Me in a nutshell
I am an NHS whistleblower and formerly a consultant of fourteen years experience. I was made redundant in 2013.
I subsequently came to mutually agreed terms with my former employer.
I campaign on patient safety, public sector transparency and whistleblowing reform.
I dig in search of that which officialdom likes to bury.
As a consultant psychiatrist, I raised many serious safety concerns. A summary of the issues I raised is published by parliament, as follows:
Submission by Minh Alexander
- I am an NHS whistleblower and was formerly employed as an NHS consultant psychiatrist. I trained in London. I was a consultant for 14 years. I also have experience of the NHS complaints system as a family member. I am submitting evidence because I want to provide PASC with examples of how dysfunctional and wasteful the NHS can be in dealing with clinical failure, in order to support the case for robust change.
Experience as a NHS employee
- As a trainee psychiatrist in the 1990s, I raised concerns about a psychogeriatric inpatient service, but the senior medical staff responsible for that service did not take my concerns seriously. Later, serious psychological and physical abuse of the elders emerged. It became apparent in the course of the investigation that there had also been other relatively junior whistleblowers. I feel that part of the problem in this matter was the hierarchical culture of the NHS, in which the concerns of junior staff are not given sufficient weight, when they may in fact bring a fresh pair of eyes. This can be very useful where poor standards have become enculturated, and it takes a relative outsider to notice and raise the alarm. The Commons library will most likely have a copy of the inquiry conducted into the patient harm (Beech House inquiry, Camden & Islington).
- In my last post as a consultant psychiatrist in a poorly resourced NHS mental health trust, I raised concerns from 2007 to the end of my employment in 2013, about patient harm, failures to report and investigate this harm, other failures of governance and Safeguarding, and generally dysfunctional organisational responses to clinical failure.
- I discovered that very serious instances of patient harm, including suicides and deaths in custody, homicides, rape and arson were sometimes not even reported through the appropriate channels. Even when they were, appropriate investigation and organisational learning was not guaranteed. Trust departments were quite often allowed to investigate themselves. Sometimes, single investigators would conduct investigations that required a team. Investigators were not always suitably skilled and experienced. The quality of reports was highly variable, and reports were not always fed back to staff. Learning was not reliable, and often there was no dissemination of learning across the organisation. It also seemed that when I raised concerns with successive Board members, there was a marked reluctance to take appropriate action, despite superficial assurances.
- I provide below a small sample of issues that I raised concern about, and the Trust’s inappropriate responses.
- Homicide: It took me from 2008 to 2010 before the Trust registered a homicide by a Trust patient as a serious incident and investigated it. There was repeated minimisation by Trust managers. For example, at one point, the killing was referred to in management papers as an “assault”. Whilst I was promised by the CEO that this incident and others would be properly addressed, the middle managers deflected my queries about progress. At one point, a manager admitted that he had been specifically instructed not to process the homicide as a Serious Incident. The Trust investigated only after I had been forced to make external disclosures to the Strategic Health Authority (SHA) and the Care Quality Commission (CQC). Even then, there were irregularities in the internal investigation process and the way in which findings were presented to the SHA. Eventually, an independent inquiry commissioned by the SHA. This was critical of Trust governance and failure to act upon harm. It is my view that the Trust response to the inquiry recommendations was dismissive, and I do not expect any real change to arise from the exercise.
- Rape: In the case of a rape that occurred in 2007, the Trust only finally investigated this in 2010. I believe this incident was avoidable. The patient was repeatedly denied access to hospital admission prior to the rape, despite my repeatedly stated concerns and police efforts to secure her appropriate mental health assessment under Section 136 MHA, on several occasions. Even after the incident, she was turned away again, before finally being admitted under my care as part of a special arrangement. (I was a community psychiatrist at that point). The Trust Board, via the CEO and Chair, were aware of the incident within a few days of it happening, but no incident investigation took place until 2010, after I had approached the CQC. The Trust incident process was irregular: it consisted only of records review by the Director of Nursing. Staff were not interviewed and the patient was not involved. The report was then sent to the wrong division, where a team of managers reviewed it and incorrectly included it amongst a thematic review of unrelated incidents. I realised the misdirection after I recognised the case details. When challenged, the Trust claimed that this all happened as a result of error. I do not believe the patient ever received an apology from the Trust. Of great concern, when the failure of investigation was discussed at a meeting, the Director of Nursing asserted that this was due to the fact that staff did not see rape as a serious matter.
