Health Education England’s damning 2020 report on surgical training & safety at Sussex. Another embarrassment for the National Guardian’s Office

By Dr Minh Alexander retired consultant psychiatrist 5 June 2023

Today Croydon Employment Tribunal is scheduled to hear a whistleblowing doctor’s claim against University Hospitals Sussex NHS Foundation Trust. The hearing is set to run until 16 June 2023.

This is a post to share a relevant report from a 2020 Health Education England review of core and higher surgical trainees’ experience at the trust, carried out after trainees raised concerns:

Urgent Concern Review (On-site visit) Core and Higher General Surgery, March 2020

Trainees valued the supervision of some consultants but otherwise raised many safety and governance issues with the HEE reviewers. These included:

  • An “unpleasant”, “toxic” atmosphere
  • Poor behaviour by some consultants
  • “Trainees informed the review team of examples of bullying and undermining by a named consultant, towards both other consultants and trainees.”
  • “The review team heard that some consultants frequently demonstrated undermining behaviour at the morning handover for the upper and lower gastrointestinal (GI) team, for example criticism of the registrars’ management of patients and arguments between themselves.”
  • “Trainees described a recent incident where the named consultant had undermined a consultant colleague in a large meeting by repeatedly accusing them of being incapable of performing a basic surgical procedure.”
  • High complication rates and poor recording of clinical outcomes

  • “The review team heard of a case in which a patient had received surgery on the wrong part of their bowel, resulting in recurrent readmissions.”

  • Trainees expressed concern at the apparent increase in death rates over a period of years, to levels which they felt were unexpected considering the demographics of the local population. Trainees reported they had requested this was investigated by the Chief Medical Officer. When asked, trainees confirmed that the Medical Director and Chief Executive had been made aware of these concerns.” [my emphasis] At the time of the review, the trust Chief Executive was Marianne Griffiths.
  • Lack of leadership in the department
  • “….a lack of ownership of emergency surgery patients.”
  • “The review team heard that some consultants frequently refused to review patients who were not going to theatre that day, resulting in trainees feeling unsupported when asking for senior advice on managing patients. The review team were informed that core trainees were often expected to act at a registrar level in terms of decision- making.”
  • Poor quality clinical work by locum doctors which was not well supervised
  • “Trainees reported a lack of confidence in the supervision provided by some locum consultants and provided examples related to clinical decision-making and dismissal of core trainees’ concerns about an unwell patient.”
  • “The review team were informed there were three gaps (two non-training and one training) on the registrar rota which are currently unfilled. Trainees reported consultants were aware of concerns about the capability of some locum registrars who had covered the rota but had responded that they were required to fill the gaps.”
  • “…..the review team were informed of a review of the last 100 elective colorectal resections performed (taking place between September 2019 and 3 February 2020), which indicated that the anastomotic leak rate was between 10.5-11.5% depending on the definition used to classify as a leak. The review team also noted of the cases reviewed: 14% returned to theatre, 12% experienced wound infections and 15% required readmission. Trainees reported they would not want a family member operated on by some of the consultants in the department.” [my emphasis]
  • “Trainees reported complications were inadequately discussed at morbidity and mortality (M&M) meetings due to the volume of complications.”
  • “The review team heard an example of a serious incident being closed down without sufficient review.”
  • “The review team heard that results of an audit showing that M&M does not meet Royal College of Surgeons guidelines had been shared with the Clinical Lead for General Surgery. Trainees reported they had also raised concern at the Local Faculty Group (LFG) around the accuracy of M&M data and received the response that all departments were struggling with this. The review team were concerned to hear of the lack of systematic governance of M&M data collection. Furthermore, the review team were informed that M&M meetings were not well attended by consultants and until recently minutes of the meetings had not been recorded.”
  • Trainees’ hours were not appropriately controlled and in some cases exception reporting had been discouraged.
  • “The review team heard that trainees regularly worked additional hours. When asked, trainees reported they did not submit exception reports because some consultants had discouraged F1 doctors from doing so. The review team were informed that the Guardian of Safe Working Hours had recognised a drop in exception reporting and approached a higher trainee regarding this. Trainees reported a lack of leadership and responsibility around exception reporting.”

Of great concern, the HEE reviewers were told that trainees were discouraged from raising concerns, including with HEE.

A senior manager was reportedly one of the individuals who had discouraged the raising of concerns:

“The review team were particularly concerned to hear of behaviours apparently intended to discourage trainees from raising concerns. The review team were informed that a consultant had sent an email to trainees ahead of the review, appearing to put pressure on trainees to provide positive feedback. Furthermore, the review team heard that a trainee had been told by a senior manager that those who raised concerns needed to appreciate the consequences of their actions in terms of the impact on service provision.”

The HEE reviewers clearly believed and took what the trainees reported seriously, as reflected in their list of mandatory requirements to the trust.

These included requirements for improved governance and resolution of the cultural issues:

“HEE require the Trust to develop robust clinical governance processes, in line with NHS England and NHS Improvement (NHSE/I) requirements, in relation to patient safety, complication rates and record keeping with regards to patient outcomes.”

“HEE require the Trust to carry out work to improve the culture and reduce the number of bullying and undermining incidents within the general surgical department.”

As part of the action plan on bullying, HEE required: “the Trust to consider an external review of the department from the Royal College of Surgeons.”

I understand that this RCS external review took place only last month, three years on from the original recommendation. I am asking the trust to confirm that this is so, and about progress in general on HEE’s requirements.

The National Guardian and CQC at Sussex

So in summary, HEE found very serious dysfunction in a major trust department, with substantial patient safety implications and reports of actual care failings.

Concerns about the death rates had been raised with Marianne Griffiths.

HEE also found evidence of suppression, including by a senior manager.

And guess who carried out a review of trust whistleblowing governance in July 2019, eight months before the damning findings by HEE in March 2020?

The former NHS National Freedom To Speak Up Guardian, Henrietta Hughes.

Hughe received concerns from trust staff in December 2017, but ignored her own policy and procedure, and astonishingly postponed a review until 2019 to give the trust time to improve.

Her July 2019 review predictably praised the trust leadership for making improvements, and reflected none of the dysfunction found by HEE the following Spring.

CQC would have been informed of the Spring 2020 HEE review findings as part of multi-agency protocols. There is no record of a CQC inspection of trust surgical services in response to the concerns.

An unannounced Care Quality Commission inspection of several trust sites in September/October 2021 took place after staff whistleblew. CQC found care failings and poor whistleblowing governance.

Yet Griffiths and co were still protected and CQC let them keep their “Outstanding” overall rating.

But the CQC continued to hear from trust whistleblowers:

“CQC then received concerns about the UGI surgical service from staff and other stakeholders. We carried out an inspection of the elective UGI surgical service in August 2022 and found serious safety and leadership concerns.”

“We have continued to receive concerns from staff about the safety of the surgical services at the Royal Sussex County Hospital.”

Finally, last month, even the CQC conceded that the trust was failing and downgraded it from “Outstanding” to “Requires Improvement” overall, and “Inadequate” on the Well Led domain.  In its inspection report, CQC noted:

“Some staff feared reprisal for raising concerns and others had simply given up because of ‘concern fatigue.’ This group of staff felt there was little point raising concerns because no action was taken when they did. When we asked staff to describe the culture of the trust, the feedback was mostly negative. Staff also felt the trust was a ‘hierarchical’ organisation which made it hard to get their voice heard.’

CQC also admitted in its briefing, upon release of its report:

“We continue to have repeated contact from staff who tell us feel unable to raise concerns through the trust’s own internal escalation processes.”

How many Sussex staff and patients suffered because Henrietta Hughes gave Marianne Griffiths et al a free pass in 2018?

Or because the CQC failed to act quickly enough on concerns, including those raised by HEE in 2020?

What is Hughes doing as the Patient Safety Commissioner?

And importantly, what do HEE’s findings of serious governance failings and suppression, CQC’s similar findings, and Sussex’s apparent failure to organise a timely external review of surgical services as advised by HEE – despite Griffiths having already been informed of rising death rates – say about Marianne Griffiths’ current investigation of North East Ambulance Service for NHS England?

A little more on the dramatis personae

Henrietta Hughes got an OBE, and here is Marianne Griffiths congratulating her about it:

Griffiths was made a dame in the 2018 New Year’s honours list, eight months after Hughes gave her the free pass.

George Findlay the former Sussex medical director, promoted to trust CEO, has opined on how much things have improved since the last CQC inspection:

NHS boss sets out how hospital trust has improved after damning report.

Findlay told the media the improvements included:

“Trust-wide focus on making it easier for people to speak up and raise concerns, including stronger support for the Freedom To Speak Up service. Results from the anonymous monthly “Pulse” staff survey show more people now feel confident that the trust would act upon concerns that were raised, up from 49 per cent in September 2022 to 58 per cent in March 2023, closing in on the best-performing trusts nationally.”

Having 42% staff who do not believe concerns will be acted upon is not great cause for celebration. And that is if one accepts that the trust’s report / its pulse surveys are reliable. It is hard to imagine that any patients with botched surgery, leaky bowels, post operative infections and readmissions, or bereaved families, would be uncorking any champagne.

Letter to Whistleblowing APPG about WhistleblowerUK’s suggestion that Boris Johnson is a whistleblower, WBUK’s financial transparency & handling of whistleblowers’ personal data

Dr Minh Alexander retired consultant psychiatrist 4 June 2023

WhistleblowersUK the much criticised external secretariat of the also dubious Whistleblowing All Party Parliamentary Group (which has no official standing or powers), has publicly suggested that Boris Johnson might be a whistleblower for stating that he will cooperate with the UK COVID inquiry.

As might be expected, this has provoked strong reactions from genuine whistleblowers.

A hopefully self-explanatory enquiry to the Whistleblowing APPG is shared below.


