Alexander's Excavations

Dr Minh Alexander retired consultant psychiatrist 24 April 2025

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

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

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

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

This is the report.

RELATED ITEMS

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

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

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

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

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

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

Dr Minh Alexander, retired consultant psychiatrist 23 March 2025

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

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

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

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

See the parliamentary rules on APPGs:

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

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

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

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

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

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

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

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

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

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

Following this, the old Whistleblowing APPG website was deactivated.

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

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

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

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

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

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

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

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

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

Related items

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

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

Byline Times: Could Whistleblowing Become Big Business?

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

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

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

By Dr Minh Alexander, retired consultant psychiatrist 25 February 2025

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

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

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

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

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

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

RELATED ITEMS

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

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

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

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

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

NCISH homicide methodology

NCISH FOI response email 27 March 2025

HQIP correspondence to NCISH about homicide funding cut

Dr Minh Alexander 26 January 2025

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

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

The list can be found here:

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

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

RELATED ITEMS

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

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

The data and a report can be found here:

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

By Dr Minh Alexander, retired consultant psychiatrist 21 January 2025

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

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

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

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

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

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

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

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

The radiologist also noted a mass in the bile duct.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hinchingbrooke Hospital patient died as CT scan not viewed

The coroner determined:

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

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

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

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

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

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

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

This was the FOI request:

FOI request to North West Anglia re missed CT scans

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

North West Anglia response email FOI 2024 – 943

North West Anglia FOI response attachment (1)

North West Anglia FOI response attachment (2)

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

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

A number of planned remedial actions are listed.

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

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

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

Related items

Nationally, these issues have been a long recognised problem.

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

This is the RCR standards document:

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

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

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

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

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

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

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

By Dr Minh Alexander retired consultant psychiatrist

Summary

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

Introduction

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

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

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

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

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

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

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

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

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

Paula Vennells’ FPPR referral

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

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

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

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

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

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

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

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

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

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

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

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

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

CQC FOI disclosures on the conduct of Regulation 5 FPPR

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

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

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

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

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

Three of these thirty investigations had been conducted internally:

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

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

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

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

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

CQC had not rejected any of the FPPR investigation reports:

“Question

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

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

Answer

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

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

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

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

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

Tamarix People

Fiona Scolding QC

Unique Health Solutions

Law2Business

Serjeants Inn Chambers / Clyde & Co

Mark Sutton QC

Bevan Brittan

Deloitte

Cordis Bright Consulting

YSC – Young Samuel Chambers

Good Governance Institute

Capsticks Solicitors

Ibex Gale

EY

3 Independent Individuals

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

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

Law2Business (1)

Serjeants Inn Chambers / Clyde & Co (1)

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

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

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

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

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

There are some interconnections with NHS whistleblower cases.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Many NHS senior managers continue to protect their own positions.

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

Personal update

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

RELATED ITEMS

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

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

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

Dr Minh Alexander retired consultant psychiatrist 11 November 2023

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

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

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

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

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

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

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

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

This is the trust’s disclosure:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

RELATED ITEMS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

Dr Minh Alexander retired consultant psychiatrist 3 November 2023

There are no credible controls on NHS managers.

Umpteen senior abusers who have harmed whistleblowers have escaped, assisted by very weak systems and collusive regulators.

The government made a token concession after the Lucy Letby murders, by saying that it had changed its mind and would back disbarment of erring NHS managers having previously rejected this.

In reality, a simple disbarring mechanism is very far from full, robust managerial regulation which proactively addresses quality in training and ongoing professional development.

The disbarring mechanism as proposed by the Kark review is purely reactive, and a very high bar of proof is needed for disbarment. Only a few unfit individuals would be removed, if at all. Simple disbarment will not address the whole picture. It will not provide consequences for misconduct short of the threshold for disbarment, whereas full professional regulation would offer a range of sanctions and control mechanisms, such as undertakings and restrictions of practice.

I report below more evidence of dysfunction, seen in the case of NHS whistleblower Dr Jasna Macanovic at Portsmouth Hospitals University NHS Trust.

Theresa Murphy former director of nursing Portsmouth Hospitals University NHS Trust, currently Chief Nurse East and North Hertfordshire NHS Trust

Murphy was appointed director of nursing at Portsmouth in 2017. She left after two years according to her LinkedIn entry.

According to information by the trust, Murphy previously styled herself as a “professor” merely on the basis of an honorary professorial title from City of London University.

Murphy chaired the retaliatory disciplinary process by Portsmouth against Dr Macanovic (or “counter-offensive” as the Employment Tribunal described it), reporting everything back to Mark Cubbon trust CEO, as noted by the Tribunal:

106. Professor Theresa Murphy was appointed to hold the disciplinary hearing. She was the Trust’s Chief Nurse and had recently joined the Trust at the invitation of the Chief Executive, Mr Cubbon. She was also part of the cabinet group who reported to directly to him, as did Dr Knighton and Mr Powell, and like them had offices on the same corridor, attending morning planning meetings together.”

The Tribunal noted that after Dr Macanovic whistleblew, the trust “assembled” complaints against her and it mounted a “campaign of harassment” against Dr Macanovic.

The Tribunal concluded that Murphy, in concert with the medical director John Knighton made a “foregone conclusion” to dismiss Dr Macanovic and that the dismissal was unfair and was explicitly motivated Dr Macanovic’s whistleblowing. It was in other words, whistleblower reprisal.

Theresa Murphy had left the trust by the time the  ET judgment in favour of Dr Macanovic was published in March 2022 and she was not subject to CQC Regulation 5 Fit and Proper Persons at that point.

But Murphy has since been recycled, being appointed as Chief Nurse to East and North Hertfordshire NHS Trust in September 2022. This brings Murphy back into the scope of FPPR and accordingly, I have made an FPPR referral to the Care Quality Commission.

East and North Hertfordshire NHS Trust claimed that Murphy had been appointed after a “robust recruitment process”.

East and North Hertfordshire NHS Trust has just been re-rated by CQC as “Requires Improvement” overall and on the Well Led domain.

Welyn Hatfield Times 3 November 2023: CQC finds improvements still needed at Herts NHS Trust

CQC noted “Staff we spoke with told us that there was not a strong enough emphasis on the safety and well-being of staff” but CQC nevertheless claimed that whistleblowing governance at the trust was good.

Based on its meaningless tick box methods, CQC also concluded that East and North Hertfordshire NHS Trust’s Fit and Proper Person (FPPR) processes for trust directors were sound:

“Leaders generally had the skills, knowledge and experience they needed to deliver quality sustainable care. This was confirmed through our interviews with senior leaders and review of documents and personnel files. The trust had a process in place to ensure that senior leaders were appointed in line with Regulation 5 of the Health and Social Care Act 2014 (Fit and Proper Persons required) and that there was on-going review. There was also clear support for leaders to develop through mentorship and access to training.”

So either CQC failed to note Murphy’s history of serious whistleblower reprisal, or CQC was unconcerned by it.

John Knighton medical director Portsmouth Hospitals University NHS Trust

Knighton was centrally involved in Dr Macanovic’s unfair dismissal, which the Employment Tribunal determined was expressly due to her whistleblowing about serious patient safety issues.

The Tribunal concluded that he conferred with Murphy director of nursing in advance of a disciplinary hearing against Dr Macanovic, and that together, the pair came to a “foregone conclusion” that she would be dismissed.

Astonishingly, during the disciplinary hearing both Knighton and Murphy repeatedly offered to allow Dr Macanovic to leave with a “good reference”.

“The questions were led by Dr Knighton, who then summarised things as follows: JK – So in summary I think Dr Lewis has described some of the atmosphere that has been pervasive over the course of the last year. I think that in conjunction with some of the witness statements and testimony investigation does describe a pervading culture of fear and intimidation resulting in a reluctance to speak up and defensive changes in clinical practice resulted from that because people are fearful of the way that practice may be changed, an inability to discuss serious and important clinical as well as non-clinical issues relating to the service and its development. I think sadly there is significant evidence Jasna that you have not worked actively with your colleagues, that you haven’t respected their skills or treated them fairly or with respect and also that you have shown a lack of insight and indeed reflection on how your behaviour may have affected others and the working of the team. Potentially at least given the appearance that you don’t care about those things as well. I think I am afraid therefore that in summary I have to say that I believe your behaviour has caused irreparable damage to the function of the renal service and to the Trust within the consultant body and therefore the management case is that unless you wish to reconsider your position and resign to pursue a career elsewhere the management case would be that the Trust must seek your dismissal, with great regret.]”

“Professor Murphy told us that she knew that this offer would be made by Dr Knighton, so clearly they had discussed things in advance.”

“Having heard this evidence, and towards the end of the hearing, Dr Knighton referred again to his suggestion of resigning with a good reference.”

“The hearing resumed on 5 March 2018 when Professor Murphy gave her decision. At the outset, she also reminded Dr Macanovic that she could instead choose to resign with a good reference.”

Clearly, the trust should not have made this offer of a “good reference” if had a real case against Dr Macanovic. Equally the trust should not have proceeded with its disciplinary process if its disciplinary charges were unfounded.

It was very serious that the two board members with prime responsibility for clinical governance and patient safety behaved in this manner to a trust whistleblower. Especially in the context that Dr Macanovic was a senior experienced, consultant of excellent standing, who did not raise concerns lightly.

I referred John Knighton to the CQC under CQC Regulation 5 Fit and Proper Persons in May 2022.

As usual, the CQC closed it all down, giving minimal justification for its actions.

This was CQC’s FPPR closure letter of 5 October 2022:

FPPR closure letter from Sean O’Kelly CQC Chief Inspector of Hospitals

The key content from CQC was as follows:

“We shared the information that you supplied to CQC with the registered provider. We asked them to consider this information and tell us about their processes for providing assurance that their directors are fit and proper.

The information that we subsequently received from the CEO satisfied CQC that the information of concern has been looked into and that the registered provider has provided evidence in respect of the individual to demonstrate their compliance with Regulation 5.

This concluded our review of Portsmouth Hospitals University NHS Trust processes, which we feel currently meet the standards required under Regulation 5. We have informed the registered provider of this, but also that we reserve the right to review the case if further information is presented to CQC.”

CQC previously misled me about the soundness of an FPPR process in the whistleblowing case of Mr Tristan Reuser, falsely informing me that an independent investigation had been arranged by University Hospitals Birmingham NHS Foundation Trust, when it had not.

I therefore asked for more information from Portsmouth Hospitals University NHS Trust about its FPPR process.

Over the course of two FOI responses, the trust disclosed the following:

• The trust spent £18,000 for an external review by a barrister.

• The trust did NOT publish a summary of the FPPR review.

• (This is despite such transparency being recommended by NHS Providers, especially in contentious cases or where public interest is heightened by whistleblowing issues).

• No remediation was required of Knighton. (The trust’s exact words were “No, remediation was not applicable.”

• “The view that remediation was not needed was the trust’s view informed by the findings of the barrister’s report.”

• In reponse to my request for the barrister’s terms of reference for the FPPR review, the trust merely replied: “The review was requested in an email and the barrister was briefed verbally during conference with counsel.”

• The trust refused to disclose the conclusions and recommendations of the barrister’s review report.

• The trust refused to disclose if it had taken any action against Knighton for his actions and omissions in Dr Macanovic’s case.

• The trust maintained that the withheld data was all Dr Knighton’s personal data.

• The only trust officers who had seen the barrister’s FPPR report were: “The Chief Executive [Penny Emerit], the Chief People Officer [Nicole Cornelius] and relevant managers within the Trust’s HR department.”

These are the relevant FOI responses by the trust:

Portsmouth Hospitals NHS Foundation Trust FOI response 28 September 2023 John Knighton FPPR

Portsmouth Hospitals NHS Foundation Trust FOI response 27 Oct 2023 John Knighton FPPR

This last item on restriction of circulation of the barrister report was very serious in terms of trust governance. It showed that the rest of the trust board were in convenient ignorance.

There was no evident genuine, collective board scrutiny of such an important matter.

In particular the Chair was not in a position to take responsibility for the apparent decisions not to take action against Knighton or to even seek any form of remediation after gross whistleblower reprisal.

Once more, the cabal of senior NHS managers laughs at patients, staff and the general public.

The message is arguably one of impunity, arguably assisted by the regulator.

It would appear that CQC either failed to examine the trust’s FPPR governance properly, possibly deliberately, or closed the FPPR referral down knowing that the trust’s governance was poor.

I have written to the trust chair Melloney Poole to protest at the poor FPPR governance, copied to the Secretary of State, Health Committee and the CQC Chair and CEO.

Notably, in her previous role as a trust NED, Poole was the MHPS designated board member assigned to Dr Macanovic’s whistleblowing case. whistleblowing case.

Very serious harm was inflicted by the trust on a blameless whistleblower to whom Poole owed a duty of care, and there was a failure to ensure a fair MHPS process.

I have suggested that if Poole feels compromised by this, she should pass the matter to another.

I have also asked CQC to review its closure of the FPPR on Knighton in view of the trust’s admissions of poor governance and failure of oversight by the wider trust board.

I have pointed out to CQC the many concerns about the links between Portsmouth and Hampshire Hospitals NHS Foundation Trust (see related posts below), recycling of directors and the poor handling of Mr Martyn Pitman’s whistleblowing case at Hampshire. Mr Pitman was suspended for two years and became very unwell. No one has yet been held accountable for this poor HR practice. Neither organisation has impressed with its governance.

Dr Macanovic was made very unwell by her ordeal, had to spend a fortune defending herself legally, was forced to relocate and uproot her family and still did not break even financially despite proving unfair dismissal for whistleblowing and receiving compensation.

Melloney Poole was promoted to Portsmouth Hospitals University  NHS Trust chair in October 2017.

Dr Macanovic was dismissed in March 2018.

In August 2020 Melloney Poole additionally took on the chair of Isle of Wight NHS Trust in addition to her duties at Portsmouth..

Penny Everitt Portsmouth Hospitals University NHS Trust CEO, who oversaw the Knighton FPPR process, was also promoted. It was announced in May 2023 that she will be group CEO for Portsmouth and the Isle of Wight NHS Trust.

RELATED ITEMS

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

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

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

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

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

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

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

Dr Minh Alexander 30 October 2023

What is MHPS?

NHS disciplinary processes are often unfair and arbitrary, with employers holding all the power. Procedural safeguards for staff are weak. There is often harsh and disproportionate discipline, with suspension applied too frequently when it is extremely harmful to health and should be used only as the last resort, for the shortest time. Reforms were advised by the National Audit Office twenty years ago, but were predictably ignored.

Doctors in the NHS are disciplined according to fig leaf procedure called Maintaining High Professional Standards in the Modern NHS (MHPS).

The procedure covers misconduct and incapability, whether due to competence or ill health.

In the process, the employer is investigator, judge, jury and executioner. There is no external scrutiny.

Even where disciplinary action is appropriate, MHPS procedure is often applied excessively harshly.

MHPS is also sometimes applied vexatiously, to unwanted doctors such as whistleblowers.

Application of MHPS in the cases of Dr Jasna Macanovic and Mr Martyn Pitman

Dr Macanovic’s whistleblowing case against Portsmouth Hospitals concluded in January 2023. She “won” comprehensively at all stages. The Employment Tribunal determined that Dr Macanovic was unfairly dismissed, expressly for whistleblowing to the General Medical Council.

Portsmouth Hospitals University NHS Trust gave “serious misconduct” – not “gross misconduct” – as the reason for dismissal.

The Tribunal rejected this and determined that Dr Macanovic did not in any way contribute to her own dismissal.

The Tribunal was refreshingly robust in pushing back against the trust’s claims that relationships had broken down irreparably as a result of Dr Macanovic’s whistleblowing.

The Tribunal determined that “It is no answer to a claim of whistleblowing to say that feelings ran so high that working relationships broke down completely…”

Reassuringly, the Tribunal gave serious weight to the patient safety issues raised by Dr Macanovic, and did not lose sight of them, keeping them central to its deliberations.

In the maternity safety whistleblowing case of Mr Martyn Pitman at Hampshire Hospitals NHS Foundation Trust, the trust’s purported grounds for dismissal was breakdown of relationships, with the technical route of “Some Other Substantial Reason” invoked.

SOSR is a classic method of dismissing whistleblowers where organisations are unable to make a case of misconduct or incapability.

Thousands of unwanted NHS staff in general have been wastefully dismissed via this route, in a system where the power lies almost entirely with employers.

Mr Pitman clearly made public interest disclosures, which the Employment Tribunal has recognised.

He suffered greatly and became very ill after prolonged suspension under MHPS.

He has two claims in the ET, one for whistleblowing detriment upon which the Tribunal has ruled, and a hearing scheduled for a claim of unfair dismissal.

The Tribunal, has concluded in Mr Pitman’s from the first hearing of his case that the harm which he suffered did not comprise detriment for whistleblowing.

It is relevant to note that regardless of the disputed issue about whistleblowing detriment, there was an NHS human resources “never event” in Mr Pitman’s case, as defined by NHS England guidance of May 2019:

“Where a person who is the subject of an investigation or disciplinary procedure suffers any form of serious harm, whether physical or mental, this should be treated as a ‘never event’ which therefore is the subject of an immediate independent investigation commissioned and received by the board. Further, prompt action should be taken in response to the identified harm and its causes.”

In contrast with the Tribunal in Dr Macanovic’s case, the Tribunal in Mr Pitman’s case gave more weight to his employer’s claims about his communication style than his patient safety concerns. It has reportedly accepted that his alleged communication style was the reason for the trust’s action against him, not his whistleblowing.

This is despite the trust’s failure to fully address Mr Pitman’s patient safety concerns and his concerns about reprisal for whistleblowing. Usually, Tribunals will take such failures into account, against employers, when ruling on whistleblowing cases.