- Under reporting: The area where I primarily worked, prison in reach, was of special concern because it featured high clinical risk but was especially poorly resourced. I raised concerns about clinical risk management throughout my employment, including about serious under reporting of adverse incidents. This was never effectively addressed.
- All the above were reported to the Board, as were the majority of my other disclosures.
- Flawed service review: The Trust commissioned an independent report about this service area in 2009 in response to serious safety concerns that I and another consultant raised. However, this review did not focus enough on the adverse incidents and safety issues that had triggered the exercise. A co-author of the review had worked with the Trust CEO previously, and was employed by the Trust after leading this review. Furthermore, there was then serious failure by the Trust to implement review recommendations, including resistance to convening a re-review. Eventually, over two years late, a re-review took place but was not fully independent because a member of staff was a co-author. This re-review was partial, and did not examine safety issues.
- General handling of serious incidents and provider control of “independent” review: In 2009, the Trust commissioned an independent review of its general handling of serious incidents. This was as a result of the Trust coming under pressure due to the number of deaths, particularly in acute services and crisis care. However, the Trust selected the cases for review, which automatically introduced bias. Despite this, there were significantly critical conclusions. This included a finding that the same types of incidents were recurring due to failure of learning. However, there was not full learning from this review, partly becausethe Trust controlled dissemination of the findings. It released only summarised information. I only obtained the full copy in 2012. I do not believe the majority of senior clinicians were ever privy to the full findings and learning. The review advised the Trust that its risk register should be changed, to reflect the fact that preventing harm to patients was a greater priority than harm to organisational reputation. Indeed, such was the organisational aversion to self-scrutiny, that on one occasion, the previous medical director advised me in writing that there was little utility in tracking suicide rates.
- Trust behaviour towards complainants: In 2011 I learned from the PHSO that a patient had complained about her care, but that the Trust had excluded me from the complaint process for two years, despite the fact that I was a relevant witness. In fact, there was correspondence from the Trust to the patient informing her that her Trust records did not support her concerns, when this was quite untrue. As a result of the PHSO contacting me directly, I was able to provide evidence in support of the patient’s concerns, which refuted some of the claims in the Trust’s response to the patient. The PHSO eventually fully upheld the patient’s concerns, and judged that the multiple failings by my Trust amounted to service failure. I was extremely concerned that a very vulnerable patient was treated in the above manner by the Trust. As part of her complaint, the patient had observed that she felt that she was punished for raising concerns about her care. There was an absence of appropriate support provided to her during the complaints process, and no proactive arrangement by the Trust to help her access independent advocacy support. This was despite the fact that risk of suicide had been flagged in her records. Also, the patient had very meagre resources, but the relationship with the Trust deteriorated to the point that she disengaged and had to pay for private treatment, for a serious major mental illness. I raised concerns with two successive chief executives and other Board members about the way in which the Trust approached this patient’s complaint, and how it gave her untrue information that her Trust records did not support her complaint. My concern was never addressed. The PHSO reference number for this case is: HS-96585.
- Regulatory action: The governance of the Trust was so disordered that my disclosures to CQC eventually led to regulatory action by both CQC and Monitor, who breached the Trust’s terms of authorisation on grounds of governance. There was negative publicity for the Trust, and all but one member of the Trust Board departed.
- Failures to address concerns: Problems continued in the Trust, and promises by new directors to address unresolved safety matters were not kept. In fact, there was sometimes active pressure in the opposite direction. In April 2012 the new chief executive wrote to claim that the new medical director would carry out an urgent investigation. He subsequently did not respond to my queries about the fact that there was no sign of any investigation.
