Shockingly, this revealed that some NHS trusts were not bothering to collate data about long COVID in their staff.
A number of NHS trusts did not even bother to respond to the FOI request.
NHS Resolution holds some of the relevant data because NHS staff are starting to sue employers for COVID injuries.
But NHS Resolution said that it could not run a computer search for this data because long COVID is not assigned a specific injury code in its systems:
The Department of Health and Social Care callously said that it held no central data on NHS staff affected by long COVID, and crucially, that it had no intentions to collate this data:
The DHSC could not say authoritatively if the data was held elsewhere.
To fill in the gaps from Grace Pritchard’s FOI request last year, I have sent a similar request to all the trusts that did not bother to answer Grace’s questions.
I will post the replies below as they come in.
The first reply received has come from West London NHS Trust, which runs Broadmoor hospital:
The trust has disclosed 71 cases of long COVID in staff so far.
Of great concern, the trust has indicated that it has NOT been asked by NHS England for information on long COVID in its staff:
“5. Has NHS England asked the trust to specifically report data on how Long COVID has affected trust staff?
Response: No”
The concerted wilful blindness by oversight bodies is a great betrayal of the duty of care to frontline keyworkers.
I have written to Amanda Pritchard NHS England CEO, copied to the parliamentary Health and Social Care Committee, the Office of National Statistics, Health and Safety Executive and the Secretary of State.
BY EMAIL
Amanda Pritchard
CEO NHS England
24 November 2022
Dear Ms Pritchard,
Collation of data on long COVID injuries in NHS staff
I am writing to raise a concern that NHS England does not appear to be collating data on long COVID injuries suffered by NHS staff.
Please see below an FOI response from West London NHS Trust which records 71 staff affected by long COVID, and which indicates that the trust has not been asked by NHS England to report specific data on long COVID injuries amongst staff.
No central public body seems to be tracking the level of COVID injury amongst NHS staff.
ONS collates long COVID data by occupation, which allows a rough estimate, but it does not publish data by employer.
Some NHS Trusts are collecting data about long COVID in their staff.
NHS Resolution holds data on personal injury claims by NHS staff affected by long COVID, but says it has no specific code for long COVID and therefore cannot run a computer analysis.
This is a brief post to raise awareness that an interview of Mr Shyam Kumar about his whistleblowing experience at the Care Quality Commission will take place on 24 November 2022 and will be streamed:
Mr Shyam Kumar was appallingly treated by the CQC. An Employment Tribunal made decisive findings that he suffered detriment and was unfairly dismissed explicitly because he made public interest disclosures.
The ET rejected the CQC’s unpleasant dissembling during the ET process, which shockingly and falsely tried to cast him as a troublemaker and bully all through proceedings.
The details of the case and key documents can be found here:
On 11 September 2022 I asked Ian Trenholm, CQC’s CEO several questions about CQC’s and his own actions with regard to Mr Kumar’s case, and CQC’s whistleblowing governance.
Despite an indication from Trenholm’s Office that there would be a response, none has been issued, This is despite reminders.
These are just a few of the unanswered questions that I put to Ian Trenholm:
“8. Would you like to comment on the fact that only 47% of CQC staff replied affirmatively in the 2019 CQC staff survey to survey question number 62: “62. I think it is safe to challenge the way things are done in CQC”
In 2019, the NHS staff survey revealed that 71.7% of staff who participated stated that they would feel secure to raise a concern about unsafe clinical care.
Would you also like to comment on why only CQC staff surveys for 2018 and 2019 are published on this CQC webpage:
Were there no CQC staff surveys in 2020 and 2021, or is it that the survey was done in those years but the results were not published?
If CQC did carry out staff surveys in 2020 and 2021, will it now publish the results on this webpage?
Thank you.
Yours sincerely,
Minh
Dr Minh Alexander
Cc Ian Dilks CQC Chair, CQC press office”
Of concern, the CQC has been allowed to control an investigation into its own behaviour in Shyam Kumar’s case and a “selected” number of other cases of NHS trust whistleblowers.
There is no transparency about how the NHS trust cases have been selected – which gives rise to a concern that the selection is in CQC’s favour.
Of immense concern, the investigation terms of reference did NOT include any examination of CQC’s general whistleblowing governance. This is incomprehensible given:
CQC’s recurrent history of victimising its own whistleblowers
CQC’s appalling behaviour in Mr Kumar’s case
Surely when something so serious has happened, such as a regulatory cover up, it should be automatic to review the whole system which gave rise to it?
The exclusion of any examination of CQC’s general whistleblowing governance from the investigation is a slap in the face for CQC staff. Indeed, it is intimidatory, and possibly intended to be so.
But it is not so surprising given that CQC seems not to have accounted for its workforce relations in recent years.
Also, CQC recently unlawfully evaded an FOI request about its whistleblowing governance and failed to disclose internal reports by its own Freedom To Speak Up Guardian:
What is going on at CQC that requires such obfuscation?
No matter how much CQC tries to spin and manipulate its investigation to its advantage, a strong stink is still present.
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.
Ian Trenholm CQC CEO was previously CEO of NHS Blood and Transplant 2014-2018. There have been several recent media revelations of bullying and Race discrimination at NHS Blood and Transplant, some of which reportedly took place when Trenholm was CEO.
Dr Minh Alexander retired consultant psychiatrist 12 November 2022
The UK is not good to its public servants.
ONS has just compiled basic data on armed forces veterans for the first time. It was astonishing that there were previously no such no official figures.
Frontline NHS staff injured by COVID19 whilst trying to keep services afloat despite government mismanagement of the pandemic, have been treated with disdain by the government..
NHS Resolution holds some of the central data on NHS staff long COVID cases, but says the data is not specifically coded to allow a computer search and analysis. See:
I asked the Department of Health and Social Care if it knew of any central data, and whether it held central data on long COVID-affected NHS staff.
The answer was ‘No’ and ‘No’.
Asked whether it intended to collate this data in future, the answer was also ‘No’.
The DHSC suggested I try ONS, but ONS only holds long COVID data by occupational group, and not by employer.
In the midst of an epic NHS workforce shortage, the DHSC knows of no central data about staff who have left the NHS due to long COVID:
“The numbers of NHS staff to date who have left their employment due to long covid
DHSC does not hold this information. Standard publications of information by NHS Digital does not record this level of detail and we are not aware of any specific NHS collections known to DHSC.”
The government’s treatment of key workers on the COVID frontlines is beyond words.
Will the unions campaign hard enough to ensure that COVID injured NHS staff are better treated and NHS staff are better protected from transmissible diseases?
It is not only a matter of justice but of public health. Unprotected workers are part of the engine of transmission and infection.
I have sent the DHSC’s FOI response to the COVID public inquiry.
By Dr Minh Alexander retired consultant psychiatrist 8 November 2022
The Care Quality Commission has a long history of politicisation, arbitrary regulatory behaviour and poor conduct towards whistleblowers, both its own and those from regulated bodies.
These extraordinarily omitted to explore CQC’s general handling of internal whistleblowing matters.
The ToR only focussed on a single internal CQC whistleblowing case and and examination of CQC’s conduct towards whistleblowers from regulated bodies:
“In relation to
(1) the protected disclosures made to the CQC by Mr Kumar; and
(2) a sample of whistleblowing concerns received by the CQC related to NHS Trusts, the size and date range of which is to be agreed:
The Review will:
(3) consider how CQC used these disclosures in its regulation of the relevant NHS Trusts and whether appropriate action was taken, taking account of all relevant factors including whether ethnicity played any part in the management of those disclosures; and
(4) make recommendations for improvement.
(5) Should the reviewer consider, during the course of the review, that these Terms of Reference require amendment, they will make a written proposal to that effect to the CQC Board for their consideration.”
This represents a defiant lack of apology to CQC’s workforce about its poor behaviour and it fails to ensure psychological safety for any current or future CQC whistleblowers.
It is possible of course that the above omission contains an implied threat to CQC’s workforce, and is a message that silence is preferred.
On 7 September 2022 Martin Morton social care whistleblower and former Social Services manager asked the CQC about its whistleblowing governance, via the What Do They Know website.
Included in his FOI request was a request for disclosure of the CQC’s own Freedom To Speak Up Guardian’s reports.