Subject: WhistleblowersUK’s suggestion that Boris Johnson is a whistleblower, financial transparency and handling of whistleblowers’ personal data

Date: 4 June 2023 at 11:04:04 BST



All Party Parliamentary Group on Whistleblowing

4 June 2023

Dear Ms Robinson and colleagues,

WhistleblowersUK’s suggestion that Boris Johnson is a whistleblower, financial transparency and handling of whistleblowers’ personal data

I write to raise further serious concerns about your external secretariat, WhistleblowersUK.

On 3 June 2023 WhistleblowersUK tweeted to suggest that Boris Johnson was a whistleblower in respect to his claimed plans to disclose pandemic related documents to the COVID inquiry.

“Is former PM @BorisJohnson #BlowingTheWhistle?”

Mr Johnson is known for the opposite of telling truth. He was fined for a criminal breach of COVID lockdown laws, committed as prime minister. He currently faces further allegations about other breaches of the COVID lockdown.

He has been criticised for abrogation of responsibility during the pandemic. The many COVID policy failures under his premiership, such as the forced discharge of COVID positive patients into care homes, unnecessarily killed and injured thousands. The misconduct in public office that killed so many has been chronicled by Keep Our NHS Public.

Billions that could have been spent on public services, and on protecting the population from the clinical and economic effects of COVID, made their way into private pockets during his tenure.

He brought disgrace many times to his Office as prime minister.

Genuine whistleblowers find it appalling that WhistleblowersUK could suggest that Mr Johnson is any way a “whistleblower”.

It is a fundamental misapplication of the concept to apply it to the individual who was the controlling mind in our country’s tragic COVID misadventures. The many, many families whose lives have been changed forever by COVID losses deserve much better.

Moreover, it is most unfortunate to associate the term “whistleblower” with someone of Mr Johson’s character.

I acknowledge however, that under the US style bounty hunting model of financial rewards/ incentives that key members of the Whistleblowing APPG and WhistleblowersUK have sought to establish, that a criminal ratting out another criminal could be accepted as “whistleblowing” and rewarded. As in the case of Bradley Birkenfeld and other examples. If however, the APPG does not intend to replicate this aspect of the US model, please let me know.

I should add that the Chair of WhistleblowersUK has ignored a letter asking for clarification about WhistleblowersUK’s financial charges to whistleblowers seeking help, and the handling of whistleblowers’ data. Please see the correspondence forwarded below of 4 May 2023.

1.   I would appreciate your comment on the tweet by WhistleblowersUK which equates purported compliance by a controlling mind with a public inquiry into gross failures with mass loss of life, to whistleblowing. Does the Whistleblowing APPG stand by the suggestion that Boris Johnson is a whistleblower?

2.   I wonder also if the APPG would be kind enough to ensure that I receive a response from Tessa Munt on the outstanding questions on transparency about WhistleblowersUK’s financial charges to whistleblowers and WhistleblowersUK’s handling of whistleblowers’ highly sensitive data. 

I previously raised questions of finances and conflict of interest with respect to WhistleblowersUK’s role as APPG secretariat in 2019. But this only led to Sir Norman Lamb’s resignation from the APPG because WhistleblowersUK refused to answer. The other APPG members were happy to continue with WhistleblowersUK as secretariat despite the lack of accountability and transparency. For the newer APPG members, my unanswered questions to the APPG in 2019 are documented here: Norman Lamb MP has resigned from the Whistleblowing All Party Parliamentary Group

A key issue arising from information on WhistleblowersUK’s website is: Does WhistleblowersUK share whistleblowers’ highly sensitive personal data with third parties such as NAVEX Global, and without disclosing that it does so?

Many thanks and best wishes.

Dr Minh Alexander


The Earl of Minto, Minister of State, Department for Business and Trade

Baroness Heather Hallet

Dr Philippa Whitford MP

Keep Our NHS Public

Lord Wills Whistleblowing APPG member

Lord Sikka Whistleblowing APPG member

Baroness Neville-Jones Whistleblowing APPG member

Date: On Thursday, May 4th, 2023 at 4:08 PM
Subject: Data processing by WhistleblowersUK

BY EMAIL & Twitter

Tessa Munt

Chair of WhistleblowersUK

4 May 2023

Dear Ms Munt,

I am directing this to your council email address as I did not wish to sign into your private website, having noted the message displayed about data collected by the LibDems.

The current  “Help me” section of the WhistleblowersUK website tells whistleblowers seeking help that their data is processed under the “WhistleB” process and overseen by WhistleblowersUK’s data controller. Could you kindly advise who is WhistleblowersUK’s data controller and whether any third parties have any role in processing the data of whistleblowers who contact WhistleblowersUK? For example, does WhistleblowersUK use dropboxes or digital platforms by third parties such as Navex Global? Please can WhistleblowersUk provide details of all third party involvement and also make such third party involvement clear on its website so that whistleblowers seeking help are fully informed? Also can WhistleblowersUK explain what the WhistleB process is?

Also, under“Our Purpose”, WhistleblowersUK now states that it provides “affordable” help. Can this be made be more transparent, and any financial charges for services to whistleblowers be explicitly published upfront? Also can any WhistleblowersUK’s requests for a share of financial settlements and awards be made explicit upfront? I ask as a document making indicating such charges and levies has never been published by WhistleblowersUK as far as I am aware.

Many thanks,

Dr Minh Alexander

Dimensions UK CEO’s apology for Sally Lewis’ death and CQC’s inexplicable failure to prosecute

Dr Minh Alexander retired consultant psychiatrist 1 June 2023

This is a brief post to share information about a disturbing failure by the Care Quality Commission to prosecute a private provider for egregious care failures. These failures led to an exquisitely vulnerable patient’s death, in a governance context of a regulatory revolving door.

Sally Lewis had a learning disability and lived in sheltered accommodation run by the company Dimensions UK.

Sally Lewis died avoidably from constipation on 27 October 2017, a known risk in her case, because of a failure to follow a care plan to monitor her bowel function and to administer vital laxative medication. It was a very painful death, with sections of her bowel found to be necrotic (dead) at post mortem.

There were many opportunities to stop this deterioration, as her family repeatedly raised concerns with staff about a deterioration in Sally’s overall wellbeing and distension of her abdomen, but this did not prompt appropriate action.

The details of Sally’s inquest this week and reactions  to it can be found via tweets by her family, a supporting inquest blog,  an INQUEST briefing and media accounts such as this: Inquest finds neglect contributed to constipation death.

I concentrate here on serious questions arising from CQC’s conduct.

CQC inspection background  

Sally Lewis died at a Dimensions UK facility called The Dock.  

A 2014 CQC inspection report gives the usual cursory, superficial account of the care one expects from CQC social care reports.  

Laughably, as evidence of user choice, the CQC report produces the example:  

“We heard a person being offered choice at mealtime. One staff said: “Would you like cheese or ham?””

As evidence of respect, CQC quoted what staff claimed they did:

“Staff told us how they demonstrated respect for people they were caring for. Staff said: “I knock on the doors”  

CQC connection at Dimensions UK

Unattractive aspects of the CQC in recent years include the way in which some of its most senior officers have walked through the revolving door to highly lucrative jobs in the private sector, and links between the regulator and the regulated.

Months after retiring from CQC, David Behan CQC’s former CEO took up a job at the care home giant HCOne, and started arguing in parliament that people should pay a tax for their future care home care:

Workers ‘should be forced to have pay docked to pay for care in old age’  November 2018

Even more outrageously, he was appointed by Dido Harding onto NHS England’s board despite his position on HCOne’s board, which one would have imagined created direct conflicts of interest. He also became Chair of Health Education England, raising similar concerns about conflicts.

Mike Richards former CQC Chief Inspector of Hospitals shortly after retirement walked into similar posts in the private sector but was also welcomed as a NED onto the board of the Department of Health.

At Dimensions UK, CQC’s former Head of Adult Social Care Policy until 2015, Rachael Dodgson became the company’s Managing Director in 2019 and then its Chief Executive last year.

Dimension UK’s annual report 2021/22 shows a turnover of over £200 million and places Dodgson’s remuneration in the pay band £180,000 to £189,999.

Was there any regulatory capture in the period following Sally Lewis’ death that affected CQC’s objectivity?

The CQC failure to prosecute for Sally Lewis death

CQC has the following legal time limits for bringing a prosecution for serious care failures:

“The CQC may bring a prosecution within a period of 12 months from the date on which sufficient evidence to warrant the prosecution came to their knowledge. However, this is limited to no more than 3 years after the commission of the relevant offence.”

From the MoU between the CQC and the NPCC:

“Under section 90(2) HSCA 2008 where CQC are investigating criminal offences into
specific incidents under Regulation 22(2), 12, 13 or 14 RAR 2014, the statutory time-limits require that CQC prosecutions must be commenced within twelve months of the date at which sufficient evidence in the opinion of the prosecutor to justify a prosecution came to the prosecutor’s knowledge. Additionally, no prosecution can be brought where information is laid more than 3 years after the commission of the offence.”

CQC informed the BBC that it attempted to prosecute but the case was thrown out because the judge concluded that the CQC had erred in calculating dates.

“The CQC said following proceedings at magistrates’ court in March 2022, the district judge concluded it “had made an error in relation to the timing of the decision to prosecute”.

CQC did not seek to prosecute Dimensions UK until 2020.

Why did it take almost three years to prosecute such obvious and serious care failings, and where the link between the care failings and death were so clear?

Surely the risk to a prosecution of delaying until 2020 should have been obvious?

Rachael Dodgson’s apology

The coroner found neglect, a very serious outcome for Dimensions UK.

The company, via Counsel, reportedly tried to argue even at inquest that constipation was not a well known side effect of Sally’s medication regime of anti-psychotics (it was).

After the coroner ruled, Dodgson issued a most objectionable apology, woven with mulitple threads of organisational self-justification.

She failed to properly apologise for the fact that a vulnerable person died slowly in front of her organisation’s eyes despite frantic warnings by the family, by adding qualifications, casting blame on Sally’s behaviour, not fully acknowledging the scale of failure and importantly, not showing enough empathy or even reportedly making a personal apology to the family.

