Author: minhalexander

Dr Minh Alexander retired consultant psychiatrist 26 November 2025

Introduction

This is a brief report on the continuing failure of the wasteful Freedom To Speak Up model, which is being retained by the NHS despite abolition of the National Freedom To Speak Up Guardian’s Office.

An external review of failings in breast cancer care, the “Aubrey Report”, has this week been published by County Durham and Darlington NHS Foundation Trust (CDDFT).

Aubrey Report: The Report of the Independent External Review of Governance within the Breast Surgery Services

The Aubrey report was commissioned following advice received from the Royal College of Surgeons, related to its invited service review in January 2025.

About the author of the Aubrey Report   Mary Aubrey the author is described in the report as Director and Specialist Expert Advisor in Governance. Her LinkedIn entry describes her as a part time NHS director “Providing specialist advice and support on progressing the NHS Trust to moving to excellence and exiting RSP 4 in 2026”.   She is also listed on the website of the private company Quality Governance Solutions 15267661  where she is described as a CQC associate.  A search shows that she has acted for CQC as an executive reviewer in past CQC inspections. For example, during the 2019 inspection of Royal Berkshire NHS Foundation Trust.

Care Failings

The Aubrey report found multiple failings spread over a long period of time, which resulted in poor care, summarised as follows:

“Patient harm due to outdated clinical practices and unnecessary procedures:

Patients experienced avoidable harm, including delayed diagnoses, unnecessary mastectomies and axillary clearance, and benign procedures that were not clinically indicated. These failures resulted in significant physical, emotional and psychological consequences for patients and staff”

“A lack of documented breast reconstruction planning in at least six cases highlights missed opportunities for shared decision making. Additionally, technical errors, including incorrect skin marking leading to repeat surgery, underscore preventable harm and resource inefficiencies.”

A local media report gives a devastating report of one patient who was left bed bound after sepsis:

Woman bedbound after CDDFT breast cancer service experience

“This has been totally devastating. It has ruined my life, without a doubt,” says Moira, who is in her 60s….I never thought this would be the case at this age. I have had a very busy life and career, but now I am dependent on the care of others.”

“She says she is completely bedbound unless hoisted into a chair by her carers.”

The patient describes a traumatic encounter with a surgeon:

“This surgeon was in his suit and put surgical gloves on – and without warning from him, and without any kind of anaesthetic, cut open my wound.”

“He began taking out handfuls of blood clots from my breast and putting them into a surgical bowl.

“While it wasn’t painful, it was uncomfortable and felt very concerning. Blood was pooling underneath me and down my left-hand side, which the nurses cleaned after the surgeon left the room.

“From the faces of the nurses who were present, I could tell this wasn’t normal.

“I didn’t know what to do, as I wanted my breast to get better, but the faces of the nurses told me everything I needed to know. They didn’t say anything about what he had done.

Related governance failings including whistleblowing failures

The Aubrey report also noted a failure of the legal, organisational duty of candour:

“Despite clear evidence of harm, including unnecessary axillary clearance, mastectomies, excessive surgery due to poor diagnostics, and benign procedures that were not clinically indicated, the Executive Medical Director and former Executive Director of Nursing delayed the initiation of Duty 12 of 232 of Candour. Action was only taken in February 2025, a nine-month gap that represented a significant breach of statutory obligations.”

According to his LinkedIn entry, the Executive Medical Director was in post from 2017 up to November 2025. The former Executive Director of Nursing according to his LinkedIn entry was in post 2015 to December 2024 and is now a NED at York and Scarborough Teaching Hospitals NHS Foundation Trust.

Mary Aubrey concluded that there were repeated missed opportunities to identify and correct the patient harm, with multiple red flags and warnings from different sources, including from senior personnel, which the trust board failed to act upon.

For example:

“Despite multiple early warnings from 2012 to 2025 including internal audits, external reviews, national surveys, and benchmarking data, effective action was not taken until 2025. This prolonged delay reflects deep-rooted leadership and governance failures, where Executive Directors, Care Group Triumvirate and Specialty leaders repeatedly failed to intervene, challenge poor practice, or implement improvement recommendations.”

“Concerns raised in 2017. 2018, 2019, 2021, 2023, and 2024 were either ignored or subject to delayed action, despite clear red flags. Service and Care Group leaders did not act on, or escalate warnings from colleagues across pathology, radiology, booking, MDT coordination, medical records, operational management and clinical nursing.”

These listed whistleblowing episodes all fall firmly within the period when the NHS Freedom To Speak Up arrangements should have been embedded. They were introduced in 2015 and it is reasonable to expect that by 2017, all trusts should have had compliant structures and informed boards. It was certainly what the central propaganda claimed. But there may have been issues of capacity, as a CQC report of 2019 stated:

“On our last inspection we raised concerns about the capacity of the Freedom to Speak Up Guardian (FTSUG). While two champions had been recruited and working hours increased there was still work to do to increase capacity and raise the profile of the role within the trust.”

Aubrey noted dysfunctional culture within trust breast surgery services with issues of bedside manner, rudeness within teams, insularity and resistance to feedback and change.

For example: “Cultural and behavioural issues, including poor communication, lack of psychological safety, and unprofessional conduct from some consultants, contributed to staff distress, high turnover, and reluctance to raise concerns.”

The RCS invited review noted problems with multidisciplinary decision making, challenge and leadership.

Moreover, Trust staff showed fear during Aubrey’s investigation and asked for anonymity.

Their fears proved justified when Trust executives tried to identify them. Aubrey wrote:

“Staff repeatedly expressed to the Reviewer their desire to remain anonymous, particularly where roles were unique and individuals could be easily identified. Attempts by some Executive Directors to identify contributors not only breached this understanding but also reflected a leadership approach perceived to prioritise control over accountability. This incident highlights broader cultural challenges within the Trust, where psychological safety appears compromised and staff remain apprehensive about potential retaliation or scrutiny when raising concerns.”

It is a measure of dysfunction that trust executives felt free to attempt to identify staff in plain view of an external investigator.

Clearly, whether or not the trust Freedom To Speak Up Guardian service was adequately resourced, it had no chance if the trust executives had no respect for staff confidentiality.

Unsurprisingly, the Aubrey report concludes that whistleblowing governance at the trust was flawed. There is possibly an implication that Freedom To Speak Up procedures – “formal mechanisms” –  failed:

“As outlined above, staff reported feeling discouraged by managers from whistleblowing due to apprehension about retaliation, including warnings from managers that speaking up could adversely affect their careers. This culture of deterrence contributed to the persistence of harmful practices and undermined efforts to strengthen safety, transparency, and accountability within the service. Concerns were not escalated and the Trust Board did not have effective systems to detect and address suppression of concerns within the areas affected. While the Trust’s staff survey scores for ‘Raising Concerns’ are in line with national averages, qualitative feedback from interviews and helpline data suggests that formal mechanisms were not always experienced as psychologically safe or effective by staff” [my emphasis]

There was specific criticism of Non-Executive directors who should challenge, and who often hold “champion” roles for FTSU arrangements:

“The cultural factors outlined above combined with staff apprehension around whistleblowing and limited scrutiny from Non-Executive Directors, including the former Trust Chairs during their tenure. and assurance committees created conditions in which unsafe practices were able to persist unchallenged and without accountability.”

It is almost always the case that such summarised details do not convey the depth of suffering of individuals and their families who are at the butt end of such failures of whistleblowing governance. To be at the mercy of trust executives whose goal is “control”, above all else, can be a life-changing nightmare that may extend for years.

In short, Aubrey’s report sets out a fairly typical and familiar anatomy of an NHS scandal.

CQC failings

And of course, no NHS scandal is complete without a Care Quality Commission whitewash. The CQC currently rates CDDFT as “Good” overall and “Good” on the “Well Led” domain despite the poor leadership and its whistleblower hunting tendencies.