- Suicide risk management: I continued to bring safety matters to the attention of the Board, up to the end of my employment. For example, in November 2012 I informed managers, including the CEO, of a case in which there had been recurrent serious self harm and recurrent self ligation, but in which no incident reports had been filed. I received no assurance that this was addressed, and saw no evidence that my concern was investigated. This was despite concerns about Trust suicide risk management being identified by Prison and Probation Ombudsman’s death in custody investigations. Staff often saw incident reporting as an imposition/ unwelcome bureaucracy. This was in part fostered by a lack of feedback from the centre, and failure by managers to demonstrate to staff that incident data was being used constructively.
- Failure to report to the SHA: I raised concern that a cluster of suicides had not been reported to the SHA for consideration of independent investigation, in line with DH protocol for mental health services. Trust managers including Board members did not respond and I made an external disclosure to the SHA. In the course of correspondence, the CEO claimed that the SHA had advised that no external review was needed. The SHA advised me that it had not given the Trust such advice.
- Failure to act appropriately in response to patient concerns and conflicts of interest in investigation processes: I also raised a concern about a complaint by a patient of institutional abuse against himself and other patients who had been detained under the Mental Health Act on a locked Trust ward. He had raised concerns with various other staff before telling me, but no one else had triggered the appropriate Safeguarding processes. The Trust would not ensure that the patient had access to independent mental health advocacy. It arranged for the investigation into the complaint to be led by the manager of the ward where the alleged abuse took place. This was despite me raising concerns about objectivity. The patient was also unhappy with the investigation being carried out by the ward manager.
- Board unaccountability: In November 2012 the CEO eventually claimed that an investigation had taken place into my various concerns. The medical director refused to confirm this, but avoided giving me a clear answer about whether she had carried out an investigation, as the CEO had claimed. I formed the impression that most probably, no investigation was carried out, or at most, a superficial exercise (which would have excluded my evidence), had taken place, which the organisation was unwilling to share with me. The CEO did not respond to me thereafter, and the Chair supported this obstruction. My employment ended with the governance issues in this state of impasse.
- Regulators’ role in governance failure: Regulators were made aware of all the above issues, over several years, but there was insufficient improvement in Trust handling of clinical harm. Erratic incident reporting continued. Investigations remained inconsistent in quality and objectivity. I felt a lot more could have been done by regulators to hold the Trust to account in this area.
- CQC openness: CQC have recently announced that they are commencing work on the quality of incident investigations, but have advised to date that they do not intend to consult publicly about how they intend to approach the work. I feel this is a major omission. Whistleblowers and complainants in particular would be able to provide valuable insights into what is currently not working well, and help point the way to solutions.
Experience as a relative
- Variable care and negative organisational attitudes: My husband has experienced a number of serious illnesses, and his care by the NHS has ranged between “superb” and “terrible”. The best experience was with a Trust that had open governance and patient centred ethos. At the “terrible” end of the scale, it has at times been impossible for the patient & carer voice to be heard. I have sometimes practically lived in hospital with my husband out of concern for the poor care provided. In such circumstances, I found that raising concerns was difficult and met with reprisal. Once, I made a Safeguarding referral because of the level of mistreatment against my husband and the hostility of staff.
- Delay in cancer treatment: My husband’s cancer treatment was delayed for over 6 months The complaints process was stressful because the hospital in question seemed determined to minimise issues, and showed little interest in learning. We found ourselves blamed at some points. A PHSO investigation revealed that staff had even written a derogatory comment about my husband “giving them the runaround” with respect to keeping appointments. This was unwarranted, not least because my husband had been acutely ill as a result of harm caused by that Trust’s interventions. He required care in hospital, and was not able to attend for clinic appointments. It did however reveal that he was simply regarded as a nuisance, instead of the seriously ill patient that he was. PHSO upheld his complaint in full, but it could not turn the clock back.
- Lack of appropriate investigation and dubious “independent” investigation mechanisms: The Trust only finally carried out a root cause analysis, approximately 3 years after the harm, because they were directed to do so by the PHSO. It is also noteworthy that shortly after my husband complained to PHSO, the Trust decided to reopen the local case. It offered my husband the option of an “independent” review under its auspices. However, it did not seem to us that the investigators offered were clearly independent and unconnected to the Trust. Neither have we found PALS to be helpful or neutral. They largely seem to be a part of Trust machinery, and not a genuine resource for patients.
