered.
However, despite apparent lack of registration, the website of the old Whistleblowing APPG was maintained, giving the impression that there was still a Whistleblowing APPG. It continued to display the crowned portcullis.
An X social media account (@AWhistleblowing) also continued to operate, purportedly claiming that it was the account of the Whistleblowing APPG, and it displayed the crowned portcullis. It was still active in January 2025.
The troubling private organisation WhistleblowersUK which was previously the secretariat of the old Whistleblowing APPG and has advocated for financial rewards to be introduced, continued to claim that it was the APPG secretariat on its LinkedIn account and its website.
WhistleblowersUK’s X social media account also claimed in December 2024 that Gareth Snell MP had been appointed as Chair to the Whistleblowing APPG, and copied Mr Snell and the X account at @AWhistleblowing.
I made enquiries to double check and the registrar’s office confirmed that there was indeed no registered Whistleblowing APPG.
I then raised concerns with the parliamentary Commissioner for Standards. After several exchanges of correspondence, it seemed that little action would be taken because the Commissioner’s office implied there was no applicable power. I asked (a) if the Standards Commissioner had actually seen my correspondence (b) if there was a gap in the rules which needed to be rectified. I was subsequently informed that the matters I had raised were a suitable matter to raise with the Commissioner, as an issue of misuse of parliament’s authority. It was also confirmed that the Commissioner had seen my correspondence.
As well as the possible misuse of parliamentary authority through incorrect claims that there was a Whistleblowing APPG and unauthorised use of the crowned portcullis, I also informed the Standards Commissioner that:
Gareth Snell MP’s published registered interests did not include any reference to the fact that he was Chair of a Whistleblowing APPG
2. Tess Munt MP was listed as a vice chair of WhistleblowersUK on WhistleblowersUK’s website but this had not featured in her published registered interests.
Following this, the old Whistleblowing APPG website was deactivated.
However, the X social media account @AWhistleblowing, purporting to be an account by the Whistleblowing APPG, remained in place.
I asked Tessa Munt to confirm if she was indeed Vice Chair of WhistleblowersUK, but as on previous occasions when I raised concerns about WhistleblowersUK, I received no response.
When I approached Gareth Snell, I received brief responses from his office which indicated that he had indeed been named as the Chair of the group but stepped down because of pressure of other commitments:
The X social media account which claimed to be an account by the Whistleblowing APPG has now finally also been altered. The same X handle @AWhistleblowing now represents itself as The “Office of the Whistleblower”:
The “Office of the Whistleblower” is a reference to a US body which runs a flawed whistleblowing programme, awarding vast sums to a very small number of financial sector whistleblowers but failing many more.
US bounty hunting lawyers wish to see an equivalent body set up in the UK, which would expand their market. But to be clear, there is currently no body called “The Office of the Whistleblower” in the UK.
WhistleblowersUK continues to claim on its LinkedIn account that it is the parliamentary secretariat to a now non-existent Whistleblowing APPG. This is how the account appears today:
Tessa Munt continues to be listed on WhistleblowersUK website as a Vice Chair of the organisation, but there is still no corresponding entry in her parliamentary registered interests.
I will ask the Standards Commissioner for an update but am unsure if this will be forthcoming. We may never know what exactly happened but it does seem for now that those who wish to turn UK whistleblowing into a lucrative business for lawyers and other middlemen have less parliamentary access than they did previously. But further attempts may be made to set up another APPG to press their aims.
By Dr Minh Alexander, retired consultant psychiatrist 25 February 2025
In the wake of publication by NHS England of its independent investigation into the three killings and three attempted murders by the mental health patient Valdo Calocane, I transferred data on NHS England’s published independent homicide investigations onto a spreadsheet to support public access.
I also examined NHS England’s approach to commissioning independent investigations on mental health homicides, and other matters such as information on the contractors whom NHSE hires to undertake these investigations.
The resultant report, including the spreadsheet of all mental health homicide independent investigations published by NHS England, can be downloaded here:
Huge thanks to the charity Hundred Families for their comprehensive database on mental health homicides and very helpful reports. I could not have done this work without the charity’s meticulous documentation and tenacious pursuit of the truth behind mental health homicides.
On a personal note, warm thanks to all well wishers. Although I have done some work on mental health homicides recently, personal circumstances are still a constraint and I am sorry not to be able to pick up much at present. Best wishes to all.
RELATED ITEMS
(1) This is data on coroners’ Prevention of Future Deaths reports about Nottinghamshire Healthcare NHS Foundation Trust, which was the trust responsible for Valdo Calocane’s care:
(2) I pointed out in the above report on NHS England’s handling of the investigation of mental health homicides that the NHS fails to independently investigate all mental health homicides which meet the criteria for investigation.
Part of the evidence for this comes from 2008 data by the old National Confidential Inquiry into Suicides and Homicides by People with Mental Illness (now the National Confidential Inquiry into Suicides and Safety in Mental Health since funding for studying homicides was cut).
I asked the National Confidential Inquiry if it ever repeated its analysis on the proportion of eligible homicides which were investigated, and it replied that it had not. These are the documents arising from that FOI:
Alexander's Excavations 