This “Good” rating is from 2019. One would have hoped that with all the concerns about the breast service and poor trust governance that the trust should have been inspected more recently.

But was CQC even aware of the breast service failings? The trust’s breast service lost training status as early as 2012 and the Aubrey report rightly concludes that the loss of training status was a red flag:

“The Breast Surgery Services was flagged for failing to meet the standards required for safe and effective medical education, and for not providing a supportive training environment which are both essential for surgical trainees. This led to the withdrawal of training accreditation in 2012. The loss of surgical trainees was a direct result of GMC action and serves as a fundamental indicator of breakdowns in supervision and clinical governance.”

“The loss of trainee status in the Breast Surgery Services represents a significant red flag for the organisation”

But as far as I can see, CQC did not specifically inspect the breast service in 2019. Or if it did, it raised no specific concerns.

Moreover, the CQC inspection report of 2019 claimed generally “It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.”

General ineffectiveness of the Freedom To Speak Up model and questions about the Fit and Proper Person Framework

In conclusion, this affair only reinforces concerns that the government’s Freedom To Speak Up project has been a wasteful, deflective propaganda exercise that has done very little to help NHS patients and staff.

At least the lead propagandist’s Office, the National Guardian’s Office has been disbanded. But the decision to continue wasting scarce public funds by continuing with a local model of Freedom To Speak Up Guardians is a classic but disappointing NHS fudge.

There has been little transparency about how the latter will work, only a few cryptic comments in a NGO’s newsletter and a brief NHSE update about how some central functions will transfer to NHS England. I have asked NHS England via FOI for more precise details.

I have also written to Jim Mackey NHSE CEO to ask if and how the findings of the Aubrey report will be used by NHS England with respect to new NHS Fit and Proper Person arrangements following the Kark review. This is with respect to general findings of executive failure to act upon red flags and safety indicators, the failure of organisational duty of candour and the reported attempts by trust executives to breach anonymity of staff reporting concerns to an investigator. It is unclear to me if the FPP framework and related database/ disbarring mechanism have been finalised six years after completion of the Kark Review on Fit and Proper Persons in the NHS, but I have asked NHSE for a completion date if not.

PERSONAL UPDATE

My wonderful husband Ian has died. I am not back at work at full strength and cannot respond to requests as much as usual, but will aim to post from time to time. All my very best.

RELATED ITEMS

1. CDDFT has as per NHS standard operating policy, announced a cultural reset. The trust also reports early progress in rectifying the safety issues.

CDDFT response to the Aubrey report

2. Robert Francis continues to express ineffectual dismay about how NHS managers still respond shockingly to NHS whistleblowers. Eye-roll.

3.Fundamental failure of the NHS Freedom To Speak Up Project: Dr Rajai Al- Jehani unfairly sacked by Royal Free NHS Foundation Trust for whistleblowing on breaches of Human Tissue law, with suppression of linked investigations by University College London

4. Think whistleblowing in the NHS is confidential? Think again

5. Letter to Bill Kirkup and James Titcombe. Request for evidence of claimed “increased protection under the Freedom to Speak Up policy” and exposition of some contrary evidence

The local MP Lola Mc Evoy has published this statement on the matter, which acknowledges that staff whistleblowers were ignored:

By Minh Alexander retired NHS consultant psychiatrist 17 September 2025

This is a very brief note as I am still taking a break for family reasons.

A UN Commission of Inquiry has just reported its conclusions that the state of Israel has been pursuing a protracted genocide in Gaza:

Legal analysis of the conduct of Israel in Gaza pursuant to the Convention on the Prevention and Punishment of the Crime of Genocide

This is considered to be a weighty indicator of the eventual ruling of the international court on the genocide case against Israel.

At present, the UN Commission considers there is a duty on all states parties to the genocide convention to do all they can to actively halt the Gaza genocide and restrain Israel. This includes the tool of economic pressure.

Concerns have been raised about NHS bodies purchasing supplies from Israeli companies.

An example of this is an Israeli company which supplies wheelchairs.

A particular issue is that Kings are involved and the Chair of Kings is no other than David Behan the former regulatory chief of the Care Quality Commission. Who one might hope should take extra care to ensure a high level of legal and ethical compliance. Cough.

Campaigners, including trust staff, remain very concerned.

I have been sent this flyer for anyone with an interest in these matters:

All best wishes and see you when I see you.

A reported exchange between campaigners and Behan at Kings:

Dr Minh Alexander, retired consultant psychiatrist 3 May 2025

This is a brief follow up to my last post, in which I reported on issues surrounding a dangerous shortage of NHS mental health beds in England. 

The issues are set out in detail in that report. The issues relevant to mental health crisis services can be summarised as follows.

Mental health beds have been relentlessly cut despite protests by patients, families, professionals and Royal Colleges.

Politicians and senior NHS leaders have claimed that there has been investment in community services to compensate for bed loss, and policy has been devised to reduce access to beds.

The introduction of a gatekeeping function by community-based mental health crisis resolution teams has been key, and has in some instances inappropriately and unsafely blocked access to inpatient care.

The services offered by crisis teams have been flourished by politicians and senior NHS leaders as part of the justification for cutting mental health beds, but crisis teams are neither sufficiently resourced nor safe. NHS crisis services currently lack crucial elements needed for fidelity to a recommended model of safe and sufficiently intensive care.

An aspect of these safety failures has been failure of risk assessment and management. The failures are reflected in repeated coroners’ Prevention of Future Deaths reports.

Crisis teams were mandated by The NHS Plan 2000, with a requirement for establishment by 2004.

By 2014 the National Confidential Inquiry into Suicides and Homicides by People with Mental Illness (NCISH) warned that work was needed on the safety of crisis services. Crisis teams accounted for about twice as many suicides as inpatient services (and the running total suggests that they still do).

NCISH also questioned the practice of using crisis teams to facilitate early discharges from hospital. However, the practice has continued, and is in fact required by NHS England guidance on mental health bed management:

“A review of all inpatients individually, to agree on the appropriateness of their continued stay in light of current and predicted levels of activity, and consider whether any of them could be discharged early with increased follow-up by community mental health teams.”

Moreover, NCISH found in 2014 that 43% of suicides under crisis teams were by patients who lived alone.

NCISH advised that providers should be cautious about treating such higher risk patients under crisis resolution/ home treatment teams, and should review their entry criteria for such services.

“CR/HT [Crisis Resolution/Home Treatment] may not be suitable for patients at high risk or those who do not have adequate family or social support: services should review their criteria for its use.”

NCISH advised that more suicide prevention work was needed with regard to crisis teams:

“CR/HT should be a priority setting for suicide prevention in mental health services.”

Failure to improve since NCISH’s 2014 warning

I asked the National Confidential Inquiry about repetition of its 2014 analysis of the social circumstances of people who died by suicide under the care of crisis teams, to see whether NCISH’s advice had been implemented and whether there had been a drop in the proportion of suicides by people who lived alone.

The Inquiry advised that the analysis was repeated in the four following years up to 2018. This showed no reduction in the proportion of patients who were living alone when they died of suicide under crisis service care:

Period	Page of annual report	Proportion of CR/HT suicides in patient  who lived alone
Report 2014 (2002-2012 data)	Page 42	“666 (43%) CR/HT patients lived alone”
Report 2015 (2003-2013 data)	Page 27	“In 795 (43%) the patient lived alone.”
Report 2016 (2004-2014 data)	Page 29	“In 833 (43%) the patient lived alone.”
Report 2017 (2005-2015 data)	Page 36	“In 883 (44%) the patient lived alone.”
Report 2018 (2006-2016 data)	Page 55	“In 834 (43%) the patient lived alone.”

