North East Ambulance Service commissioned an external whistleblowing and bullying investigation which remains secret

Dr Minh Alexander retired consultant psychiatrist 6 August 2022

North East Ambulance Service has been exposed for breaches of coronial legislation and failures of disclosure to coroners, which have included concealment of care failures by the trust.

Former Health Secretary Sajid Javid announced that an independent investigation would take place into these matters, but not a public inquiry as requested by NEAS whistleblowers and bereaved families. The terms of reference are still awaited. The following written exchange took place in parliament on 1 August 2022:

Dehenna Davison Conservative MP, Bishop Auckland

To ask the Secretary of State for Health and Social Care, when he expects the independent review into the North East Ambulance Service (NEAS) to be completed; if he will publish the report of that review; and what steps he plans to take to help ensure that the standard of service provided by NEAS improves as quickly as possible.

James Morris Assistant Whip, The Parliamentary Under-Secretary for Health and Social Care

NHS England is establishing governance arrangements for an independent review to formally commence as soon as is practicable. The families and staff affected will have an opportunity to contribute to the review’s Terms of Reference in due course. Once the review is completed, its report will be published independently of the National Health Service. Local commissioners and the NHS will support the implementation of any recommendations to improve the culture within and the quality of service provided by the North East Ambulance Service as soon as possible. Further details will be available shortly.

NHS England advises that the North East Ambulance Service NHS Foundation Trust has measures in place to improve the standards of service it provides. An investment of £38 million has been agreed for 2022/23 to improve clinical care, recover ambulance response times, increase the operational and Emergency Operations Centre (EOC) workforce and the establishment of an additional EOC in the south of the Trust’s area.

External auditors AuditOne undertook an investigation at NEAS in 2020, resulting in two reports. NEAS has so far disclosed only one of these reports under FOIA, a final report of June 2020.

This revealed that trust managers failed to heed legal advice from the trust’s own solicitors about complying with coronial law.

The trust initially claimed in response to a recent FOI request, for an earlier and more clinically detailed interim AuditOne report of March 2020, that disclosure was exempt due to prejudice to the conduct of public affairs. It is currently responding to a request to internally review this refusal.

Alongside the 2020 AuditOne investigation of coronial process at NEAS, the trust also commissioned an external investigation into governance and workforce issues, including whistleblowing governance and bullying.

This was reportedly carried out by external investigators, Jennie Stanley (nee Fecitt) and Tracy Boylin.

NEAS was asked about the number of external whistleblowing and bullying and harassment investigations that it has commissioned in the last three years. It declined to answer on grounds that the numbers were too small and that disclosure might breach privacy through identifiability.

Asked why it opted to pay for private investigative services instead of seeking a review by the National Guardian’s Office, NEAS replied that it held no information about this.

NEAS refused to give even a summary of the recommendations arising from the Stanley report on whistleblowing and bullying.

It wriggled out of this with the implied claim that there are no existing summaries to disclose, and that it is not required under FOIA to generate new information:

“The Freedom of Information Act states that public authorities are not required to create new information to comply with a request for information under the act.”

Whilst this may be technically correct, assuming that NEAS is telling the truth that it has no existing summary of the recommendations to disclose, it seems a poor return for public expenditure.

Surely the public are entitled to at least a short explanation of why an investigation was needed, and what now needs to be done?

NEAS also contended that the information requested constituted personal data, and claimed this as a further exemption.

In the circumstances, given that bullying seems inked with poor whistleblowing governance, NEAS whistleblowers’ claims that the trust tried to apply unlawful gagging clauses to stop them raising public interest concerns and requiring whistleblowers to destroy evidence of wrongdoing, serious breaches of coronial law and apparent cover up of fatal care failures, the public interest arguably overrides the privacy exemption by NEAS.

NEAS has been asked to:

  1. Clarify whether it has an existing summary of the Stanley report recommendations and to disclose if so;
  2. The seniority of the individuals whose privacy NEAS claims would allegedly be breached – are of them any directors? This has a bearing on the public interest test in favour of disclosure.
  3. Disclose the original recommendations of the Stanley report.

Local MPs have been informed of NEAS’ withholding of what appears to be significant data from public scrutiny.

In terms of wider issues arising of accountability and transparency, it may be useful to note NHS Providers’ guidance on FPPR investigations, which recommends publication of publication of a summary of all investigation reports, for public confidence.

Perhaps NEAS would be wise to think on this principle.

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Related items

Paul Calvert North East Ambulance Service Whistleblower says NHS internal Freedom To Speak Up mechanism is “entirely ineffective, being used to cover up and delay matters”

SSOTP: Robert Francis’ exemplar trust has feet of clay, and Jeremy Hunt’s safety claims are un-evidenced

The toothlessness of the National Guardian’s Office: Why it cannot be a model for protecting whistleblowers

Recent examples of NHS whistleblowers who were unprotected and unfairly dismissed despite the introduction of the ineffective Freedom To Speak Up model include Nephrologist Dr Macanovic and Jane Archibald Senior Nurse. Both of these blameless professionals have had to suffer years long ordeals and legal battles that are still not concluded:

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

Whistleblower Jane Archibald’s unfair dismissal by North Cumbria Integrated Care NHS Foundation Trust, and a “nurse” who was not qualified but ran epilepsy clinics and advised on epilepsy medication

Safe Staffing in Our NHS: Betsi Cadwaladr University Health Board

Dr Minh Alexander retired consultant psychiatrist 1 August 2022

This is a brief post to share FOI data for anyone interested in events at BCUHB

Lack of NHS safe staffing and the linked issue of chronic NHS underfunding are unresolved issues that seem likely to remain with us for the foreseeable future, given our economic woes and troubled politics.

A cycle of politically driven suppression and bullying trail in their wake.

The same story plays out time and gain, and the same care scandals recur, despite investigations and inquiries such as the Mid Staffs public inquiry. The latter was politically awkward in that it advised that care should be driven by fundamental standards (ie. not resource driven). The inquiry laid a heavy emphasis on ensuring safe staffing levels, after cost-cutting, unsafe staffing levels were uncovered as a pivotal failure in the Mid Staffs disaster.

But then Robert Francis was knighted and appointed to the Care Quality Commission’s board and Jeremy Hunt the then Health Secretary scrapped NICE’s work on safe staffing standards and refused to introduce legislation on mandatory safe staffing.

On the frontline, a vicious cycle is set up of forced errors from thinly spread, stressed staff making inevitable errors and omissions and then being harshly scapegoated and punished for what are primarily system failings. Or they may not report incidents for fear of blame. Or if they raise concerns about system faults, they are bullied for that too.

Unsafe staffing is brutalising for both staff and patients. Burnt out staff cannot give of their best.

Quarter 4 vacancy data for the NHS in England roughly showed a one in ten vacancy rate.

2021/22 sickness data for the NHS in England showed overall sickness rate of 5.38%, with higher levels in nurses and midwives.

At Betsi Cadwaladr University Health Board, nursing staff raised concerns about unsafe staffing and associated bullying with local MPs:

Ysbyty Gwynedd nurses reveal shocking treatment of staff

Nurses at Welsh hospital ‘overworked, bullied and afraid to speak out’

BCUHB consequently announced an investigation into these matters. The investigation should have concluded in July.

Via an FOI response of 19 July 2022, the health board has disclosed that staff raised a total of 3006 adverse events affecting staff levels over a three year period:

“From 1st April 2019 to 31st March 2022, there have been 3006 adverse events that affected staffing levels, please note this figure includes staff reporting positive COVID-19 statuses.”

This is a copy of the health board’s whistleblowing policy.

This is a copy of the health board’s very brief terms of reference for the investigation into alleged bullying.

This was the investigation methodology:

The investigation was reportedly overseen by an external party, but my reading of the terms of reference is that an internal “review support team” assisted the external investigator:

Royal College of Nursing

This is a link to the RCN’s ongoing work on safe staffing:

Safe Staffing for Safe and Effective Care

Public Accounts Committee refers evidence on CQC’s handling of Fit and Proper Persons in the NHS to the National Audit Office

By Dr Minh Alexander retired consultant psychiatrist 30 July 2022

Earlier this month I submitted evidence to parliament via Public Accounts Committee (PAC), one of the more rigorous committees in holding the Care Quality Commission to account.

I asked PAC to consider CQC’s track record of failure in the last eight years to properly apply Regulation 5 Fit and Proper Persons (FPPR). This is supposed to ensure that service providers have suitable directors who have not been guilty of or privy to serious misconduct or mismanagement.

Unsurprisingly, it was recently confirmed by FOI that CQC has NEVER found any NHS trust to be in breach of FPPR.

Unusually, the Committee has advised that it has passed the evidence to the National Audit Office, “who may be able to look into your [my] concerns”.

I have no idea if anything will come of this.

The NAO does solid work most of the time, but it had a touch of the vapours when dealing with an issue of whistleblowing policy and the CQC some years ago. It examined itself and the CQC amongst some other bodies, as examples of Prescribed Persons under our woeful whistleblowing legislation, and came to some surprisingly sunny conclusions.

Prescribed Persons or the Pretence of PIDA: How UK Whistleblowers are Ignored

We shall see.

In the meantime, the correspondence exchange with PAC is provided below.

CORRESPONDENCE WITH PUBLIC ACCOUNTS COMMITTEE

—–Original Message—–
From: NATHOO, Heather <REDACTED>
To: Minh Alexander <REDACTED>
Sent: Thu, 21 Jul 2022 12:10
Subject: RE: Almost non-existent regulation of failing NHS managers is still the norm – gagging

Dear Dr Alexander

Thank you for your email to the Public Accounts Committee and for sharing the information below. I have forwarded this to my colleagues at the National Audit Office who will be able to look into the details of your concerns. They will be in touch if they have any questions.

If the PAC have any upcoming inquiries related to CQC then there is also the opportunity to submit written evidence. Evidence can be submitted anonymously.

The committee is currently agreeing on its future programme. Whilst I am not aware of any plans to look into the CQC in the near future, our website will be kept up to date so it’s worth checking intermittently to see what we have open.

Thank you again for writing to the PAC, and all the best

Heather

Heather Nathoo
Chair LiaisonPublic Accounts Committee

From: Minh Alexander

Subject: Re: Almost non-existent regulation of failing NHS managers is still the norm – gagging

Date: 5 July 2022 at 18:07:17 BST

To: [Public Accounts Committee and others, email addresses redacted]

BY EMAIL

Dame Meg Hillier MP and Public Accounts Committee colleagues

Health and Social Care Committee

5 July 2022

Dear Dame Meg and colleagues,

Re: Almost non-existent regulation of failing NHS managers is still the norm – gagging

Further to my letter on this subject yesterday, I forward a just published article by The Independent as additional evidence.

Patients will suffer as a result of NHS ‘gagging’ clauses, whistleblower warns

This covers an important additional detail in the case of whistleblower surgeon Mr Tristan Reuser.

His trust, University Hospitals Birmingham NHS Foundation Trust tried to settle with him in the latter stages of the Employment Tribunal litigation. The trust explicitly sought to gag him and to arrange settlement entirely outside of the ET process.

The effect of this would have been to conceal the damning reasons issued by the ET for its cost order against the trust, in which it criticised the trust severely for failure to disclose documents, from which the ET could not rule out “deliberate dishonesty”.

Settlement was not reached but the trust was reportedly willing to pay almost £100K for silence, which in the circumstances seems a serious misuse of public funds.

There has been no accountable [sic] for this conduct by trust managers, illustrating the general point that regulation of failing NHS managers is still almost non existent.

Yours sincerely,

Dr Minh Alexander

—–Original Message—–
From: Minh Alexander
To: [Public Accounts Committee and others, email addresses redacted]
Sent: Mon, 4 Jul 2022 15:13
Subject: Re: Almost non-existent regulation of failing NHS managers is still the norm

BY EMAIL

Dame Meg Hillier MP and Public Accounts Committee colleagues

Health and Social Care Committee

4 July 2022

Dear Dame Meg and colleagues,

Re: Almost non-existent regulation of failing NHS managers is still the norm

I write to raise a serious concern that the Care Quality Commission and others are continuing to fail to protect the public and NHS staff from failing NHS managers.

As far as I can see, there has been no real learning from the MidStaffs disaster or the related public inquiry which concluded that a key contributory factor was serious failure by the trust board.

CQC AND REGULATION 5 FIT AND PROPER PERSONS

The government has gone through the motions of enacting a recommendation of the 2013 MidStaffs Public Inquiry report by amending the CQC’s regulations in 2014 and giving the CQC the responsibility of regulating whether service providers have Fit and Proper directors.

However, the CQC has now admitted that it has NEVER found any NHS trust to be in breach of CQC Regulation 5 Fit and Proper Persons since 2014:

CQC FOI disclosure 25 May 2022 FPPR Fit and Proper Persons

CQC weakly contends that it might have done, had some individuals not resigned or been sacked before the FPPR process concluded.

However, as CQC has not ever breached any trusts even in the face of gross evidence of unethical conduct, such as Employment Tribunal-tested evidence of whistleblower reprisal or being party to manipulation of evidence, it is arguable as to whether CQC’s contention is credible.

CQC has claimed on many occasions to the public (patients, families and whistleblowers) that it has no responsibility for determining whether providers’ directors are Fit and Proper Persons.

It has instead typically claimed that its remit is limited to regulating the soundness of providers’ processes for ensuring their directors’ fitness.

Usually, the CQC gives no account of how it achieves this. Referrers are faced with a black box into which they insert a referral, from which they then receive the briefest of letters from the CQC telling them that the regulator has been satisfied that the providers’ process is satisfactory and that there is no breach of Regulation 5.

Very seriously, I discovered that the CQC failed even to ensure a sound FPPR process with any diligence. This arose from an FPPR process concerning the CEO of University Hospitals Birmingham NHS Foundation Trust. I asked for confirmation that the CQC had reviewed original assurance documents, as some parties were concerned that this had not happened. In replying to me, the CQC misled me by claiming that an “independent” FPPR review had been arranged by the trust.

This was untrue. It became evident that a subordinate trust employee and a lawyer from a firm previously retained by the trust, which had undertaken almost £500K worth of work for the trust in the previous three years, had conducted the FPPR review.

A trust non executive director who had been a party to related

 disciplinary processes criticised by an Employment Tribunal was also involved in the FPPR review, creating another conflict of interest.

The details of the matter can be found here:

It now appears that the same retained law firm also conducted a previous FPPR review for the trust, which may have been an FPPR review on the same director. I am waiting for the trust’s clarification.

A question arises of how many times has the CQC accepted such compromised FPPR evidence?

The CQC dug itself in deeper by claiming that it had no say over how trusts conducted FPPR reviews, despite its published and internal material making it plain that its regulatory process includes assessing whether providers have “robust” FPPR process.

As a late development in the case, the Employment Tribunal published reasons for a cost order issued against University Hospitals Birmingham NHS Foundation Trust on 5 May 2022, which were damning:

ET reasons to award costs against University Hospitals Birmingham NHS Foundation Trust

There were serious criticisms of the trust for failures to disclose highly relevant documents either to the Tribunal or to the whistleblower Mr Tristan Reuser surgeon under GDPR. The Tribunal concluded that it could not rule out “deliberate dishonesty” by the trust and also observed that it considered that there could be future failings of governance by the trust.

I sent the above ET reasons document to Rosie Benneyworth the CQC Chief Inspector for Primary Care and current Chair of CQCs FPPR panel. She did not respond.

The truth is that the CQC admitted to whistleblowers in 2014, and again in its internal guidance to its own staff, that:

1)    CQC can make a determination of whether providers directors are unfit, if it so wishes

2)    CQC does not have direct powers to remove an unfit director, but can indirectly pressure a provider to remove an unfit director by using other powers

“It is not the responsibility of CQC to ensure fitness although we can take action against the provider if we believe an unfit person to be in a directorship position.”

The internal CQC guidance which makes this clear can be found here:

It appears that CQC simply does not have either the political will or the permission to act.

Disclosed correspondence of 4 May 2022 from the CQC to the Health Secretary about CQC’s failures in regulating maternity safety at Shrewsbury and Telford Hospital NHS Trust, reveals renewed CQC promises that the organisation has purportedly – yet again – revamped its processes:

CQC letter 4 May 2022  to DHSC re maternity safety and Ockenden report

Amongst these is a claim of September 2021 that CQC will regulate leadership more effectively in the future.

“…We’ll work with others to develop solutions to ensure that all services have support and leadership…”

CQC Our strategy from 2021

This seems an empty claim when set against the reality of how CQC actually responds when asked to take action under Regulation 5 Fit and Proper Persons.

NHSENGLAND/IMPROVEMENT, DHSC AND THE KARK REVIEW

As a result of concerns about the disappointing lack of action under Regulation 5 Fit and Proper Persons and in view of very similar governance failures at Liverpool Community Health NHS Trust as were seen at MidStaffs, the government in 2018 commissioned the Kark Review on addressing failures of NHS management:

Kark Review Fit and Proper Persons in the NHS

The review stopped short of recommending full regulation for NHS managers but it did consider a range of structured measures, including creation of a database to help track findings of misconduct and unethical behaviour, and a disbarring mechanism.

This too has simply not been acted upon.

NHS England/Improvement set up a steering group – the so called Kark Reference Group – but this was not transparent and minutes were not public. The majority of the minutes remain withheld.

A recent meeting with NHSE/I revealed that the NHS was still waiting for permission from Ministers to implement the Kark review recommendations in some form:

Minutes of telephone meeting with NHSE/I 18 May 2022

It is not even clear if a Kark register on NHS managers, if approved, will be retroactive. So it is possible that the longer the delay in implementation drags on, the more historical misconduct will be omitted from any register that is eventually set up.

NHS whistleblowers continue to be seriously harmed all the time.

Some of these whistleblowers are falsely promised that CQC will protect them and will hold erring NHS directors to account with Regulation 5. I have recently seen text correspondence from the CQC to this effect. The reality is the opposite.

A cabal of senior NHS managers, operating through a revolving door between providers and regulators, and sometimes the Department of Health and Social Care, more often than not acts with impunity. Failure is rewarded, cronyism and cover ups are the norm, faux governance and questionable investigations are arranged time and again, thus wasting public money to protect senior individuals’ reputations.

Only today, I received news that NHS England/Improvement is proposing effectively to investigate itself in an extremely serious matter of covered up deaths, exposed by whistleblowers who made futile attempts to seek help from NHSE/I.

This self-serving behaviour and impunity contrasts with the arbitrary, harsh discipline that is meted out to frontline staff when it suits abusive managers to do so, in the name of control or cover up. The panoply of abuse includes wholly unnecessary or even malicious suspensions, engineered dismissals through employer-provoked breakdown of relationships and vexatious referrals to professional regulators.

Some NHS boards refuse to accept the enormous impact of their harsh disciplinary actions against frontline staff. The Chair of University Hospitals Birmingham NHS Foundation Trust astonishingly stated in correspondence that GMC referrals should not be seen as punitive, despite the well-publicised deaths of and illness in doctors who are referred.

FOI disclosure by University Hospitals Birminghan NHS Foundation Trust 6 June 2022 on FPPR from Harry Reilly Chair

This is all the more remarkable because this trust admitted that of 26 GMC referrals made by the trust over a ten year period, none resulted in any further action against the referred doctors by the GMC. This raised questions about the quality of this trust’s referrals and whether the trust referred the right doctors.

UHB FOI disclosure April 2022 GMC referrals

The failure by the government and the NHS to act on NAO 2003 recommendations to track NHS staff suspensions rather says it all about poor NHS managers being allowed to flourish:

This normalised abuse represents an unaffordable waste of precious and very expensively trained and developed personnel, especially at a time when the workforce has been strained and depleted by the pandemic and socioeconomic factors.

We also see the cost, human and economic, in the continuing trail of NHS-related public inquiries and external reviews into serious care failings.

The prospect of being referred to a professional regulator is something that does not currently constrain NHS managers.

If it were, this might perhaps inject more accountability to the public, as opposed to the downwards pressure from the Department of Health and Social Care that has so often been identified as an unhelpful factor in care failings.

REQUEST

I would be very grateful if PAC could turn its attention to the poor regulation of failing NHS managers, and in particular the CQC’s poor performance, NHSE’I’s failure to implement the Kark review and the DHSC’s reported failure to give NHSE/I permission to implement Kark.

I would also be grateful if PAC and HSCC would take this evidence submission into account whenever they next hold their respective CQC accountability hearings.

Yours sincerely,

Dr Minh Alexander

Retired consultant psychiatrist and NHS whistleblower

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Whistleblowers have continued to emerge at UHB:

Multiple whistleblowers flag ‘heartbreaking’ incidents at major trust

A FIFTH never event of the wrong type of blood given has just been reported at UHB:

Major trust records fifth never event at troubled department

University Hospitals Birmingham NHS Foundation Trust also made the headlines on 5 June 2022 because of reportedly poor treatment of doctors in training in obstetrics and gynaecology, requiring regulatory intervention:

Trainee doctors in ‘meltdown’ at major hospital maternity department

Based on Tristan Reuser’s case and others, NHS Resolution agreed that NCAS’ successor body will consider safeguards against being fed false information by unscrupulous employers:

Will the Practitioner Performance Advice(formerly NCAS) do more to deter referring employers’ untruths about medical whistleblowers? Perhaps.

In true NHS musical chairs style, it was announced on 7 June 2022 that Rosie Benneyworth current chair of the CQC FPPR panel is being posted to HSIB:

Dr Rosie Benneyworth appointed interim Chief Investigator

“We know that most people get good care in the NHS, but sometimes they don’t get the outcomes they need or things go wrong. In these circumstances, it is vital that as a system we reflect and learn from these events to improve the safety of care”

“Rosie takes up her post with HSIB on 1 August 2022.”

Let us hope that Benneyworth does not take to tearing up any rule books at HSIB.

A particularly gross example of CQC conflict of interest and failure on FPPR was when it passed its notorious former Chair Jo Williams as a Fit and Proper Person, removing obstacles to her recycling back into the NHS fold:

Jane Archibald’s shocking whistleblowing case about a cover up of an unqualified assistant being allowed to run epilepsy clinics and vary complex epilepsy medication featured a failure by her former CEO Stephen Eames to respond to her disclosures. He simply did not respond to her correspondence. NHSE/I has been asked to review his suitability for his current post as CEO of the Humber region ICS.

Whistleblower Jane Archibald’s unfair dismissal by North Cumbria Integrated Care NHS Foundation Trust, and a “nurse” who was not qualified but ran epilepsy clinics and advised on epilepsy medication

Dr Jasna Macanovic’s recent NHS whistleblowing case adds to the pile of managerial recycling scandals. John Knighton the medical director found by the ET to be centrally involved in her premeditated unfair dismissal has been protected by the trust and Mark Cubbon the trust CEO who failed to ensure her protection as a whistleblower has been promoted to a senior post at NHS England.

An FPPR referral has now been made arising from the executive failures in this matter.

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

Sir Robert’s Flip Flops

The Flexible CQC, FPPR & Kettering General Hospital NHS Foundation Trust\

Post Office Horizon scandal: How Dido Harding helped to recycle Paula Vennells, FPPR and a suggestion for the BEIS Minister

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

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FPPR: CQC has lost all moral authority, but what will the National Guardian do?

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

National Guardian ‘Expects’

National Guardian’s letter to NHS Ambulance Trusts

By Dr Minh Alexander retired consultant psychiatrist 27 July 2022

This is a brief post to share correspondence.

The National Guardian’s Office previously signalled an intention to carry out a thematic case review  of ambulance services, with no details provided.

In March of this year I asked for more information.

By correspondence of 6 April 2022, the National Guardian’s Office informed me that it first discussed the idea of reviewing speak up culture in ambulance trusts in June 2020.

The NGO refused to disclose any relevant correspondence with ambulance trusts, along with other requested documents, on grounds that these were all intended for publication.

The NGO later published some cursory plans for the review without publishing the withheld correspondence.

After prompting, the NGO has now reluctantly disclosed a single item of correspondence to ambulance trusts dated 13 April 2022.

This letter by the National Guardian announces an initially desk based review of information already in the public domain. The NGO also seeks access to reviews previously conducted by individual ambulance service trusts.

That is to say, the National Guardian’s work on the ambulance review did not begin until almost TWO YEARS after it was planned, and only after I made enquiries in March.

This is despite the obvious governance mess and great distress of ambulance service staff over several years and the much-publicised staff suicides at East of England Ambulance service.

Whistleblower warned of ‘suicide risk’ at ambulance trust before three deaths 25 November 2019

Report into deaths of three workers tells East of England Ambulance Service Trust to act on mental health 13 May 2020

The letter, which is signed by the National Guardian herself, claims that the ambulance service review was first decided in “early 2020” and that it did not go ahead because of the pandemic:

“In early 2020, the National Guardian’s Office (NGO) proposed a speak up review of NHS Ambulance Trusts.”

“During the pandemic, with ambulance trusts facing unprecedented pressures, it was not possible to undertake a review.”

In my view, this makes it sound like the ambulance review was planned before the pandemic got underway and was then parked because of the pandemic.

The truth is the ambulance review was planned in June 2020, when the pandemic was established. The UK had only just emerged from its first lockdown. As the NGO previously informed me:

“As you have indicated, the piece of work we are about to undertake was triggered as we seek to better understand the relationship between the FTSU Index and CQC ratings. This was first discussed with our Advisory and Liaison Board in June 2020.” [my emphasis]

Why was it not possible to at least undertake the desk based element of the review?

Tone deaf to the signs of emergency care collapse in recent months, the National Guardian’s letter maintains its self-justifying narrative for not acting until now with the following argument:

However, as the pressures ease to some degree, we would like to commence the review.”

The NGO’s flexible approach to history aside, this is the letter to ambulance trusts:

National Guardian Jayne Chidgey Clark’s 13 April 2022 letter to NHS Ambulance Service Trusts

My reading of this letter is that trust managers have little to fear and that ambulance whistleblowers have little reason to expect much from this exercise.

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Related Items

Whilst the National Guardian’s Office sat on its hands, ambulance whistleblowers continued to suffer very serious detriment and patients and families suffered along with them:

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

Paul Calvert one of the NEAS whistleblowers gave an interview to the Northern Echo revealing disclosures to NHSE England/Improvement in 2021. In his disclosure correspondence he reported that NEAS’ internal whistleblowing arrangements – the Freedom To Speak Up structure – was used to delay and prevent transparency:

Paul Calvert North East Ambulance Service Whistleblower says NHS internal Freedom To Speak Up mechanism is “entirely ineffective, being used to cover up and delay matters”

I have asked NHSE/I if it has looked into this extremely serious concern. The regulator has indicated that it will get back to me on this issue.

There was a conflict of interest in NEAS’ freedom to speak up arrangements in that the Freedom To Speak Up Guardian held a corporate role and reported directly to the Executive Nurse on a number of matters.

Staff suicides at West Midlands Ambulance Service NHS Foundation Trust

Professional regulators fail to protect frontline health and care staff from rogue employers: The HCPC and NHS ambulance trusts

The National Guardian’s Office does not put a blue light on for ambulance staff

CQC’s zero enforcement of FPPR, the abusive North Tees trust board and its persecution of whistleblowers senior nurse Linda Fairhall and surgeon Mr Manuf Kassem

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

 

More Secret Whistleblowing Reports at HSIB, Susan Newton Consulting Limited and implementation of the Kark Review

By Dr Minh Alexander retired consultant psychiatrist, 23 July 2022

Dysfunctional organisational dynamics affecting patient safety, at the Healthcare Safety Investigation Branch, were reviewed by the Kings Fund last year. NHS England hired the Kings Fund to undertake this review, but it did not openly announce that it had done so. Nor did it transparently publish the review report. The existence of the review only came to light because of whistleblowing to the press, and the review report had to be obtained via FOIA.

The King’s Fund report also revealed that there had been previous reviews about HSIB culture and leadership. The Kings Fund reported staff were mistrustful because these previous reviews had not been shared with staff and or had been altered before being shared with staff.

For context, NHS Improvement originally hosted HSIB, but NHS Improvement was officially absorbed as part of NHS England this month.

HSIB staff come under NHSE’s HR policies and processes.

I asked NHS England to share any previous undisclosed reports of reviews on HSIB, besides the King’s Fund review.

NHSE shared only one such report, an internal report which was critical of the HSIB maternity investigation programme set up in haste under pressure from Jeremy Hunt former Health Secretary.

However, in the public domain was evidence that another investigation had possibly been undertaken. Susan Newton a former Monitor HR manager had privately conducted whistleblowing investigations – possibly for NHS England – as part of work done through her company, Susan Newton Consulting Limited.

Taken from Susan Newton’s LinkedIn entry

The timing of these investigations fitted with the known timeline of emergent whistleblowing at HSIB, which was first reported by the press in 2019.

Via FOI, NHS England disclosed that between 2017 to 2022 it had spent a total of £140,595.70 on Susan Newton’s services:

NHS England FOI disclosure 19 July 2022 Ref: FOI-2205-1762519) NHSE:0426711

These services included two specific investigations into whistleblowing in 2021 and 2022 respectively.

Investigations undertaken by Susan Newton the last five years, according to NHS England. are shown below:

Table from NHS England FOI disclosure 19 July 2022

The summary of recommendations provided by NHSE arising from Susan Newton’s investigations confirmed that she investigated whistleblowing at HSIB, and concluded that there were failures in the handling of conflicts of interest affecting HSIB investigators:

“Changes were made to the way HR cases were managed and a flowchart was created for staff raising concerns, complaints and issues, this means that all staff are aware of how we handle employee relations issues.

Conflicts of interest: recommendations were made to improve the management of declaring and mitigating conflicts of interest, including how work is allocated to investigators.

Teams now complete a declaration of Interest form annually and are in addition required to highlight situations which may present themselves where a conflict is identified. The team leaders have a record of all the conflicts within their team to ensure cases are allocated correctly. Improvements will be made to the Standards of Business Conduct Policy as Healthcare Safety Investigation Branch (HSIB) moves towards independence as the policy does not provide the level of detail the teams require.”

Conflicts of interests amongst HSIB investigators have the potential to be extremely serious and to pose a threat to patient safety. The greatest potential for conflicts of interest arises from the maternity investigation arm of HSIB, which is not centrally located but dispersed through the regions and drawn from local personnel:

HSIB has sent 152 letters of concern to NHS trusts about maternity safety, including 15 letters to one trust

The above FOI disclosure also suggests that NHSE – and specifically HSIB – so lacks competence at distinguishing between staff whistleblowing and complaints that a diagram is needed to help its managers understand and to apprise staff of the proper organisational response:

Changes were made to the way HR cases were managed and a flowchart was created for staff raising concerns, complaints and issues, this means that all staff are aware of how we handle employee relations issues.”

NHSE’s FOI response also gives further confirmation of concern about HSIB’s culture, governance and leadership:

“Organisational culture: recommendations were made to review culture, leadership and governance of the organisation”

NHSE explained in its FOI response that following on from the investigation by Susan Newton, the King’s Fund were commissioned to undertake their review of HSIB.

Two shocking but unsurprising matters arising from NHSE’s FOI response are:

  1. NHSE’s previous failure to disclose the existence of these investigations by Susan Newton when it was previously asked to disclose all unpublished reviews of HSIB.

If NHSE considered this information fell under an exemption of FOIA, it was under a legal duty to confirm that it held the data and to cite the specific exemptions to disclosure which it believed applied.

  • The King’s Fund’s decision to only mention these highly significant whistleblowing investigations by Susan Newton in a single sentence in its report:

“At the beginning of the work, staff had been clear that they would not trust the report outcomes if they were first shared with the executive team, owing to a perception that the findings of previous reviews had been changed before publication, or not shared at all.”

This is especially so given that NHSE has now revealed that it was Susan Newton’s whistleblowing investigation which specifically paved the way for the King’s Fund review.

The King’s Fund was tightly supervised by NHSE and the DHSC during its conduct of the HSIB review, through a steering group. And due to redaction, we were unable to see what instructions the key supervising NHSE officer Aidan Fowler gave when he commented on the draft of the King’s Fund report.

Did the King’s Fund self-censor or was it asked to make minimal reference to highly relevant source material?

It is not a good look for an oversight body which regulates the whistleblowing governance of provider organisations to be less than candid and transparent about whistleblowing by staff under its care, or about whistleblowing investigations paid for out of the public purse.

Importantly, it is implied that the HSIB whistleblower(s) may have suffered detriment, because Susan Newton investigated a grievance related to whistleblowing.

However, we remain in the dark as NHSE’s secrecy about this affords putative abusers an escape route from accountability.

All the above emphasises that it is quite wrong that the legislation concerning Fit and Proper Persons in the NHS only applies to provider organisations. The misdeeds of those in oversight bodies are arguably much more serious and have much greater impact on patients, all the way up to the DHSC.

The Kark review recommendations sought to broaden the scope of the NHS Fit and Proper Person test, albeit stopping short of posing any threat to the incumbents of the DHSC.

I have now received confirmation from NHSE that ministerial approval has been given for the Kark implementation to proceed. The work since 2018 has been so slow that part of the current implementation is to decide on what will be implemented,

It has also been claimed that Terms of Reference have also been produced. A request for sight of these terms of reference has yet not borne fruit.

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A Study in Delay II : The National Guardian, maternity safety & University Hospitals Sussex NHS Foundation Trust

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

By Dr Minh Alexander retired consultant psychiatrist 16 July 2022

Summary: North East Ambulance NHS Foundation Trust like other NHS ambulance trusts is highly stressed and has been failed by the government. It is also a dysfunctional organisation. Most recently, it was alleged by the Sunday Times to have covered up care failings and related patient deaths, and to have withheld and or “doctored” evidence submitted to coroners. It was alleged that such failings continued. The trust denied this. The concerns revolved around a trust committee called the SEACARE group which operated 2019-2020, reportedly meeting weekly on at least 75 occasions. The trust’s lawyers Ward Hadaway and external counterfraud auditors AuditOne criticised the operation of this committee, respectively in 2019 and in 2020. They advised NEAS that the SEACARE group usurped the trust’s pre-existing mechanisms for coroner liaison and made unsafe decisions to withhold and or altered evidential documents disclosable to the coroner, which might amount to criminal offences. Very seriously, AuditOne concluded that NEAS failed to act on the 2019 legal advice from Ward Hadaway, raising a possible issue of wilfulness in NEAS’ conduct. AuditOne also noted that expert staff from the trust’s Coroners and Claims team were criticised when they appropriately disclosed evidence to which the coroner was entitled.  The trust has not to date openly published the 2019 report by Ward Hadaway or two 2020 reports by AuditOne. I obtained one of the AuditOne reports and provide it in this post. The SEACARE group fell within the executive portfolio of NEAS’ previous Executive Nurse Joanne Baxter, who now works at Gateshead Health NHS Foundation Trust. Gateshead’s CEO Yvonne Ormston, who was CEO at NEAS between 2014 to 2019, was asked if a Fit and Proper Person (FPPR) review of Joanne Baxter was indicated by the above events. She has responded generically but not specifically. Joanne Baxter’s published details indicate that she is also an executive reviewer for the Care Quality Commission. This means that she inspects providers on the Well Led domain on CQC inspections.  

In 2019 NEAS established an unusual group, named SEACARE, which was reportedly an acronym of different teams which fed into the group.

According to a hitherto unpublished account by the private company AuditOne, the SEACARE group screened material for external release with the purported aim of checking compliance with GDPR personal data handling obligations and ensuring “accuracy”:

A trust quality report signed off by NEAS’ CEO in 2020 gave a slightly different account of the SEACARE group, describing it as a group which screened incidents for moderate and more serious harm, for onwards referral to other trust processes for learning from incidents:

“Each incident reported as a moderate harm is reviewed weekly at a group called SEACARE, this group includes patient Safety incidents, patient Experience concerns, Adult safeguarding concerns, Children’s safeguarding concerns, Audit from the learning from deaths process, Risk which incorporates coronial requests and concerns and External requests for information related to care provided by NEAS. Incidents determined to have a moderate harm level are further reviewed at Clinical Review Group, which enables a multi-disciplinary discussion to take place, and incidents are reviewed against the NHS England Serious Incident Framework. Incidents identified to potentially met the criteria are then discussed with the Director of Quality & Safety (Executive Nurse) or Medical Director and when confirmed, reported externally. This process ensures the correct level of review and scrutiny occurs and an opportunity for real learning and action to take place, in order to minimise the risk of harming occurring to patients.”

The contradictory private versus published accounts of the SEACARE group’s function gives concern as to motive for establishing the SEACARE group, as raised by the Sunday Times and other media.

Strangely, coronial requests for information were placed within the ambit of the SEACARE group. The two main reasons given by the trust for SEACARE’s existence, ensuring GDPR compliance and the trust’s assessment of harm, are irrelevant to the legal obligations upon the trust to comply with coroners’ requests for information. If the coroner asks for documents, the trust must disclose, whether or not it believes they are relevant and regardless of GDPR. It is for the coroner to determine relevance. Could the decision to give SEACARE influence over coronial process have been based on a consideration of reputational risk, given the CEO’s words?

Risk which incorporates coronial requests

But interference with evidence that is disclosable to a coroner, to manage reputation, is a potentially very serious matter, with possible criminal penalties:

Coroners and Justice Act 2009

The SEACARE group fell within the portfolio of the Director of Nursing Joanne Baxter, whose full title was Director of Quality and Safety and Executive Nurse.

A trust diagram from 2020 shows the SEACARE group’s place in the trust committee structure:

The creation of the SEACARE group and its remit to screen information released to coroners was odd and significant because NEAS already had a dedicated and qualified team which liaised with coroners: The Coroners and Claims team.

By creating SEACARE, the trust arguably placed a filtration system in place to control documents which reached the Coroners and Claims team.

AuditOne noted that inserting the SEACARE group into the coronial process caused additional delays:

On on 21 May 2022 the Sunday Times reported that particularly damning evidence was contained in a report by the private company AuditOne, which it claimed revealed that SEACARE group had withheld evidence from coroners and altered statements.

On 26 May 2022 NEAS chief executive Helen Ray issued a statement minimising the concerns and claiming that the trust had NOT withheld evidence from coroners. She cited as proof that all was now well the fact that the police and the Care Quality Commission had taken no further action.

“We fully accepted the findings of these reviews, and a task group was established to ensure full disclosure to coroners of any historical reports and a change to the process in place for dealing with future disclosures. This was led by three of our non-executive directors, supported clinically by our medical director, Dr Mathew Beattie.

The claims made that we continue to fail in respect of disclosure are incorrect. We have reaudited our process, worked with coroners and with the CQC, and have embedded regular reviews to ensure these issues cannot reoccur.

The Care Quality Commission formally responded in late 2020 to confirm they had closed the matter with no further action deemed necessary.

Northumbria Police also investigated following allegations that we had deliberately failed to disclose, conceal or destroy evidence. We worked closely with the police and their investigation was closed with no action taken. The police referred the matter back to the coroners in our region, with whom we have worked with and kept informed of our reviews and actions.”

As followers of NHS scandals will be aware, assurance by the CQC does not count for much, as the regulator has been complicit in a number of scandals and cover ups. It functions as a government flak catcher. It is particularly energetic in situations where its own regulatory failures have contributed to patient harm.

Indeed, CQC is based in the North East, and many of its functionaries are drawn from the local area. What impact does that have on the regulation of local trusts such as NEAS?

Longstanding failures of ambulance services are a systems issue  

The government has failed ambulance services and the public for many years   It has been plain that something is seriously awry in the way that ambulance services are organised, managed, funded and how the rest of the system impacts on ambulance services.  

Ambulance trusts have the highest levels of bullying.  

Emergency call handling has been repeatedly criticised.  

Shortage of paramedic staff and their working conditions are chronic problems.  

Broken, defunded social care, delayed hospital discharges and an inadequate number hospital beds cause wasteful and dangerous ambulance queues.  

A previous examination of coroners’ reports to prevent future deaths (PFD’s) showed particular problems clustering around ambulance trusts, but related to other systems problems.  

NEAS is no exception and has over the years attracted adverse media attention and the trust’s failures have also been debated in parliament by MPs, who have reported terrible stories of harm to constituents.    

As for the reported police decision not to pursue any action, time will tell whether NEAS committed crimes in its handling of data disclosable to coroners. Bereaved families have called for a public inquiry. One of the NEAS whistleblowers has also been calling for a public inquiry because he believes there has been a multi-agency cover up, such that only a public inquiry has the power to uncover the facts.

There is a petition: Public Inquiry Deaths Cover Up – The North East Ambulance Service.

I asked the trust for a copy of the AuditOne report cited by the Sunday Times to see what it said about the alleged tampering with evidence to coroners.

NEAS refused to give data on spurious grounds of prejudice to the conduct of public affairs, but it did admit that the SEACARE group met weekly for a total of 75 times between 18 June 2019 to 1 December 2020. I have asked for an internal review of the trust’s decision to withhold the report and other data.

I subsequently learnt that the trust had already previously disclosed an AuditOne report under FOIA. A good Samaritan sent me a copy.

This is the report:

Workforce Investigation Final Report by AuditOne June 2020

This final report gives mostly summary conclusions. It notes that an earlier, interim report was submitted by AuditOne to the trust in March 2020, presumably with more detail about cases and related trust governance failures. I surmise that this earlier and still unpublished interim report was the report cited by the Sunday Times, which discusses cases in some detail.

The final June 2020 AuditOne report also refers to a 2019 review by trust lawyers, Ward Hadaway. Ward Hadaway was reportedly critical and flagged up serious issues with the SEACARE group’s interference with the coronial process:

This revelation about the legal advice to NEAS in 2019 is especially serious in terms of the timeline. It implies that NEAS continued the flawed operation of the SEACARE group despite this very clear warning in 2019.

This report of Ward Hadaway’s advice also suggests that NEAS vilified staff in its Coroners and Claims team for simply doing their job, for complying with legislation and acting in the public interest.

The question that therefore arises is whether the trust intended that evidence sent to coroners should be controlled by the SEACARE group.

This links back to the fact that an element of intent defines the above criminal offences of obstructing a coroner by destroying, concealing or interfering with disclosable evidence.

The final AuditOne report of June 2020 report gives very little insight into their methodology. There is no firm indication that an in-depth investigation was conducted. It is possible of course that methodology was set out in the interim report.

The final AuditOne final report is also light on substantiating detail and facts. Again, some of the detail may have been contained in AuditOne’s interim report.

Some of the final AuditOne report’s findings are implied, but nevertheless still very serious.

For example, it is implied that the trust substituted edited corporate responses for individual statements:

The final AuditOne report also concluded that the SEACARE group possibly unlawfully withheld documents from coroners:

AuditOne concluded that the trust was at “real risk of committing criminal offences” and that the SEACARE group’s role in coronial process was “not fit for purpose”:

AuditOne recommended that control of the coronial process within the trust should be rightly returned to the Coroners and Claims team.

The whistleblowers were vindicated.

The SEACARE group was, according to the trust, dismantled after December 2020.

But the trust still reportedly tried to gag the whistleblowers, using unlawful clauses such as those requiring them to destroy evidence supporting their public interest disclosures:

North East Ambulance whistleblower ‘bullied’ over cover-up claims

Responding to this media coverage, NEAS’ current CEO Helen Ray reportedly made these comments:

“Claims made that we continue to fail in respect of disclosure are incorrect.

“We have reaudited our process, worked with coroners and with the CQC.

“We are confident that the system in place now is robust.”

NEAS’ claims that there is nothing to see and that all necessary learning and action has been taken hardly sits well with the trust’s continuing secrecy and failure to openly share both of the 2020 AuditOne reports and the 2019 Ward Hadaway report on its website.

The AuditOne investigator was a former Detective Sergeant with Northumbrian police and the AuditOne reviewer was an NHS counterfraud insider.

Their final report of June 2020 was submitted to the NHS Chair, Carolyn Peacock NED and Jennifer Boyle Trust Secretary.

Jennifer Boyle was also the trust Freedom To Speak Up Guardian, with NEAS receiving tiny numbers of staff disclosures.

Carolyn Peacock was the Non Executive Lead for Freedom To Speak Up.

The NEAS Executive Director for Freedom To Speak Up was Joanne Baxter NEAS Director of Quality and Safety and Executive Nurse 2013-June 2020, who therefore also held the director portfolio for the SEACARE group.

Baxter moved to Gateshead Health NHS Foundation Trust, where she is now working as Chief Operating Officer under Yvonne Ormston Gateshead CEO and former CEO of NEAS 2014 to 2019.

I asked Ormston if Gateshead had considered a review of Baxter’s fitness under CQC Regulation 5 Fit and Proper Persons, in view of the scandal about the SEACARE group and the Health Secretary’s announcement of an independent review. This was her reply of 8 July 2022:

Dear Dr Alexander

We conduct annual fit and proper person tests for all of our Board Members in line with CQC requirements and our policy. We also require all Board Members to complete a self-declaration, which forms part of the fit and proper person annual checks. Should information be declared or become known to us during the year that may impact upon individual compliance with fit and proper persons requirements, we undertake fit and proper person testing more frequently.

Best wishes

Yvonne Ormston

What’s more, Baxter is an executive reviewer for the CQC, which means that she inspects other providers on the Well Led domain on CQC inspections.

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Related Items

Paul Calvert one of the above NEAS whistleblowers gave an interview to the Northern Echo revealing disclosures to NHSE England/Improvement in 2021. In his disclosure correspondence he reported that NEAS’ internal whistleblowing arrangements – the Freedom To Speak Up structure – was used to delay and prevent transparency:

Paul Calvert North East Ambulance Service Whistleblower says NHS internal Freedom To Speak Up mechanism is “entirely ineffective, being used to cover up and delay matters”

I have asked NHSE/I if it has looked into this extremely serious concern. The regulator has indicated that it will get back to me on this issue.

There was a conflict of interest in NEAS’ freedom to speak up arrangements in that the Freedom To Speak Up Guardian held a corporate role and reported directly to the Executive Nurse on a number of matters.

Staff suicides at West Midlands Ambulance Service NHS Foundation Trust

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The National Guardian’s Office does not put a blue light on for ambulance staff

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

The wilfully blind CQC and half a million pounds worth of conflict of interest

By Dr Minh Alexander retired consultant psychiatrist 29 June 2022

The government’s regulatory poodle, the Care Quality Commission (CQC) has a history of bending with whatever political winds are blowing.

CQC wrongly claimed that University Hospitals Birmingham NHS Foundation Trust arranged an “independent” FPPR review of its CEO David Rosser.

This FPPR review, instigated in 2020, was in fact conducted by a trust employee with help from Bevan Brittan LLP a law firm which was an existing supplier to the trust. Bevan Brittan’s own publicity material had named UHB as a “key client”:

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

One imagines it is not good for business to upset key clients.

Auditors and conflicts of interest

As a general principle, there have been many corporate scandals related to failures of audit, and auditors have been fined vast sums of money.

It is generally considered bad practice for firms to audit clients to whom they provide non-audit services, because of the temptation to give good audit results in return for continued business.  

The Institute of Chartered Accountants in England and Wales’ code  frowns on the practice.  

The Financial Reporting Council introduced auditing standards in 2016 to prevent abuses and strengthened the standards again in 2019.  
 

Even if Bevan Brittan did a perfectly satisfactory and fair job on the 2020 Rosser FPPR review, justice needs to be seen to be done, and a conflict of interest is unacceptable.

The matters were compounded by the fact that the investigating UHB employee falsely told Mr Tristan Reuser, a whistleblower who was a centrally affected in this affair, that Bevan Brittan had no prior connection with UHB.

From email by Berit Reglar of 3.11.2020, answering questions by Mr Reuser about the trust’s proposed FPPR process

Clare Sardari @SardariClare NHS whistleblower recently asked UHB how much money it spent on Bevan Brittan’s services in the years leading up to the 2020 Rosser FPPR Review.

The trust was unresponsive. Clare Sardari had to complain to the ICO, who ordered the trust to respond. The data has now finally been released.

UHB’s FOI response Ref 2174 28 June 2022 shows that in the three years prior to Bevan Brittan being hired to undertake the 2020 Rosser review, UHB spent £497,000 on Bevan Brittan’s services.

It also shows that UHB has a contract with Bevan Brittan.

Some might see this as a possible conflict of interest.

Interestingly, UHB’s FOI response also shows that Bevan Brittan undertook an FPPR review for UHB sometime in the period 1 April 2017 – 31 March 2020.

So it appears that not only did the trust falsely inform Tristan Reuser in November 2020 that there was no previous link between Bevan Brittan and UHB, the trust omitted the significant fact that Bevan Brittan had undertaken a previous FPPR review for UHB.

Could this have been an earlier, undisclosed FPPR review on David Rosser?

In November 2020 Tristan Reuser specifically asked if UHB had previously reviewed Rosser under FPPR.

UHB refused to say whether there had been a previous FPPR review on David Rosser, claiming that it was undisclosable personal information:

From email by Berit Reglar of 3.11.2020, answering questions by Mr Reuser about the trust’s proposed FPPR process

It does seem odd that my FPPR referral on Rosser, made in October 2018 and shortly followed by other referrrals, did not apparently lead to an FPPR investigation until the autumn of 2020. Or so it seemed.

It is conceivable therefore, that there was a prior FPPR review on Rosser by Bevan Brittan, in the unexplained gap, which for whatever reason, was suppressed.

Supporting this possibility, I have seen a letter from Nadine Dorries of August 2020, who was then Minister of State for Mental Health, Suicide Prevention and Patient Safety, to Sheryll Murray MP. The letter related to concerns about David Rosser’s conduct, which had been raised by one of Murray’s constituent.

It stated that following the publication of the Employment Tribunal judgment in favour of Mr Tristan Reuser in 2018, “an independent review took place in 2018” at UHB.

The same letter of August 2020 went on to state that UHB had “since commissioned a further Fit and Proper Persons Regulations (FppR) review.”

The letter therefore seems to suggest that there was indeed an earlier FPPR review on David Rosser.

Additional supporting evidence for the existence of an earlier FPPR review comes from an FOI request by Martin Morton, social care whistleblower, made in 2019.

UHB admitted in the 2019 correspondence with Martin Morton that an FPPR review had been conducted at cost of £5,000, albeit the trust did not reveal the subject of the FPPR:

“The review was conducted with the support of external legal firm due to the context of the complaint”

The saga of UHB’s untruthful FOI response to Martin Morton

This detail is included as another example of UHB’s record as an unreliable historian.

An FOI request about FPPR referrals to UHB in 2019 by Martin Morton social care whistleblower was met with an untruthful initial response by UHB of 23 September 2019.

The trust claimed that there had never been any FPPR referrals on trust directors. In fact, there had been several FPPR referrals.

This untruth by UHB was reported to the CQC. UHB corrected its FOI response on 26 September 2019 to a half truth, claiming that there had been a single FPPR referral.
UHB claimed that the correct information had been prepared (with the involvement of its legal officer David Burbridge) but had not been sent to the trust’s FOI team in “error”.

If there was an early FPPR investigation on David Rosser by Bevan Brittan, it would make a mockery of the ‘official’ FPPR review that was instigated in autumn 2020.

The latter could not be said to be a fresh, independent and untainted review, despite by the CQC’s claims that the external element by Bevan Brittan was “independent”.

It would also reflect even more badly on the trust’s claim that Bevan Brittan had no prior link with the trust.

I have asked the trust Chair for answers.

And exactly how much of this did CQC know?

CQC claimed that the trust’s explanations for its 2020 FPPR process were “reasonable”

“The trust gave their reasons for carrying out the review lead by a member of UHB staff (who is a qualified and practising solicitor) supported by an independent HR lawyer. The panel accepted that their decision was reasonable.” [my emphasis]

How does CQC define independence?

How does CQC assess whether an FPPR reviewer is independent?

Does CCQ even make an assessment, or does it simply accept what a trust claims?

Is the CQC happy to look the other way even if knows that an FPPR reviewer is not independent at all?

In a letter of 26 April 2022, Rosie Benneyworth the CQC Chief Inspector of Primary Care and Chair of CQC’s FPPR panel went so far as to claim that :

“It is not for CQC to determine the process on how the CQC carries out the review of the FPPR.”

Based on the Rosser/ Reuser example, one is left with a most unfavourable impression.

Rosie Benneyworth has not responded to my last letter challenging CQC’s actions in this matter. She is off to be the next Chief Investigator of the Healthcare Safety Investigation Branch.

Therefore, I will now pass the evidence of CQC’s failings directly to parliament.

PETITION

Please click and add your signature to this petition to reform UK whistleblowing law – whistleblowers protect us all but weak UK law leaves them wholly exposed and it is a threat to public safety

Replace weak UK whistleblowing law and protect whistleblowers and the public

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Whistleblowers have continued to emerge at UHB:

Multiple whistleblowers flag ‘heartbreaking’ incidents at major trust

A FIFTH never event of the wrong type of blood given has just been reported at UHB:

Major trust records fifth never event at troubled department

University Hospitals Birmingham NHS Foundation Trust also made the headlines on 5 June 2022 because of reportedly poor treatment of doctors in training in obstetrics and gynaecology, requiring regulatory intervention:

Trainee doctors in ‘meltdown’ at major hospital maternity department

Based on Tristan Reuser’s case and others, NHS Resolution agreed that NCAS’ successor body will consider safeguards against being fed false information by unscrupulous employers:

Will the Practitioner Performance Advice(formerly NCAS) do more to deter referring employers’ untruths about medical whistleblowers? Perhaps.

A particularly gross example of CQC conflict of interest and failure on FPPR was when it passed its notorious former Chair Jo Williams as a Fit and Proper Person, removing obstacles to her recycling back into the NHS fold:

Jane Archibald’s shocking whistleblowing case about a cover up of an unqualified assistant being allowed to run epilepsy clinics and vary complex epilepsy medication featured a failure by her former CEO Stephen Eames to respond to her disclosures. He simply did not respond to her correspondence. NHSE/I has been asked to review his suitability for his current post as CEO of the Humber region ICS.

Whistleblower Jane Archibald’s unfair dismissal by North Cumbria Integrated Care NHS Foundation Trust, and a “nurse” who was not qualified but ran epilepsy clinics and advised on epilepsy medication

Dr Jasna Macanovic’s recent NHS whistleblowing case adds to the pile of managerial recycling scandals. John Knighton the medical director found by the ET to be centrally involved in her premeditated unfair dismissal has been protected by the trust and Mark Cubbon the trust CEO who failed to ensure her protection as a whistleblower has been promoted to a senior post at NHS England.

An FPPR referral has now been made arising from the executive failures in this matter.

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

Sir Robert’s Flip Flops

The Flexible CQC, FPPR & Kettering General Hospital NHS Foundation Trust\

Post Office Horizon scandal: How Dido Harding helped to recycle Paula Vennells, FPPR and a suggestion for the BEIS Minister

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

Steve Trenchard, NHS regulators & FPPR

FPPR: CQC has lost all moral authority, but what will the National Guardian do?

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

National Guardian ‘Expects’

Paul Calvert North East Ambulance Service Whistleblower says NHS internal Freedom To Speak Up mechanism is “entirely ineffective, being used to cover up and delay matters”

By Dr Minh Alexander retired consultant psychiatrist 26 June 2022

The story of a serious NHS cover up at North East Ambulance Service NHS Trust (NEAS) was reported by the Sunday Times on 21 May 2022:

NHS ambulance service doctored documents to cover up truth about deaths

This was helpful reportage, apart from a bum note of someone slipping in a misleading and inaccurate claim of Jeremy Hunt being an anti-gagging NHS hero, when he was no such thing.

Paul Calvert, a former police officer, latterly a coroner’s officer and one of the whistleblowers who revealed the failings at NEAS, has continued to talk to the media.

He has now revealed more details of a typical NHS whistleblower’s journey, and the often futile attempts to escalate through successive layers of indifferent, incompetent and or malign management.

Calvert, like so many other NHS whistleblowers who have been failed, attests to the ineffectiveness and in his case the harmfulness, of NHS whistleblowing arrangements.

He has criticised a wasteful, non-evidence based central plank of NHS whistleblowing policy since 2015: the use of internal Freedom To Speak Up Guardians.

This is a model where a trust employee is appointed by senior trust managers to act as a purported reporting point for whistleblowers. This individual is supposed to challenge senior trust managers if necessary, and to make referrals outside of their organisations to regulators. In good trusts it is unnecessary, in corrupt trusts it is a conflicted, compromised non-starter.

Paul Calvert has shown the Northern Echo his disclosure correspondence, including his disclosures to to the central whistleblowing team at NHS England, in which he whistleblew about harmful internal Freedom To Speak Up arrangements at his trust:

“In his first approach to a “Freedom to Speak Up” casework manager at NHS England, Mr Calvert wrote: “I have a reasonably held belief that the North East Ambulance Service have caused harm, to members of the general public, by concealing, altering and destroying relevant information that should have been supplied to HM Coroner.

“The trust’s patient safety department does not have the necessary policies and processes in place, in order to ensure the trust meets its statutory obligations as prescribed by law.

“For the past year, myself and colleagues have continued to raise our concerns, with the relevant individuals.

“We are aware that these concerns not only failed to be addressed, but are constantly ‘pushed under the carpet’.”

Mr Calvert, who is from Peterlee, told the case worker he had already raised his concerns with his MP, Grahame Morris, who represents Easington and subsequently discussed the matter in Parliament.

Mr Calvert has said is he aware of 90 cases where changes have been made to medical reports at inquests to hide mistakes by ambulance crews where someone has died.

They include the case of 17-year-old Quinn Beadle, from Shildon, who died by suicide in 2018.

Key details omitted from the report to coroner in the hearing the establish the circumstances surrounding her death.

In his email last July, Mr Calvert said: “The North East Ambulance Service are continuing to fail members of the public and putting lives at risk by failing to address these very issues.

“I am of the opinion that these matters require urgent attention to prevent the public suffering any further harm.”

Mr Calvert, who claims he has been the victim of bullying and is unable to work due to ill health, said NHS England did “little to nothing” regarding his concerns and merely passed his information to the Care Quality Commission.

He said: “The trust continues to ignore that there is a problem and is unwilling to listen or consider the concerns being raised or acknowledge the supporting evidence regarding this.

“The trust also continues to bully and harass the members of staff who are attempting to raise the concerns, taking punitive action against the people speaking up, whilst the parties responsible for the failings are afforded complete impunity.

“However, the mechanisms for raising concerns within the trust are entirely ineffective, being used to cover up and delay matters, rather than investigate and address the concerns raised. [My emphasis]

It seems unclear from the Northern Echo report whether NHS England did anything about this extremely serious allegation, even though it would have been well within its power to take action. I have sought clarification from the NHSE/I Head of whistleblowing.

Corporate Freedom To Speak Up Guardians at North East Ambulance Service

According to trust board papers Jennifer Boyle former Trust Secretary was previously trust Freedom To Speak Up Guardian.

Her LinkedIn entry  shows she was NEAS trust secretary between May 2015 to June 2021.

She has since moved to Gateshead Health NHS Foundation Trust where she is also Trust Secretary, working under Yvonne Ormston CEO, who was NEAS CEO until 2019.

According to NEAS trust board papers, the role of NEAS Freedom To Speak Up Guardian has since been taken over by another person from trust corporate services, Paula Gent, whose LinkedIn entry describes her as “Executive Personal Assistant to Director of Strategy, Transformation and Workforce at North East Ambulance Service”, but makes no reference to the Freedom To Speak Up role.

Hard to see how corporate appointments would make whistleblowing frontline staff feel very comfortable, or understood.  

Shockingly, NEAS’ whistleblowing policy  tells trust staff that there is no guarantee that their highly sensitive disclosure emails will only be opened by the Freedom To Speak Up Guardian. It does NOT say who else might open their emails:

So does life imitate caricature?

The NHS National Freedom To Speak Up Guardian

Sitting at the head of the failed NHS Freedom To Speak Up project is a propaganda outpost of the Department of Health and Social Care, known as the Office of the National Freedom To Speak Up Guardian. It came embedded with DHSC personnel from the outset.

In a totally conflicted and compromised arrangement, the National Guardian is funded and overseen by NHS England/ Improvement and the Care Quality Commission (CQC), but is also supposed to hold these bodies to account.

 The National Guardian’s compromised governance

The role of the NGO and how it sits within the NHS is set out in the position specification for the post.

The National Guardian is appointed by the CQC, with participation from NHSE/I. She reports to the CQC chief executive. She also reports to the government via the Department of Health and Social Care.

Her funding comes from CQC and NHSE/I. She produces annual reports for CQC and NHSE/I boards.

CQC and NHSE/I oversee her work through a board which consists of a representative from CQC, NHSE/I and the National Guardian.

This committee used to be called the “Accountability and Liaison Board”. Latterly the name  has been softened by the NGO to the “Advisory and Liaison Board”.

Farcically, despite all the above, we are expected to believe that the National Guardian is “independent”:

“the role is independent”

“The NGO will set its own priorities, have its own budget and identity and speak independently of its sponsor bodies.”

AND that the NGO will hold the whole system including CQC, NHSE/I and DHSC to account:

“Make recommendations to individual and national organisations (NHS trusts and foundation trusts, NHS England, NHS improvement, CQC and the Secretary of State for Health) on trends, common issues and interventions to drive and support culture change across the NHS”

Yes, and pigs can fly.

And where are the National Guardian’s reviews on NHS England/Improvement, CQC and DHSC’s whistleblowing failures?

Oh yes, of course, there aren’t any.  

The National Guardian is not in the business of giving NHS staff truthful information about the real risks of whistleblowing. She and her Office pump out rose-tinted claims about how staff will be supported by Freedom To Speak Up Guardians, when the evidence shows that this does not reliably happen.

I have challenged misinformation by the National Guardian’s Office on several occasions. There is a current complaint about the latest National Guardian lodged with the Chair of the CQC about such a matter.

The latest concerns by Paul Calvert represent another hole in the jerry-built Freedom To Speak Up wall.

National Guardian’s planned review of speaking up in ambulance services

The National Guardian’s Office started THINKING about a thematic review of speaking up culture of ambulance trusts in June 2020, after the staff suicides at East of England Ambulance Service NHS Trust made national headlines.

The NGO continued thinking about it until this spring, when I started asking about progress.

The NGO FOI response to my enquiry stated that the work was “in the early stages”:

“We are in the early stages of this review process, and therefore have not agreed
final parameters yet”.

The NGO refused to disclose relevant correspondence, claiming exemption on grounds of Section 22 FOIA documents intended for publication. Nonsense of course, as such documents would not be published. Importantly however, they would show the dates on which work had actually commenced.

Overall, the NGO has displayed little sense of urgency, despite the obvious distress and strain on ambulance services:

The National Guardian’s Office does not put a blue light on for ambulance staff

By the point that I started asking questions, other ambulance staff suicides, at West Midlands Ambulance Service, had been publicised.

Even the Director of Nursing at WMAS has repeatedly been in recent news, making dire predictions of unsustainable service pressure, inevitable patient deaths and looming service collapse:

Nursing director warns his ambulance service will entirely collapse in August

It is unsurprising that the National Guardian’s Office is so little trusted by frontline NHS staff that it receives very few whistleblowing disclosures. This includes NHS ambulance staff.

The April FOI response revealed that the National Guardian had received a mere twelve whistleblowing disclosures from NHS ambulance staff in the period 1st April 2017 to 31st March 2021

This week, the National Guardian finally published terms of reference for her thematic review:

National Guardian Terms of Reference June 2022 for NHS ambulance trust thematic speaking up review

Only five of the 10 ambulance trusts will receive in depth scrutiny. It is not revealed which five trusts have been selected. I have asked the NGO to specify which trusts have been chosen and why.

Former ambulance staff can contribute to the thematic review.

BUT individual whistleblowers’ cases will NOT be investigated.

No embarrassing details wanted, just a demonstration that “something” has been done.

This perfectly complements Sajid Javid’s announced review of NEAS, which has not satisfied relatives or whistleblowers, who want a public inquiry:

Families back petition for public inquiry into North East Ambulance Service failings amid ‘cover-ups’ claim

PETITION

Please click and add your signature to this petition to reform UK whistleblowing law – whistleblowers protect us all but weak UK law leaves them wholly exposed, lets abusers off the hook and it is a threat to public safety.

Replace weak UK whistleblowing law and protect whistleblowers and the public

RELATED ITEMS

More NHS recycling: Henrietta Hughes is Sajid Javid’s preferred candidate for Patient Safety Commissioner

The THIRD National Freedom To Speak Up Guardian – What is her expertise in whistleblowing?

‘Perversion of Justice’ The Abandoned NHS Whistleblower

The National Guardian’s Office finally apologises for a breach of whistleblower confidentiality but fails to demonstrate sufficient learning

Whistleblower Jane Archibald’s unfair dismissal by North Cumbria Integrated Care NHS Foundation Trust, and a “nurse” who was not qualified but ran epilepsy clinics and advised on epilepsy medication

Mr Tristan 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

The Disinterested National Guardian & Robert Francis’ Unworkable Freedom To Speak Up Project

The toothlessness of the National Guardian’s Office: Why it cannot be a model for protecting whistleblowers

More NHS recycling: Henrietta Hughes is Sajid Javid’s preferred candidate for Patient Safety Commissioner

By Dr Minh Alexander retired NHS consultant psychiatrist 21 June 2011

Yesterday it was announced that Henrietta Hughes, former regional Medical Director for NHS England London, is Health Secretary Sajid Javid’s preferred candidate for Patient Safety Commissioner.

Many harmed NHS whistleblowers, who know her from her last government job as National Freedom To Speak Up Guardian, will likely groan inwardly at this news.

The Patient Safety Commissioner is a new role, which is as yet ill-defined. Perhaps predictably so.

It is limited in scope to the safety of medicines and medical devices:

“The core role of the Commissioner will be to promote the safety of patients in the context of the use of medicines and medical devices and to promote the importance of the views of patients and other members of the public in relation to the safety of medicines and medical devices.”

It was proposed in a 2020 review led by Julia Cumberlege which had been tasked with making “recommendations for improving the healthcare system’s ability to respond where concerns have been raised about the safety of particular clinical interventions, be they medicines or medical devices.” The review examined the care failures over pelvic mesh surgery, valproate and primidos.

The review proposed the creation of a Patient Safety Commissioner, which in its general description sounded very similar to the slippery job description of the NHS National Freedom To Speak Up Guardian.

A loose, vague remit to do what it pleases, with limited accountability attached to this freedom. The Cumberlege review states:

“The Commissioner would be free to look at whatever they wish to within her/his remit of patient safety, open to requests for areas to consider and free to publish their findings. The Commissioner would be accountable to the Parliamentary Health and Social Care Select Committee. Alongside annual hearings and using the power to bring matters to the attention of the Committee, the Commissioner could receive and act on information and requests from the Committee, and from the Secretary of State for Health.”

“…the Commissioner would have a general statutory power ‘to do anything which appears to it to be necessary or expedient for the purpose of, or in connection with, the performance of its functions. This would give the Commissioner the power to take a permissive and flexible approach to gathering information necessary for specific issues and to issue advice to those who are engaged in activities relating to improving patient safety. Giving the Commissioner the power to bring matters to the attention of both Houses of Parliament and the Secretary of State for Health and Social Care would provide a proportionate and focused means of highlighting where improvements are needed.”

Something that could have been written by Sir Humphrey.

Or perhaps the long-served William Vineall, Director of NHS Quality, Safety and Investigationsof the Department of Health and Social Care since 2016, who appears to be the appointing officer judging from the DHSC job advert.

The person specification is tragi-comic:

“Set an example of integrity and ethical leadership, reinforcing the position’s reputation as an open and independent role, which puts the needs and interests of the public, patients and service users first.”

There is the briefest of draft legislation in play with respect to the Patient Safety Commissioner’s office.

The DHSC webpage about the Patient Safety Commissioner basically says that the job description hasn’t quite been written yet.

The PSC will be under an obligation to publish a set of principles to govern the way in which they carry out their core duties. The PSC must take steps to consult patients and to ensure that patients are aware of their role.

The everyday workings of the PSC are to be finalised. Regulations will be made setting out further details about the appointment and operation of the commissioner, for example the terms of office.”

There is no guarantee therefore, that the final Office will reflect the recommendations of the Cumberlege review.

It seems more likely that the Patient Safety Commissioner will be another political tool for the DHSC, and more waste of public money on window dressing.

The Department doth protest too much about independence:

How independence will be safeguarded

We expect the Secretary of State to work with the PSC to agree how their independence will be safeguarded.

It is common for commissioners to be sponsored by the government departments with relevant policy responsibility while maintaining their independence.”

So good they had to say it twice:

Independence

To be effective, it is fundamental that the commissioner has the freedom to act independently.

It is common practice for commissioners to be sponsored by the government department with relevant policy responsibility. The Children’s Commissioner does an exemplary job whilst being sponsored by the Department for Education. The Victims’ Commissioner does the same and is sponsored by the Ministry of Justice.

A relationship with DHSC would allow the commissioner a powerful place within the system. A commissioner which is entirely removed from the policy department can be more easily overlooked by government. It is crucial that the right person is appointed into the role, someone who is confident and knowledgeable of the sector to bring weight and intelligence to the commissioner position.

Independence will necessarily be exercised in the carrying out of the commissioner’s functions. For example, the commissioner will have the power to make recommendations or reports to the Secretary of State, who will then be under a duty to consider and respond, ensuring that the department is kept accountable. We will expect that the commissioner makes any such reports or recommendations independently, without recourse to or clearance from the Secretary of State or DHSC.”

So we are to believe that the woman who introduced compulsory smiling for her staff, and who started her tenure as National Freedom To Speak Up Guardian by opining that NHS staff should be less grumpy,is a weighty appointment?





NHS whistleblowing tsar tells staff to behave as if they’re in film Love Actually

Are we to believe that Hughes, who oversaw an embarrassingly small number (nine) of case reviews in her five years as National Guardian and turned away desperate whistleblowers based on objectionable exclusion criteria which put patients at risk, will always put patients first?

Are we to believe that Hughes, who tore up her own rule book to help NHS trust managers in Brighton to the disadvantage of whistleblowers, with later impacts on maternity care when whistleblowers were again sidelined, will never side with the NHS establishment?

Are we to believe that Hughes, who spent part of her meagre National Guardian budget on PR, awards which she and her Office judged and paid for and rose tinted stories in the trade press, will soberly pursue her core role as PSC without gimmicks and self-serving stunts?

Are we to believe that Hughes, whose optimistic statistical claims have been found wanting by the UK Stats Authority, and who made an extraordinary unsubstantiated claim that the Freedom To Speak Up project prevented harm and saved lives, will have the authority to hold organisations to account over the accurate handling of clinical outcome data?

I complained yesterday to the new Chair of the CQC about the National Guardian’s Office ongoing public communications, which mislead NHS staff about the real risk of whistleblowing.

In my correspondence, I included an example kindly supplied by vindicated whistleblower Dr Jasna Macanovic Consultant Nephrologist, who received a typical rebuff by the National Guardian’s Office during Henrietta Hughes’ tenure. Dr Macanovic wrote:

“I contacted the national office myself and was told that they do not get involved in individual cases or disciplinary processes and that I will be free to submit a case review form if/ and when I win a case for unfair dismissal in court.”

“This approach is appalling. I was lucky enough as I had a cast-iron case, and was resilient and financially capable of taking the case to the court. I do not know anyone else around me who would have survived this process. The ferocity and avalanche of unwarranted insults would have destroyed anyone.”

It is preposterous to tell whistleblowers to come back years later after they have been mauled by the litigation process. It is not only a great injustice to the whistleblower, but an incomprehensible reaction to the patient safety issues that have been buried along with the whistleblower. What happened on Hughes’ watch was the equivalent of more soil being shovelled on top.

Under Hughes’ leadership, other NHS whistleblowers received similar responses.

This was a far cry from the role described in the Freedom To Speak Up Review  on NHS whistleblowing which proposed the role of the National Guardian. It was supposed to be a “nimble” office that sought redress for both harmed whistleblowers and patients who were harmed by failures to handle whistleblowing properly:

“…to recommend to the relevant systems regulator or oversight body that it make a direction requiring such action.

This may include:

– addressing any remaining risk to the safety of patients or staff

 – offering redress to any patients or staff harmed by any failure to address the safety risk

– correction of any failure to investigate the concerns adequately”

Conveniently for the government and many senior NHS managers, Hughes never accepted responsibility for helping to ensure such redress.

She also refused to support the one thing that would make a real difference to whistleblowers and therefore patients – legislative reform and replacement of useless UK whistleblowing law. Even though her role included identifying and acting on barriers to speaking up.

If Hughes is confirmed as Patient Safety Commissioner, it would be surprising to see any real change of direction.

Henrietta Hughes’ declaration of interests

Since leaving her post as National Guardian in September 2021, Hughes has been busy.

In December 2021, she set up a company, Accelerate Improvement Ltd Company number 13784948. This is categorised under “Other human health activities”. The firm has not yet filed accounts according to Companies House. I have been unable to find any digital footprint for the firm beyond basic company details.

In March 2022, she was announced as a new non executive director at South Central Ambulance Service NHS Trust. (SCAS)

Her SCAS declaration of interest was most interesting:

The declaration revealed interests at the heart of government with a seat on the Health honours committee – a useful lever on power, in company with David Behan and Dido Harding amongst others.

There is also a seat at the General Medical Council and at the Medical Protection Society – a medical defence union, defending doctors against negligence claims.

The latter is an awkward fit with her putative role as the Patient Safety Commissioner.

Hughes is also Chair of Childhood First South, Childhood First East Anglia and Childhood First Midlands three businesses categorised as “Other residential care activities not elsewhere classified”, for children. They have charitable status. According to Companies House, she became a person of significant control of these companies on 10 November 2021.   

It was also announced that she would take up the Chair of the Institute of Integrated Systemic Therapy in September 2021, of which she is listed as the person in significant control.

The Institute of Integrated Systemic Therapy was formerly a company named “Childhood First” until 2015, and appears to be the parent company for the regional Childhood First branches. It has charitable status. According to the company’s reports, it runs children’s homes, as therapeutic communities, and fostering services. Fee income in 2020/21 was almost ten million pounds:

Which of these many jobs will Hughes give up to become the Patient Safety Commissioner?

Whatever, the trajectory is clearly one of an insider, not a challenger.

Here is Henrietta Hughes and her former Office, independently and rigorously challenging NHS England – her former employer and one of the key sources of suppression and top-down bullying in the NHS:

Oh how they trembled.

One can see why the Minister is delighted too:

As one commentator from Left Foot Forward quipped after Hughes’ supremely embarrassing oxytocin/Love Actually gaffe,

“Fortunately for health PR, with Dr Hughes in charge of NHS whistleblowing, we’re unlikely to hear about the problems in the first place.”

Patients and families similarly need to brace for problems with the Patient Safety Commissioner. The likely scenario will be that a few cases/ issues will be paraded, but under the iceberg’s waterline, more people will be failed.

And expect propaganda. Lots and lots of it.

PETITION

Please click and add your signature to this petition to reform UK whistleblowing law – whistleblowers protect us all but weak UK law leaves them wholly exposed, lets abusers off the hook and it is a threat to public safety.

Replace weak UK whistleblowing law and protect whistleblowers and the public

RELATED ITEMS

Here are just some cases of NHS whistleblowers who continued to be severely harmed during the years in which Henrietta Hughes was the NHS National Freedom To Speak Up Guardian:

This case of ‘Paul’ (a pseudonym for the story) reported by Byline Times documents how an NHS whistleblower was failed by Henrietta Hughes’ Office, in a repetition of behaviour very similar to her strategic inaction at Brighton:

‘Perversion of Justice’ The Abandoned NHS Whistleblower

“But Paul did not have much luck with the National Guardian’s Office. It turned out that it had previously given the trust in question three months to improve its treatment of whistleblowers – in a case review which the NGO confirmed to Byline Times was published in 2018 – and this deadline had been far exceeded. Instead of recognising this as a systemic issue, the NGO decided not to do anything in order to give the new trust chief executive time to deal with these issues. This appears to be the complete opposite of being a ‘guardian’ of helping people to speak up.”

Henrietta Hughes’ Office breached a whistleblower’s confidentiality at Harrogate. The trust chief executive told the whistleblower that it was Hughes herself who breached confidentiality. An NHS Improvement investigation concluded that it was an underling who breached confidentiality. But Hughes failed to ensure that the whistleblower received a timely apology from her Office or that there was proactive learning:

The National Guardian’s Office finally apologises for a breach of whistleblower confidentiality but fails to demonstrate sufficient learning

Other whistleblowers harmed on Hughes’ watch have included:

Whistleblower Jane Archibald’s unfair dismissal by North Cumbria Integrated Care NHS Foundation Trust, and a “nurse” who was not qualified but ran epilepsy clinics and advised on epilepsy medication

Mr Tristan 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

These are some of the posts about the policy failures relating to Hughes’ role as National Freedom To Speak Guardian:

The Disinterested National Guardian & Robert Francis’ Unworkable Freedom To Speak Up Project

The toothlessness of the National Guardian’s Office: Why it cannot be a model for protecting whistleblowers

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

By Dr Minh Alexander retired consultant psychiatrist 16 June 2022

Summary: The Employment Tribunal (ET) has been very critical of governance by University Hospitals Birmingham NHS Foundation Trust (UHB) in the whistleblowing case of Mr Tristan Reuser, surgeon. Misleading, inaccurate information was given to an advisory body to justify Mr Reuser’s suspension. David Rosser the medical director, now CEO, made a misleading declaration in referring Mr Reuser to General Medical Council. Other concerns have added to governance failings identified by the ET. There are questions about whether the General Medical Council and Care Quality Commission have taken robust enough action against those who treated Mr Reuser unfairly. The GMC at least issued Dr David Rosser with a warning for making a misleading declaration to the GMC. Twenty five of twenty six GMC referrals by the trust since 2012 had medical director sign off. It is therefore important to ensure that doctors are fairly treated. The CQC is especially open to criticism because it has deemed UHB is compliant with CQC Regulation 5 Fit and Proper Persons despite the ET’s criticism of David Rosser. FOI material from the trust has revealed an apparent conflict of interest in the trust’s Fit and Proper Person process (FPPR). A non executive director who worked with David Rosser as MHPS Designated Board member, overseeing the trust’s suspension and disciplinary action against Mr Reuser, later helped to oversee the trust’s FPPR review on David Rosser’ detrimental actions against Mr Reuser. CQC also misleadingly claimed to have received an “independent” Fit and Proper Person (FPPR) review report on Rosser. However, the report was in fact jointly written by a UHB trust employee and a solicitor from a law firm that had a prior commercial relationship with the trust. When CQC was challenged, the chair of the CQC FPPR panel Rosie Benneyworth Chief Inspector of Primary Care tried to brazen it out. She has so far not accepted that CQC has done anything wrong. In response to an FOI request, CQC admitted to accepting at least three FPPR investigation reports that were written partly or entirely by NHS trust staff. CQC has also admitted that it in fact asked UHB to carry out an external FPPR review. Through hindsight goggles, CQC excused its failure to enforce acceptable practice by UHB by denying it has powers to insist that providers follow better FPPR process. This is despite numerous references in CQC’s published and internal guidance to its intention to ensure “robust” FPPR process by providers. As a small concession, CQC apologised in its FOI response for its previous misleading claim that the Rosser FPPR review was “independent”. But CQC still insisted that support to the FPPR review from a law firm which was an existing UHB supplier was “independent”. Shockingly, there is evidence that CQC was informed of the above conflicts of interest which compromised the Rosser FPPR process before the CQC decided to rubber stamp the trust’s governance. I will be making a fresh FPPR referral to CQC on the board of University Hospitals Birmingham NHS Foundation Trust and the trust’s former chair Jacqui Smith based on several matters, including the abuse of process by the trust board in asking a subordinate to determine a senior’s fitness. Natural justice and common decency would tell anyone – except it seems the CQC – that the latter is very, very wrong.  Evidence of CQC’s further failures on FPPR will also be submitted to parliament.

Background and the GMC’s findings

Mr Tristan Reuser was an experienced senior surgeon at University Hospitals Birmingham NHS Foundation Trust who the Employment Tribunal determined was unfairly dismissed after he whistleblew about patient safety issues of safe staffing and theatre cover.

The ET also found that his then medical director Dr David Rosser, now the trust CEO, made a misleading referral to the General Medical Council omitting the fact that Mr Reuser was a whistleblower. This was in contravention of GMC’s procedures to protect whistleblowers. Under guidelines produced for the GMC by former Court of Appeal judge Sir Anthony Hooper, an incorrect declaration of this sort should trigger a review of the referring senior doctor’s Fitness to Practice.

 The ET’s criticism was serious and raised doubts about whether Dr Rosser made an inadvertent mistake.

These are the relevant passages from the Employment Tribunal judgment of 8 October 2018 which raised doubt about whether Dr Rosser’s failure to inform the GMC that Mr Reuser was a whistleblower was a matter of simple oversight.  

Misleading the GMC  

23.1 The GMC were given inaccurate and misleading information and those failings were serious.  

23.2 The respondent suggested that these failings were both inadvertent and after the decision to dismiss and hence irrelevant. However, it seems to me that I am entitled, and required, to consider all the circumstances when, for example, considering whether to draw adverse inferences in the whistle-blowing claim. It is also potentially relevant in the context of assessing the independence and neutrality of Dr Rosser.  

23.3 In his referral to the GMC Dr Rosser’s failure was far more than the omission of a piece of insignificant information. He was required to address whether the claimant had raised protected disclosures and asserted positively that, “To my knowledge Mr Reuser has not been involved in any whistleblowing episode or other attempt to raise concerns within the organization.”  

23.4 It may well be that Dr Rosser was unaware of the full details of the Hooper Review on the handling by the GMC of cases involving whistle blowers but, as the responsible officer, he was required to be aware of the main principles and purpose. For example: “If a doctor being referred to the GMC has raised concerns about patient safety or the integrity of the system with the organization making the referral, then the necessary steps should be taken to obtain from the organization material which is relevant to an understanding of the context in which the referral is made.” “Investigators assessing the credibility of an allegation made by an organization against a doctor who has raised a concern should take into account, in assessing the merits of the allegation, any failure on the part of an organization to investigate the concern raised and/or have proper procedures in place to encourage and handle the raising of concerns.”  

23.5 In relation to that latter quote, it was not in dispute that the respondent had failed to properly investigate and respond to the claimant’s concerns. It is possible that, irrespective of any link to the reasons for the claimant’s dismissal, Dr Rosser wanted to conceal this failure.  

23.6 The Hooper review continues: “Failure to answer the question truthfully would no doubt lead to the signing doctor’s fitness to practise being investigated and, if discovered during the course of the investigation, would be an important factor in assessing the credibility of the allegation.”  

23.7 Dr Rosser was taken in re-examination to the GMC response to Hooper and confirmed that he believed all documents from the GMC were given to him by the GMC liaison officer.  

23.8 Dr Rosser initially suggested that he must have overlooked the claimant’s whistleblowing letter when writing to the regulator. That appears surprising given that the letter was included with, and referred to in, the Claimant’s Statement of Case and emailed separately to the disciplinary panel before the hearing. It was also referred to at the hearing just 4 days before Dr Rosser wrote to the GMC.  

23.9. Dr Rosser accepted that he was required to consider the documents on both sides before reaching a decision. The decision was reached and written on the same day as the GMC referral was made. Dr Rosser wrote both letters. It is unlikely, therefore, that he had forgotten the protected disclosure.  

23.10. In response to this challenge, Dr Rosser’s second, somewhat contradictory, explanation was that he misunderstood the legal terminology and did not consider that the letter should be treated as a protected disclosure.  

23.11 It seems to me surprising that the Respondent’s Responsible Officer would not understand what amounted to a whistle blowing episode, not least because he asserted that he had focussed on encouraging reporting of concerns. He certainly ought to have enquired about any whistle blowing episodes before making an express representation about them to the regulator.  

23.12 In any event his assertion was that there had been no “other attempt to raise concerns within the organisation.” If Dr Rosser had not identified the claimant’s letter as containing protected disclosures it remains difficult to understand how he did not view them as “concerns”.  

23.13 Dr Rosser has not written to the GMC to inform them that he misled them. He asserts that he told the liaison officer but there is no record of that discussion. If Dr Rosser did inform the GMC it is, at best, surprising that they did not write to Mr Reuser to inform him of the new information received, nor was there any mention of it in their findings”    

David Rosser’s referral did not result in any GMC action against Mr Reuser.

Instead, I and others referred David Rosser to the GMC for his misleading GMC referral and he subsequently received a warning on 22 July 2021 for his misleading referral.

An FOI request by fellow NHS whistleblower Maha Yassaie @Lady_yassaie has revealed that 25 of 26 of GMC referrals by UHB since 2012 were signed off by the medical director:

University Hospitals Birmingham FOI disclosure 14 April 2022 GMC referrals Request No 2141 2022/23

It is important therefore that doctors are treated fairly by the medical director.

Shortly after the GMC warning, Rosser relinquished his GMC registration. This coincided with challenges to the GMC from some referrers about the veracity of the regulator’s claims that Rosser’s error in misleading the GMC was an isolated incident.

I have seen correspondence from a year prior to the July 2021 GMC warning, about an earlier concern raised with the GMC about incorrect evidence by Dr Rosser on another occasion. The individual who raised this concern with the GMC also wrote to the then UHB chair Jacqui Smith in October 2019 raising this issue and they questioned Rosser’s fitness. Smith reportedly never replied.

Another referrer had raised concern with the GMC about David Rosser signing off a incorrect declaration on maternity safety at his trust, which had to be retracted. His personal sign off was revealed by an FOI request to NHS Resolution. The incorrect declaration was amongst several made by a number of trusts, which resulted in wrongly paid discounts on insurance having to be repaid to NHS Resolution, as reported in an Independent story of 7 March 2021.

This is a screenshot from the FOI of the 2019 sign off in Dr Rosser’s name, taken from the trust’s declaration document for year two of NHS Resolution’s maternity incentive scheme:

According to the GMC’s record of the investigation hearing on 22 July 2021, David Rosser’s barrister Fiona Horlick QC argued that his incorrect declaration to the GMC:

“was clearly an isolated incident in a previous unblemished career”

The GMC record indicated that David Rosser was in attendance when this submission was made on his behalf. Did he at this point recall that he had also made a mis-declaration to NHS Resolution, a mis-declaration publicised by the press four months before the GMC investigation committee hearing? If he did, should he have disclosed this to the GMC?

Although the GMC claimed in its warning of July 2021 that David Rosser was “developing” insight, he later gave an interview to the Health Service Journal which seemed to minimise his actions in misleading the GMC. He stated in the interview:

“At the end of the day, after two and a half years of intensive investigation, the accusation was that I made a mistake on the GMC referral. I can live with that frankly, that I made an administrative error,” he added.”

University Hospitals Birmingham NHS Foundation Trust withheld damaging documents from the Employment Tribunal

UHB withheld documents which revealed that it had suspended Mr Reuser based on false information. It should in fact have given Mr Reuser the documents at the time of his suspension as a matter of policy.

The trust later failed to produce the documents during the legal disclosure process for the Employment Tribunal and it also failed to disclose the documents in response to a subject access request by Mr Reuser.

Mr Reuser only managed to obtain the revealing documents through a subject access request to the National Clinical Assessment Service (NCAS), to whom UHB had provided the false information which had led to NCAS agreeing his suspension.

The ET judge noted:

“25.1 The Respondent disclosed no documents at all from NCAS, either in
the litigation or via the SAR. Mr Reuser obtained them direct from NCAS. I was
invited to draw the inference that they were withheld intentionally.”

In the ET judge’s view, the information given to NCAS by the trust was seriously misleading:

“25.2 It appears that Dr Ryder gave NCAS seriously misleading and inaccurate information as identified earlier in my findings. This further supports my view on apparent bias and/or incompetence at a senior management level.”

UHB’s disreputable behaviour during ET proceedings resulted in a cost order for £20,000 against the trust.

Cost orders against NHS trusts are very rare. Tribunals do not like to impose costs on cash strapped public bodies.

The fact that a cost order was made represented a significant criticism of UHB.

Does the CQC which need a dictionary to understand the word ‘independent’?

Despite the specific criticisms by the original ET judgment against David Rosser regarding his reliability as a witness;

Despite his misleading GMC referral on Mr Reuser;

Despite his ultimate responsibility as medical director for the unjustified suspension and unfair dismissal of a medical whistleblower;

CQC last year typically concluded that David Rosser was a Fit and Proper Person under Regulation 5 (FPPR).

CQC accepted assurance by UHB that Rosser had been thoroughly investigated in this respect and had passed.

Because of concerns about the independence of the FPPR process undertaken by the trust, I asked CQC to confirm that it had reviewed primary documents itself and that it had satisfied itself that there was no conflict of interest in the trust’s process.

The CQC replied that it had satisfied itself that UHB’s process was sound and that its FPPR panel had received a copy of an “independent” FPPR report by two individuals, Berit Reglar and James Gutteridge.

The problem with this is that, astonishingly, cursory checking revealed that Berit Reglar is a longstanding trust employee, and that James Gutteridge is a partner at Bevan Brittan LLP, a law firm that had done recent work for UHB and which in some of its promotional material had listed UHB as a “key client”.

Furthermore, I have now seen correspondence in which Berit Reglar stated that she was in joint charge of the Rosser FPPR investigation process.

When I confronted CQC about its false claim that UHB’s report was “independent”, the regulator through Rosie Benneyworth Chief Inspector of Primary Care and current Chair of CQC’s FPPR panel, firmly stuck its chin out. Benneyworth insisted that CQC had done nothing wrong. In doing so, Benneyworth appeared to tear up the CQC FPPR rule book to justify what her panel had done, claiming that CQC had no say over a trust’s FPPR process:

I have challenged Benneyworth’s response:

Correspondence to Rosie Benneyworth CQC Chief Inspector Primary Care re FPPR issues at University Hospitals Birmingham NHS Foundation Trust

Based on past experience I imagine her letter could well have emanated from CQC’s regrettable legal department. CQC has not yet responded to my challenge.

It transpired on further checking that the CQC had been warned of the conflict of interest regarding Bevan Brittan, an existing supplier, acting as an “independent” FPPR investigator. This was before CQC shut down the FPPR.

University Hospitals Birmingham NHS Foundation Trust spending on Bevan Brittan

Oddly, although it is routine for public bodies including NHS bodies to publish details of financial transactions above £25K, the published transparency trail for UHB stops after 2017.

The ICO’s records show that UHB unlawfully tried to resist an FOI request for details of spending over £25K in 2018, citing a “prevention of crime” and a “commercial interests” exemption. This is the ICO decision notice overruling UHB’s refusal:

ICO Decision Notice 26 July 2019 Ref FS50810179  ordering University Hospitals Birminghan NHS Foundation Trust to disclose details of spending over £25K

Why did UHB stop routine publication of this financial information? Why would it not wish to be held accountable or to allow the public to scrutinise the record for any matters of possible concern?

Most recently, UHB was asked by NHS whistleblower Clare Sardari @SardariClare for information on its spending on Bevan Brittan’s services, but has failed to supply this so far, resulting in an ICO order to disclose.

Strikingly, it has been alleged that UHB met David Rosser’s full legal expenses, and that a statement to this effect was made by trust officers at a governors’ meeting in July 2021. The trust has been asked to clarify if there is any basis to this allegation, and has not yet responded.

Additionally CQC had been sent evidence that the trust, through Berit Reglar the internal FPPR investigator, gave Mr Reuser false information that Bevan Brittan had no prior connection with the trust:

From email by Berit Reglar of 3.11.2020, answering questions by Mr Reuser about the trust’s proposed FPPR process

The loss of trust arising from this and other matters was such that Tristan Reuser decided not to take part in the trust FPPR process.

Moreover, Mr Reuser became concerned about an issue of impartiality because Berit Reglar made an incorrect assumption about him in the course of correspondence. She admitted that she wrongly assumed he had made a GMC referral:

From email by Berit Reglar 3.11.2020, answering questions by Mr Reuser about the trust’s proposed FPPR process

[NB It is relevant to note here that the GMC decided to only pass a single anonymous referral to its investigators, but withheld my earlier referral on identical grounds. One possible explanation is that this circumvented the requirement to provide feedback to a named referrer.]

FOI data on CQC’s handling of FPPR

I requested update data on whether CQC had ever made a finding of breach of regulation 5 Fit and Proper Persons and to see how many of the “independent” FPPR reports CQC has accepted had in fact been written by NHS trust personnel from the very trusts under investigation.

In an FOIA disclosure of 25 May 2022 the CQC admitted that it had not found a single NHS trust to be in breach of Regulation 5 Fit and Proper Persons since the regulation was introduced in 2014. Shocking, but no surprise to many NHS whistleblowers who are familiar with the whiff of collusion between CQC and abusive employers.

According to the FOI disclosure, CQC’s FPPR panel has accepted 95 FPPR referrals for consideration since 2014 but only 29 formal FPPR investigation reports were produced arising from this, raising questions about the rigour of CQC’s regulatory process.

The CQC claimed that three of the 29 formal FPPR investigation reports produced were authored partly or wholly by NHS trust staff, one of which would have been the Rosser FPPR investigation.

Significantly, CQC claimed that that it originally advised University Hospitals Birmingham NHS Foundation Trust to commission an external FPPR report:

“In the case of the review for the FPPR referral made for University Hospitals Birmingham (UHB) we suggested to the trust that they may benefit from an external independent review.”

CQC made post hoc excuses for not ensuring that UHB followed a suitably “robust process”, despite all its guidance, internal and published, indicating that CQC expects providers’ FPPR process to be “robust”. CQC gave these mealy mouthed excuses for letting UHB get away with a flawed and conflicted FPPR process:

“CQC are not in a position to insist on how the trust carries out their review of the fitness of an individual when an FPPR referral has been made.”

“there is scope for the trust to do a proper review without going out to someone independent.”

In UHB’s case, CQC tried to whitewash UHB’s flawed process thus:

“The trust gave their reasons for carrying out the review lead by a member of UHB staff (who is a qualified and practising solicitor) supported by an independent HR lawyer. The panel accepted that their decision was reasonable.”

CQC did at least apologise for misleading me by initially claiming that the UHB FPPR investigation into Rosser was “independent”:

“You asked if CQC reviewed any primary sources of information such as independent review reports on Dr Rosser’s fitness as a trust director (as opposed to any summarised information provided by the trust Chair) and in response to your question we referred to the Berit Reglar and James Gutteridge review as the independent review. We should have stated this was an internal review with independent support. Please accept our apologies for the error in our reference.”

Note that CQC still maintains that support to UHB’s FPPR review from the law firm Bevan Brittan, which was an existing trust supplier, was “independent”.

So conflict of interest would seem to be a highly plastic concept in the CQC-verse.

Cutting through all of CQC’s self interested squirming, CQC has had the power all along to force NHS trusts to remove unfit directors if it pleased.

It has simply chosen not to do so.

FOI data from University Hospitals Birmingham NHS Foundation Trust on the FPPR process on David Rosser

The trust did not respond to an FOI on this issue despite several reminders, including to its Chair, until ordered to do so by the Information Commissioner.

In a response of 6 June 2022, the trust disclosed terms of reference of September 2020 which showed the FPPR review into David Rosser was conducted because of:

  1. The dismissal of Mr Reuser and the related ET findings against the trust and David Rosser
  2. Allegations concerning MHPS process and GMC referral of another individual

The terms of reference stipulated that it would be an internal process supported by an external lawyer.

Importantly, UHB stated that the terms of reference were drafted by David Burbridge the trust’s Chief Legal Officer, “with CQC input and approval”.

There was also a letter from the trust Chair Harry Reilly responding to some concerns and questions that I had raised, which contained data that I had requested.

In this letter Harry Reilly responded to my concern that the trust had not recognised what a grave step a GMC referral was, in relation to ET criticisms of trust process. Reilly maintained that referral to the GMC “should not be seen as a punitive measure”.

This is so devoid of empathy that it is hard to comment on. There is no acknowledgment here of the damage done to doctors, regardless of intent.

Doctors have died of suicide and suffered acute illness such as heart attacks and strokes whilst under GMC investigation. After the GMC’s recent bizarre pursuit of Dr Arora over trivia, Chaand Nagpaul the BMA Chair went to war on the dysfunctional GMC process, calling for radical reform with the comment:

“Being notified and being investigated by the GMC can be one of the most traumatic experiences in a doctor’s life”.

But the rigid, stonewall attitude by UHB perhaps explains why it has kept digging itself into HR holes and does not seem to learn.

In addition, the trust claimed to me in its FOI response that there was no known conflict of interest in its FPPR process on David Rosser. However, the FOI response revealed that one of the trust’s non executive directors, Jon Glasby a social worker by background, acted as a support to the former trust Chair Jacqui Smith in the Rosser FPPR process:

This raised an additional issue of conflict of interest because Glasby had previously worked with David Rosser (then as Medical Director) to oversee the trust’s suspension of and disciplinary action against Tristan Reuser, in Glasby’s capacity as MHPS Designated Board Member:

MHPS (Maintaining High Professional Standards) is the disciplinary/incapability process for doctors

The apparently incorrect denial of conflict of interest in a statutory disclosure under FOIA has to be noted as another example of the trust providing unreliable information.

I have written to Harry Reilly trust chair to ask for the trust’s response to the apparent conflict of interest concerning Jon Glasby. There has been no response so far.

And should the CQC have detected this clash when it assessed the soundness of the trust FPPR process?

The trust maintained in its letter of 6 June 2022 that it adhered to NHS Providers’ guidance on FPPR. This is debatable given that NHS Providers’ criteria for triggering a fully external FPPR review is contentiousness. In the context of the Reuser litigation, that would seem to be fulfilled. Also, if the whistleblower at the centre of the matter did not have confidence in the process and had already withdrawn, the process had de facto been disputed.

Shockingly, I have now seen correspondence which shows that the CQC was informed that Jon Glasby was inappropriately involved in the Rosser FPPR review, BEFORE CQC decided to accept the trust’s FPPR evidence as satisfactory.

Separate to this, Mr Reuser wrote to Jon Glasby himself in November 2020, after the conclusion of his case in both the ET and the EAT. He asked if Jon Glasby had been kept properly informed of trust actions under MHPS, in the light of the ET and EAT’s serious criticisms of his suspension by the trust.

Glasby reportedly never responded to this letter. But by this point, the trust had drafted the terms of reference for the Rosser FPPR review. Did Glasby fail to respond to Tristan Reuser’s letter because he had already been appointed to the Rosser FPPR process and was conscious of the tension arising?

Trust learning from the Reuser case

UHB seem to have taken a cherry picker’s approach to the NHS Providers’ guidance on FPPR. This guidance emphasised the importance of retaining public confidence and it recommended publication of the outcome of FPPR investigations. It is unclear whether UHB has ever done so. I have asked Harry Reilly UHB chair to clarify if a summary outcome was ever published, and it not, whether the trust intends to publish a summary.

Letter 6 June 2022 to Harry Reilly Chair UHB re concern about FPPR conflict of interest & transparency

A previous enquiry that I made to the former trust chair Jacqui Smith about trust learning was repeatedly ignored. The trust eventually cursorily admitted in a seven month overdue FOI disclosure of 30 March 2022 that some level of wrongdoing was acknowledged, as board training was undertaken:

“The Trust has reflected upon the errors made in relation to the disciplinary process concerning Mr Reuser and the subsequent Employment Tribunal and has undertaken related training with all Board members, including the Trust’s current Responsible Officer (RO). This includes consideration of all relevant factors and advice when making a referral to the GMC.”

The reluctance to admit even this is not reassuring evidence of genuine learning or a change in attitude by the trust board. And there is no note of empathy.

I will be re-referring the UHB trust board and its former chair Jacqui Smith, now chair of Barts Health NHS Trust and Barking, Havering and Redbridge University Hospitals NHS Trust to the CQC under FPPR. This will include grounds of what I believe is the serious abuse of process in instructing a subordinate to determine the fitness of a senior. Although CQC is hardly fit to adjudicate given its part in rubber stamping UHB’s impropriety in its FPPR process.

Overall, the whole matter may look to some like CQC collusion with the trust.

How many other FPPR referrals have been processed in this shady way by the CQC, behind closed doors?

Ultimately, the ongoing evidence of CQC failure on FPPR will be submitted to the relevant parliamentary committees.

The regulation of NHS managers

If we revisit the original reasons for FPPR – the horrors of MidStaffs – and we contrast this against CQC’s obvious inaction, the question arises of what patient harm has CQC enabled in the last eight years of FPPR non-enforcement, in concert with cover ups and poor quality management of the NHS?

It has been a decade since the MidStaffs public inquiry, and the senior ranks of the NHS have continued to fiercely resist accountability, let alone regulation. The senior NHS ranks have been increasingly stuffed with government cronies, many of whom are financiers with little obvious connection to healthcare.

Instead of accountability, we see endless, incestuous recycling of the same individuals, revolving between provider and regulatory bodies, and sometimes the Department of Health. Shaking hands with a knowing wink as they keep swapping seats.

An example of CQC’s troubling proximity to the providers that it is supposed to regulate, and the fast-spinning CQC revolving door  

Ellen Armistead was CQC Deputy Chief Inspector of Hospitals  

CQC disclosed that she chaired the CQC’s FPPR panel between February 2016 and June 2019  

Armistead left CQC in June 2019, and became Chief Nurse and Deputy Chief Executive of Calderdale and Huddersfield NHS Foundation Trust in July 2019.
Ellen Armistead’s bio from the Calderdale and Huddersfield NHS Foundation Trust website

The Kark review report on managing NHS managers’ fitness was carried out four years ago but remains unimplemented. Kark stopped short of full regulation but did recommend a central database and a barring mechanism, with full future regulation if these initial partial measures were not enough.

When I enquired again for the umpteenth time recently, I was told that there were still no implementation terms of reference to share with me because the work on the Kark report was still at an early stage – after four years!

A telephone meeting was held with NHS England/Improvement on 18 May 2022 and brief meeting minutes have now been agreed. It was revealed that there had not been Ministerial authorisation to go ahead with Kark implementation, but that was anticipated. A question about whether the Kark register will be retroactive has not so far been answered. If not, some will doubtless be pleased to delay the register’s establishment for as long as possible. It is anticipated that it will be at least a year before any Kark database is operational.

In the meantime, the odd report of the Messenger review of NHS and social care leadership which seems to come with no supporting evidence or references, has been published to a tepid welcome.

If patients are to be effectively protected, and frontline clinicians given the proper professional independence to care for them, the senior NHS management cabal must be tackled.

So of course must be the malign political influence of the Department of Health which sits at the apex of the pyramid of bullying and suppression.

Another example of the CQC revolving door

Mike Richards was a former CQC Chief Inspector of Hospitals who chaired CQC’s FPPR panel between December 2014 to February 2016.

He personally shut down the FPPR referral on the notorious Paula Vasco Knight
who was recycled back into the NHS with the help of Monitor despite an ET finding of whistleblower reprisal. Richards was severely embarrassed when she was shortly after charged with a criminal fraud.

Upon his retirement from the CQC Richards was rewarded with a seat as a non executive on the Department of Health and Social Care’s board.

He also took up some positions in the private sector with PwC and Incisive Health.

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RELATED ITEMS

Is there a ‘club culture’ at the heart of the NHS’s quality regulator?

CQC’s zero enforcement of FPPR, the abusive North Tees trust board and its persecution of whistleblowers senior nurse Linda Fairhall and surgeon Mr Manuf Kassem

Disclosed: CQC’s internal technical guidance on Regulation 5 Fit and Proper Persons and an internal audit on CQC’s woeful handling of FPPR

Whistleblowers have continued to emerge at UHB:

Multiple whistleblowers flag ‘heartbreaking’ incidents at major trust

A FIFTH never event of the wrong type of blood given has just been reported at UHB:

Major trust records fifth never event at troubled department

University Hospitals Birmingham NHS Foundation Trust also made the headlines on 5 June 2022 because of reportedly poor treatment of doctors in training in obstetrics and gynaecology, requiring regulatory intervention:

Trainee doctors in ‘meltdown’ at major hospital maternity department

Based on Tristan Reuser’s case and others, NHS Resolution agreed that NCAS’ successor body will consider safeguards against being fed false information by unscrupulous employers:

Will the Practitioner Performance Advice(formerly NCAS) do more to deter referring employers’ untruths about medical whistleblowers? Perhaps.

In true NHS musical chairs style, it was announced on 7 June 2022 that Rosie Benneyworth current chair of the CQC FPPR panel is being posted to HSIB:

Dr Rosie Benneyworth appointed interim Chief Investigator

“We know that most people get good care in the NHS, but sometimes they don’t get the outcomes they need or things go wrong. In these circumstances, it is vital that as a system we reflect and learn from these events to improve the safety of care”

“Rosie takes up her post with HSIB on 1 August 2022.”

Let us hope that Benneyworth does not take to tearing up any rule books at HSIB.

A particularly gross example of CQC conflict of interest and failure on FPPR was when it passed its notorious former Chair Jo Williams as a Fit and Proper Person, removing obstacles to her recycling back into the NHS fold:

Jane Archibald’s shocking whistleblowing case about a cover up of an unqualified assistant being allowed to run epilepsy clinics and vary complex epilepsy medication featured a failure by her former CEO Stephen Eames to respond to her disclosures. He simply did not respond to her correspondence. NHSE/I has been asked to review his suitability for his current post as CEO of the Humber region ICS.

Whistleblower Jane Archibald’s unfair dismissal by North Cumbria Integrated Care NHS Foundation Trust, and a “nurse” who was not qualified but ran epilepsy clinics and advised on epilepsy medication

Dr Jasna Macanovic’s recent NHS whistleblowing case adds to the pile of managerial recycling scandals. John Knighton the medical director found by the ET to be centrally involved in her premeditated unfair dismissal has been protected by the trust and Mark Cubbon the trust CEO who failed to ensure her protection as a whistleblower has been promoted to a senior post at NHS England.

An FPPR referral has now been made arising from the executive failures in this matter.

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

Sir Robert’s Flip Flops

The Flexible CQC, FPPR & Kettering General Hospital NHS Foundation Trust\

Post Office Horizon scandal: How Dido Harding helped to recycle Paula Vennells, FPPR and a suggestion for the BEIS Minister

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

Steve Trenchard, NHS regulators & FPPR

FPPR: CQC has lost all moral authority, but what will the National Guardian do?

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

National Guardian ‘Expects’