It was poor that CQC had not already published these reports. NHS trusts routinely publish these types of reports by their Freedom To Speak Up Guardians. That is to say, instead of being an exemplar as a regulator should, CQC is a governance laggard.
The CQC acknowledged the Morton FOI request and initially indicated that it would provide a response by 5 October 2022, the statutory deadline.
But CQC then changed course and stated to Martin Morton, on 6 October 2022, that it had encountered unspecified difficulties:
“Unfortunately, we are not currently able to respond to your request due to an unforeseen delay in processing your request.”
This was not a lawful response.
By 4 November 2022, as he had still not heard, Martin Morton prompted the CQC with the admonition that he would refer the matter to the ICO if necessary.
Faced with this, on 7 November 2022, the power-abusing CQC finally responded. This is the CQC’s response:
The response shows that in the course of five years, only 131 speaking up cases were raised with CQC’s own Freedom To Speak Up Guardian.
This is a small number of Speaking Up cases for a large organisation (over three thousand FTE workers), if compared to the reporting rate at NHS trusts.
Moreover in 2021/22, there was a sharp fall in CQC’s speaking up cases.
Is this because CQC’s victimisation of yet another of its own whistleblowers became public?
The CQC denies that any of the 131 speaking up cases featured detriment.
Most remarkably, in its FOI response of 7 November 2022, CQC continued to evade the request for copies of reports by its own, internal Freedom To Speak Up Guardian.
Instead of disclosing its own Freedom To Speak Up Guardian’s reports, CQC bizarrely pointed Martin Morton to published reports by the National Guardian.
What could CQC be hiding?
What content in the internal Freedom To Speak Up Guardian reports is CQC so reluctant to disclose?
This shabby organisational behaviour, whilst a review into CQC’s whistleblowing governance is underway, is hardly reassuring evidence of genuine remorse and learning.
Martin Morton continues to pursue the disclosure of the CQC Freedom To Speak Up Guardian reports.
In other news, CQC has tried to apply a patently invalid FOIA exemption to an FOI request by another whistleblower, but it retreated when challenged.
More coming soon about that misdemeanour.
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.
Summary: North East Ambulance Service (NEAS) has like other ambulance services been under chronic, major pressure. Like other ambulance trusts, it has poor workforce metrics. Like other ambulance trusts, it has had staff suicides. Of concern, NEAS tried to obfuscate about these suicides when asked about them via FOI. There are other questions about NEAS’ reliability in reporting. NEAS appears to have under-reported bullying in another FOI response, and there are questions about the fact that it appears to be an extreme outlier in reporting a lower number of serious incidents than other ambulance trusts. Moreover, NHS England is in control of the investigation into NEAS’s deaths scandal, but the terms of reference for the investigation reportedly ignore possible manipulation of coronial reporting processes. They have been described by a “source close to the investigation” as a “white wash”. A properly independent judge led inquiry is needed given the serious questions of probity and alleged criminal breaches of coronial law.
Background
North East Ambulance Service NHS Foundation Trust (NEAS) is, like other ambulance trusts, a highly stressed and neglected organisation.
NEAS is currently under the microscope after whistleblowers disclosed that it had been altering staff statements for coroners’ inquests and failing to report deaths to the coroner.
NHS England has been criticised for not acting upon the NEAS whistleblowers’ disclosures, yet NHSE has been left in charge of an investigation into these matters.
That serious conflict of interest was of itself appalling, but it has since emerged through a Health Service Journal report 0f 13 October 2022 that the terms of reference for NHS England’s investigation omit a vital area, and represent an attempt by NHS England to “whitewash” the matter.
“Mr Calvert said the AuditOne review was made aware of “numerous cases” and “not just the five” being examined by the new inquiry. Another source close to the investigation, who asked to remain anonymous, echoed the concerns about the limited number of cases being examined, and added: “What’s missing is an analysis of attempts to conceal facts from coroners, there’s nothing in the terms of reference about this.
The families want a full independent inquiry, this is going to be a whitewash.” [My emphasis]
Moreover, the person whom NHS England appointed to lead its investigation is an NHS insider, Marianne Griffiths former CEO of University Hospitals Sussex NHS Foundation Trust.
When a contentious whistleblowing matter arose at her trust, she and her board were improperly protected by the then National Guardian, Henrietta Hughes:
There is a serious question over whether this obfuscation of organisational failings and poor culture at Sussex contributed to later failures of whistleblowing governance, which affected maternity safety:
Information about staff suicides at NEAS from several sources led to the submission of an FOI request to NEAS about this.
NEAS responded on 12 October 2022, and initially tried to evade disclosure of this information. NEAS answered as follows:
“How many NEAS trust staff have died by suicide or suspected suicide since 1 April 2016?
The Trust would confirm that it is the coroner who decides whether a death was suicide.”
(NEAS FOI disclosure ref. 22.271)
NEAS was challenged about the fact that its FOI response had not met the legal obligations under FOIA to:
Confirm whether or not it held the requested information
Indicate which legal exemption it relied on if it held the information, but did not want to disclose it.
On 18 October 2022 NEAS responded again, disclosing that there had been three staff suicides or suspected staff suicides since 2020:
NEAS denied that it held data before 2020.
In addition to the tragedy of ambulance trust staff’s working conditions, a very serious issue arising from this FOI matter is that NEAS initially attempted to evade the question about staff suicides.
This surely shows continuing organisational failure and secrecy?
For context this is an FOI disclosed by NEAS in 2018 about staff sickness related to mental health issues:
It has been reported that NEAS in fact established a mental health advisor post as part of Occupational Health services, following staff suicides. NEAS have been asked to confirm if this is correct, and to provide details about these issues.
Has NEAS issued a false FOI disclosure about levels of bullying?
In another area, NEAS’ reporting is also in doubt.
I have seen an FOI response by NEAS of 28 September 2022 which reports tiny numbers of reports of staff-staff bullying in recent years:
2019 < 5 cases
2020 6 cases
2021 < 5 cases
This is the relevant extract from NEAS’ FOI disclosure:
This data is strange because it does not match up with NHS Staff Survey data.
a) 15.7% of NEAS staff reported being bullied by a manager in the previous twelve months
Scaling this up, based on an NEAS workforce of approximately 2,700 staff gives an estimate of 424 staff who experienced bullying by a manager in the previous twelve months.
b) 19.4% of NEAS staff reported being bullied by a colleague in the previous twelve months:
Scaling this up, based on an NEAS workforce of approximately 2,700 staff gives an estimate of 524 staff who experienced bullying by a colleague in the previous twelve months.
c) 43.5% of NEAS staff reported the last incident of bullying and harassment that they experienced was reported:
Therefore, the total recorded incidents of reported bullying at NEAS that year should have been something like 43.5% of the hundreds staff who experienced bullying, and not the tiny single figures reported in NEAS’ FOI disclosure of 28 September 2022.
Questions arise of whether NEAS made a false statement under FOIA about its recorded incidents of bullying, or whether there is something terribly wrong with NEAS’ systems for recording and tracking the serious workforce issue of bullying.
Both options are disturbing.
NEAS claimed in its annual report of July 2022 that it planned to investigate the numbers of bullying incidents,
“In addition to the activities that have already commenced we have identified actions that will be progressed over the next 12 months, including….. Investigating the data around bullying and harassment in more detail and triangulate with free text comments, Freedom to Speak Up Guardian, grievances and exit interviews to get a more detailed picture.”
Is it really plausible that NEAS was unaware that its FOI release of 28 September was a gross misrepresentation of its levels of reported bullying?
Is NEAS under-reporting serious incidents?
Someone has drawn my attention to a suspiciously low number of serious incidents reported by NEAS.
NEAS has been asked about its apparent outlier status on serious incident reporting.
Public inquiry in light of allegations of criminal breaches
The charade about NEAS’ governance will likely continue, given HSJ’s revelations about the deeply flawed terms of reference for Marianne Griffiths’ investigation of NEAS.
An NHS insider investigation seems a seriously inadequate response to matters which raise Article 2 and alleged criminal breachs of coronial law.
In light of ongoing evidence that NEAS may be obfuscating, given the Article 2 issues and given the extremely serious issues of alleged criminal breaches of coronial law, a fully independent judge led inquiry with statutory powers is needed.
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.
Mark Tattersall Consultant Obstetrician has whistleblown on this practice. He has made past disclosures about patient safety and his evidence on this is held by parliament.
There have been concerns at East Kent maternity services for around a decade, in the context of generally poor trust governance and the CQC placing the trust into special measures in 2014.
The trust came under increased scrutiny as a result of an avoidable death of baby Harry Richford on 9 November 2017. Harry’s mother was a healthy young woman, her pregnancy had been uneventful, and Harry’s death was shocking and unexpected. Harry died due to poor care, which centred around the poor supervision of a locum doctor whom the trust rostered for out of hours duties without checking his competence. The family’s search for the truth and media investigations led to increasing awareness that other families had been affected and that EKHUFT had repeatedly failed to refer cases to the coroner. Systemic failings were confirmed after the commencement of local Healthcare Safety Investigation Branch maternity investigations in 2018. The government ordered the Kirkup investigation as the scale of the failures emerged.
In this post I share documents provided by Harry Richford’s family via @DerekRKENT to explain a key concern – regulatory failure to keep other babies and mothers safe. The documents give an audit trail of failures by EKHUFT to learn, and denial by the Care Quality Commission (CQC) of these systemic risks to the public.
EKHUFT became an embarrassment to the authorities in 2014 when it had to be placed in special measures because of poor governance and unsafe care. Thereafter, CQC reported improvement. Despite evidence of continuing organisational failure and harm, CQC claimed to the Richfords in 2018 there was no breach of EKHUFT’s organisational legal duty under CQC Regulation 12 to provide safe care related to Harry’s death. Two years later, CQC reversed and prosecuted the trust, the first prosecution of its kind.
CQC’s denial that Harry Richford’s death was linked to systemic failings was disproved by the trust’s internal investigation, five expert reports and the coroner’s findings, all of which identified organisational related failings by EKHUFT. CQC denied organisational failure even though EKHUFT failed to refer Harry’s death to the coroner. It was also despite the fact that the trust reported to external authorities that Harry’s death was “expected”, even though EKHUFT had identified that the death was linked to care failings. CQC also claimed it had never seen a highly critical Royal College of Obstetricians and Gynaecologists (RCOG) report on EKHUFT which was carried out before Harry’s death. The RCOG identified many examples of previous poor care, organisational failings and risks, including those which specifically led to Harry’s death. CQC claimed it had not reviewed the report until 2019, despite CQC being aware of a related action plan before that, and despite the fact that the RCOG report was commissioned with the involvement of the CCG and NHS England, who have joint working arrangements with the CQC.
Most recently, it was found that the coroner’s Prevention of Future Deaths report on Harry Richford was not published as it should have been on the chief coroner’s website, and that NHS England’s and EKHUT’s responses to the coroner are missing.
Will the pending Kirkup report reveal the whole truth about the failures at EKHUT and the failures of oversight bodies?
Of relevance to EKHUFT’s future management, since April 2022 the CEO of EKHUFT has been the former CEO at Homerton, under whose tenure the ‘ Unhappy Midwives’ whistleblowing scandal arose. This related to multiple maternal deaths (usually very rare) and poor maternity care. Another Homerton maternity whistleblower, Pam Linton senior midwife, reported concerns to CQC but later discovered via a Subject Access Request that nothing appeared to have been done about her concerns.
Harry’s family in their own words:
Harry Richford’s family tenaciously investigated the factors contributing to Harry’s death and they have set out a summary of their experiences at this website:
For example, through poor staffing and skill mix, poor supervision, lack of drilling for emergencies, lack of quality monitoring, inadequate equipment, inadequate administrative support, poor team processes and dynamics or leadership unconducive to safety culture.
4.138 The review team discussed with NHS England that the National Maternity Assessment Tool recommends the following minimum staffing levels for governance teams:
• Maternity governance lead (who is a midwife registered with the NMC)
• Consultant obstetrician governance lead (Minimum 2 PAs90)
• Maternity safety manager (who is a midwife registered with the NMC or relevant transferable skills).
• Maternity clinical incident leads
• Audit midwife – a lead midwife for audit and effectiveness
Practice development midwife
Clinical educators, to include leading preceptorship programme
Appropriate governance facilitator and administrative support within the maternity department.”
In 2012, the NHS Litigation Authority (now rebranded as NHS Resolution) analysed ten years’ of maternity claims. NHSLA detected patterns in care failings and recommended systems solutions:
“The key risk management themes to emerge from the project are discussed. Namely, the need to: engage with the risk management process at all levels; provide suitable learningand training; ensure appropriate supervision and support; have in place up-to-date protocols and guidance with which staff are familiar; learn lessons from claims.
The report concludes that the most effective way to reduce the financial and human cost of maternity claims is to continue to improve the management of risks associated with maternity care, focusing on preventing incidents involving the management of women in labour, including the interpretation of CTG traces.”
Safe staffing
A critical organisational factor is safe staffing, in both numbers and skill mix.
Under conditions of inadequate staffing in healthcare, staff may make more mistakes and face disciplinary action for what are systems issues. They may report fewer incidents in consequence, fuelling a downwards safety spiral. Hansard recorded such an example at Mid Yorkshire Hospitals in 2016.
Jeremy Hunt former Health Secretary and self-styled ‘champion’ of maternity safety, who made political capital out of appearing to support the patient safety cause, decided not to introduce mandatory NHS safe staffing standards:
We continue to see healthcare scandals, many of which are maternity scandals, across the NHS. As well as harm to the public, there is compensation and litigation cost for the public purse, particularly for maternity cases.
Nationally, some maternity outcomes had previously been on an improvement trajectory. Rates of neonatal deaths, infant deaths and stillbirths fell steadily in previous decades. The rate of safety improvement has slowed under recent Conservative governments. ONS data is available up to 2020 and shows the following trajectory, set against government targets for reduction by 2025:
The final Ockenden report on Shrewsbury and Telford Hospital NHS Trust, published this year, emphasised the importance of safe staffing:
“In the last year since our first report was published we have seen significant pressures in maternity services in the recruitment and retention of midwives and obstetricians.
“It is absolutely clear that there is an urgent need for a robust and funded maternity-wide workforce plan, starting right now, without delay and continuing over multiple years. This has already been highlighted on a number of occasions but is essential to address the present and future requirements for midwives, obstetricians, anaesthetists, neonatal teams and associated staff working in and around maternity services. Without this maternity services cannot provide safe and effective care for women and babies. In addition, this workforce plan must also focus on significantly reducing the attrition of midwives and doctors since increases in workforce numbers are of limited use if those already within the maternity workforce continue to leave. Only with a robustly funded, well-staffed and trained workforce will we be able to ensure delivery of safe, and compassionate, maternity care locally and across England. ”
Current official guidance on calculating required staffing seems elliptical and coy about setting a minimum standard, reflecting the government’s refusal to legislate for minimum staffing. Guidance refers the reader to other guidance, which leaves the ultimate decision with each local provider.
Midwifery staffing red flags
But NICE midwifery guidance from 2015 does recognise that clinical red flags should trigger a review of midwifery staffing:
“A midwifery red flag event is a warning sign that something may be wrong with midwifery staffing. If a midwifery red flag event occurs, the midwife in charge of the service should be notified. The midwife in charge should determine whether midwifery staffing is the cause, and the action that is needed.
• Delayed or cancelled time-critical activity.
• Missed or delayed care (for example, delay of 60 minutes or more in washing and suturing).
• Missed medication during an admission to hospital or midwifery-led unit (for example, diabetes medication).
• Delay of more than 30 minutes in providing pain relief.
• Delay of 30 minutes or more between presentation and triage.
• Full clinical examination not carried out when presenting in labour.
• Delay of 2 hours or more between admission for induction and beginning of process.
• Delayed recognition of and action on abnormal vital signs (for example, sepsis or urine output).
• Any occasion when 1 midwife is not able to provide continuous one-to-one care and support to a woman during established labour.
• Other midwifery red flags may be agreed locally.”
Based on the still steady stream of maternity care scandals, surely we are currently awash with such red flags?
Seriously unsafe midwifery staffing at East Kent Hospitals University NHS Foundation Trust?
In October 2021 the media reported that CQC had found severe staffing shortage in maternity services at East Kent, following unannounced inspections in July 2021.
Was the CQC wilfully blind to organisational failings in maternity care at East Kent?
CQC appeared to ignore internal trust findings and external expert findings of organisational failure
At East Kent Hospital University NHS Foundation Trust, the Care Quality Commission bizarrely refused to acknowledge a link between a serious incident – the death of baby Harry Richford seven days after a catastrophic, avoidable birth injury – and evident systems issues.
This was despite the trust’s internal Root Cause Analysis (RCA) report concluding very clearly that there were multiple systems issues:
“This leads us to conclude that this incident occurred due to system failures.”
The trust RCA acknowledged that there was inadequate vetting of and supervisory support for the locum junior doctor involved in Harry’s death.
The RCA contained a hint that other staff were concerned about having a locum on call, as one midwife rolled her eyes in front of Harry’s mother upon being told which registrar was on call on the fateful night of Harry’s birth.
This raises many questions about organisational factors. It also linked to an earlier RCOG finding that maternity staff had stopped raising safety concerns because Leads did not act upon them.
Whistleblowing governance at East KentHospitals University NHS Foundation Trust
The Royal College of Obstetricians and Gynaecologists (RCOG) was in 2015 commissioned to review governance failures and dysfunctional team relationships in East Kent maternity service.
The College reported that there were issues of poor reporting culture, especially by doctors.
Staff reporting was discouraged by the fact that past concerns were not acted upon.
This speaks loudly of organisational and senior leadership failure.
The Richfords objected to the trust’s internal RCA investigation.
In response, EKHUFT commissioned two expert reports from a neighbouring NHS trust.These reports concluded that there were some failings. Overall, they were not as critical as later expert reports commissioned by the coroner but organisational failure is implied by:
– A concern that the trust may not have adhered to national guidelines on neonatal resuscitation. (This contradicted the trust internal RCA which concluded that resuscitation guidance was followed).
– A suggestion that EKHUFT should put in place a more robust system of training and drilling to ensure that staff were better equipped to deal with neonatal emergencies and resuscitation.
But CQC denied there was organisational failure by EKHUFT in Harry Richford’s case despite the trust’s RCA findings and these local external reports.
CQC appeared to ignore the probity implications of EKHUFT’s flawed reporting to external authorities about Harry’s death
CQC denied there was organisational failure despite the trust’s flawed decision not to refer Harry’s death to a coroner.
The trust justification for this was recorded in the RCA report. An argument was made that no referral was needed because the cause of death was known (and that it was hypoxia). This is a flawed argument. It failed to acknowledge other relevant criteria requiring a referral to the coroner, such as whether a death could be related to a clinical procedure.
The CQC should have seen the trust’s failure to refer Harry’s death to the coroner as a big red flag about organisational competence, probity and safety culture.
Instead, on 17 August 2018 Emma Carroll then a local CQC inspector (now Inspection Manager) wrote to Harry’s family that three management reviews by CQC had concluded that there had only been errors by individual staff, and that the trust itself was not in breach of regulations:
“We have held three management meetings to discuss the information shared by yourself and the trust, including the RCA, both independent reviews, the trust’s action plan and additional information requested from the trust. We have not received confirmation from the senior coroner as to whether they will be progressing with an investigation. However, I have requested CQC are made an interested party which means we will receive the final Coroner’s report.
After an extensive review, we do not believe there has been a breach in regulation. The concerns raised in this incident are centred on an individual’s decision or error. The criminal offences CQC can prosecute against only apply to registered person failures.”
Derek Richford, Harry’s grandfather, challenged this bizarre position.
The exchange of correspondence between Derek Richford and Emma Carroll on 17 August 2018 can be found here.
Instead of shutting down enquiries about organisational failure, the CQC should have been actively pursuing whether EKHUFT had failed to refer other deaths to the coroner, whether there were common themes between deaths and the level of risk posed to the public by EKHUFT’s systems failure.
The coroner later noted with concern the trust’s outrageous claim that Harry’s death was “expected” and its failure to inform the coroner of Harry’s death:
“Concern 17
The child death notification form was incorrectly completed in that Harry’s death was recorded as ‘expected’. No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry’s death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.”
Normally, arrangements for reviewing child deaths are very formal and involve substantial multiagency scrutiny.
On a related theme of reporting to external authorities, the coroner also found that EKHUFT’s report about Harry’s death to a national database was inaccurate:
“Concern 18
The MBRRACE form in respect of Harry Richford was inaccurate in a number of important areas. The form is important to provide robust national data to support the delivery of safe, high quality maternal and new born care as well as identifying errors and faults, if any, where there has been a maternal or infant death so that future deaths can be avoided.”
The CQC should have noted that EKHUFT’s MBRRACE submission was inaccurate and that this too was a warning sign.
The coroner noted another serious warning sign about EKHUFT managers’ accountability and transparency:
“Concern 19
Important independent reports do not appear to have been shared within the East Kent Trust’s staff, for instance the HSIB report into Harry’s death appeared during the inquest to be unknown to a number of the staff.”
Both the medical experts, an obstetrician and a paediatrician, concluded that Harry would have been born alive and in good condition if his care had been appropriate.
At inquest, the trust’s lawyers contended there was no neglect but the coroner rejected this and ruled that a contributory factor in Harry’s death was neglect:
“The cause of death was 1a Hypoxic Ischaemic Brain Encephalopathy. There was a narrative conclusion setting out some seven failures in the care of Harry Richford together with a conclusion that his death was contributed to by neglect.”
Coroners’ findings of neglect
A finding of neglect by a coroner is a very serious matter.
“Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide or procure basic medical attention or shelter or warmth for someone in a dependent position – because of youth, age, illness or incarceration – who cannot provide it for himself. Failure to provide medical attention for a dependent person whose physical condition is such as to show that he obviously needs it may amount to neglect. So it may be if it is the dependent person’s mental condition which obviously calls for medical attention (as it would, for example, if a mental nurse observed that a patient had a propensity to swallow razor blades and failed to report this propensity to a doctor, in a case where the patient had no intention to cause himself injury but did thereafter swallow razor blades with fatal results). In both the cases the crucial consideration will be what the dependent person’s condition whether physical or mental appeared to be”.
Thus, Harry’s case also raised Safeguarding issues, which placed a particularly serious duty on CQC to protect other similarly vulnerable patients.
CQC’s denial of organisational failure was discredited by HSIB’s findings
The exercise was reported in January 2019 and came to similar conclusions as the coroner’s experts.
The Healthcare Safety Investigation Branch (HSIB) also identified abundant evidence of organisational failures and lack of learning by EKHUFT.
Of note, HSIB identified that the trust had not followed its own policy (Engaging the Temporary Workforce, 2014) on checking the competence of locum staff. This policy recognised that the trust had a duty to proactively mitigate risk when locums are assessed as not being competent, for example by restricting practice or increasing supervision.
The trust had also not followed RCOG guidance on consultant attendance for certain procedures if a trainee has not been signed off as competent:
“The RCOG green-top guideline 2011 and Trust guideline 2015, recommends that a consultant obstetrician should attend in person for a trial of instrumental delivery if the trainee has not been assessed and signed off as competent. The Trust guideline also identifies caesarean section at full dilatation as a procedure the consultant should attend inperson if the trainee has not been signed off for independent practice for the procedure. The locum doctor’s competency was unknown.”
“Sharing pre-published HSIB investigation reports and recommendations. To be open and transparent when in receipt of information regarding the safety of services that are registered with CQC and funded by the NHS in England. The information is shared with the CQC in a timely way through the named CQC contact or by a representative delegated by them.”
HSIB began its local maternity investigations in 2018. In February 2020, at the same time as the coroner’s PFD report was issued, HSIB produced a summary report on its local investigations at EKHUFT. In this report, HSIB observed that the same errors kept being made at EKHUFT:
“From December 2018, HSIB engaged frequently with the Trust to present evidence of recurrent patient safety concerns in its maternity services. Despite repeatedly raising these concerns with the Trust, HSIB investigators continued to see the same themes reoccurring and in August 2019, asked the Trust to self-refer themselves to their CCG and the CQC.”
HSIB also wrote to the CQC about the problems at EKHUFT in August 2019.
CQC knew without any doubt by August 2019 that there were organisational failings, linked to ongoing serious harm. By January 2020, a rare maternal death was amongst the EKHUFT incidents investigated by HSIB (page 3 HSIB summary report).
The reported reason for delay was COVID operational pressures.
A question arises of CQC’s competence in identifying organisational failings and system risks, and or alternatively, its willingness to acknowledge them.
