TITLES, BRIEF SUMMARIES AND LINKS TO ARTICLES & CORRESPONDENCE ARE PROVIDED. THE LIST STARTS WITH THE MOST RECENT ITEMS.
‘Acceptable Hazard’? Lack of sprinklers and deliberately caused fires in mental health trusts
Estate Return Information Collection (ERIC) data published by NHS Digital shows a higher incidence of fires in mental health trusts. FOIs to mental health trusts show that a large proportion of these fires are caused deliberately, caused by patients and occur in inpatient areas. Despite this, these is almost no sprinkler coverage in mental health trusts, despite deaths and injuries. Neither NHS Improvement nor the Department of Health and Social Care were able to show that they were actively managing these risks and had good governance in place. of concern, current Government fire safety guidance for the NHS repeatedly states that where sprinklers are used, other fire safety measures may be cut back. A spreadsheet is shared, which summarises the FOI data obtained from mental health trusts and three acute trusts which also reported a high number of fires.
St. Andrews Healthcare, Whistleblowing, Safeguarding and Public Protection
Published 16 February 2018
A whistleblowing claim against St. Andrews Healthcare will be heard in private on 23 February 2018. Annual accounts show that St. Andrews’ annual income now exceeds £200m. Its services are mostly funded by the NHS. NHS England’s published spending transparency data, on purchases over £25K, shows that NHS England directly purchases almost £300m of services from St. Andrews between January 2014 and July 2017. Some background data on whistleblowing, Safeguarding and public protection matters relating to St. Andrews is presented.
Letter to David Behan CEO CQC, requesting review of previously rejected regulation 5 Fit and Proper Persons referrals
Published 12 February 2018
The CQC has royally botched FPPR in the service of its political masters. Implementing FPPR properly would risk rocking the boat as disgruntled NHS directors, who know where the political bodies are buried, and who have previously maintained omerta about Whitehall’s sharp practices, may obviously become a threat to power. However, the scandal of recycled poor NHS managers is hard to hide as the patterns keep recurring. Pressure on CQC has increased with the publication of Bill Kirkup’s review on events at Liverpool Community Health NHS Trust and his recommendation of another review of CQC’s implementation of FPPR. I have written to Behan to formally request review of all the FPPR referrals which CQC previously rejected out of hand. Examples are given of major service and governance failures that have occurred following CQC’s various refusals to act upon FPPR referrals.
What’s up at Wirral? NHS Improvement’s investigation of executive whistleblowing at Wirral University Teaching Hospitals NHS Foundation Trust
Published 10 February 2018
NHS Improvement has commissioned an investigation into mishandled whistleblowing disclosures by directors at Wirral University Hospital NHS Foundation Trust. The track record of regulators on such matters is described. The government’s response to the publication of Bill Kirkup’s review on Liverpool Community Health NHS Trust on 8 February 2018 is discussed. FOI data is provided on past NHS commissions undertaken by NHS Improvement’s chosen investigator for Wirral.
After the Bawa-Garba judgment. Some responses from the Court of Appeal, CPS, Criminal Cases Review Commission and GMC.
Published 8 February 2018
Institutional responses to enquiries have raised questions about gaps in the criminal justice system’s governance of Diversity and the handling of Gross Negligence Manslaughter, and about the GMC’s handling of offending by registrants. No Equalities analysis has been undertaken on the work of the Court of Appeal. The Criminal Case Review Commission stats suggest that BME applicants are over-represented. The outcomes by Race are not yet available. Neither the Crown Prosecution Service nor its specialist unit for Gross Negligence Manslaughter cases, the Special Crimes and Counter Terrorism Division, have kept central records of Gross Negligence Manslaughter cases against doctors. The GMC has implied that it is not tracking offending by registrants, through claims that it is unable to produce data on the number of registrants who have been convicted of offences in the last four years, or a ready breakdown of the types of offences in question.
Of Arbitrariness and Arbiters: The Freedom To Speak Up Project three years on
Published 7 February 2018
The National Guardian’s Office has been inconsistent in its approach to individual whistleblowers seeking help and protection. There is lack of clarity about which cases will be reviewed, with conflicting decisions and policies. A previous complaint about the NGO’s refusal to step in and review a case, which was followed by the whistleblower being sacked, was not upheld by NHS Improvement or Robert Francis. However, Francis and NHS Improvement recommended that the National Guardian should set out more clearly what sort of recommendations may be made following case review. Further events have raised continuing issues of fairness. There also appears to be no evidence that the National Guardian has acted on the recommendation to clarify the range of actions that may be made following case review. A further complaint has been made about the inconsistency, and Robert Francis has been asked to clarify his position on his original recommendation in the report of the Freedom To Speak Up Review that the NGO should facilitate redress for harmed whistleblowers.
The National Freedom To Speak Up Guardian’s Social Medial Policy
Published 31 January 2018
This most interesting document was disclosed after an enquiry and how reveals that the National Guardian and her team intend to with ‘negative’ comments on twitter, which includes muting, blocking and reporting those who fall into disfavour. The document shows little sign of reflection that criticism might be justified, and betrays complacency and a lack of fitness to perform its central function of facilitating healthy dissent. But that was never what the Department of Health and Social Care really wanted the Office to do.
Safe in their hands? Government’s response to coroner’s warnings about the NHS
Published 29 January 2018
This is a full update report to an analysis of August of four years data published by the Chief Coroner on reports on action to prevent future deaths. The update focuses on the NHS and the actions of central bodies from the Department of Health and Social Care downwards. There are troubling anomalies about missing PFDs and responses to PFDs from the Chief Coroner’s website, variance between what the Chief Coroner and some coroners say, and a lack of systematic response by the NHS to the intelligence from coroners. The DHSC was especially resistant. The DHSC, NHS England, CQC and NHS Improvement all refused to disclose their responses to key coroners’ warnings. All the supporting correspondence with these bodies and disclosed documents are uploaded and linked in the report.
UK Whistleblowing Law is an Ass: Helen Rochester and the Complicit CQC
Published 25 January 2018
This is an update on the case of Helen Rochester, doughty former nurse and care home whistleblower, who has embarrassed the gruesome CQC but also been twice shafted by the same. Rochester has added another example to the pile of UK whistleblowing law (PIDA) failures. The judgment is provided and discussed. The case for law reform continues to build. The CQC continues to sink further into its own stink and mess, and has not demonstrated one jot of learning.
BMA Says No to Whistleblowers
Published 23 January 2018
The British Medical Association fails many whistleblowers and often claims their cases aren’t worth backing. It has been secretive and reluctant to account for how it spends members’ fees. Over a period of years, it has reluctantly yielded small amounts of information, but cumulatively, the implied picture is one of an improbably low level of legal merits assessments passes. For good measure, the wealthy BMA likes to wine and dine its old boys and the great and the good in style, but refuses even to allow sacked whistleblowers near cost-neutral access to online medical journals. Glaswegians have bracing expression: “I wud nae gie ye the steam of my sh**”.
The Assimilation of Whistleblowers
Published 20 January 2018
Power seeks to contain and control dissent, and has an endless repertoire of dirty tricks, such as divide and rule, fielding controlled opposition and infiltrating and disrupting. Whistleblower campaigners are amongst the recipients. I tell the tale here of a Scottish whistleblower who was expelled from the whistleblowing organisation Patients First because he covertly recorded a Minister. Patients First took the position that only “leadership of PF in consultation with legal advisers” could take a decision to secretly record a politician, and that “It would never be the prerogative of a maverick individual to make such a decision”. Most importantly, Patients First demanded not only that the whistleblower should apologise to the Minister, but that he should destroy the audio recording despite his concerns that it was evidence of illegal actions by the Minister. Patients First insisted on the destruction of the recording despite admitting in writing that they did not actually know whether the recording was evidence of illegal activity. A whole contingent of Scottish whistleblowers broke away from Patients First as a result of this incident, and established a new campaign group, ASAP Scotland http://asapnhs.uk/
A critical consultation by the Scottish government starts on 30 January 2018 on whistleblowing policy and infrastructure. A prominent Patients First member from the English NHS has been recruited without to my knowledge sign of advertisement. What happens next will affect the future of Scottish patients and NHS staff for years.
The Flexible CQC, FPPR and Kettering General Hospital NHS Foundation Trust
Published 16 January 2018
An FOI to Kettering General Hospital NHS Foundation has revealed that CQC issued the trust with a warning notice which included concerns about the trust’s handling of Fit and Proper Person issue under Regulation 5. However, CQC failed to disclose this in the relevant inspection report, despite the context that this was a trust with a significant whistleblowing issue at the time. The whistleblowing matter, about an alleged waiting list fiddle, was exposed by the BBC a month after CQC published the report which failed to reveal the FPPR problems. Within two months of the BBC coverage, the trust CEO and Chair had resigned. These events add to existing concerns about CQC’s role in protecting senior NHS managers and covering up failings.
More loopholes in Jeremy Hunt’s ‘support’ scheme for whistleblowers
Published 21 December 2017
The NHS whistleblower employment scheme, run by NHS England and NHS Improvement has been sneakily re-named the ‘whistleblower support scheme’ and no provision has been made for super-gagged whistleblowers, who remain in the cold. Little due diligence seems to have been exercised in appointing panellists who will sit in judgment of whistleblowers. A list which I have seen but am not at liberty to disclose shows that just under half are Freedom to To Speak Up Guardians. Some panellists are managers from trusts that have admitted to super-gagging whistleblowers, or as evidenced by external review are from trusts that have harmed whistleblowers or covered up wrongdoing.
CQC’s asleep on the night shift
Published 16 December 2017
The dilatory CQC doesn’t like to discommode itself and shift from its soft armchair by the fireside. Disclosed FOI data obtained by care home whistleblower shows that nationally, over a three year period, only 1.5% of CQC inspections take place out of hours. Rochester reported insitutional abuses to the CQC, such as dragging vulnerable care home residents out of bed in the wee hours to suit the home’s purposes, but CQC did not inspect at an early enough hour to detect this and gave the home a good report. CQC has resisted calls from the Royal College of Nursing to inspect more at night, and resisted coroners’ calls for action on unsafe staffing at night. What a faithful watchdog. It does the DH proud.
Two years of national CQC whistleblowing data on health and social care services
Published 14 December 2017
CQC has reluctantly handed over national data on all whistleblowing by staff of service providers from all sectors for the years 2015/16 and 2016/17. It shows marked variations between providers, with some usual suspects but also some CQC pets attracting very high levels of whistleblowing by their own staff. Of a total of 16,457 whistleblowing contacts in 2015/16 and 2016/17, there were 9,760 outcomes which basically consisted of shoving whistleblowers’ disclosures in a drawer (no further action or information noted only for future inspection). CQC’s full spreadsheet of all the whistleblowing contacts is provided. Read it and weep.
WRES, CQC and more NHS hot air on Race
Published 28 November 2017
This is an update report on NHS England’s handling of NHS workforce Race issues and CQC’s role in ineffectual enforcement of the WRES programme. CQC revealed via an FOI disclosure that its inspection methodology omits to record the ethnicity of provider staff who are consulted during inspections. NHS England has not yet responded to an enquiry about whether its WRES team have vetted CQC inspection methodology. And to cap it all, it has been revealed that although CQC misleadingly reported in 2015 that an FPPR investigation into Race issues at Southport and Ormskirk Hospital NHS Trust was ‘thorough’, the FPPR investigators never actually spoke to BME whistleblowers who raised concerns. Relevant correspondence with NHS England is provided.
The long shadows cast by whistleblowing
Published 23 November 2017
This explains the gravity of the violence done to whistleblowers. It gives the current example of a whistleblower who has been failed by all, including the Secretary of State, who is now in end stage renal failure due to high blood pressure and will need a kidney transplant. The parliamentary health committee has failed in its duty to date to provide serious challenge to government failures on whistleblowing governance, refuses to hold a follow up hearing and has not even made efforts to find out if whistleblowers have received the ‘apology and practical redress’ that the committee recommended in January 2015. They haven’t.
Sir Robert Francis and Reform of Whistleblowing Law
Published 17 November 2017
Robert Francis seriously failed whistleblowers and the public interest in 2015 when he had the chance to recommend substantive reform of UK whistleblowing law, which he acknowledged was “weak”, but shrank from a confrontation with the Department of Health. Instead, he made a timid recommendation for an inconsequential adjustment, which the DH accepted and used for public relations. Francis made comments at a financial sector conference on 7 November 2017 – which were recorded – which clearly show that he is fully cognisant of the legislation’s flaws. He went as far as saying that it needed “looking at”, but when an NHS whistleblower in the audience asked if he thought reform of the law was needed, Francis seemed a little discombobulated and eventually replied that a review of how the NHS applies the law was needed. I have written to Francis to ask if he will act upon his serious criticisms of the law itself. In addition to the issues about the inadequacy of UK whistleblowing law, Francis revealed at the conference that he had expected the NHS to operate a whistleblower re-employment scheme, and was not best pleased with the tepid employment support scheme with which NHS England and NHS Improvement have been trying to fob whistleblowers off. The recordings of his comments at the conference, a transcript and the correspondence are provided.
Carry on smiling: National Guardian turns Helen Rochester away
Published 24 October 2017
The National Guardian is establishing a tokenistic advisory group as an afterthought, despite promising that this would be done at an early enough stage to influence the crucial determination of her case review process. She has refused an application from Helen Rochester a whistleblower who has been twice seriously harmed by her employer the CQC. The National Guardian’s proposed terms and conditions for her advisory group also have an unfortunate whiff of control and secrecy. Details are provided.
Who speaks for the dead? Ivy Atkin and the unaccountable CQC
Published 22 October 2017
The CQC has been attempting to evade proper accountability for its disastrous regulatory oversight – or lack of it – of Autumn Grange care home, which culminated in the horrific death of Ivy Atkin at 3St 13lb. CQC’s chief executive David Behan promised to publish a very belated internal review on the matter, but CQC later reneged on this. When I complained about CQC’s behaviour, the CQC simply deemed my complaint invalid. Yet despite claiming that my complaint had no legitimacy, the CQC suggested that it could be escalated to the PHSO. I have written to Peter Wyman CQC chair to rebut CQC’s claim that my complaint is invalid. The relevant correspondence and references are provided.
Waste Industry: The NHS Disciplinary Process & Dr John Bestley
Published 21 October 2017
This is an update paper about disciplinary action, suspensions and dismissals by the NHS. It illustrates typical NHS bad practice through the case of Dr John Bestley who was unfairly dismissed by Humber NHS Foundation Trust, which was criticised for suspending him long after there was any reason to do so, thereby causing serious damage to his health. Dr Bestley received compensation through both the Employment Tribunal process and via a subsequent claim for personal injury against the trust. There was a failure by the NHS, including by professional and system regulators, to learn lessons from the affair. Ongoing suspension statistics show that there has been little learning since the National Audit Office report of 2003 which showed very poor management of suspensions by the NHS. Central government and its arms lengths bodies need to take much more responsibility for ensuring good practice, and to stop relying on oppressive human resources practices for political ends.
Jeremy Hunt’s Secret Whistleblower (Non-Employment) Scheme
Published 14 October 2017
This is an update and digest of the shabby sham perpetrated by the Department of Health and its organs against sacked whistleblowers who are supposed to be helped back into employment. There has been refusal by NHS Improvement to share relevant records, and Liverpool John Moores University which has been contracted to evaluate NHS England’s pilot scheme has refused to answer questions about methodology despite NHS England promising that whistleblowers would have a say. Both NHS England and NHS Improvement have recently changed the names of their programmes from ‘Whistleblower Employment Support Scheme’ to just ‘Whistleblower Support Scheme’. Exile continues.
Will Simon Stevens uncork ALL the Race data?
The implementation of NHS England’s Race Equality programme, WRES, has been a disappointment to many. It still does not measure important parameters such as Race pay inequality and Race Employment Tribunal claims against the NHS. Challenges to the administration of the WRES programme have sometimes been ignored, resisted or deflected. It has now emerged that there is a raft of Race data gathered and held on behalf of NHS England, via the national staff survey, that has not been analysed and or reported. Uber tokenism or what? Simon Stevens has been asked to unlock the vaults.
Postscripts on Paula: NHS England’s apologia & regulatory reticence
Former ‘inspirational’ NHS trust chief executive Paula Vasco-Knight became notorious in relation to a nepotism and whistleblower reprisal scandal. Yet still the NHS establishment protected and recycled her whilst continuing to degrade and abuse whistleblowers. She eventually fell nevertheless after a grubby fraud of a paltry £11k came to light. NHS England has admitted that it knew about the fraud allegations all along and did nothing to stop her being recycled to NHS board positions. CQC and NHS Improvement have refused to shed full light on the relevant events. Disclosed correspondence from the unholy trinity is provided.
Ivy Atkin’s death and more CQC evasion
Published 6 October 2017
The CQC continues to avoid accountability for its failures in the Safeguarding catastrophe at Autumn Grange care home, which led to the haunting death of Ivy Atkin, weighing only 13 St 13 lb. Although CQC’s chief executive David Behan stated in November 2016 that CQC’s internal review of these failures would be published, CQC now seeks to conceal the full contents of this document. A copy of a detailed complaint to the CQC Chair about his organisation’s obfuscations is provided.
CQC, coroners’ warnings and the neglect of older people in hospital
Published 2 October 2017
The new CQC chief inspector Ted Baker has waved his stick at a beleaguered NHS that is highly stressed and reluctantly failing patients. The CQC has a birds-eye view of health and social care. It has been well aware of what has been happening for years. It has not advocated for patients as it should have. Analysis of published data by the Chief Coroner shows that there have been at least 200 coroners’ Section 28 warning reports on poor inpatient care of older people in the last four years. There is a pattern of unmet need that government repeatedly fails to rectify, which amounts to institutional neglect. I have referred the government’s failures to its latest PR device, the Healthcare Safety Investigation Branch.
Letter to BMA Chair of Council, President and Past Presidents
Published 27 September 2017
The BMA has not distinguished itself in the matter of Dr Chris Day or other whistleblowing cases, and many questions remain unanswered about its practices. I have asked the new BMA Chair of Council to review the state of play, to publish data about BMA member services, to provide better support for sacked whistleblowers and to lobby for whistleblowing law which the BMA itself acknowledged – three years ago – is inadequate. The letter to the BMA is provided.
National Guardian: Measuring Up?
Published 25 September 2017
The National Guardian has published her first tranche of data on staff whistleblowing to local Speak Up Guardians for. Almost one third of trusts failed to return any data. The National Guardian claims that staff’s experience of whistleblowing was ‘overwhelmingly’ positive without supplying proper data to substantiate her claim. Her data is seriously incomplete in any case given that one third of trusts failed to return any data. Other methodological flaws and issues are reported in this piece.
NEWSFLASH: CQC denies denial
Published 16 September 2017
The CQC Chair has denied that the CQC chief inspector denied the truth of allegations by the campaigning charity Compassion in Care that CQC has breached the confidentiality of 47 whistleblowers. The relevant correspondence is provided for readers to make up their own minds. CQC has been asked if it will audit whether it has complied with its policy of whistleblower confidentiality, and whether it will include whistleblowers in the design of the audit.
Helen Rochester v CQC, Act II : Wherein a Whistleblower Sues a Prescribed Person
Published 9 September 2017
Helen Rochester, an unrepresented, unemployed care home whistleblower has made a claim in the Employment Tribunal against the Care Quality Commission, a multi-million corporation. The CQC has mishandled her serious patient safety concerns on two occasions over four years. It now given her latest employer a clean bill of health and there are serious questions about the validity of CQC’s regulatory judgment. Rochester’s ET claim against a PIDA Prescribed Person is most unusual and one of several recent claims which challenge received wisdom on the types of cases that may be heard in the Employment Tribunal. Regardless of the legal merits of the claim, there are many questions to be answered about CQC’s conduct but CQC and the National Guardian, a CQC employee, have battened down the hatches and seem reluctant to account. Indeed, CQC denies any wrong doing.
National Guardian ‘Expects’
Published 3 September 2017
The National Guardian continues to demonstrate that her office presents little challenge to the system that repeatedly fails whistleblowers. Having been informed of CQC breach of whistleblower confidentiality and complicity in reprisal, she took over two months to respond and her response does not demonstrate that she has established the extent to which such CQC malpractice is widespread. This part of a pattern of resistiveness and reluctance by her office to offer NHS whistleblowers real protection.
Whatever happened to Jeremy Hunt’s Just Culture Task Force?
Published 30 August 2017
A sequel to the Whitehall farce ‘Call for Just Culture Task Force members to stand down’ published on 25 January 2017. In short, the DH appears to have battened down the hatches and doesn’t want to play…or answer awkward questions. It insists that the creature lives, even though it does not appear to breath.
Four years of published coroners’ Section 28 reports in England and Wales
Published 24 August 2017
This data was collated from reports published on the Chief Coroner’s website because although many coroners’ warnings are now published, which is positive, the data is presented in such a way that it is hard to search and track patterns. Patterns are also partly obscured by mislabelling of some deaths. There is missing data about what proportion of Section 28 reports have been published. There are no published responses to 62% of coroners’ warning reports and it is therefore unclear if the audit cycle is being reliably closed and the public is being effectively protected. At least 57% of Section 28 reports relate to the NHS and there are questions about whether the entire NHS all the way up to the Department of Health is learning enough from coroners’ reports. Notwithstanding reservations about the data’s limitations, such as incompleteness, there appears to be an escalation in serious safety concerns by coroners about ambulance services, which seems to partly reflect pressures on the rest of the NHS.
After Grenfell: Home Office FOI disclosure on prison fire safety
21 July 2017
Prisoners and prison staff are particularly vulnerable to risk of fire because of the locked environment, security restrictions around evacuation and added risks of arson. Questions had been raised in parliament about fire safety even prior to the Grenfell tower fire and all the related, subsequent concerns about public protection. The prison fire safety issues were set in the context of more general concerns about serious pressures on the prison estate and other safety issues. An FOI enquiry to the the Home Office Crown Premises Fire Inspection Group revealed that 11 prisons have received fire safety enforcement notices due to serious fire safety risks, most recently. The information has been passed to the Justice Committee.
Letter to the Health Service Journal’s Patient Safety Correspondent
Published 10 July 2017
This is an invitation to the Health Service Journal to devote more space and serious debate to whistleblowing policy issues in its annual patient safety conference. Ongoing failures and inadequacies of government policy are laid out and specific areas for discussion are suggested. A call is made for a level playing field between whistleblowing campaigners and senior government and health service officials at the next annual conference, so that power can be held properly to account.
The NHS in the Employment Tribunal: A 5 month sample
Published 6 July 2017
There has previously been little information available about ET claims against the NHS. Workers are at a disadvantage due to inequality of arms, the more so since the introduction of ET fees in 2013. Few cases succeed and the fate of claimants who withdraw cases is unclear. The government has started publishing ET decisions. Over 600 ET decisions about NHS bodies have been published since February 2017. Longer follow up is needed but preliminary examination shows that few claimants ‘win’ against the NHS, including whistleblowers. Supporting data is provided. Whistleblowing law reform is needed for a range of reasons but the National Guardian for NHS whistleblowing is refusing to actively pursue law reform.
Breach of confidentiality by CQC and complicity in referring a whistleblower to the Disclosure and Barring Service
Published 22 June 2017
CQC has been repeatedly criticised for failing to detect serious care failure and for failing to take warnings seriously. This article reports an important example of serious CQC failure towards whistleblowers. The regulator seriously breached a whistleblower’s confidentiality to their employer. The CQC compounded this failure by complicity with reprisal in a later incident, by suggesting that another employer should refer the whistleblower to the Disclosure and Barring Service. Far from being an honest broker, there are serious questions about CQC’s role in causing detriment to whistleblowers.
East Lancashire Hospitals NHS Trust: Triumph CQC style
Published 14 June 2017
The gruesome CQC as an important part of the denial machine has just fittingly published a good news offering called “Driving Improvement”. The report gives a glowing account of how a number of poorly performing trusts have improved, with CQC’s steady hand on the tiller. Amongst them is East Lancashire Hospitals NHS Trust, which persecuted surgeon whistleblower Aditya Agrawal, super-gagged 109 staff and helped recycle the notorious former NHS CEO Paula Vasco-Knight after an Employment Tribunal found that she had victimised whistleblowers. CQC doesn’t mention these awkward facts in its nice shiny report. So I have, with relevant documents and FOI disclosures.
Healthcare Safety Investigation Branch
Published 7 June 2017
HSIB’s establishment has been controversial, with little transparency and little apparent engagement with patients, families and staff. FOI data has been obtained about HSIB’s staffing and structure. The data shows amongst other matters that HSIB is exclusively or almost exclusively white. It will also have two full time comms staff, under the line management of a Department of Health Deputy Director who has been seconded to NHS Improvement as HSIB’s Director of Corporate Affairs.
Ian Paterson and failure by oversight bodies
Published 1 June 2017
Ian Paterson breast surgeon was sentenced to 15 years imprisonment on 31 May 2017 for criminal injuries due to unnecessary surgery that he carried out fraudulently, by deceiving patients and colleagues. He had also carried out a so-called cleavage sparing mastectomy procedure which was not accepted or evidence based, leaving patients at greater risk of cancer recurrence. His case represents a colossal failure of NHS governance, as despite serious concerns about his surgical practices since at least 2003, he was not suspended from medical practice until 2012. Whistleblowers who raised concerns about Paterson were repeatedly ignored. There are concerns that his employer Heart of England NHS Foundation trust has not really come clean. HEFT’s whistleblowing governance continues to be poor with 51 external whistleblowing disclosures to CQC since 2011. All the NHS oversight bodies involved have many questions to answer, and a public inquiry is clearly needed. Relevant documents and FOI disclosure data is collated and provided in this piece.
SSOTP: Robert Francis’ exemplar trust has feet of clay and Jeremy Hunt’s safety claims are un-evidenced
Francis based his Speak Up Guardian proposal on the prototype Cultural Ambassador at Staffordhire and Stoke on Trent Partnership NHS Trust (SSOTP), which he held to be a success in the absence of evidence other than an increased number of staff reports, and despite the fact that the experiment was never evaluated. There is evidence that the experiment has not succeeded and that both staff and patients have been harmed as a result of the trust’s failure to respond to escalating concerns about safe staffing. The Cultural Ambassador received 110 concerns about safe staffing and many questions remain about why staff concerns were not properly acted upon, and why staff were forced to disclose to the CQC and to the media. The CQC issued SSOTP with a formal warning which included a requirement to make improvements in Duty of Candour. The CQC also noted negative staff feedback about the Cultural Ambassador service. Far from being an exemplar, SSOTP serves to illustrate how misconceived the Freedom To Speak Up project is. The National Guardian has been asked to review SSOTP’s whistleblowing governance failures and to stop promoting SSOTP as an example of good practice. FOI material and correspondence are provided.
Steve Trenchard, NHS regulators and FPPR
Published 26 May 2017
This piece looks at an example of NHS recycling of senior managers after wrongdoing. Steve Trenchard former NHS trust chief executive at Derbyshire Healthcare was suspended and then resigned after an Employment Tribunal was severely critical of his conduct in the matter of sexual harassment against Helen Marks, a fellow director, by the trust chair. The ET found that Trenchard acted unfairly against Marks and helped to cover up the actions of the trust chair. Trenchard was hired by another NHS trust, five months after his resignation from Derbyshire Healthcare. FOI data reveals that the NMC and a CCG had a hand in his recycling and that the CQC took little action under FPPR when it examined matters at Derbyshire Healthcare.
FPPR: CQC has lost all moral authority, but what will the National Guardian do?
Published 23 May 2017
The CQC has thoroughly disgraced itself on its enforcement of the Fit and Proper Person Regulation (FPPR). It failed spectacularly in the case of former NHS CEO Paula Vasco Knight whom it secretly cleared shortly before she was charged with criminal fraud and eventually convicted. It secretly cleared her former Director of Workforce in November 2016 and again omitted to tell the referrer. The crowning ‘glory’ now is that CQC has cleared even David Loughton, NHS CEO, despite a repeatedly troubled history on whistleblowing and critical independent investigation findings. Of relevance, the National Guardian has maintained that she will refer findings of serious misconduct by those who victimise whistleblowers to regulators. She has now been asked what she will do if regulators subsequently fail to take appropriate action.
National Guardian complaints: Keeping it in the family
Published 20 May 2017
The National Guardian’s office is supposed to be free to hold any part of the system to account for failures of whistleblowing governance in the NHS. However, it is under CQC’s thumb because CQC part funds, employs and manages the National Guardian. Shockingly, the National Guardian’s funding bodies which the National Guardian should in theory hold to account, will also adjudicate complaints about the National Guardian, introducing an additional conflict of interest. The National Guardian has not yet published her complaints policy, but a very inadequate policy has been revealed when a whistleblower who made a complaint was given a copy. The document is provided.
National Guardian reprieves employers, but condemns whistleblowers and patients
Published 18 May 2017
The National Guardian has confirmed that she will not be accepting ‘live’ cases for review, at least initially. Greater clarification is needed about wether this applies only to employers’ internal processes or to external processes such as referrals to professional regulators and the Employment Tribunal claims. Critically, this is a very unsafe if the National Guardian will not act on whistleblowers’ reports that employers have not responded to patient safety matters, until lengthy employment processes have concluded. A concern has been formally raised about this and clarification has been sought the National Guardian’s precise definition of ‘live’ cases.
Speak up Guardians: A Whiter Shade of (Corporate) Pale
Published 16 May 2017
This is an early, quick and dirty look at the emerging characteristics of Speak Up Guardians. As part of the tokenistic nature of the government’s reforms on whistleblowing, the establishment of Guardians has been neglected. There has been almost no quality control and the situation is like the Wild West, but more disorganised. Published data is of questionable reliability but it is looking as if power appoints in its own image, with over-representation of white staff, plus and unhealthy sprinkling of corporate types. Robert Francis has effectively admitted that there is no evidence base for the Speak Up Guardian model. This correspondence is provided.
Whistleblowers Wanted: Dead or Not Live
Published 9 May 2017
Correspondence disclosed to a whistleblower has revealed internal correspondence by the National Guardian’s office which indicated that ‘live’ cases may not be accepted. This is absurd as Robert Francis recognised the importance of early intervention to prevent serious harm to whistleblowers. It is also quite ridiculous given that ‘historic’ cases have already been excluded from the National Guardian’s remit. Anyone would think that referrals are not welcome. Further clarification has been requested from the National Guardian.
CQC and National Guardian defend Fortress DH
Published 6 May 2017
The National Guardian, CQC and Department of Health closed ranks to wrongly claim that the National Guardian had no remit at all to intervene in individual whistleblower cases. David Behan CQC chief executive has now admitted that the National Guardian DOES have a responsibility to challenge employers to correct malpractice in individual cases. There are still unreasonable barriers in place by the National Guardian, which will disadvantage whistleblowers and deny them help.
4 years of CQC mental health whistleblowing data
Published 24 April 2017
The CQC is reluctant to part with any real information about whistleblowing, but has been forced progressively to collect and disclose more. However, it continues to record whistleblowing contacts in an unsatisfactory manner, that does not clearly reveal the number of whistleblowers and concerns involved. It also does not routinely publish national whistleblowing data beyond very cursory, global analyses. More detailed data has to be laboriously gathered by FOI. A recent CQC FOI disclosure on 4 years of mental health whistleblowing illustrates the vagaries that CQC relies on to keep a lid on things, and a total of over 700 so-called whistleblowing ‘enquiries’ between 2013 and 2017. These ‘enquiries’, as defined by CQC, may involve more than one whistleblower and or concern.
Health Education England hasn’t done its whistleblowing homework
21 April 2017
As another example of the tokenistic nature of the Freedom To Speak Up project, it is now apparent that Health Education England, notorious for reprisal against junior doctor whistleblower Dr Chris Day, has not provided guidance on the proper training for trust Speak Up Guardians. This is despite the government promising almost two years ago that HEE would do so. The relevant documents and background are provided.
National Guardian Newsletters: The Unexpurgated Version
Published 19 April 2017
The National Guardian agreed in February 2017 to publish her newsletters, for transparency, and to allow whistleblowers to track her office’s activities. Three newsletters were subsequently published but two have since been removed from the CQC website. All the newsletters released by the National Guardian will from now on be posted on this page, until and unless a full record is restored on the CQC website.
NHS bodies: 5 years of ICO decisions
Published 18 April 2017
This report looks at patterns in five years’ data of upheld complaints about NHS responses to FOI requests. The picture is one of a multi-billion corporation throwing its weight about and sometimes defying even the ICO. There have been over 500 ICO decision notices about NHS bodies, and almost 200 upheld complaints. Two NHS bodies emerge as behaving especially badly: NHS England and the Department of Health. There are signs suggestive of politicisation by public servants whose duty it is to be neutral, and various games are evident. At the Department of Health, repeated spurious claims have been made that disclosure of information would prejudice the effective conduct of public affairs or infringe on ministerial prerogative, which have been rejected by the ICO. The Department has absurdly even refused to provide data on grounds of national security, also rejected. The database extracted from published ICO decision notices is provided.
Jon Andrewes fraud: NHS Improvement responds
Published 11 April 2017
The NHS regulator NHS Improvement and its predecessor were hoodwinked by Jon Andrewes, fraudster, and appointed him to two NHS trust board positions on the basis of a faked CV. NHS Improvement says it is considering its approach to checking qualifications. NHS Improvement makes excuses for its past failure to undertake checks, and its account of events in the Andrewes affair contradicts information given by one of the affected trust. Importantly, Andrewes was for a period a Freedom To Speak Up Guardian, which only adds to concerns that the Department of Health is not taking whistleblower protections seriously.
Engineered failure to investigate NHS whistleblowers’ concerns
Published 8 April 2017
The whole system is currently designed so that there is no enforcement of reliable investigation of whistleblowers’ concerns. Very flawed UK whistleblowing law does not compel employers to investigate. Regulators tacitly allow employer failure to investigate and also controversially claim that they themselves cannot investigate individual whistleblowers’ concerns. The Department has also given us window dressing in the form of local Speak Guardians and a National Guardian who have been designed not to investigate. The newly launched Healthcare Safety Investigation Branch also looks set to be little more than window dressing and shows little interest in or expertise on whistleblowing. Real reform requires an enforceable legal duty upon employers to investigate whistleblowers’ concerns.
At the NHS Improvement Soup Kitchen
Published 26 March 2017
The NHS continues to drag its feet on welcoming back exiled whistleblowers, over two years after it promised to do so, and in contrast to the lightning speed at which duff senior managers are recycled. This is a report from a workshop by NHS Improvement on 24 March 2017, about how NHSI’s part of the whistleblower employment support scheme will operate. The level of allocated resource – up to £10k per whistleblower – is inadequate and may get worse. NHS Improvement is open to expressions of interest, either from potential applicants or any whistleblowers who would be willing to help with application panels or reviewing and advising on paper work. NHS Improvement’s draft protocol is provided.
Protest by Compassion in Care and supporters at CQC headquarters, Buckingham Palace Road, 22 March 2017
Published 23 March 2017
Compassion in Care supports whistleblowers from all sectors and seeks substantial reform of whistleblowing law. It also campaigns specifically on social care quality and abuse in care. It has amassed a mountain of evidence over almost a decade of work, including of regulatory failure and wilful blindness to both poor care and whistleblowers’ concerns. Very seriously, Compassion in Care reports that the Care Quality Commission has disclosed whistleblowers’ identities to employers and it will be publishing a report about this later this year. The charity has written to the Prime Minister copied to the CQC protesting CQC’s failures and David Behan CQC CEO’s knighthood. A protest was held outside CQC headquarters on 22 March 2017.
25 ‘Best’ and 25 ‘Worst’ NHS trusts on speaking up. Allegedly.
Published 22 March 2017
This post provides a database on the 2016 NHS staff survey data for all 2040 NHS trusts, set against the most recent CQC ratings. The data raises additional questions about the efficacy of Robert Francis’ non-evidence based model of local Guardians. Three trusts with established Guardians, in place for several years, returned mediocre results on the question about staff confidence and security in raising concerns about unsafe care. An analysis of the 25 ‘Best’ and 25 ‘Worst’ trusts is included, and also an analysis of the difference between doctors’ and managers’ reported experiences of speaking up: doctors seem less optimistic. NHS staff survey results on speaking up are also compared to recent results by a Royal College, which showed much lower medical staff confidence about speaking up.
Whistleblower Discrimination: Hunt’s Razzmatazz
Published 20 March 2017
Jeremy Hunt the ever spin-tastic Health Secretary is trying to grab more disingenuous “whistleblowers will be protected” headlines, with draft regulations about NHS whistleblower blacklisting. He’s only two years overdue and the proposals are in reality little help. He only proposes more waste through litigation, that most whistleblowers can ill afford both in terms of financial and health costs. There’s a lot of real action that he COULD take to manage whistleblower victimisation better, and to avoid whistleblowers being sacked and made unemployable in the firs place. It speaks volumes that he hasn’t.
How many NHS trust governors are disciplined and silenced?
Published 17 March 2017
The disempowerment of NHS foundation trust governors was identified by the Mid Staffs Public Inquiry as a contributory factor to safety failings. Little has changed, as illustrated by recent difficulties experienced by Southern Health NHS Foundation Trust governors. The Health Committee has indicated that it would welcome submissions providing evidence that trust governors are disciplined or silenced. The background and key correspondence is provided.
Just Culture: Sanctions for whistleblower suppression and reprisal
Published 15 March 2017
Fair and proportionate punishment for culpable behaviour is an accepted part of just culture, and creating a learning environment. A discussion paper put to the NHS whistleblowing organisation, Patients First, is provided. This lays out the arguments why sanctions for whistleblower suppression and reprisal are an essential component of culture change, and why impunity is harmful to safety culture.
National Guardian: Behan replies
Published 12 March 2017
David Behan CEO of the Care Quality Commission has replied to correspondence raising concerns about the National Freedom To Speak Up Guardian’s proposals and advice from her office to a current whistleblower, that it cannot intervene to help individuals. Behan’s reply is ambiguous and did not clarify whether the National Guardian will challenge employers to look again at badly handled cases. His reply was purportedly on behalf of all three CEOS of the CQC, NHS England and NHS Improvement. Clarification has been sought on the crucial issue of whether the National Guardian will implement Robert Francis’ recommendation that her core role will be to challenge others to look again at badly handled cases, where concerns have not been properly addressed or whistleblowers appear to have suffered detriment.
National Guardian: ‘Fantastic’….or airbrushed fantasy?
By Minh Alexander and Clare Sardari @SardariClare Published 9 March 2017
The Department of Health has often protected itself in recent years by claiming, in a fragment NHS, that regulators and other oversight bodies are independent. There is much scepticism about this. Presently, there is a concert of silence by the relevant NHS bodies about who knew what when about the Paula Vasco-Knight fraud, which may not be unrelated to a desire to minimise the embarassment of her sentencing on 10 March 2017. Whistleblowers are also being airbrushed out of the National Guardian’s picture, in favour of Good News. This will be under-pinned by the fact that she has restricted her annual caseload of whistleblower case reviews to just twenty, when there are probably hundreds who need help, judging from available data.
Freedom to Speak Up Guardian jailed
Published 7 March 2017
Jon Andrewes former NHS trust chair was jailed yesterday for fraud, by obtaining over £1 million salary for NHS director posts for which he was not qualified. He faked CVs in order to secure the senior jobs. Importantly, publicly available records also show that he was a non executive director at a neighbouring trust, when he was additionally appointed as that trust’s Freedom to Speak Up Guardian. This is another nail in the coffin of the discredited Freedom to Speak Up Review and its weak and ineffective proposals. The information on Jon Andrewes has been submitted to parliament and the relevant correspondence is provided.
Published 3 March 2017
The Healthcare Safety Investigation Branch was meant to be an independent body that would investigate serious NHS clinical failures and hold any part of the system to account if necessary. The government has done its best to neuter the recently established agency and a DH deputy director has been seconded to HSIB. HSIB is already doing its business in the dark. It also seems phobic of working with whistleblowers despite acknowledging that the right approach to whistleblowers is a key issue. Matters are still in play and the government’s response to Conradi’s request for statutory independence and more powers is awaited, but the body may end up as another NHS white elephant.
Published 28 February 2017
The shadow of the Department of Health falls across the National Guardian’s office for NHS whistleblowing. Signature messages are clear in what Henrietta Hughes the National Guardian, has been saying about the management of NHS whistleblowing. Accountability is minimised. Instead, ‘blame’, is framed as a dirty word. “Good news” is de rigeur.A transcript of a conference presentation and answers by Henrietta Hughes is provided.
If I was Secretary of State
Published 23 February 2017
A social media discussion on whether or not suppression in the NHS has a political root, I was asked what I would do to prevent whistleblower suppression if I was Secretary of State. I set out here examples of political punches being pulled, and the main things that the Secretary of State could do to redeem himself, and improve whistleblower protection and Safeguard patients – if he was serious.
National Guardian: Letter from Wonderland
Published 20 February 2017
Over a year after the National Freedom to Speak Up Guardian’s office was established, the latest National Guardian has finally unveiled draft proposals for how her office will conduct case reviews of whistleblower cases. Expectations were not high, but the draft proposals are particularly disappointing as they try to deviate from even the narrow, insufficient remit set out by Robert Francis, DH and CQC. Case reviews were intended to focus on failures in individual cases and to help address unresolved concerns and injustices to individual whistleblowers. However, loopholes and shifted goal posts abound in the National Guardian’s proposed protocol for case reviews, which serve to protect employers and dilute the focus on indivdual cases and divert to systems issues. A letter has been sent to the CEOs of the three funding bodies (CQC, NHS England and NHS Improvement about this disturbing turn in the development of the National Guardian’s office. The correspondence is provided.
Whistleblowers need more than hand-wringing headlines, Sir Robert
Published 10 February 2017
Robert Francis failed patients and whistleblowers by not reporting what sort of disclosures have been buried, by providing no effective measures to protect whistleblowers and by recommending that there should not be a proper inquiry into whistleblowing. He recently refused to meet to discuss the lack of progress since he published his report on NHS whistleblowing two years ago. Yet he now publicly bewails the fact that culture has not changed enough. He needs to take responsibility by retracting ineffective recommendations and putting right his omissions. Recent correspondence with Francis is provided.
Newspeak at the National Guardian’s office
Published 8 February 2017
There are continuing delays at the National Guardian’s office, which is still not yet accepting whistleblowers’ cases for review. Two recent meetings with the National Guardian only raise further, significant questions about the effectiveness of this office. The National Guardian says she feels independent, but she meets frequently with David Behan the Chief Executive of CQC, her chief paymaster. She shows reluctance to criticise CQC’s gross failures on whistleblowing, and her plans for the office are sketchy. The impression of a tokenism by the DH remains, and tellingly, the DH refused to be interviewed by the BBC about the lack of progress on NHS whistleblowing. The agreed records of the two meetings with the National Guardian are provided.
CQC: A Chief Inspector DOESN’T call
Published 27 January 2017
CQC gave Paula Vasco-Knight former NHS CEO the Fit and Proper Person (FPPR) rubber stamp in February 2016. She was sacked three months later and subject to criminal charges. Yesterday, she pleaded guilty to fraud at Crown Court. Fresh questions arise about what CQC knew when it shut down the FPPR in February 2016, because it is now evident that an investigation into the fraud was well underway before CQC did so. A complaint has been made about CQC’s handling of the FPPR referral on Vasco-Knight, but there are also concerns about how this complaint is being handled by CQC.
Call for Just Culture Taskforce core members to step down
Published 25 January 2017
An NHS Taskforce on Just Culture was a proposal by the Expert Advisory Group which helped with the establishment of the Healthcare Safety Investigation Branch. This was accepted by the government. However, there has been no public consultation and Jeremy Hunt has asked a small inner circle to kick off the Taskforce. This replicates club culture and is inimical to Just Culture. I have asked all of the Taskforce “core group” to support Just Culture by standing down and asking the Department of Health to consult properly on the establishment of the Taskforce. The relevant correspondence is provided
Ticket to ride
Published 19 January 2017
Alyson O’Connell is an NHS whistleblower, nurse and cancer patient who is making a long journey, by coach, from Wales to contribute to a National Freedom To Speak Up Guardian consultation event. The coach fare is the princely sum of £26. O’Connell has been unemployed for five years, sometimes doesn’t know if she can meet her mortgage payments and faces an uncertain future. So far, the National Guardian’s office has declined to reimburse O’Connell’s minimal travel expenses.
National Guardian independence: the CQC denies some more….
Published 19 January 2017
The majority of whistleblowers are unconvinced that the National Guardian’s office is independent as it has been located firmly within the NHS, at CQC. CQC has in various documents made it clear that there will be a relationship of oversight between CQC and the National Guardian. Curiously, CQC’s chief executive denied this at a CQC Board meeting on 18 January 2017. Notwithstanding CQC’s denial and inconsistencies, the office should be properly independent, and a test of the latest National Guardian’s mettle is whether she seek statutory independence.
SMILE, SHINE & SAG
Published 17 January 2017
This is a written submission to the National Guardian’s consultation on how her “Stakeholder Advisory Group” (SAG) should be established. In particular, questions are raised about the improbable plan devised by Robert Francis that she should “review” cases but not investigate them, and still produce recommendations for improvement although she is seemingly prevented from testing evidence.
The CQC denies….
Published 8 January 2017
A CQC press statement has been disclosed which shows that ludicrously, the CQC is spinning that gagging clauses were banned by the NHS in 2013. They weren’t, they were just tweaked, and they still have the effect of silencing staff. I have written to Mike Richards CQC Chief Inspector of Hospitals to point out CQC’s many failings on this important aspect of whistleblowing governance. The letter and supporting evidence are provided.
National Clinical Assessment Disservice
Published 6 January 2017
The little known but important quango the National Clinical Assessment Service (NCAS) is implicated in the mistreatment of NHS whistleblowers but despite agreeing in 2015 to reform its processes, appears to have resisted reform. Details are given of the background and the concerns that whistleblowers have expressed about NCAS. This is additional evidence of the Freedom To Speak Up Review’s ineffectiveness and the need for more robust reform of whistleblowing governance.
National Guardian: Tidings of comfort and joy
Published 26 December 2016
A letter to the National Guardian about her reported plans to seek good news stories about NHS whistleblowing. Good news culture has been identified as an obstacle to patient safety by the Mid Staffs Public Inquiry and other authorities. The National Guardian needs to engage with all, especially critics. She needs to show that she will robustly evaluate NHS whistleblowing governance, as opposed to relying upon employers’ superficial reports and selected cases brought to her attention.
Good News Culture at the National Guardian’s Office? or “Stop the tokenism used as cover”
Published 23 December 2016
Letter byRichard von Abendorff patient safety campaigner, and Patients Association Patient Safety Ambassador, to the Patients Association regarding concerns about the National Freedom to Speak Up Guardian’s office. The National Guardian has called for good news stories about NHS whistleblowing – but do we want anecdote and selected cases as opposed to real evaluation, robust evidence of effectiveness and genuine staff confidence?
New Employment Scheme (but not as you know it)
Published 19 December 2016
The much derided National Guardian’s office lurches from one mishap to another. With an absurd role specification, embarrassing resignations, stunningly silly comments to the press, and failure to actually process any cases after a long delay, it has singularly failed to command any credibility. The latest National Guardian seems to be keeping a wide berth of whistleblowers. A delegate list for a critically important consultation looks unimpressively corporate. The majority of whistleblowers are not invited to this bash, which will discuss how the machinery for choosing cases for review will be established.
Covering up cover ups: CQC’s revisionism
First published 15 December 2016
A critique of a damage limitation exercise by the CQC et al, the so called CQC Deaths Review. The review is a response to independent auditors, Mazars, letting the cat out of the bag about dismal NHS failure to investigate properly or in hundreds of cases, at all, deaths at Southern Health NHS Foundation Trust. The CQC has done its best to draw public attention away from deliberate NHS cover ups. It has also failed once more to defend the rights of people with learning disabilities and mental illness.
Tall Stories by the CQC
First published 9 December 2016
This is a response by four NHS whistleblowers to CQC’s evidence to a Health Committee accountability hearing on 6 December 2016. The CQC is in denial of its failures, especially in relation to whistleblowers. It hits out at critics and has not engaged with almost all the issues raised by campaigners in a letter to the Times. A letter to Peter Wyman the CQC’s chair is included. This questions the CQC’s evidence to parliament and invites the CQC to respond to a recent report on its serious whistleblowing failures.
Whistleblowers unheard by CQC
First published 2 December 2016
A report by four NHS whistleblowers summarising how the Care Quality Commission is part of the machinery of suppression through repeated acts of omission and commission. Importantly, the CQC has unparalleled national data on whistleblowing in health and social care but has revealed very little about this data. CQC has repeatedly failed to conduct central analyses or demonstrate proper learning. This has the added effect of preventing full access via Freedom of Information, because the CQC refuses FOI requests on grounds that it would exceed cost limits to collate data. Data that has been obtained reveals very disturbing inaction by CQC in response to even the most serious allegations of management fiddling and reckless endangerment of patients.
Is CQC’s handling of Regulation 5 “Fit and Proper”?
Published 21 November 2016
CQC has finally responded to an FPPR referral on controversial former NHS CEO Paula Vasco-Knight. It has conceded that St. George’s handling of FPPR is ineffective but questions remain about CQC’s prosecution of FPPR, and the basis upon which Mike Richards Chief Inspector gave St Georges and Vasco-Knight a pass in February 2016, which was not disclosed by CQC itself.
DH, Robert Francis’ National Guardian and the dark art of delay
Published 21 November 2016
The DH was asked in July 2016 how it would evaluate and track the effectiveness of the much scorned National Guardian’s office. The DH has taken four months to reply that, in short, it will have meetings with the CQC. Jeremy Hunt has been asked if he will ensure that specific performance metrics and a proper means of evaluating the office will be developed. A lack of evaluation would of course help the DH to use the National Guardian to further delay genuine whistleblowing reform.
The ever-anomalous CQC. Another soft-shoe shuffle around inconvenient data
Published 18 November 2016
As nine past Health Secretaries made an unprecedented attack Jeremy Hunt’s failures on mental health, a look at the CQC’s annual community survey of adults receiving specialist mental health care reveals that a persistently low response rate has been tolerated, and that the instrument does not distinguish well between trusts. Where there are outliers, the CQC does not seem to take much notice of this. Norfolk and Suffolk NHS Foundation has just been uprated by CQC and released from special measures, but the survey results support campaigners’ concerns that these are unjustified actions. Deaths continue to mount.
Morecambe: All that glisters…
Published 15 November 2016
Morecambe Bay is writ large in the the Secretary of State’s PR drive. It was praised for revealing a past, irregular compromise agreement that undertook not to investigate a senior midwife. However, when asked to disclose all such compromise agreements, the trust gave only a partial answer and avoided the years before 2011. Is the trust truly a miracle of transformation under Jeremy Hunt’s reign?
Coroners’ warnings: terminal inexactitude and CQC opacity
Published 11 November 2016
An analysis of coroners’ data which shows that 206 coroners’ warnings reports (Reports to Prevent Future Deaths, formerly known as Rule 43 reports) about serious failures by care providers have been sent to CQC since July 2013. There are only published CQC responses to nine of these warnings. It is not at all clear to what extent CQC has acted upon coroners’ warnings. Shocking case examples are given. CQC’s inspection reports do not reliably report on whether providers have been issued with warnings by coroners. CQC has given inconsistent accounts of when a memorandum of understanding with coroners was established and has not yet explained why it has done so. The data from which the analysis is derived is provided.
Does PHSO go easier on the big boys?
Published 4 November 2016
The Parliamentary and Health Service Ombudsman shies away from acknowledging that there is cover up in the NHS, or that it comes from the top. A quick and dirty look at FOI data on outcomes of complaints to PHSO about the Department of Health, NHS England and the Care Quality Commission against PHSO data on outcomes for all NHS organisations raises a question of whether rates of upheld complaints are lower for central bodies.
DH complaints handling
Published 2 November 2016
FOI data from the DH and PHSO, cross checked with DH publications, reveals that the DH has not followed its own guidance on good complaints governance. It has not been fully transparent about complaints made against it, it has not paid due attention to the narrative of complaints (Recommendation 40 Mid Staffs Inquiry) and it has not measured the experience of complainants. The PHSO received 914 complaints about the DH but only 0.5% were fully upheld and only 0.7% were partly upheld. According to the PHSO data, the majority of the complaints investigated related to inspection and regulation.
Letter to parliament: CQC’s inconsistent regulation of restraint in mental health
Published 31 October 2016
The use of physical restraint, inluding high risk prone (face down) restraint has increased as cuts to highly stressed mental health services have continued. The NHS has contended that this is due to better reporting but this is unlikely to be the whole explanation. The CQC accepts that the unwarranted, avoidable use of physical restraint is a Safeguarding issue, but it has been less than straightforward with the public. This letter submits evidence to parliament about these issues.
Northumberland Tyne and Weary
Published 29 October 2016
Debunking the CQC’s rating on 1 September 2016 of Northumberland Tyne and Wear NHS Foundation Trust as ‘Outstanding’, taking into account poor patient feedback, mediocre 2015 patient survey results, serious escalation of dangerous prone restraint in the face of government policy and safety alerts deterring this practice and repeatedly topping the national charts for violent incidents. But hey, it helps the Secretary of State spin against increasingly vociferous criticism of the government’s mental health cuts and failures.
FOI disclosure 26 October 2016 by PHSO on complaints made about NHS England
Published 26 October 2016
Notes on a disclosure which showed that less than 2% of complaints to the PHSO about NHS England had been fully or partly upheld. Discrepancies between PHSO & NHS England’s data are noted. Opacity in NHS England’s reporting of how it handles complaints against itself is also noted.
Jus’ like that, says Henrietta
Published 21 October 2016
The Ministry of Love has brazened it out and refused to acknowledge that it has mishandled the office of the National Guardian for NHS whistleblowing. The Ministry also refused to acknowledge dismay and offence caused by the latest National Guardian, due to some very revealing comments made in her first press interview.
Fit and Proper Mess
Published 19 October 2010
An update on evidence of the CQC’s, Jeremy Hunt’s and Department of Health’s failures to hold seriously erring NHS directors to account. An NHS chief executive who was found to be Fit and Proper last year, and who was recycled after major failures by his former trust, has led his present trust into special measures.
Morecambe and wise counsel
Published 17 October 2016
A little shot of antidote to Jeremy Hunt’s spin about Morecambe, maternity safety and his false claim to be the patients’ champion. Morecambe Bay’s continuing poor treatment of whistleblowers is summarised.
Letter. Unheeded deaths warnings. Neglect and care home owner with criminal convictions. Indefensible CQC.
Published 16 October 2016
Letter to parliament of 15 October 2016 about CQC’s long history of failure, a new analysis showing persisting unreliability in CQC response to coroners’ deaths warnings, and a shameful attitude by CQC in not reviewing its part in the profoundly shocking care home death of Ivy Atkin, who weighed 3 st and 13 lb. CQC’s value for money is discussed. A CQC FOI revealing the cost of an ineffective Southern Health inspection in 2014, which did not report on hundreds of un-investigated deaths, is provided.
CQC’s “better than ever”…or didn’t you know?
Published 14 October 2016
A post about the horrific death of Ivy Atkin, weighing 3 st 13lb, from gross neglect at Autumn Grange. CQC had issued an inspection report 20 days before the death, which gave the care home a clean bill of health. The CQC disclosed by FOI that it had not undertaken any internal review of its inspection activities at Autumn Grange, but insisted its processes were “better than ever”. A CQC Non Executive Director tweeted caringly, “Er, this was 4 years ago…..”
Published 12 October 2016
St. Robert of Richmond House, the NHS denial machine and the building of a brand by the Department of Health and Care Quality Commission.
A letter to the ever-listening Cat Quality Commission
Published 11 October 2016
Letter to Peter Wyman Chair of the CQC, to bring his attention to the strong negative reactions by whistleblowers, NHS staff and the public to comments by Henrietta Hughes National Guardian that NHS staff must be cheerful, so that no one is intimidated from whistleblowing. Questions are raised about CQC’s processes for appointing the current and previous National Guardian.
Published 10 October 2016
This is a response to comments made by the replacement National Guardian in her first press interview, in which she asserted NHS staff must be more cheerful, so that no one feels intimidated from speaking up: “she said that change could happen “just like that” if staff always acted as they would on a good day”. Henrietta Hughes’ introduction of a rule for her staff on smiling at a distance of 10 feet, in her previous role as an NHS England senior manager, is noted.
Care home deaths and more broken CQC promises
Published 8 October 2016
This is an analysis a year on from revelations by The Bureau of Investigative Journalism and the Independent that CQC had failed to act on serious coroners’ warnings about care home deaths. CQC promised in response to this scandal that it would make improvements. Cross checking between a total of 66 coroners’ Reports to Prevent Future Deaths (PFDs) since July 2013 and CQC inspection reports showed that there was no published evidence that 18 of the PFDs had yet been followed up with inspections. The CQC’s response to coroners’ warnings in terms of evidence of inspection is still slow and erratic.
Published 4 October 2016
An update on the cringeworthy saga of the Department of Health & CQC’s handling of the central plank of Robert Francis’ recommendations on NHS whistleblowing -the office of the National Guardian. Key issues of the National Guardian’s role and remit remain unresolved even at this late stage. A further letter to Dr Henrietta Hughes the latest appointee is included.
Do “Complaints Matter” to CQC?
2 October 2016
An analysis is provided of published information on CQC’s handling of complaints about itself. Concerns and questions are raised about transparency, learning and accountability, set in the context of CQC’s own expectations of best practice in complaints governance. Related correspondence to the Health Committee is attached.
Jim Reaper and gags up north
30 September 2016
Notes on an FOI disclosure by Northumbria Healthcare NHS Foundation trust on 15 February 2016, showing 62 compromise agreements, 61 of which contained non-disparagement clauses and 45 of which contained clauses preventing signatories from disclosing the existence of the compromise agreements.
PHSO FOI disclosure 21 September 2015 on handling of complaints: PHSO has CQC’s back
30 September 2016
This article briefly summarises the role that the PHSO has played in the NHS denial machine, the culture of “circular assurance” amongst NHS bodies – which listen to each other rather than complainants and whistleblowers – and provides FOI data which showed that since CQC’s inception, PHSO had not upheld a single complaint out of the 354 complaints that it had received about CQC.
Is the BMA worth £163? Are new socks better?
This article summarised the troubled history of the BMA’s handling of whistleblowing cases and its related governance of these activities. The BMA’s submission to the Freedom To Speak Up Review, an internal report of a review of BMA’s handling of whistleblowing matters and related correspondence are provided. New correspondence to Dr Mark Porter Chair of the BMA Council seeking information on whistleblowing cases is included.
Homerton maternity whistleblowers, FOI disclosure of the London Clinical Senate report on four maternal deaths and the National Guardian for whistleblowing
This article briefly updated the story of the Homerton maternity whistleblowers and provided a copy of the London Clinical Senate review of four maternal deaths. A past link between the recently appointed National Guardian for whistleblowing and the NHS’ handling of the Homerton whistleblowers’ concerns is noted. Links to a website about the Homerton whistleblowers’ disclosures and various other documents and audit trail are provided.
Sir Robert’s Flip Flops
Published 26 September 2016
This article tracked how Robert Francis u-turned on accountability for reprisal against NHS whistleblowers, even though he acknowledged that it constitutes serious misconduct. His original recommendations on criminal sanctions and sackings are collated and set against his later recommendations from the Freedom to Speak Up Review, which were considerably weaker. The contrasting advice of Francis’ lead researcher, Prof David Lewis, who supports criminal sanctions to deter whistleblower reprisal, is referenced.
Letter to Health Committee 23 September 2016
This correspondence raised serious concerns that the Care Quality Commission has made misleading claims about inspecting NHS compromise agreements, based on evidence from review almost 200 current CQC inspection reports.
NHS Gagging. How CQC sits on its hands
Published 23 September 2016
This article presented evidence that despite Jeremy Hunt’s claims in 2013 that he took action against NHS gagging, the Care Quality Commission and Department of Health have in fact turned a deliberate blind eye to continuing and widespread gagging. A new analysis was provided of 200 current CQC inspection reports, which showed that despite misleading claims by the CQC, there is in fact no evidence that CQC inspects NHS trust compromise agreements.
Letter to the Director of the National Clinical Assessment Service (NCAS) 22 September 2016
This letter questioned whether NCAS had taken action, that it said it would a year previously, to ensure better tracking of whistleblower cases and safeguards against abuse of process by NHS employers who refer whistleblowers vexatiously to NCAS in reprisal for whistleblowing. The letter also raised serious concerns about FOI data which showed that disproportionately more non-white doctors are referred to NCAS, and that NCAS is clearly not tracking Race detriment properly because it has no ethnicity data for almost half of the doctors who are referred. The FOI data is provided.
FOI disclosure 21 September 2016 by Health and Safety Executive on complaints received against NHS bodies and Priory Group since 1 April 2014
This FOI disclosure revealed that there have been 222 complaints against NHS bodies in the UK and 38 complaints against English mental health trusts since 1 April 2014. There have been four complaints against the Priory Group. The NHS bodies with the most number of complaints has been extracted and a table is given. Basildon and Thurrock have been the subject of 5 complaints despite claims by the CQC that the trust has improved, and is now ‘Good’.
Club culture at the heart of CQC
First published 9 September 2016
This article reported findings from a review of almost 200 current Care Quality Commission inspection reports, for patterns in CQC’s choice of inspector chairs. The choice of CQC inspection chairs were predominantly white, male and corporate and the majority of 103 inspection chairs appointed by CQC were current directors of NHS trusts.
Letter to 9 September 2016 to David Behan CQC Chief Executive on CQC under-reporting of coroners’ mental health deaths warnings
This letter asked CQC why it had cited only 3 coroners’ warning reports in a 2014/2015 report when there were in fact 92, five of which were marked as having been copied to CQC.
Hot air about Just Culture
First published 1 September 2016
This article argues that NHS cover ups are ultimately due to top down political pressure, and that whilst governments say they want to ensure NHS learning on safety issues, the NHS is managed in a bullying way by politicians, which encourages suppression and unfairness to patients and staff.
CQC Deaths Review: All fur coat…
First published 13 August 2016
This article reported evidence, from examining all current CQC inspection reports on English mental health trusts, which showed that CQC is reporting inconsistently and incompletely about mental health deaths and coroners’ Reports to Prevent Future Deaths.
Letter 8 August 2016 to Health Committee about lack of progress on NHS Improvement’s employment support scheme for whistleblowers
This letter raised concerns about lack of any apparent progress by NHS Improvement, refusal to further involve whistleblowers, to share documents or to give a clear and specific timetable for the work. An FOI response from NHS Improvement is included.
CQC’s Fit and Proper Parade
First published 29 July 2016
This article summarised the serious failure by the Care Quality Commission to hold any NHS directors to account under the new Fit and Proper Person Regulation (Regulation 5), and very questionable irregularities in CQC’s poor response to referrals, including misleading responses to a referral in the case of Paula Vasco-Knight, which were exposed by Freedom of Information disclosures.
No one believes Jeremy Hunt on patient safety and whistleblowers, not even his own appointees
First published 11 March 2016
This article examined the newly formed office of the National Guardian for NHS whistleblowing, and draws on information from a meeting with the first National Guardian, Eileen Sills (in post January – March 2016). A minute of the meeting is provided.
Safety campaigners’ letter to the Times 10 February 2016 about government inaction on whistleblowing, and measures required
This letter, by Professor Brian Jarman and others, was written on the anniversary of the Freedom To Speak Up Review to draw attention to lack of government inaction about NHS whistleblowing, despite promises to reform this major area of governance failure. A brief outline was given of the measures needed for genuine reform.
CQC FOI disclosure 15 January 2016 on Section 48 investigations conducted since inception in 2009
This FOI disclosure revealed that CQC had conducted six Section 48 investigations since 2009 (less than one a year) and that CQC had not investigated any mental health trusts despite immense service pressure and well publicised indicators of deteriorating mental health service safety.
Letter from whistleblowers 26 November 2015 : CQC a fraying rope
This letter from a group of experienced whistleblowers, to Mike Mire Acting CQC Chair, summarised how CQC has been failing to respond appropriately to whistleblowers’ concerns and supporting whistleblowers, and how CQC had failed to effectively regulate whistleblowing governance by provider organisations, or to hold senior managers to account for whistleblower reprisal.
Letter to Jeremy Hunt 16 October 2015 about his role regarding Homerton maternity whistleblowers
This letter asks questions about the Secretary of State’s and the Department of Health’s role in a major system failure to respond to black whistleblowers’ concerns about unsafe care and Race discrimination in the provision of maternity services, followed by a cluster of maternal deaths.
Critique of Francis’ model of trust-appointed Guardians
First published 21 June 2015
This is part of evidence submitted to the Department of Health on 4 June 2015, in response to its consultation on how the Freedom to Speak Up Review should be implemented.
It explains the lack of evidence base for Robert Francis’ proposals for a network of local Freedom to Speak Up Guardians, employed by NHS trusts.