In addition, data for the period 2012 to 2022 also suggests that this lack of improvement has persisted. Between 2012 and 2022, 841 patients who lived alone died by suicide under the care of crisis teams:

“Based on this 2012-2022 dataset, there were 1,970 patients under CRHT services in England who died by suicide, of whom 841 (44%) were living alone.”

This is the FOI response by the National Confidential Inquiry.

Taken with the NCISH 2014 data for the period 2002 to 2012, when there were 666 crisis team patients who died by suicide and lived alone, a total so far of 1507 crisis team patients who died by suicide lived alone.

Questions arise about what actions have been taken by NHS England and the Care Quality Commission to ensure learning from the National Confidential Inquiry’s warnings. Also, if no effective action was taken to reduce the risk of suicide by patients under crisis teams, was this due to inefficiency or unwillingness to impede the political drive to cut beds?

RELATED ITEMS

1) Waiting “for the grown ups to arrive”. Dangerous shortage of mental health beds, the government’s deflection of coroners’ warnings and normalisation of bad practice by NHS England A lengthy but indexed report with data, on the wilful blindness of politicians and NHS England to the harm caused by unsafe cuts to mental health beds.

2) NHS England’s handling of independent investigations on mental health homicides A report with data on how NHS England fails to ensure learning from mental health homicides. As part of this, NHSE has not shown appropriate accountability and there is opacity on how only a proportion of mental health homicides that are eligible for independent investigation are actually independently investigated. Access to mental health services, including to mental health inpatient treatment, has been a factor in these homicides.

3) The government has announced a cut in the proportion of spending on mental health. This is on top of years of proportionately lower spending on mental health.

Mental Health: Expected Spend for 2025-26 Statement on 27 March 2025

4) The government announced on 22 April 2025 that it intends to hold a statutory public inquiry into the mental health homicides and attempted murders in Nottingham, which will be chaired by a retired circuit judge, HH Deborah Taylor:

“Resident Judge at Southwark Crown Court and Recorder of Westminster until her retirement from the Judiciary in December 2022. In 2022 she was Treasurer of Inner Temple, where she advocated for greater diversity at the Bar.

Deborah will continue in her role as Chair of the Criminal Legal Aid Advisory Board which she has held since July 2023.”

The terms of reference for this statutory inquiry have not yet been published.

Dr Minh Alexander retired consultant psychiatrist 24 April 2025

I have continued work on NHS England’s questionable handling of mental health homicides by looking at the bed shortage, which poses risk to patients, their families and the public, and the government’s approach to it.

There is shortage of complete and reliable official safety data on mental health services and a range of sources have to be examined.

Because of the unsatisfactory data by the NHS, I sorted through hundreds of coroner’s Prevention of Future Deaths reports issued on mental health deaths since April 2019 and these gave a picture of recurring failures, which points to systemic safety issues.

I have produced a report on the mental health bed shortage, the underlying issues and the consequences. The report is lengthy but for those in a hurry, the salient facts and my conclusions are contained in the summary and the conclusions. The supporting evidence in between is indexed, so it is possible to pick out areas that may be more useful to some readers.

This is the report.

RELATED ITEMS

The government has announced a small cut in the proportion of spending on mental health. This is on top of years of proportionately lower spending on mental health.

Mental Health: Expected Spend for 2025-26 Statement made on 27 March 2025

The government announced on 22 April 2025 that it intends to hold a statutory public inquiry into the mental health homicides and attempted murders in Nottingham, which will be chaired by a retired circuit judge, HH Deborah Taylor:

“Resident Judge at Southwark Crown Court and Recorder of Westminster until her retirement from the Judiciary in December 2022. In 2022 she was Treasurer of Inner Temple, where she advocated for greater diversity at the Bar.

Deborah will continue in her role as Chair of the Criminal Legal Aid Advisory Board which she has held since July 2023.”

The terms of reference for this statutory inquiry have not yet been published.

Dr Minh Alexander, retired consultant psychiatrist 23 March 2025

In this post I set out a concern that I raised with the parliamentary Standards Commissioner about misrepresentation about the existence of a Whistleblowing APPG.

There was a  regrettable Whistleblowing APPG, set up with funding from US bounty hunting law firms with a vested financial interest in changing UK whistleblowing law, but it has not featured in parliament’s official APPG register since summer 2024.

This may be related to the fact that its former chair Mary Robinson lost her parliamentary seat in the last general election.

A group of parliamentarians uniting on an issue can only call itself an All Party Parliamentary Group if it is registered and it may not display the crowned portcullis, symbol of parliament, if it is not registered.

See the parliamentary rules on APPGs:

All-Party Parliamentary Groups Guide to the Rules 12 September 2023

However, despite apparent lack of registration, the website of the old Whistleblowing APPG was maintained, giving the impression that there was still a Whistleblowing APPG. It continued to display the crowned portcullis.

An X social media account (@AWhistleblowing) also continued to operate, purportedly claiming that it was the account of the Whistleblowing APPG, and it displayed the crowned portcullis. It was still active in January 2025.

The troubling private organisation WhistleblowersUK which was previously the secretariat of the old Whistleblowing APPG and has advocated for financial rewards to be introduced, continued to claim that it was the APPG secretariat on its LinkedIn account and its website.

WhistleblowersUK’s X social media account also claimed in December 2024 that Gareth Snell MP had been appointed as Chair to the Whistleblowing APPG, and copied Mr Snell and the X account at @AWhistleblowing.

I made enquiries to double check and the registrar’s office confirmed that there was indeed no registered Whistleblowing APPG.

I then raised concerns with the parliamentary Commissioner for Standards. After several exchanges of correspondence, it seemed that little action would be taken because the Commissioner’s office implied there was no applicable power. I asked (a) if the Standards Commissioner had actually seen my correspondence (b) if there was a gap in the rules which needed to be rectified. I was subsequently informed that the matters I had raised were a suitable matter to raise with the Commissioner, as an issue of misuse of parliament’s authority. It was also confirmed that the Commissioner had seen my correspondence.

As well as the possible misuse of parliamentary authority through incorrect claims that there was a Whistleblowing APPG and unauthorised use of the crowned portcullis, I also informed the Standards Commissioner that:

1. Gareth Snell MP’s published registered interests did not include any reference to the fact that he was Chair of a Whistleblowing APPG

2. Tess Munt MP was listed as a vice chair of WhistleblowersUK on WhistleblowersUK’s website but this had not featured in her published registered interests.

Following this, the old Whistleblowing APPG website was deactivated.

However, the X social media account @AWhistleblowing, purporting to be an account by the Whistleblowing APPG, remained in place.

I asked Tessa Munt to confirm if she was indeed Vice Chair of WhistleblowersUK, but as on previous occasions when I raised concerns about WhistleblowersUK, I received no response.

When I approached Gareth Snell, I received brief responses from his office which indicated that he had indeed been named as the Chair of the group but stepped down because of pressure of other commitments:

The X social media account which claimed to be an account by the Whistleblowing APPG has now finally also been altered. The same X handle @AWhistleblowing now represents itself as The “Office of the Whistleblower”:

The “Office of the Whistleblower” is a reference to a US body which runs a flawed whistleblowing programme, awarding vast sums to a very small number of financial sector whistleblowers but failing many more.

US bounty hunting lawyers wish to see an equivalent body set up in the UK, which would expand their market. But to be clear, there is currently no body called “The Office of the Whistleblower” in the UK.

WhistleblowersUK continues to claim on its LinkedIn account that it is the parliamentary secretariat to a now non-existent Whistleblowing APPG. This is how the account appears today:

Tessa Munt continues to be listed on WhistleblowersUK website as a Vice Chair of the organisation, but there is still no corresponding entry in her parliamentary registered interests.

I will ask the Standards Commissioner for an update but am unsure if this will be forthcoming. We may never know what exactly happened but it does seem for now that those who wish to turn UK whistleblowing into a lucrative business for lawyers and other middlemen have less parliamentary access than they did previously. But further attempts may be made to set up another APPG to press their aims.

Related items

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

The Ferret: “Bounty hunting” by US law firms in UK could exploit whistleblowing

Byline Times: Could Whistleblowing Become Big Business?

Qui Tam. A tale of malicious informants and corruption in ye Olde England. And its evolution to the modern bounty hunting model

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

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

By Dr Minh Alexander, retired consultant psychiatrist 25 February 2025

In the wake of publication by NHS England of its independent investigation into the three killings and three attempted murders by the mental health patient Valdo Calocane, I transferred data on NHS England’s published independent homicide investigations onto a spreadsheet to support public access.

I also examined NHS England’s approach to commissioning independent investigations on mental health homicides, and other matters such as information on the contractors whom NHSE hires to undertake these investigations.

The resultant report, including the spreadsheet of all mental health homicide independent investigations published by NHS England, can be downloaded here:

NHS England’s handling of independent investigations on mental health homicides

Huge thanks to the charity Hundred Families for their comprehensive database on mental health homicides and very helpful reports. I could not have done this work without the charity’s meticulous documentation and tenacious pursuit of the truth behind mental health homicides.

On a personal note, warm thanks to all well wishers. Although I have done some work on mental health homicides recently, personal circumstances are still a constraint and I am sorry not to be able to pick up much at present. Best wishes to all.

RELATED ITEMS

(1) This is data on coroners’ Prevention of Future Deaths reports about Nottinghamshire Healthcare NHS Foundation Trust, which was the trust responsible for Valdo Calocane’s care:

List of coroner’s Prevention of Future Deaths reports (PFDs) relating to care provided by Nottinghamshire Healthcare NHS Foundation Trust

(2) I pointed out in the above report on NHS England’s handling of the investigation of mental health homicides that the NHS fails to independently investigate all mental health homicides which meet the criteria for investigation.

Part of the evidence for this comes from 2008 data by the old National Confidential Inquiry into Suicides and Homicides by People with Mental Illness (now the National Confidential Inquiry into Suicides and Safety in Mental Health since funding for studying homicides was cut).

I asked the National Confidential Inquiry if it ever repeated its analysis on the proportion of eligible homicides which were investigated, and it replied that it had not. These are the documents arising from that FOI:

NCISH homicide methodology

NCISH FOI response email 27 March 2025

HQIP correspondence to NCISH about homicide funding cut

Dr Minh Alexander 26 January 2025

In preparation for the expected independent investigation report on the psychotic patient Valdo Calocane’s killings and very serious, life changing assaults in Nottingham, I have searched the Chief Coroner’s database for coroners’ warning Prevention of Future Death reports issued to the NHS mental health trust responsible for his care.

I am sharing the list of 26 PFDs for anyone who may find it useful, with some brief contextual information, sketching out some of the pressures on all mental health trusts nationally.

The list can be found here:

List of coroners’ Prevention of Future Deaths reports relating to care provided by Nottinghamshire Healthcare NHS Foundation Trust

My condolences to all bereaved, injured and otherwise affected by the catastrophe in Nottingham.

RELATED ITEMS

I have reviewed independent investigation reports on mental health homicides that are published by NHS England and transferred the data to a spreadsheet to support public access.

I also examined NHS England’s approach to commissioning such independent investigations and found some serious concerns.

The data and a report can be found here:

NHS England’s handling of independent investigations into mental health homicides

By Dr Minh Alexander, retired consultant psychiatrist 21 January 2025

This is a post to share information for any harmed patients and families who may not be aware of a pattern of behaviour by this organisation.

Due to previously mentioned personal circumstances, I cannot be as active as I previously was in responding to general correspondence, but I am more than happy to be contacted by any affected patients and families on this specific matter.

In summary, a member of my family was affected by failure by North West Anglia to act upon a CT scan report which advised that there was a lung nodule which might be cancer. We later discovered through media reportage about a coroner’s hearing, and the coroner’s formal Prevention of Future Deaths warming report (PFD), that at least two other similar incidents had occurred AFTER my relative suffered great distress and potential harm. An FOI request revealed more cases.

With my relative’s permission, I set out in summary the history, including up to date FOI data disclosed by the trust which shows at least 24 similar incidents since 2021.

The member of my family had a CT scan in January 2021 which was seriously mishandled by North West Anglia, and an opportunity to treat the lung cancer was missed for another seven months.

The CT scan was ordered by a consultant urologist in the context of blood results and clinical symptoms that raised the possibility of an intra-abdominal cancer. This was set upon a past history of aggressive kidney cancer (treated effectively with surgery).

The consultant radiologist who reported on the January 2021 CT scan wrote at the start of his report that there was a suspicious new lung nodule which could be cancer that had spread from somewhere else.

“There is a new large mixed density lung nodule seen within the posterior segment of the right upper pulmonary lobe measuring 2.1cm which could represent a new metastatic lung lesion.”

The radiologist also noted a mass in the bile duct.

The lung nodule later proved to be cancerous, and was in fact thought to be a primary lung cancer. The bile duct mass was not cancer.

Two surgical teams, hepato-biliary and urology, thereafter mishandled this case. Inexplicably, both failed to act upon the reported suspicious lung nodule and they focussed only on the mass in the bile duct.

The surgeons did not inform my relative of the lung nodule.

The existence of the lung nodule was only communicated by his GP, about two months after the scan.

We asked the hepato-biliary consultant surgeon about the lung nodule and asked him to follow it up. He agreed to do so. He later denied recall of this conversation. The trust claimed there were no records of the contact.

We again reminded the hepato-biliary surgeon about the suspicious lung nodule and it was only at this point that he acted by referring my relative to the lung team.

The lung team advised that the lung nodule was most likely to be cancer which had spread from the kidney, and they recommended a PET scan to measure the metabolic activity in the nodule. This was not initially communicated to my relative.

Instead of ordering a PET scan (which required the involvement of another NHS trust), the relevant surgeons offered another CT scan, without explaining why a CT scan was being arranged or what the lung team had advised. My relative did not even know which doctor had ordered the CT scan. Only persistent enquiries revealed the sequence of events.

When we asked for details of the findings and advice from the lung team, we were met with resistance and obfuscation.

The trust’s then clinical lead for surgery refused to provide my relative with a copy of the advisory letter from the lung team to the surgeons. He advised that the only access to this document was by making a formal Subject Access Request under the relevant legislation.

This is despite an established practice in this NHS trust of copying outpatient correspondence to patients.

When we later received the lung team’s letter under Subject Access Request, we noted that it placed on the record the delay in acting upon the January 2021 CT scan.

My relative’s subsequent experience of the trust was of more chaos, inconsistencies and obfuscation. My relative’s care was eventually transferred to another trust as all confidence had been lost. This all added to the clinical delay.

My relative had little confidence in the trust’s internal processes for handling this incident, and did not believe that there was any genuine learning.

We were very disturbed but not surprised to note local media reports of the death in January 2023 of another patient, Mr Richard Roe. This occurred after failure by North West Anglia to view or act upon findings of cancer on a CT scan. Mr Roe had also reportedly been under the care of the trust’s hepato-biliary surgeons. These were the local news reports: 

Man died at home after doctors failed to identify cancer in CT scans

Hinchingbrooke Hospital patient died as CT scan not viewed

The coroner determined:

“A subsequent CT scan on 11.10.21 identified a lesion in excess of 3cm in the tail of the pancreas. The reporting radiologist recommended the scan be reviewed by the Hepato-Biliary MDT but the scan was neither actioned nor viewed. Had it been viewed the scan would have shown the presence of pancreatic cancer.”