The apology was insensitively illustrated with this smiling image:

It was reportedly not even made personally to the family:

“As for suggesting you’d like to apologise to Sally’s family, if you really wanted to do that, you need to do it in person, to them, if they want to hear from you, not to the media. This is an almost carbon copy of how Southern Health behaved at the end of Connor Sparrowhawk’s inquest…”

But cutting through the distasteful corporatisation of an apology, there was some tacit if reluctant admission of the enormity of the failure: Dimensions UK admitted that serious harm from constipation is a Never Event. Although one would need to see their operationalised details to be sure that this is translated into future action.

This is the regrettable apology by Dodgson, which only makes the questions about the CQC reverberate even more loudly:

“Our response following the inquest into the death of Sally Lewis

“The way we supported Sally Lewis in respect of her constipation simply wasn’t good enough. We could and should have done better. For that I am truly sorry and would like to apologise again to Sally’s family.

Our last CEO previously set out what had gone wrong, based upon our understanding at the time. The inquest has undertaken a deeper examination of the circumstances surrounding Sally’s death; it is clear that our processes, systems, management oversight and day-to-day support for Sally’s bowel management were not what they should have been.

That was almost six years ago and, in that time, a huge amount of organisational energy has gone into making things better. In the second half of this blog I am going to talk about what is different at Dimensions now and, just possibly, what others can learn from our experiences. But first, I want to talk about Sally, who is the most important person in all of this:

We supported Sally for 20 years. Sally was known to be at risk of constipation. Her medical records and prescriptions made that clear. And yet bowel monitoring was not done consistently and robustly.  Yes, there were some ticks put into some boxes but not routinely, and whilst our colleagues verbally discussed Sally’s bowel movements between them, that wasn’t enough to make sure they, or Dimensions’ management, understood what was happening.  We did not make our expectations to colleagues sufficiently clear in terms of recording.  Furthermore, our systems and processes to check the quality of records and support weren’t delivered effectively.  And this meant that nobody put all the pieces together. When Sally died, no-one around her realised she was constipated. And as a result, she hadn’t been receiving her PRN (“as needed”) medicine.

From the start we have said that one of the key issues here is how to balance individual dignity, privacy and rights with safety.  Sally found it difficult for people to accompany her to the bathroom and this could trigger significant behaviours of distress for her.  This meant that we couldn’t monitor how often she opened her bowels and the consistency, size and shape of her faeces. That issue stands but the key issue here was our acceptance of this. We should have raised this as a risk with her GP, the care manager, her family and with all those around her so we could work together to identify a way forward. I don’t think we did enough to help Sally herself understand why it was so important to be accompanied to the loo. And I don’t think we did enough to ensure our colleagues supporting her understood clearly the risks associated with long term constipation. I would like to turn to what is different at Dimensions now. Sally’s death has had a profound effect upon our organisation, and we didn’t wait for the inquest to identify the lessons we needed to learn, although following the Coroner’s findings we will reflect and

consider carefully if there is any more we can do. We acted swiftly to make the necessary changes. We now have mandatory training for everyone supporting a person at known risk of constipation. We have a Bowel Toolkit which includes bowel management plans, improved bowel recording charts, a constipation screening and referral tool, guidance on how to prepare for a constipation appointment and more.  It is an organisational requirement that all people we support are regularly screened for constipation and bowel health. Specialist advice is available from our Health and Wellbeing Lead.

Our electronic daily records system which is now fully embedded means it is much easier for managers to scrutinise all records relating to the people we support.  And families also have access to these electronic records at any time from their own homes.  There are, simply, many more pairs of eyes able to see what is going on.  And we know that partnership working with families and loved ones results in better outcomes for the people we support.

Constipation is now one of seven ‘Never Events’ at Dimensions. Never events are a well-known concept in the NHS. Quite simply it means that, with the right training, behaviours, systems and processes, an incident that carries a potential risk of harm, injury or death should never happen. Specifically, at Dimensions, we say that “No one should suffer any harm as a result of a failure to administer or monitor the medication prescribed, or to follow established processes, for the relief or avoidance of constipation.”  And we work to provide the right training and processes, and ensure the right behaviours, accordingly.

Our CQC registrations, previously held at Operations Director level, are now held by Locality Managers across our organisation to ensure that those directly responsible for the oversight of delivery of individual care and support are closer to the people we support. That’s a critical change; if any providers reading this have yet to make a similar change, I urge them to do so.

We have also undertaken a great deal of work externally to raise awareness of the risks and issues surrounding constipation for people with learning disabilities, to enable us and others to do everything possible to keep people at risk of constipation safe and well:

We produced an animation for our colleagues which has been used by the NHS, and this accessible book, funded by Dimensions and co-produced with Beyond Words.

Many colleagues have also devised extraordinarily creative ways of delivering what we continue to believe is a very important message, and one that we will continue to deliver. Sally’s inquest is an incredibly sad but important and timely reminder that we must always make sure support plans are clear, followed by our colleagues in how they support people, and that checks take place to ensure all those things are happening, whether that’s in relation to people’s bowels or any other areas of support.

I will end this by simply saying, to Sally’s family, I’m truly sorry.  Nothing can bring Sally back but I’m determined that we will continue to do all we can to minimise the risk of this ever happening to anyone else.”

Rachael Dodgson, Chief Executive, Dimensions”

Sally Lewis’ family had no highly paid corporate lawyers or publicists.

They fought for an inquest and the truth of a loved one’s death on private means, and also endured the extra years of limbo caused by CQC’s scandalously late and unsuccessful prosecution.

They have a crowdfunding appeal for help with inquest costs:

Justice For Sally


I have asked the CQC for information under FOIA regarding its response to Sally Lewis’ death, multi-agency warnings about Safeguarding failure and its failure to mount a time prosecution. I have also asked whether in the light of Sally Lewis’ case and others, CQC should audit its application of Regulation 12 and I have sent a copy of the questions to the parliamentary Health and Social Care Committee, with a request that the committee consider CQC’s application of its responsibilities under CQC Regulation 12 at the next CQC accountability hearing.

FOI correspondence to CQC and letter to Health and Social Care Committee 1 June 2023

UHB controls its culture review, NHS executive secrecy and what value from the “TheValueCircle”?

By Dr Minh Alexander 29 May 2023

The painful spectacle of the NHS denial machine grinding on at University Hospitals Birmingham NHS Foundation Trust (UHB) continues to embarrass us all.

Instead of an effective and genuine response to staff and patient concerns about maladministration, under-resourcing and related safety matters, the upper echelons of the NHS are wasting thousands in public cash on reputation management. Literally, because the relevant commissioner, Birmingham and Solihull ICB has hired the well known professional reputation managers, Freshwater.

Part of the prestidigitation is the performative exercise of allowing UHB to control a culture review on itself. This is akin to the useless models of internal Freedom To Speak Up arrangements for NHS whistleblowing and internal NHS arrangements for conducting Fit and Proper Persons investigations under CQC Regulation 5.

UHB, through a panel chaired by Roger Kline, has appointed a private company called “TheValueCircle” to carry out the culture review. TheValueCircle was set up by a former employee of the Good Governance Institute, another private company, which has many links with UHB managers and former managers, including Jacqui Smith former UHB Chair.

Roger Kline  

Roger Kline was previously a Co-director of the now defunct organisation Patients First.  

I have written previously about Patients First.  

Roger Kline has links with the organisation B-RAP and has done joint work with this organisation.

B-RAP was until 10 January 2023 chaired by Karen Kneller, a UHB non executive director.  

Naledi Kline is a trustee of B-RAP.    

Roger Kline interacted with UHB prior to the announcement that he would chair a panel to select the organisation to conduct the UHB culture review.  

A local media report confirmed in April that he had prior links with the trust:  

“He confirmed he has prior links to UHB, having worked with some of the existing leadership in the past on a ‘fairness taskforce’ looking at staffing issues, but insisted he had ‘no interest’ in positioning the trust chiefs in a positive light if that was not what he found.”  

It is remarkable that the UHB trust board, and ultimately NHS England where Kline was previously a director, even at this late stage, appear unconcerned about any appearance of potential conflict of interests.  

TheValueCircle is notable in that one of its consultants is a CURRENT member of the NHS England board, Andrew Morris, as declared in the NHSE register of interests.

Several of its other consultants are former NHS trust directors, regulators and commissioners, some very recently stepped through the revolving door, such as Ian Hall who according to his LinkedIn entry was until June 2022 Regional Director of System Improvement, for NHS England Midlands.

This is the very NHS England region responsible for UHB and which is controlling the conduct of the UHB reviews behind the scenes, as revealed by PHSO correspondence, which is another topic for another day.

Unhealthy proximity, did I hear you say?

To understand TheValueCircle’s past work for the NHS, I looked for examples of other reviews and consultancy work. Strikingly, I found no past work product by TheValueCircle in the public domain. But I did find a comment on the company’s website about the fact that it did not produce much in the way of reports:

To find out more I requested, under FOIA, information from ten NHS bodies which appeared to have used TheValueCircle’s services in the past. They were mostly located in the West Midlands and North West regions. The results are provided below.

1) Walsall Healthcare NHS Trust

In an FOI response, Walsall reported it spent £119,232 on TheValueCircle for “Acute Partnership Development Support” and “Board Development Programme 2021/22”.

Astonishingly, the trust claimed that it held no data on which consultants from TheValueCircle carried out this work, any reports by TheValueCircle or whether NHS England had recommended the TheValueCircle.

This is the Walsall Healthcare FOI disclosure.

2) Sandwell and West Birmingham NHS Trust (and false claims)

This trust and Walsall Healthcare NHS Trust are both chaired by David Nicholson, the former CEO of NHS England who was forced to resign after the scandal of the MidStaffs Public Inquiry.

He is now a major influence again in the West Midlands region, where it all started, as the chair of multiple NHS trusts.

Although Sandwell and Birmingham NHS Trust board papers recorded that Nicholson commissioned a review by TheValueCircle as one of his first acts as trust chair in, the trust FOI department bizarrely claimed to me that the trust had NEVER hired TheValueCircle.

“We have never commissioned this company for any consultancy work, advice or any services.”

When I pointed out that this was incorrect and supplied the evidence to prove this, the trust FOI department simply ignored me. Alongside this, I actually wrote to Nicholson to ask him if he had prior experience of TheValueCircle. He responded via a message from his office confirming that a review report had been produced but with a new narrative that it was not he but his CEO who had commissioned the review. He denied that NHS England had recommended TheValueCircle.


Subject: RE: The Value Circle

Date: 18 April 2023 at 16:51:45 BST


Dear Dr Alexander

Many thanks for your email below.

Sir David has confirmed that he has not used The Value Circle previously.  Sandwell and West Birmingham used them and I understand that they produced a good report which focussed heavily on the culture and behaviour elements of governance.  This was requested by Richard Beeken the CEO.  There is no connection with NHSE.

I hope the above is helpful.

Kind Regards


Sandwell and West Birmingham did not respond properly to my FOI request until I complained to the ICO and I published my letter of complaint.

The day after, a response finally arrived indicating that the trust spent £28,200.00 on TheValueCircle’s services for a “Governance Review”.

The trust refused to disclose which consultants from TheValueCircle did the work claiming it was exempt as personal data.

Despite paying for and owning the review report on behalf of the public, the trust claimed it needed TheValueCircle’s permission to disclose it to the public:

“The report was prepared solely for the use of Sandwell and West Birmingham Hospitals NHS Trust. There is a disclaimer that the details may be made available to specified external agencies, but otherwise the report should not be quoted or referred to in whole or in part without prior consent. No responsibility to any third party is accepted as the report has not been prepared and is not intended for any other purpose. We have requested permission from The Value Circle as to what can be shared. We will respond once they have confirmed.”

The trust denied that NHS England recommended TheValueCircle and stated: “…they were chosen through a competitive bidding tender process.”

This is the Sandwell and West Birmingham FOI disclosure.

3) Dudley Integrated Health and Care NHS Trust 

No response.

I will be complaining to the ICO.

4) Gloucestershire Health and Care NHS Trust

This trust hired TheValueCircle to provide “training to our Board including a Well Led training session so that Board members would be further prepared for the then upcoming CQC inspection and also a Board Development programme.”

This cost £43,316.49 ex VAT.

The trust refused to disclose which consultants from TheValueCircle supplied the purchased services on grounds that disclosure would prejudice the conduct of public affairs. Really? Were the consultants current public servants?

The trust dubiously claimed that it could not disclose reports by TheValueCircle on grounds of commercial sensitivity.

It implied that NHS England had not recommended TheValueCircle:

“The Trust was made aware of TVC and other potential suppliers of Well Led reviews via a Trust Secretary network. TVC were appointed through a procurement exercise/tender by the Trust.”

This is the Gloucestershire Health and Care FOI disclosure.

I have asked for an internal review.

5) Shropshire Telford and Wrekin ICB (and false claims)

ICB records clearly showed that TheValueCircle was hired to work on transformation of musculoskeletal services:

To help shape the future ambition for MSK services, ICS organisations jointly commissioned The Value Circle to undertake a review of the current MSK transformation programme and make recommendations on next steps. The initial feedback which remains in draft form is attached in Appendix 1.”

This is the the relevant section of Appendix 1.

However, the ICB claimed to me that it had never conducted any business with TheValueCircle.

This has been questioned and await a response.

6) Harrogate and District NHS Foundation Trust

No response.

I will be complaining to the ICO.

7) Liverpool University Hospitals NHS Foundation Trust

This trust spent £83,160.00 (inc VAT) by hiring TheValueCircle “work in partnership to develop a new risk management framework”.

The main man from TheValueCircle, David Cockayne, was the main consultant supplied, as is the case at UHB:

“David Cockayne, Chief Executive (The Value Circle LLP) was the senior sponsor supplied to co- ordinate the work undertaken with the Trust.”

Astonishingly, for £83,160.00 of public money spent, there is purportedly no tangible product to show for it:

“In accordance with Section 1 of the FOIA, we can confirm that the Trust does not record/collate the above information. We do not hold a final written report in order to answer Q4 of your request.”

The trust denied that NHS England recommended TheValueCircle in an interestingly worded reply:

“No external body recommended TheValueCircle to the Trust”.

8) East Lancashire Hospitals NHS Trust

This trust hired TheValueCircle to provide “Support to the development of the Provider Collaborative Strategy” and paid £193,065.90 inc VAT for this service.

The trust was reluctant to disclose which consultants from TheValueCircle provided the service, copies of their reports or whether NHS England had recommended TheValueCircle to the trust. It repeatedly gave the answer:

“The Trust does not hold this information centrally.”

This is the East Lancashire FOI disclosure.

I am requesting an internal review of this given reason for non-disclosure.

Until July 2021, the CEO of this trust was Kevin Mc Gee.

An apparent testimonial by Mr Mc Gee appears on TheValueCircle’s website:

I have asked Kevin McGee to kindly confirm that this comment was correctly attributed to him.

9) Blackpool Teaching Hospitals NHS Foundation Trust

This is another trust under Kevin McGee’s oversight as CEO.

The trust disclosed that it had hired TheValueCircle for the following jobs:

“From 19/20 the Trust commissioned 3 pieces of work:-

• a review of our Wholly Owned Subsidiary – Atlas
• a review of our Divisional Structure and consideration of a Tertiary Division
• a support piece of work for the Development of the Provider Collaborative for L&SC – this was commissioned by BTH but was for the entire PCB across Lancashire and South Cumbria.”

This all cost £350K.

David Cockayne was the main consultant for this project, as he is at UHB currently.

“David Cockayne, Chief Executive of Value Circle, was the lead contact for the projects, deploying various other consultants dependent upon the work.”

The trust refused to disclose any reports by TheValueCircle on grounds of commercial sensitivity.

Most incredibly, the trust also refused to disclose whether or not NHS England had recommended TheValueCircle on grounds of commercial sensitivity.

Shurely shome mistake?!, I hear you cry.

Surely no one at NHS England has a commercial interest in TheValueCircle getting lucrative NHS contracts?

This is the Blackpool FOI disclosure.

I am requesting an internal review of these claimed exemptions.

The last but possibly the most important example:

10) North East Ambulance Service NHS Foundation Trust

As the NEAS deaths cover up and coronial misreporting scandal swirls on, compounded by the appointment of Marianne Griffiths as an investigator despite her controversial history with whistleblowers, who is found in the mix but TheValueCircle.

I discovered that TheValueCircle had been hired from NEAS financial transparency data , which showed that the trust CEO had authorised a payment to the company in December 2022 for “external consultancy”.

In response to FOI questions, the trust disclosed that it had hired TheValueCircle to undertake a  “Well Led Independent Review” at a cost of £79,253 ex VAT and a  “Full review of Trusts Governance and Assurance Framework” at a cost of £127,660 ex VAT.

TheValueCircle consultants who did the work were Sue Hillyard, Maggie Boyd a former NHS Improvement director in the Midlands and East Region and David Cockayne.

With desperation, and despite the massive and obvious public interest arguments, the trust claimed that it would be prejudicial to the conduct of public affairs if the reports produced by TheValueCircle were shared:

“Frankness and candour are essential for good decision-making. We believe that disclosure would be likely to prevent future reviews taking place with an honesty and candour needed to ensure that corrections can be made to improve our services.

We are therefore unable to release this information and apply section 36(2)(b)(i)&(ii) and section 36(2)(c) exemptions. This exemption states that information is exempt information if, in the reasonable opinion of a qualified person, disclosure of the information under the legislation:

(b) would, or would be likely to, inhibit –
(i) the free and frank provision of advice, or
(ii) the free and frank exchange of views for the purposes of deliberation, or
(c) would otherwise prejudice, or would be likely otherwise to prejudice, the effective conduct of public affairs.

The documents requested and subsequently withheld contain the findings and opinions from external reviews that, if made public, would likely inhibit the future frankness and candour that we require to ensure our decisions are robust and informed.

In my reasonable opinion, this would likely damage the quality of advice and deliberation and lead to poorer decision making in the future. It would also inhibit the necessary frankness and candour of our staff if their discussions were made public.”

It is striking how the NHS will argue that night is day and vice versa when it suits.

When it is inconvenient, as at NEAS, embarrassing findings are hidden behind the wall of Section 36 exemption.

When it is less inconvenient, they may be published in full.

Here is an example of a fully public Well Led Review report on another NHS trust, of which Maggie Boyd was also a co-author:

Well Led review report on North West Anglia NHS Foundation Trust

NEAS also denied that NHS England recommended TheValueCircle:

“The Value Circle was not recommended by another body. Procurement exercise completed for Well Led Independent Review and further work on Governance and Assurance Framework required rapid completion post CQC inspection.”

This is the NEAS FOI disclosure.


So there you have it dear reader, UHB which has been severely criticised for secrecy and marking its own homework, allowing cover ups of patient safety and staff abuse, is being allowed to mark its own homework again using a private company about which there is studiously little transparency despite large amounts of hard public cash changing hands.

So far, even with three of ten trusts failing to respond to the FOI requests, over a million pounds were spent on TheValueCircle with nothing tangible in the public domain to show for it, even with a major scandal and many lives lost at North East Ambulance.

Why should highly paid NHS trust executives pay others with our money to do their jobs for them?

In times of austerity, when the lowest paid NHS frontline have to rely on foodbanks and 7.3 million patients wait for treatment, is not an obscene sight that money is frittered away in this fashion?

If these highly paid executives are incapable of doing their jobs, they should be shown the door. But oh, wait, there is still no sign of any implementation of the Kark review which the current Secretary of State himself commissioned but reportedly has stifled. He has not replied to a letter of 7 February 2023 asking him to reconsider his decision to reject Tom Kark’s recommendation of a disbarring mechanism. I have written once more:



As a little bonus feature, I should draw attention to the fact that one of TheValueCircle’s featured consultants Margaret McCabe is advertised as a NLP practitioner.