Conclusions and suggestions
- I feel there is currently unacceptable variation in the way NHS organisations investigate clinical failure. Good practice guidance has existed for a very long time, but has not been effectively enforced. Because of this inadequate stewardship, it is possible for serious abuses and failures of candour to occur. There is “gaming” through under reporting and misrepresentation. There is also an industry based on independent investigations / reviews that are not always truly independent, especially when commissioned by the provider organisations that are being investigated.
- This has all been tolerated for years, by different governments. In my view, the most critical factor is political commitment to change, that takes a longer term perspective, and reduces the image focused, top down bullying that runs through the NHS like a stick of rock. The NHS is an outlier for high rates of bullying, and it is unlikely that much will change until this is addressed.
- A more structured approach is also needed, which could include:
- Mandatory standardisation of NHS incident investigation process
- Ensuring that properly trained and experienced personnel with relevant professional expertise carry out investigations, with greater emphasis on Human Factors.
- Provision for truly independent investigation where appropriate, with rights of appeal. For example, whistleblower concerns and serious complaints.
(i) At present, I do not believe NHS England and CQC use their investigatory powers enough. In the area of mental health, there is little evidence that NHS England investigates the deaths of patients. Instead it appears to focus only on homicides by patients. CQC does not seem to fully exercise its powers under MHA 1983. In particular, CQC reports contain little information on the deaths of detained patients. CQC refused to investigate the death of a patient in 2011 on the apparent basis that this took place too long ago. The PHSO also declined to investigate this death, on reported grounds that staff decisions regarding the MHA 1983 are taken in a personal capacity. (Patients Association report on the PHSO, November 2014).
(ii) Such overlaps and gaps in between these bodies need to be rationalised into a more coherent and just system of investigation. In particular, I feel the conflict inherent in NHS England instigating investigations into patient harm, which may have arisen as a result of its commissioning decisions and management of services, perhaps needs to be redressed.
30. Clear investigation standards, which are effectively enforced by regulators, and which include effective detection of under reporting and effective implementation of investigation findings.
31. Open CQC consultation with the public, and especially key stakeholders such as complainants and whistleblowers, on how to approach its planned work on incident investigation quality.
32. Mandatory audit of organisations’ incident handling, including an element of independent audit, with published results.
33. Mandatory publication of more meaningful and detailed data about organisations’ performance in handling adverse incidents
34. Much better provision of independent advocacy services to patients and families, with automatic access for complainants. I think current resource would be more appropriately spent on independent advocacy services rather than on PALS and defending claims. Providing better advocacy would significantly reduce the inequality of arms, and drive greater transparency. Trusts treat concerns more seriously when third parties are involved. In my former Trust, management resistance to patient advocacy was illustrated when I once simply suggested at a consultation meeting, called by the Board, that it would help to improve performance if staff were empowered to advocate for patients. In response, the Director of HR replied “this is a mental health Trust, not Amnesty International”.
35. Incentivisation of safer organisational behaviours. For example, fulfilment of defined incident investigation standards, compliance with audit requirements and successful local resolution of complaints.
36. The things that should be disincentivised are whistleblower suppression, high rates of litigation, and high rates of appeal against local investigations.
37. Monitor, TDA, DH and Treasury need to stem the flow of funds for wasteful litigation, as a part of reducing perverse incentives for organisations to behave unaccountably and to use legal processes to conceal mismanagement. Where there is litigation, costs must be published.
38. Confidentiality clauses should be banned in clinical negligence litigation, to remove the barrier to learning, and prevent misuse of legal processes to conceal failures.
39. Ultimately, the strongest disincentive to unsafe behaviours would be the removal of senior managers found to be privy to concealing patient harm or suppressing staff concerns. Once removed, they should not be allowed to “recycle”. This requires robust application of CQC regulation 5, FPPR.
40. I copy below the link to the independent inquiry report, by Iodem, commissioned by the SHA into an above mentioned homicide.
41. I can also provide other supporting documents if needed.
15 January 2015
“An Independent Investigation into the care and treatment of a Service User” by Iodem, 1 March 2013: