CQC Whorlton Hall Cover Up: More CQC responses & culpability

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


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

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

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

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

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

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


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

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

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

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

Screenshot 2019-06-26 at 07.47.36

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

Screenshot 2019-06-26 at 08.49.38


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

Screenshot 2019-06-26 at 08.50.31


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

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

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

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

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


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

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

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

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

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

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


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

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

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

– August 2015

– March 2016

– August 2016

– November 2016

– September 2017

– March 2018

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

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

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


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

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

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

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

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

– the use of rapid tranquillisation outwith policies

– the use of seclusion outwith policies and protocols

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

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


“the report was deleted and never published”

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



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


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

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

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

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


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

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


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

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


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

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

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

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



The CQC’s response to these questions in summary

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

In short, the CQC admits that:

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

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

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

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

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

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

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

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

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

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

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


“CQC settles case with former deputy chief executive Jill Finney


9 December 2014

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

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

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

The parties have agreed the following statement.

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

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

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

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

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

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

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

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

The stench has only got a whole lot stronger.

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

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

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


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

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

“Dear Dr Alexander

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

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

Yours sincerely

Robert Francis”


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

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

CQC is not only unfit for purpose, but dangerous.

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

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


Appendix: Full CQC response  FOI 25 June 2019

Our Ref: CQC IAT 1920 0148

 Dear Dr Alexander

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 Our Ref: CQC IAT 1920 0213

Dear Dr Alexander

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

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

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

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

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


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

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



Mandy Falconer CQC Operations Manager joins Danshell as Operations Director May 2016

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Backscratcher CQC




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

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


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

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

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

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

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

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


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

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

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

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

Ex-soldier jailed for attack on disabled man

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

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

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

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

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

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

Newbus Grange Outstanding


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

Chris Shield Nurse of the Year cached web page


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

Chris Shield tweet by recognition PR about promotion


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

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

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

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

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

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

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

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



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

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


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

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

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

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

It takes time and money to service a denial machine.

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

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

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

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




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

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

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

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

Screenshot 2019-06-14 at 09.17.37.png


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

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

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

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

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



Whorlton Hall needed to fit the CQC narrative

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

BBC Timeline: Winterbourne View abuse scandal

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

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

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

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


CQC’s fixers and schmoozers

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

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

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

Screenshot 2019-06-14 at 06.44.54

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

Screenshot 2019-06-14 at 08.35.25

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

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

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

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

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

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

Barbara Keeley letter to Trenholm 14.06.2019 part 1.jpg

Barbara Keeley letter to Ian Trenholm CQC 14.06.2019 part 2


Barbara Keeley letter to Ian Trenholm 14.06.2019 part 3


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



Currently listed CQC comms and engagement staff:

Anna Jefferson, Head of Media

Laura Conn, Media Manager

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

Lauren Haslehurst, Senior Media Officer (Adult social care)

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

Maryellen Clare, Senior Media Officer (Mental Health)

Paul Darigan Social Media Manager

James Hedges Regional Communications Officer

Chris Day Director of Engagement

Louise Grifferty Regional Engagement Manager

Amy Key Head of Provider Engagement

Abigail Walker Provider Engagement Officer

Alan Pickstock Engagement Integration lead

Ayse Sema Senior Engagement and Comms officer

Brian Silk Senior Digital Engagement Advisor

Tom Coales Head of Parliamentary Government and Stakeholder Engagement

Christopher Hares Parliamentary and Stakeholder Engagement Manager

James Bryant Government Engagement Manager

Jill Morrell Head of Public Engagement

Clare Haylock Senior Engagement and Internal Insight Officer

David Fryer Regional Comms manager at CQC

Edward Foster Communications and Engagement Manager

Elizabeth Dobres Communications and Engagement Manager

Farrah Chandra Regional Engagement Officer

Fionnula Robinson Senior Engagement Manager

Holly Daniels Head of Transformation Engagement at Care Quality Commission

Quinten Manby Head of Internal Engagement



Carl Beech who is on trial for the VIP paedophile fraud and perverting the course of justice, and who was recently convicted of sex offences against children, was a CQC inspector:

Carl Beech trial: VIP child sex accuser is convicted paedophile

Westminster VIP abuse accuser ‘fled to Sweden when story collapsed’

“Beech, who worked for the Care Quality Commission health watchdog”

Carl Beech was listed by South Western Ambulance Service NHS Trust as a CQC lead inspector:

Board paper November 2014

Screenshot 2019-06-14 at 10.39.27.png







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

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

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

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

‘Wicked’ will fraud doctor Zholia Alemi jailed

 Fake will doctor lied to NHS bosses

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

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

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

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

The usual closing of ranks took place.

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

RCPsych Zholia Alemi MRCpsych correspondence

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

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

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

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


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

Date: 31 May 2019 at 10:48:40 BST

To:  Minh Alexander  <REDACTED>

Cc: MHTS Presidents Office <REDACTED>

Dear Dr Alexander

Freedom of Information (Scotland) Act 2002 (FOISA)

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

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

I hope you find this information of assistance.

Yours sincerely

Agnes Ferrie

Tribunals Operations Support

Scottish Courts and Tribunals Service

Tel: 01698 390012

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

FOI request for Mental Health Tribunal Scotland 30 May 2019

Dear Sir,

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


“Dear R Woods

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

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

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

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

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

I trust you will find this information of assistance.

Yours sincerely

Agnes Ferrie 

Tribunals Operations Support 

Scottish Courts and Tribunals Service

18th December 2018”

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

“Dear Mr Woods

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

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

I trust that this provides sufficient clarification.

Yours sincerely

Agnes Ferrie 

Tribunals Operations Support 

Scottish Courts and Tribunals Service”

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

Please can the Tribunal answer this question.

Please also answer the following additional questions:

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

1) a consultant psychiatrist;

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

If so, 

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

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

Yours sincerely,

Dr Minh Alexander”



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


Excerpt Mental Health Tribunal Scotland regulations medical members regulations

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

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




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


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

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

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

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

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

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

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


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

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

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

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

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

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

Further update 10 June 2019

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

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

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

A still unanswered question to DHSC about whether CQC will investigate individual whistleblowers’ concerns


Summary: In recent correspondence the Department of Health and Social Care official responsible for whistleblowing policy seemed to believe that CQC should ‘urgently’ investigate whistleblowers’ patient safety concerns. He agreed to take the issue up with his Department but then stopped responding to enquiries. In the aftermath of yet more grave abuse revelations at Whorlton Hall, where CQC only conducted a superficial thematic review in response to whistleblower concerns, the question about specific investigation has now been redirected to the Minister for Care and Gosport MP, Caroline Dinenage. Relevant correspondence is provided below.



Caroline Dinenage

Minister for Care

Department of Health and Social Care


25 May 2019

Dear Ms Dinenage,

Gosport, Whorlton Hall and CQC’s remit for investigating Individual Whistleblowers’ Concerns

I write regarding this simple and core issue of whistleblowing governance which remains unresolved, despite it being repeatedly raised with the government on repeated occasions, in various ways.

Latterly, I have been in correspondence with Chris Bostock, who is DHSC lead for whistleblowing policy, who kindly agreed that CQC should investigate individual whistleblowers’ concerns. He agreed to clarify DHSC’s position on this, but did not get back to me. I chased twice, and I think Chris probably received my enquiries as they generated automatic receipts, but I heard no more. Please see the correspondence below. I suspect this means that the Department does not share his view.  If so, I would be grateful if you could reconsider in the light of the grave revelations about Whorlton Hall, coming on top of the horrendous events at Gosport War Memorial Hospital.

In fact, the CQC indicated to me in Autumn 2018 that it would be reviewing its longstanding position of refusing to investigate individual whistleblowers’ concerns. The senior official who informed me of this, who leads on whistleblowing at CQC, acknowledged that CQC may have wrongly conflated whistleblowing matters with its complaints policy, when it formulated its approach of not investigating individual whistleblower’s concerns. However, I have heard nothing further, and a promised process of co-production of new procedures with whistleblowers does not appear to have materialised.

It is more than likely that defenceless people continue to suffer serious abuse under the CQC’s nose because of the CQC’s failure to function as an effective regulator, and its failure to listen properly to whistleblowers. I copy below the extract from CQC’s inspection report of 2018 on how it responded to a whistleblowing report of poor culture at Whorlton Hall. You will see that CQC undertook a superficial check and there is nothing about a specific response to the whistleblower(s)’s concerns. This is very typical of how CQC operates:



“Leadership, morale and staff engagement 

We had received information prior to our inspection about low staff morale and a culture of bullying within the service. The staff we spoke to said that morale was positive in the team and they were happy in their roles. All of the staff we spoke to felt supported, respected and valued by management and peers and felt that they worked well as a team. Staff told us that there was a culture of openness within the service and the wider Danshell group and managers empowered and actively encouraged staff to raise any issues or concerns and make suggestions to improve service delivery. Danshell had a whistleblowing policy which staff were aware of and knew how to access it. At the time of our inspection visit, there had been no discrimination, bullying or harassment cases reported by staff at the service within the previous 12 months. Danshell reported that during our visit the sickness absence rate at Whorlton Hall for the previous 12 months was 3%, which was below the NHS national average figure of 4.29% and showed staff regularly attended work. We attended a ‘flash meeting’ which was a short team meeting, which took place each day. Staff shared important patient information, including medical appointments and each team member gave an update. For example, the maintenance staff provided an update on the status of repair requests Staff were informed of any visitors that were due at the service on the day and were reminded that all visitors needed to sign in and out and wear visitor badges at all times. Meetings ended with a fun ‘question of the day’ which staff appeared to enjoy participating in.”

Indeed, the most recent CQC board papers of 15 May 2019 shows that CQC continues to dispose of an increasing proportion of whistleblowers’ concerns by taking no further action or merely noting the information for a future, routine inspection – the grey sections of the bar chart:


CQC whistleblowing bar chart board paper 15 May 2019


The way in which CQC operates is ultimately the government’s responsibility.

I think we need a completely clean slate, but if we are to keep the current regulatory model, I ask the government to at least ensure that CQC investigates individual whistleblowers’ concerns.

Indeed, this needs to be mandated across all sectors and should be set in the context of substantive reform of UK whistleblowing law.

Lastly, I would be grateful if the DHSC could disclose how many meetings DHSC officials have now held with BEIS about possible changes to UK whistleblowing legislation following the publication of the Gosport Independent Panel investigation report, and share any related, circulated meeting documents and records kept of those meetings.


With best wishes,

Dr Minh Alexander


cc Ann Reeves

Julie Bailey

Joint Committee on Human Rights including Lord Trimble and Lord


Public Accounts Committee

Health And Social Care Committee

Barbara Keeley

Laura Pidcock


From: Minh Alexander <REDACTED>

Subject: CQC’s remit for investigating

Date: 15 April 2019 at 13:03:14 BST

To: Chris Bostock <REDACTED>


Hi Chris,

I was not sure if you had received my last email (27 March, below).

Could you let me know what is the current DHSC position on whether CQC should investigate the concerns of individual whistleblowers from either Health or Social Care?

Many thanks and best wishes,



From: Minh Alexander < REDACTED >

Subject: CQC’s remit for investigating

Date: 27 March 2019 at 11:35:57 GMT

To: Chris Bostock <REDACTED>


Hi Chris,

Thanks for chasing.

From the lack of news, should I assume that this has proved to be a sticking point for the Department?




From: “Bostock, Chris” < REDACTED>

Subject: RE: CQC’s remit for investigating

Date: 31 January 2019 at 14:44:03 GMT

To: Minh Alexander <REDACTED>


Hi Minh

Thank you for the reminder – I will chase up with colleagues.



From: Minh Alexander [REDACTED]

Sent: 31 January 2019 14:41

To: Bostock, Chris <REDACTED>

Subject: Fwd: CQC’s remit for investigating


Hi Chris,

Is there any news from the Department yet/ a timescale for when there will be news?




From: Minh Alexander <REDACTED>

Subject: CQC’s remit for investigating

Date: 2 January 2019 at 09:13:46 GMT

To: Chris Bostock <REDACTED>


Happy New Year Chris

Thanks very much.


Perhaps we can talk when you get the response back from DHSC about legislation.




From: “Bostock, Chris” <REDACTED>

Subject: RE: CQC’s remit for investigating

Date: 28 December 2018 at 15:19:10 GMT

To: Minh Alexander <REDACTED>


Hi Minh

Thank you.

I have raised this within DHSC and hope to be able to get back with a definitive response when I return to work in the New Year. In particular, I have asked to be pointed towards the relevant legislation – primary or secondary. This ought to enable us to consider this issue without the need for interpretation. But, for the moment looking at this from a more general ‘feedback’ perspective, my personal view would be that any feedback, whether raised through a concern, complaint or ‘speaking up’, that raises a patient safety issue ought to be urgently investigated. And, specifically within this context, the fact it may be instigated through ‘whistleblowing’ is irrelevant in that patient safety is the over-riding concern. I would be content for an alternative viewpoint to be put forward, but any subsequent ‘care system’ action would then need to be based upon that.

If you think it helpful, I would be happy to talk this through on my return.

With best wishes for the New Year.



From: Minh Alexander [REDACTED]

Sent: 27 December 2018 14:40

To: Bostock, Chris <REDACTED>

Subject: CQC’s remit for investigating

Season’s greetings Chris.

Is there any update on this issue?

As you may already be aware, I asked Robert Francis if he might help push on this issue given that he acknowledged that system regulators have the power to investigate individual whistleblowers’ concerns, but he has been very reluctant to even answer.

His officials said a response was being prepared, but they appear to have switched to radio silence too. The Christmas holidays could be a factor.




From: Minh Alexander <REDACTED>

Subject: CQC’s remit for investigating

Date: 6 December 2018 at 14:27:55 GMT

To: Chris Bostock <REDACTED>


Hi Chris,

It would be very good news if that is definitely the DHSC’s view eg. that it expects the CQC to investigate individuals whistleblower’s concerns where appropriate.

But para 2.16 of the government’s response to Gosport is open to other interpretation. It does not specifically say that the action taken by CQC includes investigation of the whistleblower’s concerns. It only says “act upon” which can be interpreted to mean other things.

I think that the CQC might take advantage of that, given that it has striven so hard all these years to deny to that it has any remit to investigate individual whistleblowers’ concerns.

Earlier this week, CQC shared revised guidance for its inspectors on assessing providers’ whistleblowing governance:


This doesn’t say that inspectors should investigate individual whistleblowers’ concerns where appropriate. It just sets out more of the same – either ineffective questions to the whistleblower’s employer, bringing forward an inspection or passing the concern to another body. That’s all the CQC have ever done and it is how they avoid real engagement with countless whistleblowers.


These are the offending passages from CQC’s revised guidance to inspectors:


“4. How we act on information provided to us How we act depends on what we are told, and how serious the matter is. In the first 4 place, we need to decide whether: 


  • The issue is within the scope of our regulatory duties; and 


  • Whether another organisation is best placed to deal with the issue instead of, or as well as us. For example, the General Medical Council will look at a doctor’s fitness to practice and we will consider the impact on the people who use the service where that doctor works, if we regulate the service. 


CQC welcomes information from people speaking up and from whistleblowers, but we do not have powers to protect them. This is because although people can make ‘protected disclosures’ to us as a prescribed body under the Public Interest Disclosure Act 1988 (PIDA), PIDA does not give CQC any powers or any special status in relation to individual whistleblowers. PIDA relates exclusively to worker/employer relations.


Currently, people making a protected disclosure about a concern in a service they work in are protected under employment law. If a person who had raised a concern was involved in an employment tribunal in the future, the fact that they had told CQC about their concern might help any claim for unfair dismissal. However, CQC cannot intervene or be involved in any advice or any dispute with employers as a result of the concern or any other issue


  1. What we do with information We assess, prioritise and act appropriately on all information we receive when people speak up. This always involves thanking the person who tells us about their concern, ensuring they receive feedback on the actions taken where this is possible, and asking for feedback from them about how the matter was handled. It may also involve:


  • Using the information to help us to decide whether to urgently inspect the service or bring forward a planned inspection. 


  • Raising the issue directly with the provider. We will make every effort to protect the worker’s confidentiality when we do so. In some exceptional cases, we may need to progress without consent when we are concerned about the potential risk to people using services. Particular care must be taken when a worker is in a very small team or provider as it may be possible for them to be identified from the nature of the concern and subsequent action taken. 


  • Making a safeguarding alert to a local authority. We will always let the person know if we believe it is necessary to disclose their identity, for example if making a safeguarding alert to the local authority if the disclosure is about possible harm or abuse. We will follow our safeguarding procedure and actively follow up the alert. The inspector for the service will monitor the progress and outcome of the local authority’s investigation. To support that investigation, we might carry out an inspection to ensure the provider is meeting the regulations. 


  • Notifying another regulator or official body if it is appropriate for them to look into the disclosure instead of, or as well as us. This must be done in a way which would not breach the confidentiality of the individual unless they have given their consent for their identity to be revealed. • Notifying the police if the issue is about possible illegal activity. We can do this as well as any of the above actions. If we believe the disclosure is about possible abuse, it is essential that the inspector records the action taken in the safeguarding record and in the Activity Plan on Customer Relationship Management (CRM) database.”


If the DHSC thinks that CQC should investigate individual whistleblowers’ concerns where appropriate, but CQC is still denies that it has this power/ responsibility, how can the CQC be persuaded and compelled otherwise?

Back to you!

All best and early season’s greetings 🙂



From: “Bostock, Chris” < REDACTED>

Subject: RE: CQC’s remit for investigating

Date: 6 December 2018 at 09:06:49 GMT

To: Minh Alexander < REDACTED>

Hi Minh

My apologies but I have not been working for over a week.

However, I think the Gosport response confirms CQC has that power:

“2.16 All whistleblowing concerns raised with the CQC are forwarded to the local inspector for consideration. This allows the CQC to spot problems or concerns in local services that it may need to act upon.”  

Does this answer your question? If not, please get back to me.




From: Minh Alexander [REDACTED]

Sent: 04 December 2018 07:27

To: Bostock, Chris <REDACTED>

Subject: CQC’s remit for investigating

Morning Chris,

Is it possible to have a response to the question of 20 Nov below?

Thanks & BW




From: Minh Alexander <REDACTED>

Subject: CQC’s remit for investigating

Date: 20 November 2018 at 08:32:59 GMT

To: Chris Bostock <REDACTED>

Morning Chris,

I realised there was one important that we didn’t cover when we spoke.

In my email below of 25 Oct 2018 I raised this issue:

“It would be very helpful if the DHSC could either clearly confirm that CQC has the power to investigate individual whistleblowers’ concerns, or alter CQC’s regulations to make this unequivocally so.”

Is there some clarification possible on this point?

Thanks and BW,



Danshell, the providers responsible for Whorlton Hall, who were recently acquired by Cygnet, previously boasted of 100% ‘Good’ ratings by the CQC:

Danshell 100% good



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

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





Spinning Death at Gosport II: DHSC FOI revelations & National Guardian’s fake independence

By Dr Minh Alexander, NHS whistleblower and former consultant psychiatrist, 31 March 2019



Summary: Shocking documents in the archives of the Gosport Independent Panel inquiry revealed the Department of Health driving improper, aggressive NHS spin in regards to the Gosport War Memorial Hospital inquests. The government is still spinning about Gosport through its Freedom To Speak Up project. The government appointed two unsuitable figureheads with no special expertise in whistleblowing to the post of National Freedom To Speak Up Guardian. The National Guardian’s Office makes unsupportable claims that it is having a substantial impact and that NHS whistleblowers will now be treated fairly. Department of Health and Social Care FOI data, albeit heavily redacted, shows how the National Guardian’s Office and the government have worked together to spin a ‘positive narrative’ about NHS whistleblowing, as part of the government’s response to the chilling Gosport deaths disaster. Two months ago the National Guardian claimed that she would put a report before parliament to hold the government to account. In fact this was orchestrated by the government. The DHSC repeatedly claims that the NGO is independent, but behind the scenes makes it clear that it prefers the NGO to ‘be on the same page’.  Whilst this distasteful circus wastes more and more public money, the bereaved Gosport relatives remain in the cold with no justice to show for a distressing, twenty year search for answers. Whistleblowers continue to be ignored and harmed. Governments simply cannot be relied upon to hold themselves to account. We need real reforms including an overhaul of defective UK whistleblowing law. As part of this, we need a statutory agency to protect whistleblowers and the public interest, that is genuinely independent of government.





The government has appointed two figureheads to a national Freedom To Speak Up office for NHS whistleblowing. The Office was created to legitimise the confection that government has acted upon the revelations of the Mid Staffs disaster and numerous NHS whistleblower scandals.

Eileen Sills the Chief Nurse of Guys and St Thomas NHS Foundation trust, which had super-gagged whistleblowers, was the first figurehead. She was appointed for a unfeasible two days a week.

Sills embarrassed Jeremy Hunt by resigning before she took up post. But not before she revealed astonishing ignorance about whistleblowing by commenting that it was too soon to tell if the twenty year old UK Public Interest Disclosure Act would work. This is the record of the relevant meeting:

Agreed record of meeting with Eileen Sills National Guardian 23 February 2016

The second figurehead who was appointed is the incumbent, Dr Henrietta Hughes a former NHS England Medical Director, who in fact had oversight of the maternal deaths/ whistleblower scandal  at the Homerton Hospital.

Screenshot 2019-03-31 at 05.37.26


Around the time of her appointment as National Guardian, Hughes scrubbed her Twitter account, removing past interactions with other NHS managers. A few revealing tweets  remained nevertheless:

Screenshot 2019-03-31 at 05.45.38

Screenshot 2019-03-31 at 05.55.02


Henrietta Hughes gave a disastrous interview to the Times at the start of her tenure as National Guardian. She displayed ignorance – or wilful blindness – of the serious power gradients driving suppression and whistleblower abuse. She claimed that it would be easy to change things if only NHS staff were more cheery. Condescending and unempathetic managerialism, you may think. It drew widespread ridicule.

In the aftermath of this inaugural flop, there was a move to salvage the situation by establishing Hughes as a whistleblower. A few unconvincing anecdotes were peddled through the Health Service Journal:


Whistleblower guardian will ‘not be an investigation body’

Health Service Journal 12 October 2016

Screenshot 2019-03-31 at 06.11.47

“She said raising concerns should be “part of normal business as usual” in the NHS, and revealed she had done it twice in her NHS career.

The first occasion related to a member of staff who had health problems and was receiving treatment that had resulted in them losing “insight into their own clinical abilities”.

“It was a very sad situation, but that member of staff was then supported with occupational health and time off, and it was the right thing to do,” Dr Hughes said.

The second incident involved an administrator who was using a health emergency badge for parking her car and later attempted to pass herself off as a nurse when she received a parking ticket.”


But we have seen nothing of substance to show that Hughes roots for the NHS frontline. We have seen indications to the contrary:

  • The National Guardian has gone along with the DHSC and CQC to water down even her very weak role, so as not to be of any practical help to whistleblowers in serious difficulty


  • She has not sought directions by NHS regulators, as she was supposed to, to right wrongs against individual whistleblowers and patients


  • She finds excuses not to review more than a handful of whistleblower cases




We have seen glimpses of unpleasantness by her Office behind the scenes, such as collusion with the CQC and hostile briefing against whistleblowers.

I have been contacted by unhappy whistleblowers, both those who have been turned down by the National Guardian for case review, and those who have been through case review. Some whistleblowers who have had a case review have complained of feeling marginalised, not adequately protected or frankly exploited and dumped.

Extremely seriously, we saw the National Guardian take her spin to a new level in response to the publication of the Gosport Independent Panel’s investigation report in June 2018.  She claimed in a letter to the Times, on the basis of no evidence:

“If our new system of “freedom to speak up” guardians had been in place when the nurses at Gosport spoke up they would have been listened to and the right actions would have been taken.”

 In fact, the National Guardian was aware by this point that some whistleblowers are failed by their Freedom To Speak Up Guardians.

Henrietta Hughes’ Times letter was accompanied by a press release on 21 June 2018 and a photo of her looking grim. Amazingly, instead of acknowledging the courage and persistence of the bereaved Gosport families in uncovering the truth, Hughes chose to flatter politicians:

AHughes grim

Last autumn just before the government’s response to the Gosport inquiry was due to be published, her Office ran interference for the government by launching a massive PR drive:

ASpeak up Month

In January 2019, Hughes claimed in her newsletter that she was going to lay a report before Parliament, to hold the government to account:

“In the past quarter there have been significant changes in Freedom to Speak Up across England, with the Government’s response to the Gosport Independent Panel Report and its continuing commitment to drive this cultural change. I have been asked to continue to champion workers speaking up through the network of Freedom to Speak Up Guardians, to publish an independent report to lay before Parliament identifying progress towards this goal, to showcase best practice, hold the Government and the system to account and advocate for change.”

Interestingly, Hughes withheld the source of request to lay this report before parliament.


FOI disclosure by the Department of Health and Social Care about communication with the National Guardian, regarding Gosport

An FOI request was made to the Department of Health and Social Care on 22 January 2019 for any correspondence between the National Guardian’s Office and the DHSC about the plan to lay a report before Parliament.

The DHSC dragged its feet, and twice advised that it needed more time to deliberate about what information should be exempted under Section 35 FOIA – formulation of government policy.

The requested documents were eventually disclosed on 27 March 2019, but with substantial redaction and withheld attachments.

Importantly, the disclosed documents show that it was the DHSC which suggested that Hughes lay an annual report before parliament. This suggestion was made at a meeting between Hughes and Jeremy Hunt the then Secretary of State on 26 June 2018. For example, an email from the DHSC on 28 August 2018 stated:

“As stated we did flag the annual report idea that came from the SoS meeting to MS(H) and MS(C) [Minister of State for Health and Minister of State for Care], along with some other feedback on ideas that were raised with Henrietta both in the meeting with SoS and through the calls we held with you and Henrietta in June.”

The fact that there were numerous redactions of the correspondence, on the purported grounds of formulation of government policy, demonstrates that the National Guardian’s Office is just part of government machinery and not independent.

In an email of 3 January 2019, the NGO plainly asked the DHSC for instructions:

“Annual report for Parliament

Would be helpful to have an early discussion about what the expectations and processes would be for this so that we can plan and budget accordingly. Again, something for [Redacted] as a Gosport recommendation?”

 The documents show that the NGO and the government have been huddling over what to do about Gosport since June 2018, when the Gosport inquiry report was published.

The DHSC and NGO held telephone calls on this theme in June 2018.

Henrietta Hughes herself has had the following meetings with the DHSC since the publication of the Gosport inquiry:

Screenshot 2019-03-31 at 04.44.07


The suggestion of an annual report for parliament was a PR set piece by Hunt. This is because the National Guardian already routinely produces an annual report,  which could simply be copied to parliament.

The production of a special annual report for parliament is about creating an opportunity for gloss. This was confirmed by an email from the National Guardian’s Office to the DHSC of 28 November 2018, which states:

“[Redacted]. Positive narrative – we have published some ‘positive’ case studies. See our annual report here:  and have plans to produce a ‘library’ of cases. We just need to be mindful of issues around confidentiality and the sensitive nature of some of the issues involved. This is probably going to be a useful strand of work to support the new ‘National Guardian Annual Report for parliament’ coming out of Gosport.” [Redacted]”

In an email of 27 November 2018, the DHSC indicated that the Department and the NGO should be “on the same page”:

“Re Following up on Gosport response. “In terms of the post Gosport work, I am holding the pen on the programme and in process (yet to start) a programme management plan. Be good to make sure we are on the same page. I am also leading on the second commitment around annual reporting, and would be good to touch base with you on that too”.

Henrietta Hughes’ Office seemed keen to ensure a budget uplift out of the government’s Gosport programme. Email 27 November 2018:

“Jennifer/ [Redacted]/ [Redacted]/ [Redacted].

Thank you so much for working with us in the run-up to the Government response to the Gosport report. There are obviously a few recommendations in there for us so would it be possible to chat through those and get a plan together? I will want to make sure that this all gets reflected in our business plan next year and will shortly need to start having conversations with our funding partners about what gets into the plan, what gets left out and if necessary, discuss our budget if there is any suggestion that this needs to change.”

Hughes’ function as figurehead is emphasised by her absence from most of the correspondence between her Office and the DHSC.

There is only a single reference to her being consulted during the exchange of emails.

It is likely, judging from a characteristic style and also a slip up in redaction, that most of the correspondence from the NGO was by Russell Parkinson, Hughes’ Head of Office.

Screenshot 2019-03-31 at 04.56.44


And guess where Russell Parkinson NGO Head of Office worked, before he went to the NGO?


A coincidence I’m sure.

The government remains firmly in the NHS driving seat, even though it claims otherwise when politically expedient. No whistleblowing initiative in its line of management can ever be truly independent.



Spinning death at Gosport: The Department of Health and the National Guardian

Silenced voices – Witness statements about concerns at Gosport War Memorial Hospital

Gosport deaths, UK government pork pies about whistleblower protection and failure to investigate concerns

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

At the Royal Society of Medicine, without the Minister or the Judge. Whistleblower testimony rebuts government’s deception and attacks on whistleblowers


An example of how the government uses the National Guardian’s Office to make spurious claims of improvement

Statement to House of Lords by Lord O’Shaughnessy, Under Secretary of State, 22 November 2018:

 “Next, we have set up the National Guardian’s Office to ensure staff concerns are heard and addressed. Every NHS trust in England now has someone in place whom whistleblowers can speak to in confidence and without fear of being penalised.”

“The reforms we have made since Gosport mean that staff can speak up with more confidence and that failings are identified earlier and responded to more quickly.”


NHS Spinning Death


At the Royal Society of Medicine, without the Minister or the Judge

By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, 29 March 2019



Summary: A brief account of an event at the Royal Society of Medicine about NHS whistleblowing. Neither of the two main speakers, Caroline Dinenage Gosport MP and Minister for Care and Justice John O’Hara, turned up. Justice O’Hara last year recommended criminal sanctions for NHS whistleblower suppression. Remarkably, the National Guardian’s Office took no part in the event. Nevertheless, there were appearances by the Department of Health and Social Care and the government’s chosen lead researcher for an evaluation of its Freedom To Speak Up project. Echoes of Matt Hancock’s previous ‘egregious whistleblowers’ narrative were heard via the presentation on the government-sponsored evaluation research. Two whistleblower speakers, Peter Duffy surgeon ex-University Hospitals Morecambe Bay NHS Foundation Trust and Dr Peter Wilmshurst, laid bare false government promises of protection. The real risk has never been problematic whistleblowers. It is egregious government spin and failures of accountability.



The Royal Society of Medicine 26 March 2019 event “Spotlight on NHS Whistleblowing” was an interesting day. There was a mixture of non-expert well-wishers, experienced, neophyte and prospective whistleblowers. There were also the usual sorts drawn by the profile and power issues inherent in whistleblowing matters, and/or the money, personal advantage and political capital to be made from them, and a scattering of policy makers.

Sir John O’Hara  the Northern Ireland High Court judge who led the hyponatraemia public inquiry was booked. An important speaker, because in his inquiry recommendations the judge had revived the notion that whistleblower suppression should be criminalised:


The Inquiry into Hyponatraemia-related Deaths, January 2018, Page 85

2. Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.”



Previously, Robert Francis had regrettably dumped the same recommendation from the MidStaffs public inquiry, when he conducted the Freedom To Speak Up Review.

However, Justice O’Hara never arrived at the Royal Society of Medicine. The organisers speculated about travel mishaps, with no further clarification.

Two piercing presentations were given by Peter Duffy Morecambe Bay whistleblower and Dr Peter Wilmshurst cardiologist and clinical drug trial whistleblower. Both gave unvarnished testimony on the collusion of NHS system and professional regulators, very senior NHS officials, medical defence bodies and the government itself. Peter Duffy included the National Guardian’s Office in his list of officials who failed him, and reported that the former Secretary of State, the current Secretary of State and the Minister for Care had all refused to meet with him. The courage of both whistleblowers was acknowledged by audience and peers.



Peter Duffy speaking on the abject failure of the last defence for whistleblowers, the Law:

“In my opinion, the Law fails whistleblowers in at least three critical areas.

 Firstly in an Employment Tribunal you would logically expect the emphasis to be on the whistleblowing, the clinical errors and the actions of the dismissing NHS trust and its managers.  

But no. You the whistleblower are the one on trial. it’s your character, behaviour, integrity and reputation that will be impuned, with every attempt made to smear and discredit you in the eyes of the Tribunal.

It is standard practice for the NHS trust to trawl back through years of emails, HR records, occupational health records and so on, in order to find anything with which to censure or degrade you under hostile cross examination

It is a horrible experience.

It simply allows the NHS to indulge in another round of whistleblower victimisation, abuse.”

“The next area where whistleblowers are failed is over the issue of cost threats…The threat is are huge, into my case six figures. It tactically arrives at the last minute…you can’t tell the Tribunal that you the whistleblower and any witness are being threatened and intimidated, as the letter is without prejudice, so you can’t disclose it.”

“Finally the Law demands an evidential link between whistleblowers and constructive dismissal, if the whistleblower is to receive full compensation. It’s not enough to show that you blew the whistle and shortly later you were illegally sacked.

The Tribunal needs an evidential smoking gun to link the two. This evidential link is an almost impossible test, particularly as the NHS conducts a scorched earth policy towards evidence right from the start.”


I had hoped to assess what further spin the government might attempt about whistleblowing, both in the NHS and beyond. Scheduled speakers were the Department of Health and Social Care Minister Caroline Dinenage and the government’s chosen researcher for the evaluation of its Freedom To Speak Up project.

Caroline Dinenage is also the MP for Gosport, where the Gosport Independent Panel investigation concluded that hundreds of defenceless, vulnerable people perished  through the deliberate administration by NHS hospital staff of lethal opiates, that were not clinically justified.

Dinenage is therefore in the conflicted position of responsibility to the victims of Gosport and their bereaved families as an MP, whilst defending the government’s handling of the Gosport disaster as a Minister.

This government defence includes reliance on the government’s Freedom To Speak Up project as ‘evidence’ that action has been taken to protect the public.

There is of course no evidence base for the Freedom To Speak Up model of internal Guardians, employed by the very organisations that they are supposed to hold to account.

There is in fact evidence to the contrary, judging from three trusts which had prototype Guardians prior to Francis’ Freedom To Speak Up Review:



  • And Barking, Havering and Redbridge University Hospitals NHS Trust, which has long been troubled and was not long ago placed in financial special measures.


The NHS National Guardian who oversees the trust Speak Up Guardian network acts more as a controlling firewall than a protection to NHS whistleblowers. She does not track whether NHS whistleblowers’ concerns are addressed. She has not used the full extent of her  limited influence to seek directions from NHS regulators to protect whistleblowers and patients.

But this didn’t stop Dinenage telling a bereaved Gosport relative that:

“Since the publication of the report the National Guardian has started to take a more active role and approach into how the NHS deals with concerns raised by staff”

A request has been made for substantiation of this claim, and the government’s response is awaited.

At the eleventh hour Dinenage pulled out of the Royal Society of Medicine event. The DHSC official who had to cover at short notice gave a very reserved talk, without slides, which largely recounted uncontentious historical background. There was little real detail about government plans. When asked about three meetings that DHSC and BEIS have held to discuss possible changes in UK whistleblowing law, she did not reveal anything about the work being done and only advised that the work is ongoing. Afterwards, she intimated that it is possible that more detail will be revealed at a later stage. We shall see.

The National Guardian’s Office was noticeable by its absence. It did not even participate in the online debate generated by the event.

The lead researcher hired by the government to evaluate its Freedom To Speak Up project broadly described the design and conduct to date of the study. This has focussed largely on trust Guardians and the National Guardian’s Office, rather than the end users – NHS whistleblowers.

He defined the role of the local trust Guardians in terms of creating a conducive environment for speaking up, changing culture and facilitating organisational learning from staff’s speaking up.

Unfortunately, he did not list protecting NHS whistleblowers from harm, despite that being an explicit goal of the Freedom To Speak Up Review recommendations.

So far, about 100 semi-structured telephone interviews have reportedly been undertaken with NHS trust guardians, and there is a reported intention is to conduct a focussed study of six NHS trusts. No information was provided on how these six trusts will be selected, and what parties will influence the selection. This is obviously pivotal in interpreting any results.

As his talk had not covered the experiences of whistleblowers who had disclosed to Speak Up Guardians, I asked if the evaluation study would capture this perspective. He advised that the study will seek to gather the experiences of staff who have used the Freedom To Speak Up Guardian service. There was no time in the session to press for more elaboration, but the methodology and any attempts by Guardians, the National Guardian, NHS trusts the DHSC or other players to filter or control this whistleblower data could have a critical bearing on outcome. These are important questions that must eventually be answered. Not least because I understand that the DHSC was reportedly very controlling during the Freedom To Speak Up Review, and we have seen the unfortunate outcome.

Notably, the lead researcher reported that some Speak Up Guardians had alleged bullying and harassment by the “whistleblower community” on social media. Many Speak Up Guardians are of course well intentioned and will be acting in good faith. It may be that some of this is genuine feedback, whether or not it is based on reasonable conclusions. But equally, there may be an element of injected spin, ultimately driven by the government’s interests. A worrying number of Speak Up Guardians are corporate appointments, who are arguably less likely to press the frontline’s interests and more likely to deliver what they think is desired by their CEOs, the DHSC and politicians. Some are even PR/Comms managers and Directors of HR. A number are seen broadcasting about the virtues of their senior managers, which introduces issues about neutrality and lacks consideration for staff who may wish to report managerial wrongdoing. I continue to be contacted by whistleblowers who complain about the trust Guardians or the National Guardian’s Office, some bearing tales of shocking and sometimes undeclared conflicts of interest.

Moreover, we have had instances of unfortunate modelling, such as through the Secretary of State’s comments about ‘egregious’ and possibly unwell whistleblowers, when he was invited to an event of 20 November 2018 on NHS learning, chaired by Dr Philippa Whitford MP.

Matt Hancock Secretary of State, joining the debate on 20 November 2018 about two thirds of the way through:

“I’ve been struck since becoming the Secretary of State for Health and Social Care about four months ago, at the need across the system as a whole, for a culture change led by leadership. When I looked into the questions that people were asking and looked into some of the terrible stories of failure of the system to listen to whistleblowers, and within the system individuals to listen to whistleblowers, both historically and more recently.” 

and ending with these comments:

“One of the challenges is that the system needs an effective way to filter out just as innocent mistakes and acts of neglect, there is a, we’ve got to get the line right between just whistleblowing and egregious whistleblowing. And there is especially because of the nature of the fact that some of the people in the system are not well, there is a challenge. I wonder whether some of the highly defensive culture that organisations that don’t have strong enough leadership end up holding, is partly because of some genuinely egregious whistleblowing that is not reasonable. And whether or not we like it, that is a feature.”



Another example is of a guest speaker at a conference organised by the National Guardian last year, whose comments had the effect of stereotyping whistleblowers as ‘angry’.

The research presentation at the Royal Society of Medicine therefore had echoes of this ‘egregious whistleblower’ narrative.

Certainly, the incessant empire building, spinning and self-congratulation about the Freedom To Speak Up project, led by the National Guardian’s office, casts a potential shadow on some of the data being fed to the government-commissioned evaluation of the project. Not to mention some instances of negative briefing by the National Guardian’s Office, collusion with CQC and others despite protestations of independence, and also its misuse of statistics.

There is also the fact that some of the Speak Up Guardians have pre-emptively blocked whistleblowers on social media, without any prior interaction, which speaks to a desire to block out dissent and uncomfortable truths about the project into which they have bought and seek to promote.

Importantly, the National Guardian’s Office is not independent as repeatedly claimed by the government. More about that another time.

In response to the RSM audience’s doubts and to troubling accounts by whistleblower speakers and audience members about their experiences of the Freedom To Speak Up project, the government’s appointed lead researcher maintained that it had been necessary to try something.

But we don’t take that approach to clinical interventions and medicines. We insist – in principle – that they must go through formal clinical trials to make sure they work, and importantly, are not harmful.

We rely on souls like Dr Peter Wilmshurst to keep such research honest. Especially because it concerns matters of life and death. It is reckless to launch a costly national programme without evidence base or even a pilot.

Vanity projects may serve an obvious political purpose, but they can delay and obstruct real reform for years, sometimes deliberately.

Bogus and problematic whistleblowers are the minority.

The much greater risk is egregious government spin, flannel and failures of accountability.


At the Royal Society of Medicine event on 26 March 2019, the government’s lead researcher for the evaluation of the government’s Freedom To Speak Up project put up a slide describing the National Guardian’s Office as an independent body.

It is not. It is a sub-committee of the Care Quality Commission, which is an arms length body that is line managed by the government.

Here is yet more evidence of government control of the Freedom To Speak Up project and the National Guardian’s Office, as revealed in an FOI disclosure 27 March 2019 by the Department of Health and Social Care:

Spinning Death at Gosport II: DHSC FOI revelations & National Guardian’s fake independence



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

Lecture by Dr Peter Wilmshurst about extraordinary medical establishment corruption and whistleblowing about research fraud

Employment Tribunal judgments in Peter Duffy’s case against University Hospitals of Morecambe NHS Foundation Trust

The BMJ’s write up of Peter Duffy’s presentation at the RSM ‘Whistleblowers: promises of protection are repeatedly broken, meeting hears’

Silenced voices – Witness statements about concerns at Gosport War Memorial Hospital

What could a new whistleblowing law look like? A discussion document







Mr Hancock’s violence reduction plan, reportable injuries to NHS mental health staff & lack of consistent reporting by CQC

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

Summary: In 2017 The government stopped central collection of data on assaults against NHS staff despite a rising trend and much criticism. A year later, it backtracked and announced a violence reduction strategy which included a promise that the CQC would scrutinise NHS trusts’ violence reduction plans. Three datasets show that NHS mental health services staff have suffered the highest rate of assaults. The Health and Safety Executive has supplied FOI data on statutory staff injury reports (RIDDOR) by NHS mental health trusts, which shows that since April 2015, 20 mental health trusts accounted for 67% of all the non-fatal RIDDOR injury reports. According to other FOI data, these 20 trust were mostly higher users of physical restraint, with very marked variation in the rates of resultant injury to staff and patients. However, the physical restraint data they supplied was incomplete and patchy. This raises questions about the governance and regulation of this area.  The most recent CQC inspections on these 20 trusts do not report reliably on violence against or injuries sustained by staff.




Amidst condemnation, the government stopped collecting central data on violence against NHS staff in 2017.

This was despite a steady escalation over several years in the number of assaults on NHS staff and questions in parliament about this.

Philip Dunne the then DH Minister of State stated in a written answer to a parliamentary question:

“We continue to collect data on physical assaults against NHS staff through the annual NHS staff survey, with trusts also collecting data at a local level, and we are making crucial legal changes to ensure those who are violent face the full force of the law.”

Some might think this disingenuous because the NHS staff survey does not give a precise idea of the number of assaults against NHS staff, not least because of incomplete response rates. Since 2012 the survey has only asked:

“How many times in the last 12 months have you personally experienced violence at work from patients/ service users, their relatives or members of the public:

  • Never
  • 1-2
  • 3-5
  • 6-10
  • More than 10”


Included in Dunne’s written answer is this table, which he claimed was evidence of stability in the level of assaults against NHS staff:

Screenshot 2019-03-20 at 11.09.11


In fact, over the last 10 years the NHS staff survey source data shows an overall increasing trend in the numbers of assaults on NHS staff by the public:

ANHS staff survey data violence

According to NHS staff survey data, NHS ambulance trust and mental health trust staff are most likely to experience violence:

ANHS Staff survey MH and ambulance trusts

NHS Protect’s pre-2017 national data collection regularly showed that mental health services had the highest rate of assaults per 1,000 staff. These are the figures for 2013/14 which show that mental health trusts had almost 10 times more assaults per 1,000 staff than all other NHS trusts combined (223 assaults per 1,000 staff per year vs 23 assaults per 1,000 staff).

Screenshot 2019-03-20 at 07.35.29

In early 2018, an FOI by the Health Service Journal on behalf of Unison to 181 NHS trusts suggested that the number of reported assaults against NHS staff had increased by 10%, from 51,447 in 2015/16 to 56,435 assaults in 2016/17.

The FOI gave the following figures for assaults in different types of NHS trust in 2016/17, and HSJ compared it against figures from 2015/16 which had been collected by NHS Protect:


(FOI data from 181 NHS trusts)


(NHS Protect data on the same trusts)

Acute* (104 trusts) 18,720 15,469
Mental Health* (39 trusts) 33,820 32,746
Ambulance (9 trusts) 2,330 2036
Community (13 trusts) 860 708
Specialist (15 trusts) 532 416
TOTAL 56,262 51,375

*Includes combined trusts with community services.

Based on its sample of 181 trusts, HSJ commented that mental health services are:

“…by far the most physically dangerous place in the NHS to work. Staff in mental health trusts are approximately seven and half times more likely to be attacked than staff in other NHS trusts.”

By October 2018 the government managed the controversy about its decision to stop national collection of violence statistics by announcing a strategy to reduce violence against NHS staff. In a speech the Secretary of State promised:

  • New legislation: The Assaults on Emergency Workers (Offences) Act 2018 which covers NHS workers as well as other services such as the police and fire services
  • Cooperation by the police and CPS to ensure that violence against NHS workers is prosecuted
  • Resumed national collection of statistics
  • Specific regulation: “CQC will scrutinise NHS trusts’ violence reduction plans”



The Health and Safety Executive collates data reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013.

Reporting by ‘responsible persons’ (usually the employer) is mandatory.

Annual HSE RIDDOR statistics suggest that working in health services is moderately risky, and carries a greater risk of reportable non-fatal injury than construction or mining and quarrying:

Screenshot 2019-03-20 at 09.13.50

In mental health, injuries to staff can be linked to poor management of patient aggression and violence through failures of risk assessment, prevention and de-escalation, or physical restraint which goes wrong.

Factors such as insufficient staff numbers, over crowding, poor physical environment, lack of therapeutic support services and inappropriate skill mix can contribute to some of these problems.

Where mental health staff suffer injuries related to violence by patients, a concern also logically arises about the care of patients.

I asked HSE for information on recent RIDDOR reports about NHS mental health trusts, including deaths. All deaths due to work-related accident must be reported under RIDDOR, whether the deaths of employees or members of the public.


HSE provided data on:

Accidents must be reported where they result in an employee or self-employed person being away from work, or unable to perform their normal work duties, for more than seven consecutive days as the result of their injury.”


Fractures, other than to fingers, thumbs and toes

Amputation of an arm, hand, finger, thumb, leg, foot or toe

Any injury likely to lead to permanent loss of sight or reduction in sight in one or both eyes

Any crush injury to the head or torso, causing damage to the brain or internal organs

Any burn injury (including scalding)


But no data was provided on deaths. I will pursue this.

The full spreadsheet of raw data disclosed by HSE can be found here.

The data was analysed after removing a few instances of data from acute NHS trusts which had been wrongly included.

Since 1 April 2015, there have been a total of 3,992 ‘over 7 day’ absences and 761 specified injuries sustained by NHS mental health staff that have been reported to HSE.

The summary RIDDOR injury statistics for mental health trusts can be found here.

This is the distribution of non-fatal RIDDOR injuries in NHS mental health services over time:

YEAR Number of over 7 day sickness absences Number of specified injuries
2015/16 1,055 168
2016/17 989 209
2017/18 1,114 209
2018/19 year to date 834 175
Total 3,992 761

Unsurprisingly, HSE advises that there is under-reporting of RIDDOR incidents, so the real figures are higher

Over the period 2015/16 to 2017/18, NHS Mental health trusts accounted for 15.4% (3744 of 24212) non-fatal RIDDOR injuries to employees in Human Health Activities.

There was considerable variation between different NHS mental health trusts.

The number of significant, specified injuries in the period varied between 47 at Lancashire Care NHS Foundation Trust, and zero.

Below are the 20 mental health NHS trusts which had the most RIDDOR non-fatal injuries. These trusts accounted for 67% (3182 of 4753) of RIDDOR non-fatal injuries to staff since April 2015.

Screenshot 2019-03-20 at 13.00.18

The variation may be explained partly but not wholly by size of trust. ‘Outstanding’ East London NHS Foundation had a total of 233 RIDDOR injuries, but South London and Maudsley NHS Foundation trust which is the same size had 130 RIDDOR injuries.

Mersey Care NHS Foundation Trust is equivalent in size to Leicester Partnership NHS Foundation Trust, but had three times as many absences over 7 days.

Mersey Care NHS Foundation Trust runs Ashworth Hospital, which has high secure 228 beds. Nottinghamshire Healthcare NHS Foundation Trust runs Rampton Hospital, which has 357 high secure beds and West London NHS Trust runs Broadmoor Hospital, which has 240 high secure beds.

However, it is unclear to what extent specialist secure services account for higher numbers of absences over 7 days.

For example, Hertfordshire Partnership is a smaller trust and has  30 medium secure beds  but racked up 133 non-fatal RIDDOR injuries compared to 84 at Greater Manchester Mental Health NHS Foundation Trust, which has 118 medium secure beds.

Neither do the RIDDOR injuries seem to be consistently associated with rates of physical restraint.

Examination of FOI data from 2016 on physical restraint of patients in mental health trusts, obtained by Norman Lamb’s office, shows very inconsistent recording of information on use of restraint and restraint-related injuries to staff and patients in the above 20 trusts. Anomalies in the data raise questions about the quality of data provided.

Where data was provided by any of the above 20 trusts, this broadly showed high use of physical restraint compared against the mean (3926 episodes of restraint) for mental health trusts in that period (based on 48 trusts who provided information). The exceptions were Barnet, Enfield and Haringey Mental Health NHS Trust and North East London NHS Foundation Trust, so it is interesting that these trusts were amongst the 20 that generated high numbers of RIDDOR injuries despite reportedly lower levels of physical restraint.


There was marked variation in the proportion of restraint episodes that resulted in recorded injury to staff or patients. If the figures are to be believed, the chances of injury to a member of staff taking part in physical restraint at Nottingham Healthcare NHS Foundation Trust and Mersey Care NHS Foundation Trust was an eye watering 41% and 32.5% respectively.

This purportedly fell to only 2% of restraint episodes resulting in staff injury at Lancashire Care NHS Foundation Trust. But a question arises about this because Lancashire Care racked up the highest number nationally of significant, RIDDOR specified injuries to staff.

Other dubious statistics are Lancashire Care’s claim that zero patient injuries resulted from 7,371 episodes of restraint, and Southern Health NHS Foundation’s claim that only two patient injuries resulted from 10,398 restraint episodes.

The poor and incomplete data on restraint and its consequences and marked apparent variation in rates of resultant injuries suggest that this is a poorly governed and regulated area. But the level of variation does raise questions on whether some of the injuries might be avoidable.

Current CQC inspection reports on the 20 trusts with the most non-fatal RIDDOR injuries do not consistently mention violence against staff and give little hard data about assaults.

The CQC reports also do not refer to staff injuries, (from a search under ‘injury’, ‘injuries’ and ‘RIDDOR’), except in three instances.

At Mersey Care NHS Foundation Trust the CQC observed:

“At core service level, we saw that managers had access to monthly ‘dashboards’ that illustrated their team’s performance in a number of areas. These areas (or key performance indicators) included mandatory training, patient experience scores, staff sickness, staff injuries, patient harm and other incidents.”

At Coventry and Warwickshire Partnership NHS Trust  the CQC observed:

“The trust had not addressed the issue of access in to the seclusion room through an area which was too narrow for staff and patients to enter without the potential for injury.”

“The trust must ensure that changes are made to the seclusion room to prevent the risk of injury to patients and staff.”

At North East London NHS Foundation Trust the CQC observed:

“However, the majority of incidents involving patients physically attacking staff were recorded as ‘no harm’ despite many staff receiving injuries.”

At South London and Maudsley NHS Foundation Trust the CQC commented on injuries to patients due to restraint, but not staff injuries:

“The trust should ensure staff record incidents of restraint accurately including the type of restraint, position of restraint, members of staff involved, length of time the restraint took place and whether the patient received a physical health check for any injuries post restraint.”

In an inspection report of 1 March 2019  on Kent and Medway NHS and Social Care Partnership Trust, published after the Secretary of State promised that CQC would target violence against NHS staff, CQC made no mention of such matters.

It would seem that CQC is either not consistently examining and or reporting on violence and injuries to staff in NHS mental health services.

So much for the government’s promise that CQC would help enforce violence reduction. But it is not surprising because the government has form for waving the CQC about tokenistically, to defuse political pressure.

This data will be submitted to parliament and I will draw CQC’s attention to the RIDDOR data for mental health trusts.



Joint Committee on Human Rights

21 March 2019

Dear Ms Harman and colleagues,
HSE RIDDOR staff injury data for NHS mental health trusts 2015/16- 2018/19 YTD
With respect to the Committee’s recent work on the detention of children and young people in Learning Disability Units and conditions in inpatient learning disability units, I write to forward some data on reportable injuries to mental health NHS trust staff. The data shows substantial variation and adds to questions about whether there could be better staffing and conflict management in some mental health services, which might reduce the need for physical restraint and other restrictive interventions.
This is raw data from the Health and Safety Executive:
This is the cleaned data which has been analysed by NHS mental health trust:
This is a write up summarising the data:
I copy this to Health and Social Care Committee in view of some questions raised about how effectively the Care Quality Commission is implementing the government’s recently announced NHS violence reduction strategy.
I have passed the HSE data to CQC’s Chief Inspector of Hospitals, as per the correspondence below.
With best wishes,
Dr Minh Alexander
Cc Health Committee
     Baroness Lawrence
     Baroness Nicholson
     Lord Trimble
     Lord Woolf


From: Minh Alexander <REDACTED>

Subject: HSE RIDDOR staff injury data for NHS mental health trusts 2015/16- 2018/19 YTD

Date: 21 March 2019 at 08:24:58 GMT

To: Edward Baker <REDACTED>

Dear Ted,

HSE RIDDOR staff injury data for NHS mental health trusts 2015/16- 2018/19 YTD

I forward this FOI raw data from HSE on RIDDOR injuries to the staff of NHS mental health trusts for CQC’s information, in the event that CQC does not track this data:


I assume that CQC does not track it, as HSE itself does not track it.

This is the analysed data, cleaned of some data on NHS acute trusts which was wrongly included, and broken down by individual mental health trusts:


You will see that there is great variation.

With best wishes,


Dr Minh Alexander




Letter to parliament: CQC’s inconsistent regulation of restraint in mental health

Safe in their hands? Government’s response to coroners’ warnings about the NHS

4 years of CQC mental health whistleblowing data

St. Andrews Healthcare, Whistleblowing, Safeguarding and Public Protection

How are CQC inspectors supposed to assess learning from deaths? Disclosed internal guidance for CQC inspectors

Public sector gags: The wilfully blind Treasury

By Dr Minh Alexander, NHS whistleblower and former consultant psychiatrist 12 March 2019



Summary: HM Treasury is responsible for scrutinising special, non-contractual severance payments and related gags in the public sector. Parliament asked the Treasury in 2014 to track the pattern of severance payments across the wider public sector. However, the government has resisted this. It gave the job to individual government Departments, which have a conflict of interest in reporting such data. A most cursory inspection of Department of Health and Social Care data on severance payments and minimal cross checking against other sources raises questions about its accuracy. The Treasury was asked if it kept its own data on special payments and gags, but in an FOI reply the Treasury frostily maintained that it does not track the settlement agreements and gags that it signs off. Plus ça change.



HM Treasury talks a tough game. The relevant Treasury guidance ‘Managing Public Money’ makes robust statements about the use of special severance payments. For example:

It is good practice to consider routinely whether particular cases reveal concerns about the soundness of the control systems”

“Any proposal to keep a special payment confidential must be justified especially carefully since confidentiality could appear to mask underhand dealing.”

“Departments should not treat special severance as a soft option, eg to avoid management action, disciplinary processes, unwelcome publicity or reputational damage.”

“The Treasury adopts a sceptical approach to proposals for special severance settlements, in particular:

  • precedents from other parts of the public sector may not be a reliable guide in any given case;
  • legal advice that a particular severance payment appears to offer good value for the employer may not be conclusive since such advice may not take account of the wider public interest;
  • even if the cost of defeating an apparently frivolous or vexatious appeal will exceed the likely cost of that particular settlement to the employer, it may still be desirable to take the case to formal proceeding;
  • winning such cases demonstrates that the government does not reward failure and should enhance the employer’s reputation for prudent use of public funds.”


In reality, the Treasury has nodded by all sorts, as reported by the National Audit Office in two linked reports:

Confidentiality clauses and special severance payments June 2013

Confidentiality clauses and special severance payments – follow up October 2013

In its follow up October 2013 report, NAO commented:

“The Treasury has approved some severance payments, where business cases refer to failure or inappropriate behaviour. The Treasury’s guidance states that payments that reward failure, inappropriate behaviour or dishonesty should not be approved. Yet we found business cases referring to elements of alleged gross misconduct or staff harassment. These alleged behaviours do not meet the standards of the Civil Service Code. Severance terms were approved because legal advice set out that the individual would be likely to win an award in an employment tribunal and settlements would probably be cheaper and quicker and therefore a better use of resources. This may be valid for individual cases, but it may not be true for the wider public sector. For example, alternative options (such as performance management or employment tribunals) may act as a deterrent or set a precedent to reduce future claims and costs”

In a report of January 2014, the Public Accounts Committee advised that public sector settlement agreements should be tracked, because unusually high numbers of agreements “might provide an early warning of management failure”.

The Committee recommended:

The Cabinet Office guidance should set out how lessons are going to be learnt across government to prevent reoccurrence where a failure of process has occurred within an organisation.

 The Treasury should be responsible for monitoring activity across the wider public sector, and for defining what action will be taken where significant patterns or trends are identified.”

The Government broadly agreed to the above, but it rejected the proposed Treasury surveillance of pay offs and gagging. Instead, it arranged for individual government departments to monitor settlement agreements and severance payments in the wider public sector.

This seemed odd when the Treasury is the central handler and was better placed to maintain an overview. But that would assume clarity is desired.

Taking the Department of Health and Social Care (DHSC) as an example, the DHSC gives only broad figures in its annual reports for special exit packages across its departmental group (which includes central NHS bodies, CCGs and NHS trusts and NHS foundation trusts).

Across the DHSC departmental group, special severance payments have been reported as follows:

YEAR Number of departures where special payments have been made’


2014/15 51 payments, £2,025,270




41 payments, £1,222,998


2016/17 28 payments, £ 479,778
2017/18 30 payments, £ 653,735



These figures seem low. It is already known that there are hundreds of settlement agreements and gags applied by the NHS every year. For example, the notorious Liverpool Community Health NHS Trust  alone accounted for 157 super-gags between 2011 and 2016.

A recent BBC Four FOI reportedly found that £70million had been paid to NHS staff through settlement agreements over a five year period.

Not all settlements will be special severance payments that require Treasury approval. Some will relate to voluntary resignation schemes. But even so, the Department of Health and Social Care’s figures for special severance payments are likely to be wrong, and an underestimate.

NHS Improvement’s consolidated 2017/18 accounts for all NHS providers  (NHS foundation trusts and non-foundation trusts) shows equally low figures.

NHSI admitted to only 18 special, non-contractual payments by NHS service providers, of unspecified value:

Screenshot 2019-03-12 at 10.19.01


Public bodies are supposed to report special severance payments in their annual reports. A quick check of NHS bodies’ 2017/18 annual reports reveals that the Department of Health and Social Care’s special payments data cannot be fully cross checked against the data in these annual reports. The annual reports give data on exit packages in variable format, a few do not mention exit packages at all and many bodies do not specify how many special severance payments were made.

But here are some of the listed special, non-contractual severance payments in 2017/18:

Royal Wolverhampton NHS Trust – one special payment of £5,000

Cambridgeshire and Peterborough NHS Foundation trust – one special payment of £38,000

Cambridge University Hospitals NHS Foundation Trust – one special payment of £13,000

James Paget University Hospital NHS Foundation Trust – one special payment of £48,000

Essex Partnership University NHS Foundation Trust –one special payment of £10,000

Queen Elizabeth Hospital, King’s Lynn, NHS Foundation Trust – 11 special payments of £50,000 total value

University Hospital Bristol NHS Foundation Trust – three special payments, of £13,000 total value

Nottinghamshire Healthcare NHS Foundation Trust – One special payment of £12,000

Oxford University Hospitals NHS Foundation Trust – One special payment of £15,000


So my non-comprehensive flick through NHS trust annual reports has already produced a total of 21 special payments for 2017/18, which exceeds the number of 18 admitted to by NHS Improvement. This raises questions about the validity of published government data.

The Department of Health will be asked to clarify how it comes by its data on special severance payments, but it is likely that it depends on reporting by bodies such as NHS Improvement.

To see if the vagaries of Departmental reporting could be circumvented, the Treasury was asked what data it had collated on public sector settlement agreements, severance payments and confidentiality clauses since 2013, and to disclose any such data if it was held. The Treasury was also asked if it had reviewed its approval of settlement agreements and severance payments.

The Treasury’s initial response was to claim that it would exceed the cost limits under FOIA to answer these questions.

A request was re-submitted, focusing only what data was held by the Treasury.

The Treasury has responded claiming that it has no policy of keeping data on the settlement agreements and gags that it signs off:

Screenshot 2019-03-12 at 10.21.23

So there we have it, dodgy Departmental data and a refusenik, central controller who signs off gags blindfold.

Whatever propaganda gushes forth from the government and the National Guardian about commitment to greater transparency, you can be confident that the real secrets will remain locked down.

We need overhaul of UK whistleblowing law.



Gags still stop whistleblowers speaking out: Government claims about new safeguards are hollow

NHS Gagging. How CQC sits on its hands

Letter to parliament 29 September 2018: UK government doesn’t track whether whistleblowers’ concerns are addressed

Replacing the Public Interest Disclosure Act (PIDA)

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





Spinning death at Gosport: The Department of Health and the National Guardian

Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, 11 March 2019

 Summary: The NHS’ obsession with reputation management is well known and very unhealthy. It is rare to get a glimpse of its inner workings. The online Gosport Independent Panel archives of thousands documents, many of which were not cited by the Panel’s report, reveal some unsavoury secrets. For example, the intense spin by the NHS in the months prior to the 2009 inquest hearings into ten Gosport deaths. Although some officials expected a finding of unlawful killing, the inquests determined that all ten deaths were from natural  causes, albeit with medication contributing to some. The instructions for spinning Gosport originated from the Department of Health, which asked to be kept informed of the NHS comms campaign: “….in the run up to, during and after the inquest”. The spin continues. The National Guardian ran a PR campaign about the (illusory) success of the Freedom To Speak Up project just before the government’s response to the Gosport inquiry was published last autumn. She is about to be deployed again this month, to lay good news about purported good practice before parliament. This is just before the police announce their decision on whether to pursue prosecutions over the Gosport deaths. The Department of Health has confirmed that it holds records of communications with the National Guardian about this good news plan, but it is trying to find a way not to disclose the data under FOIA. The institutional resistance to transparency only serves to underline that safe handling of the most serious whistleblowing matters needs to be overseen by a properly independent, statutory body that is not managed by any government department. It also raises questions about the usefulness of a new network of medical examiners that will be controlled by the NHS itself.


Recent spin by the Department of Health

Part of the Department of Health and Social Care’s strategy in responding to the Gosport scandal is to claim that whistleblowers will be better treated from now on. This is a typical headline generated by the government spin machine:

Gosport hospital deaths: Whistleblowers promised support

When the Gosport Panel report was published last June, the National Guardian reprehensibly claimed in a letter to the Times that: If our new system of “freedom to speak up” guardians had been in place when the nurses at Gosport spoke up they would have been listened to and the right actions would have been taken.”

Last autumn just before the Department of Health was due to publish its response to the Gosport Independent Panel’s inquiry report, the National Guardian launched a distasteful, intensive PR drive, the so-called ‘Speak Up Month”. This spun copious good news about the Freedom To Speak Up project.

The police decision on whether to pursue prosecutions for the Gosport deaths will be announced this April. By sheer coincidence, the National Guardian has been asked to lay a report before parliament on more good news about purported good practice in NHS whistleblowing.

The National Guardian’s January 2019 newsletter stated:

AHH Newsletter extract

Who asked her to lay this report before parliament?

Parliament initially denied any contact with the National Guardian. When I pointed out that the National Guardian has had meetings with Sarah Wollaston MP Chair of the Health and Social Care Committee, parliament conceded that Henrietta Hughes and Sarah had met on three occasions: 14 September 2016, 13 March 2017 and 6 November 2018.

The House of Commons has made these comments about whether Select Committees and their members are subject to FOIA:

The Committee Office, made up of clerks, committee assistants, committee specialists etc., is part of the House of Commons, and it is the information held by the Committee Office that we check when a request under the Freedom of Information Act 2000 (FOIA) is made.

 The Committees themselves are made up of individual Members of Parliament, who are NOT public authorities in accordance with the FOIA. Any information that Members hold ‘personally’ – for example, their own personal notes or diary arrangements – is out of scope for the purpose of the FOIA.

 Finally, Committee Chairs sit somewhere in the middle. The work they do in the Committee with other Members falls within the scope of what the House holds. However, they may also choose to carry out work, attend meetings or conduct research in their capacity as the Chair but not on behalf of, or under instructions from, the Committee. Some of this work may be supported by the Committee Office, in which case the Committee Office may hold information about it. When working independently in this manner, Committee Chairs may also choose to share details with the Committee Office, but they are not obliged to do so.”

I asked Sarah Wollaston on 2 March 2019 if she would be willing to disclose the records of her three meetings with the National Guardian, and await an answer.

The Department of Health and Social Care was also asked for records of any communications with the National Guardian about the proposed report for parliament. The Department is overdue in its response. It has so far confirmed that it holds the data requested, but is currently considering whether an exemption applies under Section 35(1)(a) FOIA – formulation of government policy. Or in other words, the government is likely to be embarrassed if the PR manufacturing process is revealed.


The Department of Health and spin about the 2009 Gosport inquests

In 2009, inquests into ten suspicious deaths at Gosport War Memorial Hospital resulted in findings that all ten were deaths from natural causes, and that where medication was considered to have contributed more than minimally or negligibly to five of the deaths, it had been given for therapeutic purposes in all five cases. In three cases – Elsie Devine, Robert Wilson and Geoffrey Packman, the inquest concluded that although medication had been given for therapeutic purposes, it had not been appropriate to the symptoms or conditions which the deceased had been suffering. See archive document CPS000047 for the inquest jury verdicts.

This must have astonished some, including the Chief Medical Officer’s team, who assumed that the coroner would find unlawful killing:

AUnlawful Killing

The Gosport Independent Panel investigation led by Bishop James Jones has since concluded that there were hundreds of deaths due to deliberate, inappropriate and clinically unjustified use of lethal levels of opiates:

 12.10 The Panel’s analysis therefore demonstrates that the lives of over 450 people were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital, and that probably at least another 200 patients were similarly affected.”

Many staff at Gosport had expressed concern about these practices to their managers and or to the police, about what the Gosport Independent panel inquiry euphemistically termed as “shortening lives”. Some staff voiced concerns to the police about  euthanasia or deliberate killing to keep waiting lists down.

Alarmingly, there was intense news management by the NHS authorities in the months before the 2009 inquest hearings. Documents in the Gosport Independent Panel’s archives reveal considerable resources were marshalled to limit reputational damage. Trimedia, a PR firm, was hired to help manage the news about the 2009 inquest. Trimedia had been hired by the Department of Health in preceding years, as revealed by a parliamentary question in November 2008.

This news management was barely reported by the Gosport Independent Panel, although the Panel’s report devoted a chapter to “The local and National media”. The Panel’s chapter about the media largely covers what was reported by the media, and not how the authorities tried to manipulate the media.

A search of the Panel’s inquiry report produces zero hits for

“public relations”

“media relations”

or “Trimedia”

The Department of Health had previously guided and dog whistled spin about the Gosport deaths.

For example, internal 2002 DH correspondence  shows deliberations by DH comms after the Strategic Health Authority contacted the Department for advice, in relation to an enquiry from a Sunday Times journalist.

Archive document DOH000398 showed that the Strategic Health Authority had a standard form for reporting media alerts to the Department of Health, which included a box entitled: ‘Information about lines to take’.

A 2003 Strategic Health Authority document on “lines to take” on the Gosport deaths showed that the SHA was reporting back to the Department of Health on detailed planning around a File on Four broadcast.

A related, “strictly confidential” SHA email  discusses further action in response to the File on Four broadcast. This includes the comment: “…no plans to dripfeed at present”.

2006 internal Department of Health correspondence revealed an instruction to the Strategic Health Authority (SHA) to construct a comms strategy on Gosport:

“Is the SHA on top of this?”

“Push them for a comms strategy please”

In 2009, the Department of Health wanted to be kept abreast “in the run up to, during and after the inquest”.

I collate below some of the archive documents which reveal the collusion and news management by NHS bodies regarding the 2009 Gosport inquest hearings.


Document DOH700711 (supplied by the Department of Health):

This was correspondence by Richard Samuels Hampshire PCT Director of Corporate affairs, which reveals the confidential, key aims of a multiagency steering group to handle the inquests. It includes an intention to “preserve the reputation of local NHS services”:

APreseve the reputation of the local nhs services

Importantly, this document notes that the steering group was to report regularly to the Strategic Health Authority:

ASteering group will report to SHA


Document CCG100024: 

A media management ‘action plan’ of January 2009, which reveals the scale of planning and multiagency coordination, complete with plans for photo opportunities:



Document SOH100588 (supplied by Southern Health NHS Foundation Trust): 

This lists 32 individuals who were part of the “GWMH inquest project group”, including personnel from the law firm Mills and Reeve, Hampshire PCT comms team, Trimedia PR consultants, Portsmouth Hospitals NHS Trust staff and its comms team, Portsmouth City Teaching PCT and Hampshire Partnership Trust.


Document CCG100018: 

This was a “GWMH inquests – Communications Protocol Pack”. This document states that a “proactive approach” to the media would be coordinated.


Document DOH700738 (supplied by the Department of Health):

This records that Trimedia (represented by Julie Dean and Caroline Searle) and Mills and Reeve solicitors set to work on the inquest in October 2008, some six months before the inquest hearings were held.

A trade union, the RCN, was represented in the process. According to this document, Betty Woodland (BW) RCN Lead Steward brought along disclosure papers from one of the original Gosport whistleblowers, Sylvia Giffin.

Another related archive document, MRE000701,listed the RCN members who would be giving evidence to the inquests.


Document PHO103758 (supplied by Portsmouth Hospitals NHS Trust): 

This documents sets out the following strategic aims for the multiagency comms plan:

APublic Confidence



Document DOH700718 (supplied by the Department of Health):

This was a briefing by Trimedia for NHS managers on a meeting with BBC journalists on 2 March 2009. The action plan generated includes a pre-recorded interview in advance of the inquest verdicts:

APrerecorded inteview ahead of verdict



Document MRE000782 (supplied by Mills and Reeve): 

This document revealed some tactical considerations regarding the inquests and it discussed methods for bringing the media ‘onside’:


Document DOH101771 (supplied by the Department of Health):

This document noted that a media tour of the hospital had been arranged as planned, for three BBC journalists, with support from Trimedia:


The same document revealed steering group discussions about ‘vulnerable areas’ at inquest, and the need for additional cover from Trimedia on days when Dr Jane Barton and Gill Hamblin were giving evidence:

AVulnerable areas


Document SOH001158 (supplied by Southern Health NHS Foundation):

Minutes of an inquest steering group meeting noted that “positive stories” were being fed to the media.

APositive Stories


Document MRE000244 (supplied by Mills and Reeve solicitors):

This showed how the different organisations worked together to get a single story which could be presented to the coroner:

ASingle document for coroner

The inquest steering group sought to defend events at Gosport by advancing an argument that what happened was ‘common practice’:

ACommon Practice

The document also showed that a witness statement by Lesley Humphreys, formerly Quality Manager and later Operations Manager was crafted by committee:

ALesley Humphreys statement by committee


Document PHO000072:

This document additionally shows how Lesley Humphreys’ statement was developed, and that the Strategic Health Authority was involved.


Document DOH700721 (supplied by the Department of Health):

This was the confidential media spokesperson pack generated by the steering group, which included a list of “key words” that were important in crafting the right messages:

AKey words.png

Parts of this document are redacted, so who knows what other objectionable material lurked within.


Document MRE001669 (supplied by Mills and Reeve solicitors):

This was a briefing pack for NHS staff who were scheduled to give evidence at the inquests. It included a media statement, showing the direction of organisational spin:

AMedia statement for staff giving evidence


Document PHO000070: 

This included discussion of whether, in the context of the comms strategy, there was any conflict between the interests of NHS bodies and the doctors or the NMC.




Document MRE000233 (supplied by Mills and Reeve solicitors):

This refers to preparation of a coordinated approach, to ‘counter’ police expert witness evidence:

ACounter police expert evidence

This document also reveals an intent to coordinate what media line Dr Jane Barton’s lawyers and the NHS authorities would take on her management:

ABarton's management

Last but not least, there is an email trail in the archives that appears to show Dr Jane Barton’s direct involvement in the inquest preparations, and communications between her medical practice and the Trimedia public relations firm:

Document FMC000058, supplied by Forton Medical Practice:

ABarton suggests Trimedia

So there you have it, a continuous thread running from Jane Barton all the way up to the Department of Health.

A later document showed that Trimedia staff were still involved in August 2009, regarding briefing about Dr Jane Barton’s Fitness to Practice proceedings at the GMC.

One wonders if given these industrial levels of official manipulation, the forthcoming network of medical examiners which will be under the control of the NHS has much of a chance.

The Bishop hardly commented in his Panel report on the news management by the NHS.

The only sections of the Panel’s report I could find which cited the above documents were these:


8.119 Despite hoping that the Coroner would not issue a Rule 43 letter, the Trust was keen to ensure that, pursuant to Rule 43, some evidence was heard during the course of the inquests about the present state of the hospital and how things had improved. In July 2008, an inquest ‘steering group’ was set up with the aim of managing the “Coroner’s inquests effectively in order to maintain the continuity, quality and confidence of local people in health services in Gosport” (MRE000260, p1). The steering group met on a number of occasions and received input from the solicitor for the Trust. The topics discussed at meetings included the approach of the Coroner to the inquests (MRE000647, p2), the communication strategy (MRE000244, pp1–2) and the best approach to addressing, through evidence, any potential Rule 43 issues (MRE000244).”

4.90 Correspondence in the period between 2008 and March 2009 shows that Portsmouth Hospitals NHS Trust and Hampshire PCT were focused largely on preparations for relevant inquests (DOH602073, DOH602082, MRE000782, MRE000780, DOH603144, MRE000211, MRE001459, MRE001646, MRE001678, MRE001638, MRE001615, MRE001600). Although the correspondence refers to some relevant matters in passing, there is no evidence that consideration was given to any further investigation of previous clinical failures at the hospital or the mishandling of the nurses’ concerns. The GMC and the Coroner continued to take action, and this is covered in later chapters.”



Neither did Tom Kark address the toxic role of the Department of Health in driving poor culture in his recent FPPR report. This was despite his acknowledgment of the Department’s role in his previous capacity as Counsel to the MidStaffs Public Inquiry.

But their reticence does emphasise that reviews and investigations under the umbrella of conflicted government departments are hardly likely to reveal everything.

For effective whistleblowing governance and public protection, nothing less than a fully independent statutory body that reports to parliament and not governments, will do.


Continuing government spin about the Gosport deaths disaster was revealed by a Department of Health and Social Care FOI disclosure of 27 March 2019. The government and the National Guardian’s Office has been working closely to polish the government’s image on Gosport, including by spinning a “positive narrative”.

Spinning Death at Gosport II: DHSC FOI revelations & National Guardian’s fake independence



Southern Health Foundation NHS Trust was one of the successor bodies of Hampshire PCT, and took over Gosport War Memorial Hospital. Southern Health carried on the tradition of neglect by failing to investigate hundreds of deaths of mental health patients.

Katrina Percy, the much criticised chief executive of Southern Health NHS Foundation Trust was involved in the aftermath of the Gosport deaths. For example, this is a letter by Percy to the NMC, which traces the subsequent movements of the nurses involved in the Gosport affair: Document NMC100113

Gosport archive document FMC000051: the business card of Julie Dean Trimedia senior consultant, supplied to the Gosport Independent Panel by Dr Jane Barton’s medical practice:

ATrimedia business card


Letter to parliament 29 September 2018: UK government doesn’t track whether whistleblowers’ concerns are addressed

Questions about coaching of staff who gave evidence to the Gosport inquests and the Department of Health and Social Care’s role in promoting spin

Gosport deaths, UK government pork pies about whistleblower protection and failure to investigate concerns

Evidence to parliament about the Kark FPPR Review

What could a new whistleblowing law look like? A discussion document