Another question is at what level of seniority in CQC was the original flawed conclusion reached about absence of organisational failings?
Harry’s grandfather Derek Richford objected to the CQC’s 17 August 2018 denial of organisational failure. He copied his objection to Ted Baker, then Deputy Chief Inspector of Hospitals.
Importantly, the RCOG report revealed that there had been previous concerns about the supervision of junior doctors, consultant availability and the general management of the labour ward at EKHUFT:
In other words, there were systems issues aplenty.
There were numerous examples of poor care and the RCOG described some clinical practices as “dangerous”, such as the poorly supervised use of Syntocinon.
The RCOG found evidence of poor whistleblowing and reporting practice. Consultants’ poor practice tended not to be challenged, or was omitted from incident action plans. Staff stopped raising concerns because they were not acted upon:
“Safety issues relating to practice were not reported as no action would be taken by the Leads.”
Indeed, the RCOG report was commissioned because of concerns about poor governance and team dysfunction in the EKHUFT maternity service:
In other words, organisational failures and systemic risks, as opposed to CQC’s narrative of isolated errors by individuals.
Specifically, the RCOG found evidence of patient harm related to locum doctors’ omissions, whilst working out of hours:
“The locum registrar did not review the patient overnight despite this woman’s details being on the handover sheet.” (Case 6 page 16)
The RCOG was concerned that safety could be affected by middle grade locum cover at night (page 34 and 35).
This proved to be an accurate concern in the light of the later harm to Harry Richford.
Even EKHUFT’s medical director observed, in terms, in a statement of 17 December 2019 to the coroner that Harry’s death was part of a chain of persistent failure and lack of organisational learning linking back to the RCOG report:
“The analysis of the root cause of Harry Richford’s death led to actions similar to some of those in the RCOG review, CQC reports of 2014-2016 and the HSIB recommendations, indicating a failure to sufficiently embed learning.”
Shockingly, it was reported that the CQC had never, until 2019, reviewed the 2015 RCOG report despite knowing of its existence.
“But what is perhaps even more shocking is that the Care Quality Commission did not see the report for nearly three years after it was written in February 2016. The CQC confirmed although it saw an action plan based on the report, its records indicate it did not see the report itself until January 2019.”
“Review report is clear – the Trust does not have an unsafe maternity service but there isimprovement work to do around how the service is run in some areas.”
(Board papers indicated that in the corporate risk register later that year, maternity risk is rated as “extreme”).
It also stated:
“The MBRRACE-UK report has been published and shows the Trust to have a 10% lower average mortality rate for its comparator group. The RCOG report was received on the 18th February. Actions will need to be incorporated into the improvement plan. The deadline for embedding the new maternity dashboard has slipped and will be in place for the end of March 16.”
The comment about favourable MBRRACE-UK ranking is interesting in the light of the coroner’s finding that EKHUFT made an inaccurate submission to MBRRACE-UK about Harry’s death, and in light of today’s revelations in the Telegraph about possible manipulation of NHS deaths reporting.
Why did CQC claim that EKHUFT maternity services had improved and why did it deny that there were organisational failures?
EKHUFT’s response to the RCOG report is published via an undated entry on the trust’s website. It reads as a post hoc communication, drafted in the fallout from Harry Richford’s case.
EKHUFT’s response cites in its defence the praise that it received from CQC in 2018, at which time the Richfords were struggling to be heard by CQC:
“A further CQC inspection in August 2018 acknowledged that the East Kent maternity service had made great strides to drive learning, improve outcomes and improve innovation through a collaborative and multidisciplinary approach but there were continued concerns in several areas indicating that more improvement work remains to be done.”
“…it is not possible to evidence all actions from that report as having been completed. 23 recommendations were made by the RCOG. When the available evidence was reviewed the LRC concluded there was sufficient evidence that 2 recommendations had been met, that 11 had been partially met. For some of the recommendations where evidence weas [sic] insufficient…”
Why did CQC not identify this evidence of organisational failure sooner?
Was the imperative to create a positive narrative of improvement more important?
If so, from where did the imperative come?
This is how CQC progressively rated EKHUFT’s maternity service, after putting the trust in special measures in 2014
“His visit gave him the opportunity to see for himself the progress that the Trust has made and he was quoted in the post-visit press release as saying:
“I saw first-hand the great strides in improving the quality of care that the Trust is making and the positive effect these changes are having on staff and patients.
“I enjoyed meeting and talking with a wide range of members of staff from across the hospital. It was very clear that everyone is passionate and united in their desire to continue to improve services.”
This brings to mind witness testimony from the Mid Staff Public Inquiry that officials were focused on an imperative of not embarrassing the Minister.
What was CQC and NHS England’s coordination on the critical RCOG report?
A relevant recommendation from Morecambe Bay, which was accepted by the government, was that trusts should be under a duty to disclose external investigations.
“46. In the meantime, Monitor and the Care Quality Commission will continue to use their respective statutory information-gathering powers to require NHS Trusts and Foundation Trusts to notify them of both the commissioning and the conclusions of relevant external investigations.”
Did the CQC actually make any changes to its procedures, following the government’s promises in 2015 that CQC would compel disclosure of external investigations by NHS trusts?
Why did CQC reportedly not ask for a copy of the RCOG report when it first became aware of the report’s existence?
Why did CQC appear to accept the trust’s action plan as a reliable interpretation of the RCOG’s findings and recommendations, instead of insisting on seeing the report itself?
“Maternity services were reported as inadequate within the CQC report given the lack of progress…. The CCGs with NHSE and the trust have commissioned a Royal College review which is underway to support the service to make further improvements.”
“2.2 We commit to working together proactively to share information and intelligence about the quality of care in order to spot potential problems early, and manage risk. To do this we seek to explore ways of sharing data where there is a shared interest or common benefit.”
Did a risk summit of some sort take place about EKHUFT maternity services, as is common practice?
How could CQC plausibly claim that there were no systems issues if its fellow regulator, NHSE, had instigated an RCOG governance review based on CQC’s own inspection findings of systems failures?
Why did CQC change its mind about prosecution under Regulation 12 and why has CQC not applied Regulation 12 more consistently?
What changed between 2018 and 2020? The facts of Harry’s case did not change. And CQC Regulation 12 did not change.
I asked CQC to comment on its various actions and omissions,. I also asked CQC about why it informs bereaved families such as the Richfords that it cannot investigate their concerns, when the discharge of CQC Regulation 12 appears to require investigation by the CQC.
CQC has to date only acknowledged my enquiry and indicated that it would respond.
It does seem very arbitrary as to how the CQC responds to harmed patients and families.
What happens to families who are no less seriously harmed than the Richfords, but who may be less articulate and cannot navigate CQC’s obstacle course?
Reservations about the usefulness of fining public bodies aside, why had CQC not taken a similar approach to other gross and proven NHS care failures?
Has CQC obscured the real levels of unmet need and harm, and how much will Kirkup’s report reveal?
A September 2022 BBC analysis of CQC reports shows that maternity service failings are widespread, with 7% of units rated by CQC as “posing a high risk of avoidable harm”.
Given what we know about CQC’s identification of systems risks, is the real figure higher?
Kirkup’s investigation of maternity services at EKHUFT is due to report on 19 October 2022.
Will he identify all relevant failings, regulatory, corporate and individual?
I was concerned that in a previous investigation, into the death of baby Elizabeth Dixon, Kirkup placed much emphasis on failings and dishonesty by individual practitioners.
His notable comment that there had been “a twenty year cover up” generated many headlines.
But did he do justice to Elizabeth’s parents through a thorough examination of controlling minds and corporate accountability? Should he have undertaken a more searching exploration of the powerful senior management of a favoured NHS trust, Frimley Health NHS Foundation Trust?
Frimley Health NHS Foundation Trust knew about the Dixons’ concerns for years before Kirkup investigated, and had plenty of chances to put the matter right.
Let us hope for better this time round, and that the CQC’s serious failure to help prevent deaths is fairly reflected in Kirkup report. And that the role of other oversight bodies is also fully explored.
The curious non-publication of Harry Richford’s PFD report, and NHS England’s and EKHUFT’s missing responses to the coroner
The public bodies which received a copy of Harry Richford’s PFD – the coroner’s report to Prevent Future Deaths on matters arising from Harry’s inquest – were legally obliged to respond to the coroner’s concerns about mitigating risk of future of deaths.
A troubling discovery in the course of checking organisational responses to the coroner was that I found Harry Richford’s PFD was not published by the chief coroner, as it should have been.
It is not known if the PFD was originally published, and then removed at some point. If anyone clearly recalls seeing it on the website, I would be grateful to know.
A worker at the chief coroner’s office kindly checked and agreed with me that as of 11 October 2022, the Richford PFD was missing from the website, and so the organisational responses were also missing:
“We have a system to allocate reference numbers to reports. I’ve checked the website and Harry Richford (2020-0117) report has not been published but 0116 and 0118 have been. I checked our system and found a response from DHSC, I will upload these shortly on our website.”
The PFD and the government response have since been uploaded here.
The ministerial response noted the trust’s unacceptable and misleading claim that Harry’s death was “expected” and its failure to refer his death to the coroner.
The DHSC should hold progress reports by CQC and NHSE on improvement work at EKHUFT, if this ministerial commitment was honoured:
“I expect to be regularly updated.”
However, neither the chief coroner nor the local coroner have so far been able to locate NHS England’s response or the trust’s response.
At this late stage, this seems an unusual anomaly.
I will post the NHS England and trust responses below when I eventually obtain them. Or if it transpires that NHS England and or the trust failed to respond to the coroner, I will confirm this.
RELATED ITEMS
The above failures are part of a familiar pattern of government failure.
Both the CQC and Jeremy Hunt as Health Secretary failed to act on whistleblowers concerns at Homerton:
Dr Minh Alexander retired consultant psychiatrist 15 October 2022
In 2018 the government commissioned a review of Fit and Proper Persons in the NHS after a number of scandals and also concerns about the Care Quality Commission’s application of CQC Regulation 5 Fit and Proper Persons:
NHS England, despite being one of the targets affected by Kark’s recommendations, was put in control of implementing the recommendations.
Unsurprisingly, NHSE has dragged its feet and been secretive about the work undertaken these past few years, albeit it has attributed some of the delay to lack of government permission. At the last update earlier this week, NHS England advised that the terms of reference for its NEW Kark Steering Group will be finalised at the start of next month.
The GGI states on its website that it employs as a senior consultant, Mason Fitzgerald a director sacked last year by the NHS after a furore about CV inaccuracy.
GGI previously failed to answer a question about this.
Material by the GGI that is in the public domain raises questions about whether the GGI – and indeed possibly Mason Fitzgerald – may be undertaking other work with NHSE and Integrated Care Systems.
I have asked NHS England to review it systems, approach to contracts and its relationship with the GGI.
This is the relevant letter to Ruth May, with the details, and is copied to Amanda Pritchard NHSE CEO, the NHSE director responsible for the Kark report implementation and Tom Kark QC:
BY EMAIL
Ruth May
Chief Nursing Officer
NHS England
15 October 2022
Dear Ruth,
NHSE, the Good Governance Institute’s governance and Mason Fitzgerald, sacked former NHS director
I write to follow up my response to your social media promotion of the GGI’s work on a staff survey conducted by the GGI, for your team:
I am really concerned that senior NHS managers appear either oblivious of, or unconcerned about, the GGI hiring Mason Fitzgerald, an NHS director sacked last year after false CV claims.
The current GGI website profile for Mason Fitzgerald, described as a GGI ‘senior consultant’, omits to mention anything about his sacking. See attached screenshot and link:
As you may recall, Mason Fitzgerald’s false CV claim was missed by ELFT and the CQC, but emerged after he was almost appointed as CEO of NSFT. Had that appointment process been completed, he would have had power over thousands of extremely vulnerable mental health patients:
The GGI appears to be unaccountable regarding its hiring of Mason Fitzgerald. When I wrote to the Institute in April this year about it hiring him, it failed to respond.
According to the GGI’s material, a number of NHS organisations continue to use its services.
In particular, the GGI published a blog by Mason Fitzgerald on 10 October 2022, in which he stated:
“GGI is currently working with ICSs to review their governance arrangements, and, through our networks and events, we are developing thinking on how ICSs should approach their first end of year review.”
The GGI tweeted this blog on 11 October 2022, tagging in NHS England (see screenshot), raising a question of whether NHS England is a partner in this work and has commissioned the GGI to undertake this project:
According to a response to this tweet by the GGI Chief Executive, the GGI is working with 13 Integrated Care Systems:
Does the NHS therefore still employ Mason Fitzgerald, as a senior consultant, through the GGI?
If so, is it appropriate for an individual sacked by the NHS after false CV claims, to be vetting governance by NHS organisations?
I am especially concerned if NHS England promotes the GGI or contracts with the GGI in the light of its hiring of Mason Fitzgerald, because NHS England is supposed to be implementing the Kark recommendations on tracking impaired or unsuitable NHS managers.
If NHS England had implemented the Kark recommendations in a timely and effective way, Mason Fitzgerald’s subsequent role at the GGI would have been flagged up if he undertook any work for the NHS through the GGI.
I ask that:
a. NHS England and its officers stop all promotion of the GGI until the issue of the GGI’s employment of Mason Fitzgerald, and the questions arising from this about the GGI’s governance, are further clarified and addressed,
b. NHS England reviews any existing contracts with the GGI based on the evidence, through the GGI’s hiring of Mason Fitzgerald, that the GGI’s choice and deployment of consultants and its governance are in question. Please also review whether Mason Fitzgerald is currently working for NHS England, any ICS or any other NHS body under NHSE’s control, as a GGI senior consultant.
c. NHS England considers in its Kark implementation the specific issue of whether NHS managers sacked by the NHS may resume employment through the back door as consultants, and that NHSE designs Fit and Proper Person systems that are strong enough to detect such a situation.
d. NHS England considers generally in its Kark implementation how it will ensure that consistent Fit and Proper Persons standards apply to contractors and contracted services, in the same way that it currently makes other quality requirements of contractors, through the way NHSE’s contracts are drafted.
I copy this to Amanda Pritchard, Jacqueline Davies NHSE lead director for the Kark implementation and to Tom.
With best wishes,
Minh
Dr Minh Alexander
Cc Amanda Pritchard NHS England CEO, Jacqueline Davies NHSE Director of Leadership, Lifelong learning and talent , Tom Kark KC
UPDATE 15 MARCH 2023
Unsurprisingly, Ruth May CNO NHS England ignored me entirely. I wrote to her boss Amanda Pritchard CEO NHSE England in December 2022, who also ignored me.
I reminded them both via social media, but they continued in their silence.
I have now filed a formal complaint with NHSE England’s National Head of Complaints, copied to the Secretary of State and House of Commons Health Committee.
The correspondence to Pritchard and the formal complaint can be found here.
In the meantime, the Good Governance has promoted Mason Fitzgerald from “senior consultant” to “Director of Consultancy and Principal Consultant”. How much of this rise has been based on NHS work?
UPDATE 4 JULY 2023
I heard that the Kark implementation work had been held up as part of the NHS Workforce plan delay. However, the NHS Workforce plan has now been published and there is little sign of Kark review implementation in the plan. I have written to Navina Evans, erstwhile consultant psychiatrist former medical director then CEO of East London NHS Foundation Trust and former colleague of Mason Fitzgerald, now NHS England’s Chief Workforce Officer, to seek clarification.
This is on the same day of news that the Insolvency Service has banned the former CFO of Carillion for eleven years, for making inaccurate and misleading financial statements.
In the NHS, it is said that CFOs are generally penalised by the centre for NOT making over optimistic financial statements.
RELATED ITEMS
NHS England and its predecessor bodies have plenty of form on erring senior NHS managers.
A particularly tragic aspect of the pandemic is that key workers, including NHS workers who continued to work to help keep us all safe, died and suffered some of the worst COVID injuries due to their greater exposure.
For a long time into the pandemic, key workers were not supplied with suitable personal protective equipment (PPE).
This was revealed by the Liverpool Echo, so the disclosure most likely related to North West Ambulance Service.
As well as the serious COVID injuries sustained by key workers such as NHS staff, due to the major mishandling of the pandemic, there was also a cost in added workforce shortage and pressure.
Grace Pritchard a member of the public did a great public service last year by making FOI requests to NHS trusts and universities, via the What Do They Know website. She asked about statistics on staff who developed long COVID.
Her requests and the responses to these requests, are collected at this page on the website:
Disturbingly, some NHS trusts failed to respond at all to Grace Pritchard, including powerful organisations such as Imperial Healthcare, Barts and University Hospitals Birmingham.
Some NHS trusts replied, equally disturbingly, that they did not hold the requested data, implying that no one was actively tracking harm suffered by their staff. For example, St Georges, East of England Ambulance, Sheffield Health and Social Care (the home of Tim Kendall, the NHS mental health Tsar).
Table 5 of the September 2022 ONS spreadsheet gives data on the percentage of people in the “health care sector” affected by long COVID as 3.76%. This figure is an estimate based on scaling up a sample.
But this is not the same as specific, precise data on how NHS staff have been affected by long COVID.
I therefore asked NHS Resolution, which handles staff personal injury claims in the NHS, if it held national data on long COVID personal injury claims by NHS personnel.
NHS Resolution advised that it could not answer without a manual search of case files, because it has no specific code for long COVID (which could be used to run a computer analysis).
“We are unable to answer this request, as we do not have an injury code for Long Covid.”
According to NHS Resolution, to answer my question based on a manual search would reportedly exceed the legal cost limits for FOIs:
“We are unable to provide this information without interrogating individual claims files. Although NHS Resolution may hold some information relating to claims such as what you have requested (England only claims), due to the way claims are recorded on our claims database, we will not be able to identify such specific cases. It might be helpful to explain that when claims are notified to NHS Resolution they are categorised against pre-defined cause, injury and speciality codes. Unfortunately, we do not have a code thatwould allow us to readily extract claims where the injury is due to long COVID. Therefore, while there may be information held in our records, we are not readily able to identify the relevant files by searching the database. To do so would involve a manual review of all cases to identify the claims where the injury is due to long COVID. We estimate we would need to spend approximately 10 minutes reviewing each claims file to identify and extract the relevant information. We would need to review hundreds of claims.”
I have accordingly asked NHS Resolution for more details on how cases of long COVID might be coded under its systems, and I have narrowed the original scope of my request for data on long COVID claims to just three NHS trusts.
It is a concern that there is apparently no central record, at least by NHS Resolution, of the number of NHS staff who are taking legal action for COVID injuries.
I have now asked the Department of Health and Social Care whether any public body holds central data on numbers of NHS staff long COVID cases and personal injury claims, and if the Department holds any of this data, for disclosure of the data itself.
UPDATE 12 November 2022
The DHSC has responded. It does not hold data on NHS staff affected by Long COVID. It has no intention of collating this data. I have sent the DHSC’s response to the UK COVID public inquiry:
The report shows that out of all NHS England’s departments, the Healthcare Safety Investigation Branch (HSIB) has the second highest rate of whistleblowing complaints, at 3 cases per 100 staff:
Whatever NHS England has done following the much-publicised bullying and whistleblowing at HSIB in recent years, it does not seem to have reduced the need for staff to whistleblow.
The NHS England department with the highest rate of speaking up is the Commercial directorate, at 3.4 cases per 100 staff. One wonders what the disclosures concern.
The great variability in rates between NHS England departments is striking: from zero to 3.4 cases of speaking up per 100 staff.
The annual report contains the usual Freedom To Speak Up propaganda – that staff feel more able to speak up, that managers are taking it more seriously, etc…
This narrative is unconvincing though, when there is a current whistleblowing Employment Tribunal claim against NHS England.
The Freedom To Speak Up report in fact reveals that the majority of NHS England’s whistleblowers do not want their name revealed to the rest of the organisation:
“7. The number of cases received in 2021/22 (152) almost tripled in comparison to the previous year (56). The proportion of people speaking up anonymously fell from 59% to 35%. However, the proportion of people who wanted their name kept confidential rose 7% from 58% to 65%.”
Given the Machiavellian nature of the organisation, exactly how secure is its internal Freedom To Speak Up system and how confidential can any disclosures be?
We have recently seen a case emerge from the Royal Free NHS Foundation Trust of a Freedom To Speak Up Guardian cooperating with the employer’s detrimental withholding of information from whistleblower Dr Rajai Al-Jehani:
NHS England is the Great Keeper of NHS Secrets and Dirty Deeds by the Department of Health and Social Care. It has helped to suppress whistleblowers in NHS provider organisations, and it often enforces silence by these organisations, to oil the wheels of government. Silencing of its own whistleblowers is to be expected.
Moreover, NHSE’s annual Freedom To Speak Up report urges greater human resources influence over whistleblowing processes at NHSE, when in fact human resources are a weapon deployed against whistleblowers.
“Closer collaborative working between FTSU Guardians and HR BPs in relation to directorate/region wide people-related initiatives eg anti bullying; civility and respect and inclusion.”
This suggestion is contrary to the 2015 Freedom To Speak Up Review report, which was critical of NHS organisations turning whistleblowing into an employment issue.
I would advise NHS England whistleblowers to be extremely circumspect about using internal whistleblowing routes. If a better way is possible, and after taking careful advice, take it.
Lastly, let us not forget that NHS England and its predecessor bodies have provided what has been called a “donkey sanctuary” for disgraced NHS serious managers, who are removed from wreaking damage on the frontline but are allowed to keep fat salaries.
Or that NHS England has dragged its feet for years on implementing the recommendations of the Kark Review, to introduce a system for identifying, tracking and debarring unfit NHS managers.
NHS England has to date refused to do anything about Cubbon, now its Chief Delivery Officer.
And the reported rate of whistleblowing in his team? Zero
Dr Jasna Macanovic’s whistleblowing case
Dr Macanovic’s remedy hearing will be held shortly, but no compensation is enough for the years long ordeal that she suffered, with all the usual personal costs of a traumatic whistleblowing experience.
Both ET judgments issued to date in her Employment Tribunal claim contain valuable detail about the governance failures:
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.
Another recent example of an NHS whistleblower who was unprotected and unfairly dismissed despite the introduction of the ineffective Freedom To Speak Up model is Jane Archibald Senior Nurse. She was specifically failed by the Freedom To Speak Up system at her trust:
By Dr Minh Alexander retired consultant psychiatrist 8 October 2022
Summary: I write to share FOI data from the Care Quality Commission (CQC) which raises questions about CQC’s approach to its Specialist Advisors. According to the FOI response, the CQC excludes Specialist Advisors from its staff survey. A disclosed CQC document states that CQC regularly collates feedback from Specialist Advisors, and this is sent to Directorates for “continuous improvement”. However, the CQC claimed in its FOI response letter to me that it holds no analysed data from this feedback. CQC’s disclosed document shows that it collects data on whether Specialist Advisors decide to withdraw from its inspections. However, CQC claimed to me that it does not hold data on the number of Specialist Advisors who have resigned from their role. What are we to believe? That the CQC has not collated data despite its documented claims that it does? Or that CQC collated data but destroyed it? Or does CQC hold analysed data on Specialist Advisor feedback and resignations, despite its current denial? I have asked Ian Dilks CQC Chair to look into these anomalies.
Background:
The Care Quality Commission (CQC) is currently under pressure because it has been found by an Employment Tribunal to have seriously victimised one of its own whistleblowers, Mr Shyam Kumar, senior surgeon.
CQC Specialist Advisors (SpAs) are a type of inspector. They are clinicians seconded from provider organisations for their specialist expertise in various areas.
Many clinicians are registered as SpAs.
They work on an ad hoc basis and are retained on a bank.
The CQC handbook for Specialist Advisors explains how CQC handles the SpA role:
Employing SpAs on this limited contract may save the CQC money, but it does add to the concerns about the closeness between CQC and regulated organisations.
Some SpAs maintain strict professionalism. A number of such individuals either leave CQC or whistleblow, or both.
Mr Kumar’s case is of serious political significance, because a regulator should be above reproach.
It is clearly intolerable for an organisation which has a duty to enforce standards to behave so badly, and it is particularly reprehensible that an organisation which judges others’ failures of organisational learning has itself refused to learn.
“CQC’s Executive Team has appointed Zoë Leventhal KC of Matrix Chambers to lead an independent review into our handling of protected disclosures shared by Mr Shyam Kumar alongside a sample of other information of concern shared with us by health and care staff.
The aim of the review will be to determine whether we took appropriate action in response to this information. It will include consideration of whether the ethnicity of the people raising concerns impacted on decision making or outcomes.
The full terms of reference for the review will be published shortly. The review is expected to conclude by the end of this year, with Zoë reporting her findings and recommendations publicly to CQC’s Board.
Alongside this barrister-led review we will conduct a wider review, led by our new Director of Integrated Care, Inequalities and Improvement, Scott Durairaj, which will seek input from people using and working in health and social care and from our colleagues.
This will explore whether there are issues of culture, process or both within the organisation which need to be addressed so we are better able to listen and to act on what we hear when information of concern is shared with us. The review will have a focus on inclusivity, including understanding whether race or any other protected characteristic has any impact on how we treat information of concern. Terms of reference will be developed in consultation with internal and external partners and will be published once agreed.”
Mr Kumar is in fact not alone in his experience as a Specialist Advisor of being marginalised. Other doctors have experienced difficulties in the Specialist Advisor role. An important paper by another surgeon who also worked as a CQC Specialist Advisor, Hugh Cannell, gave a useful insight into working for the CQC:
Mr Cannell set out concerns about whether the CQC values its SpAs, or whether CQC employs them to give surface legitimacy, but does not actually listen to what SpAs have to say:
“The CQC, however, is hardly encouraging or valuing the work of SpAs in the way it should. Ad hoc SpAs too often appear to be regarded by the CQC’s core staff as a distraction from the important work of box ticking. Sometimes SpAs are treated as little more than window dressing.”
Importantly, Mr Cannell reported that instances of NHS trust staff whistleblowing were not always reflected in CQC inspection reports.
This chimes perfectly with Mr Kumar’s experience of being discouraged by a CQC manager from following up on NHS trust whistleblowers’ concerns, when he participated in a CQC inspection in 2015:
This CQC response contains extracts of a letter from CQC to Matt Hancock Health Secretary in 2019 about Shyam Kumar’s case. This includes an assertion that SpAs are meant to provide expert input “in a broad sense”:
“SpAs provide expert input on the quality of the service from a clinical perspective in a broad sense across the service, as well as on particularly [sic] specialties within the service. There are many different surgical and medical specialties, and it would not be possible or appropriate to bring SpAs to inspect every one of those specialities in detail on inspections.”
This is at variance to evidence by Mike Zeiderman CQC National Professional Advisor during Mr Kumar’s Employment Tribunal. Mike Zeiderman stated that he agreed with Mr Kumar’s concerns that CQC did not do enough to match Specialist Advisors to the Specialties inspected.
Surely the clue is in the name, “Specialist Advisor”?
As to inclusivity, the CQC has clarified that it does NOT include Specialist Advisors in its regular staff survey:
“Colleagues eligible to participate in our people surveys (also referred to as staff surveys) include permanent staff, fixed term and/or temporary staff, National Professional Advisors and Clinical Fellows. Contractors, bank staff, or SPAs are not eligible to participate.” [My emphasis]
This seems a questionable approach.
I asked CQC to disclose a copy of the feedback form that SpAs fill in after CQC inspections, and for analyses carried out by the CQC of the data gathered.
This is a copy of the online SpA feedback questionnaire:
This questionnaire asks important questions about how CQC inspections are conducted and whether CQC staff demonstrate CQC’s values of Excellence, Caring, Integrity and Teamwork during inspections:
The SpA feedback form implies that somebody in CQC actually reads these feedback forms, because it states:
“If concerns are raised by you the Flexible Workforce Team will contact you to discuss these”.
Even though CQC asks SpAs for this feedback, and it claims that it will respond, when Mr Kumar whistleblew in 2015 to CQC’s Chief Inspector of Hospitals about bullying and suppression during an inspection, he was repeatedly stonewalled by CQC.
Astonishingly, the CQC has claimed that it holds no analysed data from the SpA feedback questionnaires:
“We do not hold any analysis of this data.”
Has CQC never analysed this data?
Is public money spent gathering the data that is not then used?
It is hard to believe that CQC has never analysed the data.
Judging from the SpA feedback questionnaire form disclosed by the CQC, the questionnaire appears to be filled online.
How is it possible that large bank of highly accessible digital data has never been analysed by the CQC?
Or is that CQC has analysed this data, but decided that it was better to keep any analyses under wraps?
Within the SpA questionnaire form disclosed by the CQC, it actually says that the SpA feedback data is “collated and shared with the Directorate on a monthly basis”:
The options are:
– CQC did not collate data as promised
– CQC collated but shredded the analysed data
– CQC does hold the analysed data, despite its denial
Moreover, where is the employer’s duty of care to CQC’s Specialist Advisors?
CQC should transparently share analysed data with its workforce and provide proof that it is acting on concerns and difficulties.
I asked the CQC how many SpAs have resigned from CQC since 2018.
The regulator replied:
“We do not hold this information centrally and so a manual review of each personal record would be required to ascertain why they exited CQC. Therefore, we are unable to provide you with the requested information as we believe the cost of doing so would exceed the cost limit as defined by s12 of the FOIA.”
This is curious as during Mr Kumar’s Employment Tribunal it became clear that CQC has some form of database on SpAs.
How does CQC manage staffing demand if it holds no central data on leavers and resignations?
The SpA feedback questionnaire in fact includes the questions:
“Would you like to be involved in future inspections? [YES/NO]”
“Please explain why you would not like to be involved in future inspections? [FREE TEXT]
So again, a question arises of whether or not CQC has answered truthfully when it claims that it cannot say how many SpAs have resigned, and that it could only carry out a manual search which would breach FOI cost exemptions.
I have questioned, via Ian Dilks CQC Chair, CQC’s denial that it holds any analysed data on SpA feedback or data on the number of SpAs who have resigned.
LETTER TO IAN DILKS:
BY EMAIL
Ian Dilks, CQC Chair
7 October 2022
Dear Mr Dilks,
Analysis of CQC Specialist Advisor feedback and the number of Specialist Advisors who decide not to take part in further CQC inspections
Thank you for ensuring that there was no excessive further delay in the CQC answering my FOI request for information on CQC’s governance with respect to Specialist Advisors.
I received CQC’s response today – please see the attached.
I originally asked the CQC:
“4) Please disclose any analysis since 1 January 2018 of the routine feedback questionnaires completed by CQC Specialist Advisors after inspections Please disclose a copy of the questionnaire itself”
In its response, the CQC has claimed that it holds no analysed data from the Specialist Advisor feedback questionnaires:
“We do not hold any analysis of this data.”
I have to question whether this CQC claim is a factual inaccuracy.
This is because the feedback questionnaire is an online form and CQC should therefore hold a large amount of accessible digital data, no doubt with analysis in mind.
I also question CQC’s claim that it does not hold analysed data on Specialist Advisors’ feedback questionnaire because the form itself states the questionnaire data is: “collated and shared with the Directorate on a monthly basis”:
In light of this evidence that CQC does collate Specialist Advisors’ feedback data centrally and disseminate it to Directorates, please could CQC provide me with all the collated data reports that it has sent to Directorates on Specialist Advisor questionnaire feedback since 1 January 2018.
Also, I asked CQC:
5) How many Specialist Advisors have resigned from the CQC since 1 January 2018?”
CQC responded:
“We do not hold this information centrally and so a manual review of each personal record would be required to ascertain why they exited CQC. Therefore, we are unable to provide you with the requested information as we believe the cost of doing so would exceed the cost limit as defined by s12 of the FOIA.”
I struggle to see how this can be correct, because the CQC’s online Specialist Advisor feedback questionnaire gathers information about how many Specialist Advisors decide not to take part in future inspections. It asks the question:
“Would you like to be involved in future inspections? [YES/NO]”
To be more precise, can the CQC say on how many occasions have Specialist Advisors ticked the ‘NO’ box since 1 January 2018?
Many thanks,
Minh
Dr Minh Alexander
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.
Ted Baker former CQC Chief Inspector of Hospitals failed to protect Mr Kumar as a whistleblower. When Mr Kumar sought help from him regarding his experience of reprisal, Ted Baker maintained the CQC line that Mr Kumar had been sacked for inappropriate behaviour, a position that was later comprehensively rejected by the Employment Tribunal.
Ted Baker retired from the CQC but has recently been appointed Chair of the Healthcare Safety Investigation Branch, a position which one presumes requires sharp analysis and sound judgment.
The CQC’s dreadful history of handling whistleblowing within both its own organisation and provider bodies speaks for itself.
Alexander's Excavations 