The coroner noted another case from May 2021, which postdated my relative’s case:

“The evidence revealed that there is currently no method for ensuring that routine CT scan reports are reviewed by clinicians. This is despite a similar occurrence in May 2021.

The coroner, Mr Simon Milburn, issued a Prevention of Future Deaths (PFD) warning arising from Mr Roe’s case because of concern about the risk of similar future deaths. PFD warnings are only issued exceptionally for serious risks.

This is an uploaded copy of the coroner’s PFD report on Mr Roe’s death:

Coroner’s Prevention of Future Deaths report on death of Mr Richard Roe 2024-0693

Based on our experience of the trust’s unreliable disclosure of information on repeated occasions, I submitted a Freedom of Information request about the instances of trust failures to review and act upon CT scans and CT scan reports.

This was the FOI request:

FOI request to North West Anglia re missed CT scans

This was the trust’s response of 20 January 2025:

North West Anglia response email FOI 2024 – 943

North West Anglia FOI response attachment (1)

North West Anglia FOI response attachment (2)

The trust so far admits that since 1 January 2021, that there were 24 instances of failure to review CT scans/ CT scan reports, five of which in the trust’s view caused harm, and three of which were reported to the health regulator, the Care Quality Commission.

Despite the long running nature of these issues, the trust has not disclosed any remedial actions taken thus far.

A number of planned remedial actions are listed.

I will be asking some supplementary FOI questions and will post any follow up FOI results here.

I will also inform the coroner of the FOI data and also of my relative’s case, which based on the PFD report appears not to have been disclosed to the coroner by the trust.

We had already raised concerns with the General Medical Council but felt that the regulator downgraded what seemed to us to be serious failures.

Related items

Nationally, these issues have been a long recognised problem.

The Royal College of Radiologists (RCR) issues core standards to ensure that imaging results are produced in a timely way and acted upon by the clinicians who request the imaging.

This is the RCR standards document:

Standards for the communication of radiological reports and fail safe alert notification

Importantly, it emphasises the over-arching responsibility of organisations to ensure that there are failsafes and that systems are regularly audited.

A PHSO report of 2021 based on 25 complaints, noted that problems persist nationally, with failures to meet the Royal College’s standards:

“We found that some NHS trusts do not have clear and effective policies, processes or systems to ensure that imaging results are reported and acted upon.”

“Half of the cases show that Royal College of Radiologists’ guidelines on reporting clinically significant unexpected findings were not followed.”

This is an uploaded copy of the PHSO report for anyone who may find it useful:

Unlocking Solutions in Imaging: working together to learn from failings in the NHS, PHSO July 2021

By Dr Minh Alexander retired consultant psychiatrist

Summary

This post reports on inconsistent information disclosed by CQC on whether or not it has taken regulatory action under CQC Regulation 5 Fit and Proper Persons (FPPR). It also summarises FOI data from the CQC which shows that CQC apparently lacks grip on even the number of NHS FPPR investigations that have taken place. From the data available, only a small proportion of FPPR referrals result in investigations. CQC stated it has accepted all FPPR investigations that it has received, even those which made dubious or frankly perverse findings. The investigations have mostly been conducted by a small pool of external contractors, some of whom have done more than one FPPR investigation. Some contractors have also obtained other employment from the NHS trusts concerned, with questions about potential conflict of interest arising. CQC has refused to disclose the identity of three contractors, making it impossible to know if there were conflicts of interest in their appointment. This confirms the impression of secrecy and unaccountability surrounding the performance management of failing NHS senior managers, and it has serious implications for patient safety. The example of CQC’s dire handling of an FPPR referral on Paula Vennells controversial former Post Office chief executive, who became the Chair of Imperial Healthcare NHS Trust is summarised. The regulator failed to act in a timely manner and then simply shut the referral down after Vennells left the NHS. It failed to examine the trust’s wider leadership and FPPR processes. An Imperial NED had in fact written to me in an attempt to deter me from raising further concerns about Vennells’ suitability. The protection and recycling of wrongdoers continues.

Introduction

My apologies for this late post due to personal circumstances. The post is a summation of the latest information on the Care Quality Commission’s handling of the Fit and Proper Person test in the NHS.

The CQC has a poor reputation, arising in part from lack of distance between the regulator and regulated, and a revolving door between these organisations. This poor reputation includes repeated failures to enforce the 2014 CQC Regulation 5, Fit and Proper Persons which applies to NHS trust directors. It appears that almost no amount of senior management misfeasance results in overt CQC action under the regulation. I say “overt” as there has reportedly been regulatory action which CQC seems to have kept hidden from the public.

CQC’s tortuous acrobatics to avoid holding NHS trust boards to account include the regulator’s claims that it only regulates organisations’ FPPR process and not the fitness of individual directors. When the opposite suits, CQC has claimed that because some trust directors have moved on, there are no grounds to apply FPPR or to examine an organisation’s processes.

In an FOI disclosure of May 2022 CQC admitted that no NHS FPPR processes, since Regulation 5 was introduced in 2014, had led to a finding by CQC’s FPPR panel that any NHS trust was non-compliant with Regulation 5. CQC claimed that this might be due to referred directors leaving or being dismissed.

“…no FPPR referrals relating to NHS trusts have reached an outcome that the provider is noncompliant with the regulation at the conclusion of the panel process…”

This appeared to contradict CQC’s claims to parliament in 2021 that it had taken regulatory action against some NHS trusts under FPPR.

I had also previously found evidence of CQC regulatory action under FPPR at the acute NHS trust in Kettering, which the regulator had not transparently shared with the public.

The reason for the inconsistent information about regulatory action by CQC is not yet clear.

In a curious situation at University Hospitals Leicester NHS Trust, NHS England referred two former NHS trust directors after a financial scandal, only for these referrals to be rejected by CQC on the grounds that former directors did not fall under Regulation 5. Thus, a veil may be drawn over any system failings, no matter how serious.

Paula Vennells’ FPPR referral

A notable example of CQC’s behaviour is that of Paula Vennells the much-criticised former Chief Executive of the Post Office. Vennells is a key figure in the mass miscarriages of justice against innocent sub postmasters who were unsafely convicted of fraud due to Post Office computer errors, which were in fact known to the Post Office. The unsafe convictions started before Vennells joined the Post Office but continued during her tenure, both as group network director and later as CEO. Vennells left the Post Office during legal action by postmasters which was eventually successful. The Post Office resisted throughout and was excoriated by the judge for its disreputable conduct and the unreliable evidence of the Post Office’s senior managers. The subsequent and ongoing public inquiry into the scandal has yielded a wealth of damning evidence all the way up to ministerial level, of wilful blindness and collusion.

Despite the morass at the Post Office, Vennells had a soft landing after her departure from the Post Office, and took up other senior management posts including the Chair of Imperial Healthcare NHS Trust. Unusually, Dido Harding the Chair of NHS Improvement was involved in the appointment at Imperial,

taking part in the selection process. I subsequently referred Vennells to the CQC under Regulation 5 FPPR in December 2019, after the Post Office trial had ended with severe criticism by the High Court of the Post Office’s actions and omissions. Aside from the Post Office’s dissembling about the Horizon computer fiasco, the Court scrutinised the contractual relationship between the Post Office and post masters, and concluded that the Post Office behaved like a “Victorian factory owner”. This is surely a harmful culture that should not be exported into the NHS.

The CQC dragged its feet and no external FPPR investigation took place, albeit one of Imperial’s directors claimed that one had been planned. Sixteen months after my FPPR referral, CQC wrote to say that it was shutting the case down because of Vennell’s departure from Imperial. That is to say, CQC implied that FPPR revolved around an individual and not an organisation’s processes, despite its many previous claims to the contrary.

There was in fact reason to question Imperial’s FPPR process. Disclosed correspondence showed that Vennells took part in constructing comms material in response to a challenge from the public about her fitness.

An Imperial non executive also wrote to me characterising my opposition to Vennells’ appointment as a “vendetta”, as later reported by the media in January 2024.

The Imperial NED posited that Vennells might be a victim of misinformation and suggested that my opposition might “backfire” on me in some unspecified manner. The NED claimed that Imperial had given Vennells’ fitness much consideration, and he also implied that the CQC had triggered an external FPPR process:

“I can tell you privately that we have looked again and again at this issue and, as you have acknowledged, we have now agreed to bring in an external assessor to assure us, and the public, that we have shown due diligence”.

He also suggested that no action should be taken until the public inquiry had made a definitive finding about Vennells’ culpability in the Post Office affair:

“It may well be that both the new inquiries, like the past one, find no reason to chastise Paula. It might be that Fujitsu lied or withheld evidence such that her conduct was reasonable. It might that she had too much faith in British justice and in the jury system and believed that, if people had been found guilty, they were probably guilty. It might be that she was cloth eared and should have acted sooner on other evidence. It might be that she listened too intently to lawyers including (I have no doubt) those foolishly advising her to say as little as possible. Or it might be that be that she was significantly culpable, reckless, or even cynical in allowing people to lose their jobs and go to prison for the betterment of the Post Office. When we know, it will be time to act.”

It seems disturbing that thousands of patients’ and trust staff’s interests may be given lower priority than the interests of a former chief executive of a clearly failed organisation, with clear findings by the High Court. Potential patient safety risk should surely not be parked for several years whilst the interests of senior executives are protected. Who wants a director with a history of minimising bad news in a safety critical sector?

Indeed, the fact that the CQC had reportedly negotiated for an external FPPR investigation suggests that the regulator had not originally planned to defer the FPPR process until after the Post Office public inquiry, despite the Imperial NED’s assertions that no action should be taken until the public inquiry’s determinations about Vennells had concluded.

The attitude of the Imperial trust board suggests that Trust process and not just Vennell’s personal fitness was relevant to the FPPR, but it was never examined.

CQC FOI disclosures on the conduct of Regulation 5 FPPR

On 11 October 2023 and 29 November 2023 the CQC responded to FOI requests on its handling of Regulation 5 FPPR as follows:

Since 2014 CQC has received “153 referrals from trusts involving 223 directors who may have been referred once or more.”

CQC’s FPPR panel (usually chaired by the Chief Inspector of Hospitals or a deputy) had “ followed up on 96 referrals.”

Astonishingly, CQC said it did not know how many of the referrals had led to an investigation:“We don’t hold this information.”

CQC disclosed that it had received FPPR investigation reports on only a small proportion of the referrals:“We have received 30 investigation reports”

Three of these thirty investigations had been conducted internally:

“We don’t hold information on how many FPPR investigations were conducted internally. We have received 3 reports from internal reviews/investigations.”

Independent investigation reports were received in 27 of the 30 cases:

“We have received 27 reports from external independent investigations.”

When questioned about the low number of external independent investigations and asked how it satisfied itself that Regulation 5 had been met in all cases CQC replied:

“The CQC received information from the trusts that either gives assurance for regulation 5 on each of its directors or confirms what the trust is doing to ensure the regulation is being met. There are referrals recorded where directors have left the NHS during the process which would not have resulted in an investigation or report.”

CQC had not rejected any of the FPPR investigation reports:

“Question

By rejected, I mean “Did CQC find the reports to be unacceptable in nature or quality?”

For example, were any of the reports so unacceptable that CQC therefore asked for further reports or re-investigation and/or revision of some aspect of the reports?”

Answer

CQC has not rejected a report in the manor [sic] which you describe.”

Given some of the outcomes of the FPPR investigations, some sharply contradicting evidenced, legal determinations by Employment Tribunals, this too is astonishing.

These 27 investigation reports had been carried out by a small pool of external investigators:

“The number of external contractors is 17. Some contractors have been used more than once.”

CQC listed the contractors used for these external FPPR investigations thus:

Tamarix People

Fiona Scolding QC

Unique Health Solutions

Law2Business

Serjeants Inn Chambers / Clyde & Co

Mark Sutton QC

Bevan Brittan

Deloitte

Cordis Bright Consulting

YSC – Young Samuel Chambers

Good Governance Institute

Capsticks Solicitors

Ibex Gale

EY

3 Independent Individuals

In an FOI response of 20 November 2023, CQC later disclosed information on how many investigations had been conducted by each of these contractors:

Fiona Scolding KC (2)
Unique Health Solutions (2)

Law2Business (1)

Serjeants Inn Chambers / Clyde & Co (1)

Mark Sutton KC (1)
Bevan Brittan (1)
Deloitte (2)
Cordis Bright Consulting (1)
YSC – Young Samuel Chambers (1) Good Governance Institute (1)
Capsticks Solicitors (3)
Ibex Gale (2)
EY (1)
3 Independent Individuals (3)

CQC declined to disclose the identity of the three independent individuals. Interestingly, CQC justified this by asserting that barristers might expect their identities to be disclosed but that non barristers might not.

It is therefore not possible to tell if conflicts of interest surround the hiring of the  three unnamed, allegedly independent individuals on CQC’s list of external contractors.

CQC refused to disclose to which NHS trusts the 30 investigations related, further obscuring any possible conflicts of interest.

But CQC admitted that the regulator itself had previously purchased services from Deloitte and EY.

There are some interconnections with NHS whistleblower cases.

CQC disclosed that the FPPR investigation on Portsmouth medical director John Knighton was conducted by Mark Sutton KC. I referred John Knighton because of his mistreatment and unfair dismissal of Dr Jasna Macanovic, Portsmouth whistleblower, as determined by an Employment Tribunal. CQC found no breach of FPPR and Knighton remains as medical director.

Of note, Mark Sutton received further employment by Portsmouth and he later represented the trust at Dr Macanovic’s employment tribunal remedy hearing. At the Tribunal hearing, which I observed, the Tribunal criticised the Trust for attempts to shift blame (and by implication, reduce liability).

Mark Sutton also represented Hampshire Hospitals in the Employment Tribunal case of Mr Martyn Pitman, Obstetric whistleblower.

Furthermore, Law2Business is on the list of contractors who have carried out FPPR investigations.  This company was owned by a Portsmouth Non Executive Director who conducted a whistleblowing investigation at Hampshire Hospitals into Martyn Pitman’s case. Mr Pitman contended that the investigation was flawed and links between the two trusts were noted. CQC denied that Law2Business had carried out any FPPR investigations at Portsmouth or Hampshire.

Concerning the law firm Bevan Brittan, which appears on CQC’s list, this may relate to the FPPR investigation of David Rosser former medical director and then CEO of University Hospitals Birmingham NHS Foundation Trust. In this matter, the CQC wrongly claimed to me that an independent investigation had taken place, when it was an internally led investigation by a trust employee. The investigation had contributions from Bevan Brittan, which was a firm retained by the trust and had received half a million pounds from the trust in the three years before the FPPR investigation. The finding that there was no breach of Regulation 5 seems astounding given the seriousness of the Employment Tribunal’s criticism of Rosser.

With respect to the contractor Tamarix People, which has according to CQC conducted four NHS FPPR investigations, this one-woman company was previously engaged to investigate conflict between Trust Directors at Wirral.

Regarding the Countess of Chester Hospital NHS Trust, where the Letby killings took place and continued after clinical staff raised concerns, CQC declined to say if there is a current FPPR process:

“CQC cannot currently comment on any FPPR referrals that we may have received subsequent to the criminal conviction of Lucy Letby.

We consider this information – including confirming whether or not CQC has received referrals – to be exempt from disclosure under section 31 of FOIA (law enforcement / prejudice to regulatory functions).

We recognise the public interest in transparency on this matter but consider that there is an overriding public interest in prevention of any prejudice.”

These are the two most recent CQC FOIA disclosures about FPPR:

CQC FOI response on FPPR CQC IAT 2324 0556 11 October 2023

CQC FOI response on FPP CQC IAT 2324 0690 29 November 2023

In short, there is limited transparency on how NHS trusts and the CQC handle Regulation 5 FPPR, even allowing for legitimate considerations of privacy. Indeed, the public interest test under FOIA should be weighted differently for the directors of NHS trusts, who handle budgets of hundreds of millions and who hold the safety of patients in their hands

Only a small proportion of FPPR referrals result in an investigation, and where the investigations are contracted out, they are given to a small pool of investigators, some of whom may provide other services to the relevant NHS trust.

There is a potential for pro-employer bias, in what are matters of huge public interest.

The waste of public money in servicing ineffective, secretive and half-hearted enforcement of Regulation 5 is lamentable.

The greatest cost is to NHS safety culture and patients’ interests.

Many NHS senior managers continue to protect their own positions.

The annual NHS staff survey report was published yesterday, with a low response rate of 47%. It nevertheless shows that roughly a third of NHS staff still do not feel safe to speak up, and about half do not think concerns would be acted on.

Personal update

I have been unwell and also much occupied with family responsibilities. For a period, I will not be able to do as much campaign work as usual. I may not be able to respond to all messages, but I appreciate the support and concern that many have shown. I hope to resume more work at some point.

RELATED ITEMS

Sorry is the hardest word: CQC, Paula Vasco-Knight and Regulation 5 Fit and Proper Persons

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

Mr Shyam Kumar, Surgeon and vindicated NHS whistleblower’s case: CQC sacked a whistleblower for disclosures about its poor regulatory performance, and dug for dirt on the whistleblower

Dr Minh Alexander retired consultant psychiatrist 11 November 2023

Summary: Hampshire Hospitals NHS Foundation Trust has so far spent nearly £400K on external legal services by Bevan Brittan and three external reviews on Martyn Pitman’s maternity safety whistleblowing case at Hampshire Hospitals. The total payments to date of £310,060K to Bevan Brittan for work on Martyn Pitman’s case comprises over 20% of the total trust spending of £1,497, 697.11 on external legal services since 2019. Mr Pitman was suspended for two years by the trust and became very unwell. Importantly, although the trust claims that it did everything to resolve its conflict with Mr Pitman, it now admits to hiring the law firm Bevan Brittan LLP at least four months before it received an Employment Tribunal claim from Mr Pitman. This suggests that Hampshire Hospitals NHS Foundation Trust had a legal strategy in mind, despite its protestations of focus on non-legal resolutions. The wastefulness of drawn-out conflict and the sacking of NHS whistleblowers when they could be redeployed across the vast NHS (at an early stage if they wish it), is staggeringly wasteful and irresponsible.

A common feature in NHS whistleblowing cases is the abuse of public money to protect senior reputations.

Commensurate with that is the early, secretive involvement of lawyers well before formal legal proceedings. The advice purchased is usually on legal strategy to silence and or manage whistleblowers out of organisations.

A pretext for dismissal may be manufactured, such as stoking conflict and provoking the whistleblower with unfair treatment, in order to construct a claim of breakdown of relationships.

Mr Martyn Pitman consultant obstetrician a whistleblower at Hampshire Hospitals NHS Foundation Trust was dismissed because of purported breakdown of relationships. Disclosed data now reveals that lawyers, Bevan Brittan LLP, were hired months before Mr Pitman lodged a complaint to the Employment Tribunal.

The Tribunal recently heard one of two whistleblowing claims by Mr Martyn Pitman consultant obstetrician against Hampshire Hospitals NHS Foundation Trust, on whistleblower detriment. The other as yet unheard claim is one of unfair dismissal. The Employment Tribunal found in favour of the trust and in effect, no one was held accountable for Mr Pitman’s two year suspension and related serious health problems.

At the hearing, Mr Pitman’s barrister criticised Hampshire Hospitals for hiring Gary Hay a former Capsticks partner and a non executive director at a nearby and closely linked NHS trust, reportedly on the advice of Bevan Brittan LLP. Hay was hired by Hampshire Hospitals NHS Foundation Trust to conduct an “independent” investigation of Mr Pitman’s concerns about the way he had been treated. It later became evident that the trust had hired Bevan Brittan to represent it against Mr Pitman’s Employment Tribunal claim. Mr Pitman’s barrister was interested in when Bevan Brittan was first hired to act for the trust in Mr Pitman’s case.

Information was obtained via FOIA information on Hampshire Hospitals NHS Foundation Trust’s legal spending and relationship with Bevan Brittan LLP.

This is the trust’s disclosure:

Hampshire Hospitals NHS Foundation Trust FOI disclosure 741/2023 Legal services expenditure

The trust admits to at least £1,497, 697.11 on external legal services since 2019, as follows:

From the above table, the trust claims it has spent £429,697.45 on Bevan Brittan’s services since 2019.

The trust admits so far to spending £310,000K on Bevan Brittan’s services in Mr Pitman’s case. The trust is defensive in tone, and acknowledges that this was a considerable sum:

“6. Please give the total trust spending to date on Bevan Brittan’s services in the case of Mr Martyn Pitman, both on legal and any non-legal services, such as investigations or advisory services on pre litigation strategy.

Since the outset of this matter, Bevan Brittan have submitted invoices to the trust amounting to £310,060 (plus vat) in respect of their fees.

The cost of litigation is significant. The Trust has followed a number of routes to avoid the need for litigation or to reduce its scope. Unfortunately, however the Trust has been unsuccessful in this respect.”

The trust also provided requested data on itemised spending on Bevan Brittan’s services. According to this data, in the period 2019 to the present, the trust first employed Bevan Brittan in March 2021, when it paid the law firm £2,508.49.

The size and date of subsequent payments up to September 2023 are reported by the trust as follows:

Date	Payments to Bevan Brittan
29-Sep-23	£12,706.92
31-Aug-23	£8,634.84
31-Aug-23	£27,328.44
21-Aug-23	£1,057.80
31-Jul-23	£1,640.88
31-Jul-23	£14,563.44
30-Jun-23	£1,189.20
30-Jun-23	£18,591.48
31-May-23	£5,977.08
31-May-23	£17,281.68
28-Apr-23	£3,618.36
28-Apr-23	£18,665.28
31-Mar-23	£11,598.12
31-Mar-23	£23,206.80
28-Feb-23	£14,342.99
28-Feb-23	£12,443.48
01-Feb-23	£7,164.00
31-Jan-23	£8,134.37
31-Jan-23	£7,671.56
29-Dec-22	£1,461.26
29-Dec-22	£3,669.66
30-Nov-22	£487.10
30-Nov-22	£1,729.19
31-Oct-22	£1,948.37
31-Oct-22	£10,758.96
30-Sep-22	£8,153.54
26-Sep-22	£12,779.92
31-Aug-22	£3,296.64
31-Aug-22	£8,722.24
29-Jul-22	£5,795.83
11-Jul-22	£26,190.00
01-Jul-22	£4,335.31
31-May-22	£4,680.26
31-May-22	£6,741.79
29-Apr-22	£5,636.16
29-Apr-22	£1,363.82
29-Apr-22	£351.89
05-Apr-22	£9,874.68
31-Mar-22	£4,540.25
31-Mar-22	£3,646.68
28-Feb-22	£9,878.53
28-Feb-22	£1,722.44
28-Jan-22	£7,186.90
20-Dec-21	£2,230.49
02-Dec-21	£9,719.89
30-Nov-21	£20,066.57
25-Nov-21	£900.77
25-Oct-21	£414.05
18-Oct-21	£4,521.43
27-Sep-21	£1,037.64
27-Sep-21	£9,719.89
25-Jul-21	£292.25
27-Apr-21	£1,875.30
25-Mar-21	£2,508.49

Based on these itemised figures, I make the total payment to Bevan Brittan in the period to be £414,054.91, and not £429,697.45, as given by the trust’s summary data on all legal spending. This anomaly and any possible omission of payments, especially before 25 March 2021 will be queried.

Importantly, the trust admits to hiring Bevan Brittan to handle Martyn Pitman’s employment issues in July 2021. If correct, this was four months before Mr Pitman lodged an Employment Tribunal claim against the trust. It raises questions of whether the trust wanted advice on an exit strategy for Mr Pitman:

“4. Please give the date when the trust first engaged Bevan Brittan LLP to advise the trust in the matter of Mr Martyn Pitman’s employment issues at the trust

[Trust answer:] Bevan Brittan were first engaged to provide advice in this matter in July 2021.

“5. Please give the date when the trust engaged Bevan Brittan to represent it in the matter of Mr Martyn Pitman’s Employment Tribunal claim against the trust

[Trust answer] Although the complaint raised by Mr Pitman had been ongoing for some time, the formal notification that Mr Pitman had made an Employment Tribunal claim was received by the Trust in November 2021.”

At the hearing of Mr Pitman’s ET case, 25 September to 9 October 2023, it emerged that Bevan Brittan advised the trust to hire Gary Hay as an independent investigator into Mr Pitman’s concerns about being mistreated. The parties have agreed that the trust Chair made arrangements for this investigation by Gary Hay between mid April and early May 2021. So why does the trust claim that it did not hire Bevan Brittan, to handle Mr Pitman’s case, until July 2021?

The trust will be asked to disclose for what services each of the above, dated payments to Bevan Brittan were made.

The trust has additionally forked out in the region of £65K including VAT on external reviews of Mr Pitman’s case, including the Gary Hay report which cost £8,099.91 including VAT:

“7. Please disclose the cost of each external review commissioned by the trust to date in the case of Mr Martyn Pitman, the dates on which the reviews were commissioned and the parties from whom the reviews were commissioned. Please include the investigation by Gary Hay former Capsticks Partner.

In seeking to reach an early resolution with Mr Pitman the following investigations were conducted:  

The investigation conducted by Gary Hay (Law2Business) amounted to £8,099.91 plus VAT. This report was commissioned in June 2021, as a result of concern’s raised by Mr Pitman.

The review conducted by Simon Devonshire KC amounted to £21,825 plus VAT. This investigation was commissioned in June 2022 following a request by Mr Pitman  to
consider the appropriateness of the Maintaining High Professional Standards investigation conducted by the Trust.

The cost of the investigation and resultant report completed by Ibex Gale has previously been the subject of a Freedom of Information request where the Trust has confirmed the costs to have been between £30,000 and £40,000. The Trust was concerned that the publication of the detailed cost information would be prejudicial to the commercial interests.”

So in total, senior NHS managers at Hampshire have so far spent nearly £400K firing a very expensively trained and developed senior medical specialist, on the grounds of breakdown of relationships. Mr Pitman’s expertise was a resource paid for by the public but it has been thrown away by a small number of senior NHS managers.

Regardless of the merits of the Tribunal judgment which deemed that Mr Pitman had suffered no detriment for whistleblowing, this is a ridiculous waste of very valuable human resource. Even if one were to accept the trust’s claims about irreparable breakdown of relationships, which Mr Pitman’s representatives argued the trust made no meaningful attempt to address, it must surely be wrong and disproportionate to expel this precious expertise when other options are available. For example, redeployment across the wider NHS.

Whistleblowing cases often generate great tension within organisations, because somebody somewhere is being criticised. It simply goes with the territory. A failure by the wider NHS to manage this and to provide safe harbour for NHS whistleblowers in conflict with their employers is wasteful folly.

As a more clear-eyed Employment Tribunal judgment from the whistleblowing case of Dr Jasna Macanovic observed:

“13. But the fact that strong feelings were aroused, as they undoubtedly were, only strengthens the connection between the disclosure and the dismissal. People are less likely to be dismissed for pointing out a trifling problem, or when they cause no inconvenience to others.”

14. The main plank of the respondent’s case is that Dr Macanovic was not dismissed for making these disclosures but for the manner in which she did so. But that distinction was not apparent in the dismissal letter, nor to any great extent during the disciplinary proceedings, and does not seem to us to be justified in hindsight. The plain fact is that after over twenty years of excellent service in the NHS, Dr Macanovic was dismissed from her post shortly after raising a series of protected disclosures about this one issue. It is no answer to a claim of whistleblowing to say that feelings ran so high that working relationships broke down completely, and so the whistleblower had to be dismissed. The position is sufficient clear that we thought it best, unusually, to set out these views in summary form at the outset. Our detailed findings of fact and conclusions are set out below. As ever, not all points raised in evidence are
dealt with, only those necessary for our conclusions.”

 

RELATED ITEMS

Mishandling of NHS whistleblowing cases and misuse of public resources against whistleblowers have prompted regular outcry about the fitness of some senior NHS managers. 

A BBC Newsnight broadcast of 8 November 2023 on related matters at University Hospitals Birmingham NHS Foundation trust re-visited the handling of former CEO David Rosser’s referral to the CQC under CQC Regulation 5 Fit and Proper Persons (FPPR).

The BBC Newsnight broadcast can be found here, commencing at about 44.05.

Rosser and former trust chair Jacqui Smith were dismissive of concerns. Smith has posted a response to the Newsnight broadcast on social media, which criticises UHB whistleblower Tristan Reuser. She maintained the trust’s line that David Rosser made only an “inadvertent mistake” in handling Mr Reuser’s case. Smith defends her decision not to sack Rosser on that basis, but her response does not address the very serious criticisms of Rosser and of trust governance, by the Employment Tribunal in particular.

Smith emphasises that Bewick’s review concluded that care at UHB is “safe” – disputed by others. However, Smith does not address the reports of bullying and cronyism in the trust’s medical management structure which featured in Bewick’s report.

Smith has referred to the matters as old news and “historical”. Rosser claimed that the concerns about UHB related to a handful of “disgruntled” individuals.

Lastly, Smith cited the Care Quality Commission’s oversight of Rosser’s FPPR process as a mark of good governance. That is the CQC which has never, in effect, found any trust director to be unfit within the meaning of its regulation.

Care Quality Commission protects NHS directors who harmed and failed Portsmouth whistleblower Dr Jasna Macanovic

Simon Holmes, former Portsmouth medical director who launched disciplinary actionagainst whistleblower Dr Jasna Macanovic, has since acted as a MHPS designated board member at Hampshire Hospitals NHS Foundation Trust

Transparency about Hampshire Hospitals NHS Foundation Trust’s legal spending and Martyn Pitman’s whistleblowing case

Tim Powell Director of Workforce in Dr Jasna Macanovic’s whistleblowing case at
Portsmouth Hospitals University NHS Trust has been appointed Chief People
Officer at Hampshire Hospitals NHS Foundation Trust

Postscripts on Paula. NHS England’s apologia & regulatory reticence

NHS musical chairs: Darren Grayson, the Good Governance Institute & University
Hospitals Sussex NHS Foundation Trust

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

Portsmouth Hospitals University NHS Trust sacked Dr Jasna Macanovic consultant
nephrologist for whistleblowing to the General Medical Council