Her arrival was announced by David Cockayne himself.

NLP has been described as “pseudo-scientific”, “folk magic”, a “quasi-religion” and a New Age “psycho-religion”.

The current NHS National Freedom To Speak Up Guardian is master practitioner of NLP, not to mention a fire walk trainer. Nuff said.

Neuro-linguistic-programming: a critical review of NLP research and the application of NLP in coaching

Thirty-Five Years of Research on Neuro-Linguistic Programming. NLP Research Data Base. State of the Art or Pseudoscientific Decoration?


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

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

After Reuser v UHB and Macanovic v Portsmouth: New rules to deter malicious referrals of whistleblowers to the Practitioner Performance Advice service

Death of a UHB patient following an unwitnessed fall: Coroner’s PFD report

Healthwatch Birmingham & Solihull has been receiving increasing concerns from the public about UHB and has held monthly meetings with the CQC

Cygnet Health Care has Fit and Proper leaders according to the CQC, despite gross whistleblower reprisal

Death of a UHB patient following an unwitnessed fall: Coroner’s PFD report

By Dr Minh Alexander retired consultant psychiatrist 21 May 2023

University Hospitals Birmingham NHS Foundation Trust received a warning notice for under-staffing from the Care Quality Commission in December 2022 following an unannounced inspection of Good Hope Hospital over 7-14 December 2022.

The inspection took place just after BBC Newsnight broadcast about poor culture and mistreatment of staff at the trust. The CQC claimed it inspected “due to a number of concerns raised by patients and their families around the care and treatment they had received”.

The warning notice on under-staffing was served partly as the CQC found that patient falls, some with serious harm, occurred DURING the inspection:

“Staff knew about and dealt with many specific risk issues. However, in many ward areas staff told us about their concerns over the number of falls and patients with pressure damage due to staffing pressures preventing them from taking appropriate, preventative action. On the first day of our inspection, staff reported that they had unfortunately had 2 patients fall due to being unable to provide the supervision the patients were assessed as requiring.

“The service did not have enough nursing and support staff to keep patients safe. During our inspection we found most wards were operating below national guidance for safe staffing levels. The Royal College of Nursing recommend safe staffing levels of 1 qualified nurse to 6 patients. Staff told us shifts were regularly planned for 3 qualified members on staff each shift, however this regularly reduced to only 2 qualified staff members working on the shift. Even with 3 qualified nurses on each shift, this would still have been outside of the recommended safe staffing levels. On the 13 December 2022, we found Ward 16 which had medical outlier patients admitted at the time were reduced to 1 qualified member of staff for 26 patients, at the time of our visit. The registered nurse was supported by a trained nursing associate. On the 13 and 14 December 2022, we found Ward 9 had a ratio of 1 nurse to 17 patients on both days of our inspection. Staff told us the ward had a high acuity as they had a large number of patients with complex needs, many of whom required 1:1 supervision. At the time of our inspection, staff were unable to provide this due to the unsafe staffing levels. On the first day of our inspection, Ward 9 reported 2 falls as they were unable to provide the 1:1 support for them. One patient did not sustain serious harm, however, 1 patient was awaiting a head CT scan and undergoing neurological observations due to the fall. Staff told us this was not a rare occurrence due to the challenges they faced with staffing.

We raised our concerns about staffing during and after our inspection and issued the trust with a Section 29a Warning Notice advising them of timely improvements needed to be made due to serious safety concerns.”

UHB trust board papers show that inpatient falls with “severe” and “catastrophic” harm occur on a regular basis.

It raises a question of why the CQC only served a warning notice and is not actively investigating under Regulation 12.

Another UHB hospital has now been criticised in relation to a patient fall which resulted in death.

On 19 May 2023 the coroner issued a Prevention of Future Deaths report after the death of 77 year old Norma Bruton who had an unwitnessed fall at Heartlands Hospital, resulting in a fractured neck of femur and her death seven days later.

Norma Bruton Prevention of Future Deaths report 19 May 2023 Ref Ref: 2023-0165

The death occurred on 22 October 2022, shortly before the unannounced CQC inspection of Good Hope Hospital in December 2022.

“She had an unwitnessed fall on the morning of 15 October 2022 when trying to walk the short distance to her bathroom and sustained a right fractured neck of femur for which she underwent surgery on 20 October 2022. Mrs Bruton’s condition deteriorated after the surgery and she died in hospital on 22 October 2022.”

The coroner identified a concern about UHB’s falls risk assessment process and failure to take trailing attachments such as drains and drip lines into consideration as risk factors.

Bewick’s rapid review of clinical safety at UHB, published in March 2023 claimed that UHB was safe overall, despite Bewick’s awareness of the CQC warning at Good Hope Hospital. Bewick’s report maintained that mitigations were in place.

The issues of serious understaffing across all UHB sites, about which staff have been whistleblowing for years according to UNISON and others, supported by regulatory findings, long A&E waits and rates of avoidable harm from falls, are not consistent with a conclusion that clinical care at UHB is reliably safe.

Neither is the upsurge in concerns reported by the public to Healthwatch since 2021.

Will other care failings continue to emerge?

I am sending the PFD on Ms Norma Bruton’s death to the Care Quality Commission with respect to Regulation 12 issues. The Coroner has already sent it to NHS England.

NB I am occupied with a family matter at present so apologies if I am slow to respond to correspondence. Best wishes.


A previous UHB FOI disclosure revealed that there were 30 fractured necks of femur resulting from inpatient falls in the period 2012/13

Another UHB FOI disclosure showed that the majority of inpatient falls at UHB are unobserved:

The Whistleblowing Hunger Games: Why we should reject the Whistleblowing APPG

Dr Minh Alexander retired consultant psychiatrist 9 May 2023

This is a post to spell out the stark numbers behind the unethical and exploitative US bounty model of “whistleblowing” rewards that the whistleblowing APPG is trying to introduce.

All Party Parliamentary Groups have no official status whatsoever.

Some do good work.

Many are shady lobbying devices for wealthy and powerful private interests that subvert our democratic process.

They positively abuse parliament’s dignity, flinging the portcullis about as a branding and marketing tool.

The APPG sleaze story is a long running and ongoing scandal. These are the typical concerns about APPGs:

“We are concerned that if left unchecked, APPGs could represent the next great parliamentary scandal, with commercial entities effectively buying access to and influence of parliamentarians and decision-makers.”

‘Every lobbying company sees an All-Party Parliamentary Group as an ideal way of making a quick buck’

“….there remains a significant risk of improper access and influence by commercial entities or by hostile foreign actors, through APPGs”

“.External organisations providing support for APPGs are a corruption risk. It is possible that organisations are using this privileged access to MPs and the ability to book rooms within the parliamentary estate, as a way of impressing clients and at the very least appearing to influence the views of parliamentarians.”

In this context, the Whistleblowing APPG was established with money from US bounty hunting lawyers, and it has an external secretariat in the form of a private company, WhistleblowersUK.

WhistleblowersUK has advocated for whistleblower rewards, and latterly has euphemistically dressed this up as “compensation” but in contexts which indicate rewards are being posited. Members of the APPG have also advocated for whistleblower rewards and “incentives”.

The trouble with the US bounty model is that it is utterly ruthless. It is focussed on recovering money for the State, from the financial sector. It is not about other forms of whistleblowing in the public interest. It does not care about the welfare of all whistleblowers. It wishes only to identify those who will recover the most money for the State, be they genuine whistleblowers, or criminals who rat on other criminals.

Indeed, a lawyer from the US firm which funded the whistleblowing APPG publicly compared whistleblowing to the use of paid informants in law enforcement at a Bylines festival.

Bona fide whistleblowers who report wrongdoing, and suffer for it, are discarded by the US bounty system if their disclosures do not result in recovery of a sum beyond a target threshold, (a million dollars under the US Security and Exchange Commission rules). Some whistleblowers wait years under this system to receive nothing.

Then factor in secondary effects from perverse incentives: regulatory corruption, which has made an already heartless system even worse. In short, game keepers setting up a poaching monopoly for financial gain from the bounties. This is research from Kansas University which exposed the corruption.This is corroborating work by investigative journalists which supported that research. It is no surprise that monetising whistleblowing leads to unseemly consequences.

And what of the cold mathematics of SEC’s whistleblowing hunger games?

Since 2011, the US Securities and Exchange Commission (SEC) says its whistleblower programme has received a total of 64,755 whistleblowing tips about financial wrongdoing.

Source: SEC annual reports from SEC’s Dodd-Frank whistleblower programme

SEC says that from all of these tips, it has made 328 awards to individuals under its whistleblower programme:

“Since the beginning of the program, the SEC has paid more than $1.3 billion in 328 awards to individuals for providing information that led to the success of SEC and other agencies’ enforcement actions.”

Although there are complexities, that roughly gives a conversion rate of only 0.5%.

That is, 99.5% are junked. Some after many years of waiting.

And bear in mind that investigators have discovered that scandalously, SEC have given some of the awards to individuals who did not even meet SEC’s own definitions of a whistleblower.

Here is an example of a genuine whistleblower who failed to qualify under SEC’s Byzantine process:


He Waited 17 Years to Be Denied an SEC Whistleblower Award

Gene Ross discovered the theft of $175K from a client and reported it. He suffered serious detriment. After seventeen years, he was told that he would not qualify for a SEC award, although his report eventually led to SEC recovering more than $50 million from a fraud.

“What has moved far more slowly is the story of Gene Ross, father of three, who, in the process of voluntarily cooperating with government prosecutors and regulatory agencies in the criminal and civil actions against Amerindo, lost his job at Bear Stearns, which strongly discouraged his participation in the legal reckoning that followed, cut his pay, took away his sales team, and subjected him to unchecked harassment and retaliation. After leaving Bear, Ross was forced to sell his home to cover mounting legal bills that eventually bankrupted him. Yet he continued to provide evidence, documents, and testimony as a star witness in the 2008 criminal case that put Vilar and Tanaka behind bars.”

Ross commented of the SEC decision: “It kind of made me feel like a victim again.”

The real winners from the cruel SEC and other related US programmes are the lawyers and other middlemen.

And the obscene bounties that are paid out in the few, select cases are excessive set against losses suffered by victims who remain uncompensated.

Occasionally, some whistleblowers have refused SEC awards out of conscience:

Deutsche Bank whistleblower rejects award because SEC ‘went easy’ on execs.

“I request that my share of the award be given to Deutsche and its stakeholders,”

The whistleblowing APPG and its secretariat WhistleblowersUK have waged a clearly well-resourced and increasingly glossy media campaign about UK whistleblowing reform which camouflage their intentions and their vaguely and worryingly drafted law to replicate SEC’s much maligned Office of the Whistleblower.

One of the APPG’s MPs is now in power and has wasted no time in calling for a review of UK whistleblowing law:

Tory MP Kevin Hollinrake who called for whistleblower “incentives” is now in a ministerial role, launching a review of UK whistleblowing law

The Whistleblowing APPG have used poster boys and girls from health and social care in their campaigns, when whistleblowing about poor care is the last thing that would attract bounties. It is the financial sector that is the real prize. And even then only a few whistleblowers would benefit.

The great risk is that the APPG’s proposed vision would quickly descend into a racket, with the whole system trained on money making rather than public protection, with the great majority of whistleblowers discarded. The more lowly paid and disenfranchised, the more neglected. Nursing and care assistants have little enough voice already.

We have already seen quite enough degradation of our public life with greed, chumocracy and misconduct in public office.

We don’t need anymore.

No thank you to failed US policies or the bounty hunting sharks and their companions.


A much better US model is that of the Office of Special Counsel which looks after public sector whistleblowers – federal employees – it works on a lean model, seeks to apply redress during employment rather than after dismissal and works on the principle of restoring a whistleblower to the position they would have been in but for the whistleblowing. Most valuably, it can address non-financial detriment, such as restoring lost seniority and erasing unfair performance and disciplinary records. The principle is of more justice, not incentivising greed, stoking wasteful conflict or feeding a legal industry.

UK whistleblowing law, PIDA, is hopelessly weak, wasteful and was explicitly drafted to appease industry. It benefits the lawyers. It has caused no end of suffering to whistleblowers and contributed to countless public protection failures:

Replacing the Public Interest Disclosure Act (PIDA)

The law needs urgent replacement, but in that space, opportunists will exploit any chance they can to make money or build careers.

Those who have earned their daily bread from not rocking the boat and selling whistleblowing products from the last twenty years of PIDA’s jurisdiction will want to continue their business in a newly configured form. The bounty hunters will obviously want their taste. The academics will want to preserve their access to power and grants, and some may not be too discriminating about which tables they sit at. Some politicos will expect a berth in the Pullman carriage of the gravy grain.

It falls to un-captured and genuine whistleblowers with no personal agendas, seeking no personal gain, to speak up for the public interest and for future whistleblowers.

For any journos who want a quick primer on the legislative intentions of the whistleblowing APPG and the now Parliamentary Under Secretary of State at the Department for Business and Trade, here is a summary:

A Bounty Hunters’ Bill? A critique of the Whistleblowing APPG’s April 2022 Bill

UHB: Bewick was aware of the Rosser fiction, but it did not feature in his investigation report

Dr Minh Alexander retired consultant psychiatrist

The care quality and governance scandal at University Hospitals Birmingham NHS Foundation Trust blew up in early December 2022 when BBC Newsnight broadcast concerns about poor culture at the trust.

Within days, on 8 December 2022 the commissioner of the acute hospital service, Birmingham and Solihull Integrated Care Board announced three reviews into UHB.

The first review undertaken was a rapid review of clinical safety by Dr Mike Bewick a GP and former deputy Medical Director of NHS England, who set up a private consultancy after leaving NHS England, IQ4U Consultants Ltd.

Bewick was deputy to Bruce Keogh, who was formerly a consultant at UHB prior to becoming Medical Director at NHSE. Keogh’s wife remained at UHB as a medical manager.

This connection to Bruce Keogh was amongst concerns raised in a letter of 16 January 2023 by former UHB senior medics which called for a properly independent inquiry

Bewick through his company IQ4U Consultants Ltd, which appears to have no website that I could find, has undertaken a number of investigations and reviews for the NHS.

Through this company, Bewick reviewed cardiac surgery services at St Georges in 2018 after NHS Improvement gave St. Georges “support and guidance” to appoint Bewick.

Bewick’s latter role as a purported expert in safety and governance is somewhat at odds with the fact that he and others were criticised in Bill Kirkup’s report on the Morecambe Bay maternity disaster. Bewick was the then medical director for the local PCT and chaired an odd “Gold Command” response to the trust’s governance problems, under SHA directions. The Kirkup team saw little value in this misapplication of an emergency major incident procedure to ongoing governance issues, which served to burden the trust. For example:

“1.95 On 3 October 2011 the SHA, which had continued to regard the supposedly coincidental nature of the previous incidents as evidence that there was no systemic problem up to 10 September 2011,100 called a ‘Gold Command’. The intention appears to have been to offer support to the Trust in responding and accessing additional staffing, but the evidence we heard suggested that it served as much to distract senior staff in the Trust, who had to brief twice-weekly Gold Command meetings. We could find no evidence of defined exit criteria to underpin the closing down of Gold Command by Cumbria PCT, and it was not clear exactly what had been achieved when this was done. Overall, we were unconvinced that this represented the best way to address the situation.”

The Rosser Fiction

On 18 November 2022, UHB and the ICB both announced that David Rosser the controversial former CEO of UHB was stepping down for a new regional role as strategic director of digital health and care.

This was a fiction.

Rosser may have relinquished his role as UHB CEO, but he never left UHB and remained an UHB employee. He was merely “hosted” by the ICB, answering to the ICB’s CEO.

Through an FOI response of 16 February 2023, the ICB eventually admitted that Rosser had never departed and had remained employed by UHB all along.

This fact was not revealed until it was briefly alluded to in a BBC Midlands clip days before Bewick’s phase one report was published on 28 March 2023, and then covered on BBC Newsnight on the day of publication.

Information shared with Mike Bewick by the ICB

I asked Birmingham and Solihull ICB for clarification on whether Mike Bewick was informed of the fact that Rosser had NOT left UHB as publicly announced by UHB and the ICB.

The ICB answered evasively and avoided my questions.

After I pressed the matter, the ICB finally replied “Yes” to all three of the following elements of this question:

“Did the ICB inform Mike Bewick upon appointing him, to undertake the phase 1 rapid review into UHB, that David Rosser: 

a) Was still employed by UHB? 

b) Was “hosted” by the ICB? 

c) Was reporting to the ICB CEO?”

That is to say, Mike Bewick has apparently known since early December 2022 that David Rosser was still a UHB employee, and had not left the trust as claimed by UHB and the ICB.

This is the ICB FOI response of 5 May 2023.

I am not surprised that the ICB was reluctant to reveal this information.

A number of questions arise.

Has Bewick investigated the misleading claims by UHB and the ICB?

If not, why not?

This is in the context that Bewick’s investigation terms of reference were unlimited and allowed him to go where the evidence took him.

Why did Bewick not comment on the irregularity in his rapid review report on UHB?

Was he unwilling to criticise the ICB, who commissioned his services?

Or did Bewick see nothing wrong in the way that UHB and the ICB misled the public and partner agencies?

For example, Healthwatch Birmingham have indicated to me that they received only the official briefings that Rosser was stepping down from UHB and knew nothing of Rosser’s continued employment by UHB.

Does the fact that Bewick did NOT report the Rosser fiction raise a concern about his role as an investigator of UHB’s governance?

This is not the only omission from Bewick’s rapid review report.

For example, he deviated from his terms of reference in respect to the UHB staff suicides and left serious unanswered questions.

Bewick also did not examine UHB patient complaint patterns in his report, yet claimed that the trust was “safe” overall.

He repeated the claim to the BBC:

“We haven’t found any evidence that the trust is in disarray in terms of clinical safety.”

The word “any” is troubling given issues such as recurrent haematology never events, A&E delays and such unsafe staffing that the CQC issued a warning notice in December 2022 at Good Hope Hospital. Revisiting Bewick’s report, it is clear that he knew about the warning notice, page 27: “Good Hope Hospital is the only one with a CQC regulatory notice at present (S29a for quality of healthcare requiring significant improvement, issued in Dec 2022”, but he claimedthat mitigation was in place.

Moreover, FOI evidence obtained from local Healthwatch questions Bewick’s denial of safety issues. It revealed marked and ongoing escalation in concerns from the public, with monthly meetings with the CQC to reflect this.

Bewick also did not call up medical staff suspension, NCAS(PPA) referral stats or quote full GMC referral and outcome stats in his report, despite major concerns in these areas.

Bewick’s lack of data on suspended and disciplined UHB doctors, despite complaints of medical management cronyism

Bewick, the ICB, misinformation by UHB about GMC referrals and a late correction

But fiction did become fact in one respect. Rosser’s retirement was announced on the day that Bewick’s report was published.

In a theatrical flourish, Bewick told the BBC that there might be more departures. This was not in his report.

But then neither was a reported claim that Bewick would be happy for his family to be treated at UHB, parroted by the hapless ICB CEO David Melbourne at a Joint Health Overview and Scrutiny Committee in February after briefing by Bewick.

What is needed is not theatre and misdirection, but facts and the whole truth. 

Which would likely lead us to bad government policy and unsafe staffing. 

Which is ultimately what so many NHS staff have been whistleblowing about. And so many compromised senior NHS managers with fat salaries and pensions have been trying to obstruct them, and are often richly rewarded for such efforts.

So, the ICB confirmed that Bewick knew from early December 2022 that Rosser had NOT left UHB’s employ.  But Bewick kept mum. 

Does that suggest that the reviews are a face-saving confection?


Healthwatch Birmingham & Solihull has been receiving increasing concerns from the public about UHB and has held monthly meetings with the CQC

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

What’s the point of CQC’s Emerging Concerns Protocol? CQC never once triggered it at UHB nor held a regulatory risk summit in the four years up to 31 March 2022

PHSO alleges it has been excluded from NHSE/ICB’s reviews on UHB & ICB’s factual inaccuracy to the Joint Health Overview and Scrutiny Committee

Can Healthwatch Birmingham please let us see its complaints & concerns data on UHB?

Bewick’s lack of data on suspended and disciplined UHB doctors, despite complaints of medical management cronyism

Bewick, the ICB, misinformation by UHB about GMC referrals and a late correction

NHSE, ICB and UHB’s three-ring circus and Rosser’s digital assignment

What the UHB Freedom To Speak Up Guardian told the BBC

Why is CQC not investigating UHB under CQC Regulation 12?

Healthwatch Birmingham & Solihull has been receiving increasing concerns from the public about UHB and has held monthly meetings with the CQC

Dr Minh Alexander retired consultant psychiatrist 3 May 2023

I was interested in Healthwatch as a source of patient intelligence after Bewick declared University Hospitals Birmingham NHS Foundation Trust safe overall without mentioning patient complaints.

Local Healthwatch services support local communities to make use of health services.

They are ultimately funded by the Department of Health and Social Care. The funds are routed through local authorities. There are currently 152 local Healthwatch organisations which collectively receive £250,400,000 via local authorities to carry out their statutory activities for year 2022/23.

Healthwatch organisations are social enterprises which are contracted to carry out statutory activities. These statutory duties consist of:

(i) advising the Care Quality Commission through information supplied to Healthwatch England – a subcommittee of the CQC, and of

 (ii) providing local communities with information about access to local services.

The government also intended that local Healthwatch organisations should:

“…act as local consumer champion representing the collective voice of patients, service users, carers and the public, on statutory health and wellbeing boards” 

and to assist with complaints: 

“…support individuals to access information and independent advocacy if they need help to complain about NHS services.”

However, Healthwatch Birmingham does not publish data on concerns received from the public.

It has an online feedback page where some comments by the public can be seen, good and bad, and some organisational responses can also be seen.

I asked Healthwatch Birmingham for its data on complaints and concerns. 

I also asked if there was any restriction on whether this data could be routinely published, and whether commissioners request that the complaints and concerns data is reserved only for commissioners and regulators. This is because Healthwatch Birmingham informed me that despite not publishing the data, it did in fact collate it and routinely sent a report to commissioners and regulators on a quarterly basis.

Healthwatch Birmingham has now shared the numbers of concerns received from the public since 2018, but with no qualitative summary about these concerns. It has also not answered the question about whether its contract requires it to reserve data on complaints and concerns for commissioners and regulators only. 

Notwithstanding, HW Birmingham has indicated that due to escalating concerns received from the public in 2021 about UHB, it asked to meet with the CQC and has continued to do so on a monthly basis.

Over the course of 2021, we raised additional concerns with the CQC on several occasions following an increase in negative feedback and concerns from the public received by Healthwatch Birmingham and Healthwatch Solihull, and intelligence personally received by our Chair. We had also noted UHB’s poor performance in published NHS waiting list statistics and we raised these issues with the CQC. As a result the CQC agreed to meet us monthly to update us on their monitoring of UHB. These meetings continue.”

CQC conducted an unannounced inspection of UHB in June 2021 when it concluded that: “Managers shared feedback from complaints with staff and learning was used to improve the service.”

Although CQC dropped the overall UHB trust rating to “Requires Improvement”, its inspection report implied that much of the turmoil at the trust was COVID-related.

CQC maintained, despite several FPPR referrals on UHB’s then CEO David Rosser, the trust was “Good” under the Well Led domain.

In July 2021, the CQC was additionally warned by UNISON who submitted a formal dossier of staffside concerns about mismanagement at UHB.

The figures now released by HW Birmingham show that concerns from the public spiked even more sharply in 2022.

Figures for 2023 so far suggest that the rate of concerns remains much elevated.

This is the FOI disclosure by HW Birmingham about concerns raised by the public on UHB.

This is the correspondence exchange with HW Birmingham Chair and CEO.

As was reported by BBC Newsnight, in the summer of 2022 the Parliamentary and Health Service Ombudsman triggered the CQC’s multiagency Emerging Concerns Protocol for the first time ever, because of concerns that UHB’s leadership was not learning from serious incidents and was “aggressive” in response to the PHSO’s interventions.

According to HW Birmingham, although Healthwatch England is a sub-committee of the CQC and the Chair of HW England is a CQC board member, local Healthwatch organisations do NOT have the power to trigger CQC’s Emerging Concerns Protocol. So there is structural inequality – the patients’ champions may report upwards but they have no hands on any levers. Supplication only.

Neither did the PHSO think to alert the local Healthwatch, the nearest thing to the official local voice of patients, when it triggered the Emerging Concerns Protocol.

HW Birmingham’s Chair is a member of the external reference group which has the role of maintaining independent oversight of the ongoing Bewick reviews of UHB governance.

HW Birmingham has through its Chair made a number of statements about the UHB scandal:

Healthwatch statement on investigation into University Hospitals Birmingham (UHB) 9 December 2022

Healthwatch statement on delay to investigation into University Hospitals Birmingham (UHB) 9 March 2023

Healthwatch statement on Parliamentary Health Service Ombudsman (PHSO) and University Hospitals Birmingham (UHB) 14 March 2023

Healthwatch statement on the Bewick review into patient safety and concerns at University Hospitals Birmingham (UHB) 28 March 2023

Healthwatch statement on Care Quality Commission investigations into Good Hope Hospital and Heartlands Hospital 19 April 2023

In none of these statements is it disclosed that there was a very marked spike in concerns received by HW Birmingham, or that HW Birmingham has been holding frequent meetings with the Care Quality Commission in consequence. I appreciate there may be contractual constraints on Healthwatch organisations.

There is an expression: The truth, the whole truth, and nothing but the truth.

The scandal at UHB was allowed to happen. It did not spring forth fully formed. It was conceived when government policy failed to protect clinical quality, it was nourished when certain directors were appointed. It was incubated when whistleblowers were ignored and thrown back to the wolves, when safe staffing was deemed an optional extra. As at MidStaffs, poor care was normalised and regulators did not put patients first. Poor culture was not addressed and was instead perpetuated when abusive executives were excused and protected. 

Taking the microscope, and not a very good microscope at that, to UHB alone is not enough. What happened at UHB happens elsewhere still, and there will be more UHBs. 

It is the central governance of the NHS and government policy that needs proper examination, as acknowledged by the HW Birmingham statement of 9 December 2022.

But how likely is that? Rather, secrets and Bewick’s Bendy Hall of Mirrors prevail.


I have written to Mike Bewick to formally ask that he reviews UHB patient complaint data as part of his reviews:


Dr Mike Bewick

4 May 2023

Dear Mike,

FOI data from Healthwatch organisations on concerns received from the public about UHB

Please find attached FOI data from local Healthwatch organisations which shows escalation in concerns received from the public about UHB since 2021, which was such that Healthwatch has been holding monthly meetings with CQC since 2021.

I hope your reviews into UHB will now include some examination of patient complaints data, with both quantitative and qualitative analysis.

With best wishes,


Dr Minh Alexander

Cc BBC Newsnight
Nancy Cole ITV
Becky Johnson
Rob Behrens PHSO
Preet K Gill MP external reference group
Dr Chaand Nagpaul external reference group


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

What’s the point of CQC’s Emerging Concerns Protocol? CQC never once triggered it at UHB nor held a regulatory risk summit in the four years up to 31 March 2022

PHSO alleges it has been excluded from NHSE/ICB’s reviews on UHB & ICB’s factual inaccuracy to the Joint Health Overview and Scrutiny Committee

Can Healthwatch Birmingham please let us see its complaints & concerns data on UHB?

Bewick’s lack of data on suspended and disciplined UHB doctors, despite complaints of medical management cronyism

Bewick, the ICB, misinformation by UHB about GMC referrals and a late correction

NHSE, ICB and UHB’s three-ring circus and Rosser’s digital assignment

What the UHB Freedom To Speak Up Guardian told the BBC

Why is CQC not investigating UHB under CQC Regulation 12?

After the Hooper Review and UHB: GMC’s wider system for identifying rogue employers

Dr Minh Alexander retired consultant psychiatrist 1 May 2023

The ongoing scandal at UHB has helped to highlight an engineered injustice against the NHS workforce: a lack of protection against arbitrary discipline.

It is a political instrument of control and helps to serve whatever master is in power. Workforce intimidation can help to hide failures of policy and lack of resources.

In the last thirteen years, we have seen particularly extreme manifestations of this suppression, especially during the pandemic, and we now see unprecedented NHS strikes as a point of no return is reached in government’s ransacking of the public purse and public services.

I hope the letter below to the CEO of the General Medical Council pressing for active measures to identify rogue employers who abuse referrals to the GMC as an improper way to punish doctors, sometimes whistleblowers, is self-explanatory.



Charlie Massey

Chief Executive

General Medical Council

1 May 2023

Dear Charlie,

After the Hooper Review and UHB: GMC’s wider system for identifying rogue employers

I write to ask about the General Medical Council’s systems for early identification of rogue employers and thus for protecting doctors from abuse by such employers.

At University Hospitals Birmingham NHS Foundation Trust it has emerged that the consultant body raised a concern with the trust board about cronyism at every level of medical management.

Obviously this would be a grave issue both in terms of safe working environment for doctors and patient safety, as it would create an atmosphere that is unconducive to raising public interest disclosures and it would more likely result in arbitrary treatment of any doctor who raised concerns.

Unsurprisingly, alongside the concerns about cronyism affecting UHB medical management, there have also been reports of arbitrary application of discipline and rapid escalation of disciplinary procedure and GMC referrals.

UHB last year issued inaccurate FOI data about its pattern of GMC referrals and outcomes which caused alarm.

From December 2022 onwards I made several requests for corrected data, after I noticed that UHB’s FOI response could not be true.

The trust has now corrected the record and claimed that these are the true facts:


Dear Dr Alexander

Please find below a response to your email to Dame Yve Buckland, dated 29 March.

For the period 1 April 2012 to 31 March 2022:

– How many doctors the trust referred to the GMC ?

At UHB (prior to and post the merger with Heart of England NHS Foundation Trust (“HEFT”)) there were 22 referrals

At HEFT (prior to the merger with UHB) there were 16 (3 of these are dated just after the date of merger 1.4.2018, but are attributed to HEFT – we believe this may be because there was contact before the change of RO)

– How many of these referrals were signed off by the medical director?

At UHB 14/22, the remainder were signed off by Deputy Medical Director or acting Medical Director 
At HEFT 6/16 were signed off by the Medical Director and the remainder were by Deputy or Associate Medical Directors. 

– How many of these referrals resulted in no further action by the GMC?

UHB – 4 were concluded at triage, 7 were investigated and concluded with no action, 11 were subject to advice, warning, undertakings, suspension or erasure HEFT – 3 were concluded at triage, 4 were investigated and concluded with no action,  9 were subject to advice, warning, undertakings, suspension or erasure

– How many doctors died whilst under GMC investigation or monitoring?

– How many doctors died by suicide whilst under GMC investigation or monitoring?

David Burbridge
Chief Legal Officer

As you can see, this still leaves 18 out of 38 GMC referrals by UHB which ended in cases being dropped at triage or no further action being taken by the GMC, in a ten year period.


Information request

With respect to UHB:

I would be grateful if the GMC could verify if the most recent data supplied by UHB is indeed the correct picture.

Could the GMC additionally clarify in the 20 cases where it reportedly took action, in how many of these UHB cases did the action consist only of advice given to the referred doctor?

Where the GMC action comprised solely of advice given to the referred doctor, was a GMC referral really necessary or would a less formal and drastic route of addressing concern have been possible and/or preferable?

More generally:

What mechanism(s) does the GMC have in place, if any, to detect whether individual employers are making inappropriate or abusive GMC referrals?

What early warning signs does the GMC track, if any, to alert itself of poor employer practices with respect to GMC referrals?

Has the GMC estimated at national level what proportion of GMC referrals annually by employers are inappropriate and/or could have been dealt with another means?

If so, please give the total percentage of GMC referrals annually which the GMC believes could have been avoided.

What policies and strategies does the GMC have in place to address inappropriate referrals, and how does it measure the effectiveness of these policies and strategies?

What quality indicators does GMC monitor, if any, on each employer’s GMC referrals?

What comparative data does GMC collate centrally, if any, to track differences between employers’ behaviour, in terms of quality and outcomes of GMC referrals?

Can the GMC, based on its current systems and data collection, tell whether some employers are outliers in terms of higher rates of GMC referrals which end in no case to answer, no further action, or only advice given?

Does the GMC collate central data on whether it raises concerns with individual employers about poor referral practice or gives formal warnings to individual employers and medical managers about poor practices such as vexatious GMC referrals or GMC referrals which are suspected to be vexatious?

Has the GMC in the last five years disciplined any senior doctor for abusing power and vexatiously referring a doctor under their line management to the GMC, for example, by carelessly or knowingly making a false allegation?

If so, on how many occasions has this happened and what was the GMC sanction(s) applied, for example, undertakings, warning, suspension or erasure etc?

If the GMC currently has no system for tracking poor GMC referral practice by individual employers, and for publishing such comparative data, will it give consideration to doing so in future?

If the GMC does currently track this data but does not publish it, will it give consideration to doing so in future?

Will it also consider a change to Good Medical Practice guidance to specifically make it a proscribed practice for doctors in leadership positions to carelessly or knowingly make unsubstantiated or false GMC referrals or PPA referrals on doctors whom they manage?

Lastly, GMC previously kindly shared a status update on its Hooper implementation project. Could it do so again?

I copy this to Mr Reuser and to Mr Watkinson who as the GMC will be aware, were proven to have been mistreated by UHB. They were referred to the GMC based on very flawed governance processes. This included UHB supplying NCAS (now PPA) with false information. 

PPA has since kindly changed its processes, and is now considering strengthening more processes. I hope GMC will do the same.

I am aware of other doctors who have been referred by UHB to the GMC under contentious circumstances, and I hope they will in due course have some resolution of their issues.

As you will know only too well, a GMC referral is a massive upheaval in most doctors’ lives and will cause the majority huge distress and major health consequences. This will be compounded when the referring employer acts in bad faith and is not only unsupportive but actively persecutory.

I also copy this letter to Chaand Nagpaul who is on the external reference group for the ongoing reviews into UHB’s governance.

With best wishes,


Mr Tristan Reuser

Mr John Watkinson

BBC Newsnight

Nancy Cole ITV



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

After Reuser v UHB and Macanovic v Portsmouth: New rules to deter malicious referrals of whistleblowers to the Practitioner Performance Advice service

Mr Tristan Reuser surgeon & GMC. Update on GMC, whistleblowing and implementation of the Hooper recommendations

Waste Industry: The NHS disciplinary process & Dr John Bestley

What’s the point of CQC’s Emerging Concerns Protocol? CQC never once triggered it at UHB nor held a regulatory risk summit in the four years up to 31 March 2022

PHSO alleges it has been excluded from NHSE/ICB’s reviews on UHB & ICB’s factual inaccuracy to the Joint Health Overview and Scrutiny Committee

Can Healthwatch Birmingham please let us see its complaints & concerns data on UHB?

Bewick’s lack of data on suspended and disciplined UHB doctors, despite complaints of medical management cronyism

Bewick, the ICB, misinformation by UHB about GMC referrals and a late correction

NHSE, ICB and UHB’s three-ring circus and Rosser’s digital assignment

What the UHB Freedom To Speak Up Guardian told the BBC

Why is CQC not investigating UHB under CQC Regulation 12?


What’s the point of CQC’s Emerging Concerns Protocol? CQC never once triggered it at UHB nor held a regulatory risk summit in the four years up to 31 March 2022

Dr Minh Alexander retired consultant psychiatrist 29 April 2023

The Parliamentary and Health Service Ombudsman told BBC Newsnight that it triggered this protocol for the first time ever at University Hospitals Birmingham NHS Foundation Trust in the summer of 2022 because of concerns about UHB’s culture and leadership, with respect to learning from serious incidents.

PHSO advised me it attended multi-agency meetings about its concerns on UHB on 4 August 2022, 12 October 2022, 10 January 2023 and 7 February 2023.



Man died after medical staff missed opportunities to identify abnormalities on abdominal x-ray

A 65 year old man died avoidably at UHB in 2019 of intestinal obstruction after doctors failed to interpret clinical signs and read an abdominal x-ray correctly.

His sister was wrongly told that he had constipation and dehydration.

His family were awarded compensation in the higher PHSO range of £10,000.

The Care Quality Commission’s Emerging Concerns Protocol for data sharing between regulators says that no concern is too small to invoke the protocol.

I asked CQC if it had ever triggered this protocol at UHB.

CQC’s FOI reply of 28 April 2023 revealed that it had never done so, not even after receiving the dossier from UNISON in July 2021 about extensive UHB staffside concerns regarding unsafe staffing and poor management behaviour. Or the FPPR referrals on Rosser the former UHB CEO or the blood products never events.

Consistent with this lack of action upon the UNISON dossier, CQC indicated that it had not attended any regulatory risk summit meetings on UHB in the four years prior to 31 March 2022.

“CQC did not attend, and does not hold information about, any regulatory risks summit meetings (or similar) held about UHB in the 4 years up to 31/03/2022”.

CQC refused to say what regulatory risk summit meetings it had attended since then:

CQC will not disclose whether or not we have attended any regulatory risks summit meetings (or similar) about UHB since 01/04/2022 as disclosing recent information about this type of activity would be likely to be prejudicial to the exercise of our regulatory functions.”

The regulator implied that information sharing had occurred outside of its emerging concerns protocol:

“It should be noted that the ECP is not the only mechanism or legal framework for regulators to share information. Nor is it designed as a mechanism for sharing only the most serious or substantial information of concern.”

However, the lack of any regulatory risk summit meetings in the four years up to 31 March 2023 suggests that CQC simply did not consider there were serious problems at UHB (or alternatively did not wish to acknowledge them).

It was not until after the first BBC Newsnight broadcast that CQC carried out the unannounced inspections in December 2022 which led to the recent issue of a warning notice about unsafe staffing, which UHB have been whistleblowing about for years now.

CQC reported from this inspection that levels of staffing were so low that vulnerable patients were having falls and some had sustained injuries DURING this inspection. 

Trust board papers show that falls with serious or catastrophic injuries are a regular occurrence. 

Why is CQC simply issuing a warning notice and not conducting a Regulation 12 investigation given the history of repeated unsafe staffing and regular falls with serious patient injuries? 

Probably for the same reason that it did not act on UHB staff concerns in the first place and continued to rate the trust as ‘Good’ until the problems were exposed by the media.


Why is CQC not investigating UHB under CQC Regulation 12?

PHSO alleges it has been excluded from NHSE/ICB’s reviews on UHB & ICB’s factual inaccuracy to the Joint Health Overview and Scrutiny Committee

Can Healthwatch Birmingham please let us see its complaints & concerns data on UHB?

Bewick’s lack of data on suspended and disciplined UHB doctors, despite complaints of medical management cronyism

Bewick, the ICB, misinformation by UHB about GMC referrals and a late correction

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

NHSE, ICB and UHB’s three-ring circus and Rosser’s digital assignment