The judgment is not yet published, and Mr Pitman and his advisors have yet to decide on next steps.

MHPS governance at Hampshire Hospitals NHS Foundation Trust

In the context of claims and counter claims about Mr Pitman’s case, I asked Hampshire about its governance of MHPS process.

I was especially concerned by the very long period for which Mr Pitman was excluded, two years.

In my view, this is was very bad practice. Suspension is an extremely harmful event, with serious risk to employees’ physical and mental health. It should be considered and managed as a human resources emergency, applied sparingly and for the shortest period possible. Long periods of suspension raise questions of punitive motives by employers. They are also very wasteful.

Hampshire Hospitals NHS Foundation Trust has responded evasively to my FOI request. This is the trust’s response:

FOI response by Hampshire Hospitals NHS Foundation Trust on MHPS Ref 23-24 342

The trust admits to fewer than five instances of MHPS being applied in the last five years. According to the trust, all MHPS cases in this period were upheld. The trust refused to give the range in the length of suspensions, claiming that this was due to small numbers. This raises questions about whether other doctors besides Mr Pitman may have suffered prolonged suspensions.

In the last five years, three Hampshire Hospitals NHS Foundation Trust board members have assumed the critical role of “MHPS designated board member”:

1. Clancy Murphy – Non-Executive Director
2. Jane Tabor – Non-Executive Director
3. Dr Simon Holmes Non-Executive Director

MHPS designated board members have responsibility for overseeing the MHPS process, to broadly ensure fair play, to be a point of contact to whom suspended doctors can bring issues and in particular to ensure that MHPS process is timely and in accord with Article 6, the right to a fair trial.

Designated board members should not – in theory – allow organisations to punish doctors by keeping them in “MHPS jail” longer than is necessary.

At Hampshire, Jane Tabor trust NED was involved in Martyn Pitman’s case. A preliminary judgment notes that Mr Pitman raised concerns with her and with the trust Chair about his treatment, in an email of 26 February 2021:

“I would welcome the opportunity to meet with you virtually to feedback my experiences and reflections over the last 2 years, having been subjected to a Trust Disciplinary Investigation throughout this protracted time period. I also have recommendations that I wish to make that are relevant both to the Trust’s handling of my but also I believe, are potentially critical for the future health and wellbeing of every member of the HHFT workforce.”

The trust denied that this expression of concern was whistleblowing, and asked for this part of Mr Pitman’s claim to be struck out, but the judge wished to hear more detailed argument on the issue.

Regardless of the technicalities over the narrow legal definition of whistleblowing, it is disappointing that the trust minimised the concern raised by Mr Pitman, as it certainly falls within the NHS national whistleblowing (Freedom to Speak Up) policy.

As regards Simon Holmes acting as an MHPS designated board member, this is of concern in view of his past actions towards whistleblower Dr Jasna Macanovic. Holmes retired as medical director at Portsmouth in 2017 and later became at a NED at Hampshire.

The Tribunal judgment in Dr Macanovic’s case shows that Holmes was the medical director who originally launched disciplinary action against Dr Macanovic after she whistleblew to the General Medical Council about unsafe practices by her medical colleagues. This was despite the fact that several other experienced consultants had raised similar concerns. Holmes also failed to share advisory correspondence from NCAS, the body which advises NHS trusts on the proper application of NCAS. NCAS always advises NHS organisations to disclose its correspondence to suspended doctors for fairness and transparency. Unfortunately, NCAS does not check that correspondence is shared.

I asked Hampshire if it had a process for ensuring that MHPS designated board members have no history of whistleblower reprisal, and how the trust assures itself that its MHPS processes are not in fact a form of whistleblower reprisal.

The trust’s responses were weak and evasive.

Where I asked if the trust had triggered MHPS after any doctors had made public interest disclosures, the trust replied off the point. It introduced the phrase “as a result of” and replaced “public interest disclosure” with “protected disclosure” (they are legally distinct).

Question: “Please indicate if any of the MHPS investigations in the last five years have been conducted against any doctors who had made public interest disclosures, and if so, how many?”

Trust answer: “No MHPS investigation has been triggered as a result of a member of staff making a protected disclosure.”

This trust response may hide other cases of MHPS action after whistleblowing by other doctors, besides Mr Pitman.

Hampshire Hospitals NHS Foundation Trust speciously claimed that its whistleblowing and disciplinary processes are “entirely separate”:

Question: “If so, did the trust take any special precautions to satisfy itself that the MHPS investigation(s) did not represent any form of whistle-blower detriment or reprisal?”

Trust answer: “The MHPS process and the whistleblowing/Freedom to speak up process are entirely separate processes. The Trust has never and will never use the MHPS process or any other disciplinary or investigatory process in detriment or reprisal against any member of staff who has raised concerns about the safe working of the hospital.

Hampshire Hospitals NHS Foundation Trust actively encourages its staff to raise any concerns that they may have and would never take any steps which would jeopardise this.”

It is disingenuous of the trust to claim complete separation between the MHPS process and NHS whistleblowing policy.

Firstly, NHS national whistleblowing policy at the time of Mr Pitman’s whistleblowing explicitly included zero tolerance of reprisal against whistleblowers:

“We will not tolerate the harassment or victimisation of anyone raising a concern. Nor will we tolerate any attempt to bully you into not raising any such concern. Any such behaviour is a breach of our values as an organisation and, if upheld following investigation, could result in disciplinary action.”

It follows that NHS trusts should have the means to identify and deter such harassment. This therefore links whistleblowing procedures and disciplinary procedures, which may be used vexatiously.

(NB. The clause about zero tolerance of reprisal seems to have been removed from the latest version of the NHS national whistleblowing policy.)

Secondly NCAS, now PPA, the body responsible for advising NHS trusts about the application of MHPS process has recently been consulting with NHS trusts about strengthened processes and procedural safeguards. This is to reduce the likelihood that whistleblowers are punished by organisations using MHPS vexatiously.

The trust’s defensive stance in insisting there is total separation between the two processes raises concern about its governance.

The trust also responded evasively to a question which partly related to NED Simon Holmes’ track record against a whistleblower, Dr Macanovic. The trust claimed that its processes addressed whether directors had a history of adverse behaviour towards whistleblowers:

Question: “Does the trust have any system of checks to ensure that any board member whom it appoints to act as an MHPS designated board member has no past history of detrimental behaviour to whistle blowers? If so, please give details.”

Trust answer: “All board members are subject to the Fit and Proper Person Test prior to appointment. The test considers someone’s behaviour in previous posts is to ensure that anybody seeking a board position is an appropriate person to hold the position. This would include whether any person seeking an appointment to the board has been found to have acted detrimentally towards anyone using the freedom to speak up policy.”

Indeed, the trust went on to flatly deny that any designated MHPS board members had harmed whistleblowers, despite the ET’s criticisms of disciplinary action against Dr Macanovic:

Question: “Please disclose if any MHPS designated board members appointed in the last five years have had, to the trust’s knowledge, any prior history of detrimental actions against whistle-blowers.”

Trust answer: “No member of the board has any prior history of acting detrimentally towards whistle-blowers.”

Hampshire also failed to account for whether it had evaluated the experience of trust doctors subjected to MHPS. It replied regarding only one case – likely to be Mr Pitman’s case – and it gave no evidence of wider evaluation. This is presumably because no general evaluation was done and because the trust does not concern itself with collecting data on doctors’ experience of its process.

Question: “In the last five years, has the trust undertaken any evaluation of the experience of trust doctors who have been subject to MHPS investigations? If so, please give details of how any evaluation has been conducted, and the broad outcome.”

Trust answer: “The Trust has reviewed the effectiveness of this process and its impact on an individual undergoing an investigation. We are assured that the process is robust and in compliance with all guidance in relation to safeguarding the wellbeing of individuals under investigation.”

Lastly, the trust flatly denied a concern by both Mr Pitman and the BMA which has supported him, that the trust was so opaque that an FOI request and a request for personal data had to be made in order for Mr Pitman to learn what was alleged against him.

“It has not been necessary for any member of staff to use the Freedom of Information Act to discover the nature of allegations made against them.”

Although the trust has for the meantime dodged a bullet and been given the benefit of the doubt by the Employment Tribunal, it hardly impresses on accountability and transparency. It is difficult to feel reassured that future whistleblowers will be treated fairly by Hampshire Hospitals NHS Foundation Trust.

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

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

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

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

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

Last month there was a highly significant press report on the fact that UHMBT has allegedly failed to refer serious maternity cases to the coroner.

Disgracefully a bereaved couple, Sarah Robinson and Ryan Lock, were forced to refer the death of their baby Ida at UHMBT to the coroner, because the trust had failed to do so.

This was despite the fact that expert reports had identified “a catalogue of concerns” in Ida’s care.

The couple reportedly endured a “four year fight”:

NHS trust at the centre of a baby-death scandal faces another inquiry into its maternity care amid fears children’s lives remain at risk

The Senior Coroner for the area James Adeley expressed concern that Ida’s parents were forced to report matters to the coroner because the trust had failed to do so:

“Coroner Dr James Adeley told a pre-inquest hearing in Preston this week he was concerned it had been left to Ida’s parents to report her death to his office after hospital managers failed to do so.”

Importantly Dr Adeley observed that, to his recollection, UHMBT had failed to refer any baby deaths since the Kirkup report on maternity failures was published in March 2015.

“He said he was worried ‘systemic’ problems in maternity care identified by Dr Bill Kirkup in March 2015 had not been addressed. He said he could ‘not recall’ a single baby death being reported to him since.

Dr Adeley said. ‘There’s no indication that matters identified in the Kirkup Report have been addressed before this case. That suggests a lack of learning from the report continues to exist, and continues to place lives at risk.’

UHMBT was previously criticised for collusive staff responses to coroners’ inquests, as noted in Kirkup’s report:

“1.93 The coroner made strong criticisms of both the clinical practice and conduct of Trust staff, including collusion in preparation for the inquest and possible destruction of evidence already discussed. Following a Rule 43 letter from the coroner expressing these concerns…”

I therefore asked the trust via FOI for information on serious maternity incidents, related referrals to the coroner and the HSIB maternity investigation programme and the trust’s documented claims about the safety and governance of its maternity services, as submitted to the NHS Resolution Maternity Incentive Scheme.

I asked for data from 2015 onwards, following the publication of Bill Kirkup’s report of the inquiry into maternity deaths at UHMBT.

The trust delayed the FOI process by twice asking about definitions of the serious incidents, when these definitions are standard and the basis of routine data submissions to the centre.

The trust has now responded with an obfuscatory reply.

This is the trust’s FOI response of 26 October 2023:

FOI Ref 22874 response by University Hospitals Morecambe Bay about maternity safety and referrals to HSIB and the coroner

In brief, instead of giving total numbers of serious maternity incidents and total numbers of referrals to HSIB, the trust has avoided this by giving yearly totals and claiming that numbers in some years were too small to reveal.

Crucially, the trust has refused to disclose at all:

• How many investigations of baby deaths have been shared with bereaved families

• How many baby deaths have been referred to the coroner

The trust’s data indicates there have been at least 23 baby deaths at UHMBT since 2015, although the precise figure is not yet disclosed.

There seem to have been more baby deaths since 2018:

UHMBT claims that it would take too much time to retrieve the data on the number of baby deaths referred to the coroner and doing so would breach FOI limits:

“5. How many of these neonatal deaths have the trust referred to the coroner?

Due to the amount of time to answer Question 3 would be >10hours. To answer Question 5 would be an additional >10 hours. Therefore we estimate in excess of 20 hours to answer these two questions. This does not include the time it has taken to respond to the questions we have provided the information for. The Trust has used multiple systems since 2015 and a review of each care record would need to take place. This information is not held centrally and would require a review of every healthcare record.”

So extraordinarily, the trust asks us to believe that it does not track and cannot tell how many baby death it has referred to the coroner. This could imply appalling governance and failure to learn after an inquiry which slammed its maternity practices, including honesty in interactions with the coroner.

The alternative conclusion being that the trust is not being truthful in claiming that Section 12 FOIA cost exemption applies.

Although the trust claims it is unable to say how many baby deaths were referred to the coroner, it can say that maternal deaths were referred to the coroner in 2015, 2020 and 2021 (albeit without disclosing the actual numbers).

Because of UHMBT’s incomplete disclosure, it is also not clear how many of the trust’s baby deaths were referred to HSIB. At the very least, four referrals were made out of at least twenty baby deaths from 2018 onwards (when the HSIB maternity investigation programme was launched).

Also, the trust failed to disclose requested copies of its submissions to NHS Resolution’s Maternity Incentive Scheme, and instead gave very crude summary data that appears to be raw scores of compliance. Thus, it avoided revealing meaningful detail.

I have written to Aaron Cummins UHMBT CEO, 2012 to present, to ask for a valid response to my FOI request. I copied this to the Senior Coroner.

I received a response from Cummins nine minutes after sending my letter, advising me that a response would be provided “as soon as possible”.

Any further data received from UHMBT will be posted here.

In the meantime, this is a disclosed copy of the UHMBT policy governing the trust’s interactions with the coroner’s office:

UHMBT FOI disclosure: Medical Examiner’s Office Process

These are the salient passages:

1. Section B Coronial Cases

4.1.3.39 Ministry of Justice Guidance
Guidance for registered medical practitioners on the Notification of Deaths Regulations (publishing.service.gov.uk)

For registered medical practitioners on the Notification of Deaths Regulations March 2022 sets out the circumstances in which a death should be notified to the Coroner. In addition, the Lancashire Senior Coroner and Regional Medical Examiner has issued a Standard Operating Procedure for referrals to Coroner (see section 5 form 4)

4.1.3.40 Cases identified as potentially Coronial by MEO/QAP/ME should be jointly discussed. Taking into account local guidelines (see section 5 form 4) and Ministry of Justice Guidance

4.1.3.41 If there is agreement that it should be referred to Coroner then case should be discussed with Coroner’s Officer highlighting reason for referral and whether a cause of death can be offered in Ulysees B6

4.1.3.42 Where there is still uncertainty whether Coroner referral is appropriate the ME can contact the coroner to discuss case.

4.1.3.43 It is anticipated that usually in practice, it will be the practitioner who is qualified (QAP) to complete the medical certificate cause of death (MCCD) who will be making the notification to the senior coroner.

4.1.3.44 To facilitate referral the ME Service will where necessary complete Deceased Details (icasework.com) and include ME scrutiny and QAP Death Summary

4.1.3.45 Where the death is clearly unnatural it may be more appropriate for a notification to be made to the senior coroner straight away by the Consultant responsible for the patients care.eg where the Police are involved

4.1.3.46. Regulation 4(1) requires the notification to the senior coroner to be made as soon as is reasonably practicable after the medical practitioner has determined that the death should be notified.

4.1.3.47 While the regulations do not prescribe a specific time limit for notifications this notification should be prioritised. If the death arises from an event or occurrence that may be suspicious then the police should be informed immediately.

4.1.3.48 A death may have already been reported to the coroner by a person other than a medical practitioner, such as a friend or family member of the deceased, or the police. Such reports will not usually include the information required at regulation 4(3) and (4), and may not provide the coroner with the full medical picture.

4.1.3.49 Therefore, even if a medical practitioner is aware that someone other than a medical practitioner has reported a death to the coroner, the registered medical practitioner should still make a notification under the Regulations

4.1.3.50 The medical practitioner should usually take reasonable steps to establish the cause of death before notifying the coroner. This may include seeking advice from another medical practitioner, such as a medical examiner or any other responsible consultant.

4.1.3.51 If in opinion of ME case should be referred to Coroner and QAP wants to issue MCCD and does not want to refer to Coroner the QAP should be advised to discuss case with their senior Colleague.

4.1.3.52 If the ME and Consultant responsible for patient care cannot reach agreement and the ME still thinks it is appropriate to refer the case to the Coroner then the ME should discuss the case with another ME or Lead ME, or if necessary, in their absence Regional ME.to agree next steps.

4.1.3.53 A coroner’s investigation may not be necessary in all notifiable cases.

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UHMBT is currently rated “Requires Improvement” by the Care Quality Commission, including on the Well Led domain.

UHMBT has been the scene of repeated whistleblower reprisals and gaggings, going back many years. I cite a few of the cases.

Breast screening whistleblowers were harmed and gagged by UHMBT.

Public Health England confirmed in 2015 that their concerns were valid:

External review into North Lancashire and South Cumbria Breast Screening Programme

Litigation continued about the gagging.

A recent case is that of Mr Shyam Kumar, who was doubly harmed both as a trust and a Care Quality Commission employee, after he whistleblew about the unsafe surgical practice of another trust surgeon and other matters.

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

Tulloch report 2020 on orthopaedic safety at UHMBT (page 60 onwards)

But despite the trust’s questionable governance, it loomed large as a key tool in Jeremy Hunt’s campaign to present himself as a patient safety champion.

Hunt’s favourites have prospered, including Jackie Daniel the former UHMBT CEO 2012-2018, who was damed and moved onto a plum job at Newcastle.

Daniel was even mentioned favourably at PMQs in a question by the local Tory MP:

“Jackie Daniel received a Damehood for turning around Morecambe Bay Trust, very positive, along with the staff. Would my Rt Hon Friend the Prime Minister, look forward to working with her successor and carry on turning around Morecambe Bay Trust and wish Jackie well.”

In response, Mrs May MP said: “I am happy to join my Hon Friend in paying tribute to the work of the staff at the Morecambe Bay Trust and particularly to wish Dame Jackie well and to recognise and pay tribute to the work she has done turning that trust around.”

Jeremy Hunt et al’s re-branding of Morecambe Bay and a suppressed report on Race concerns

University Hospitals of Morecambe Bay NHS Foundation Trust’s handling of counter-allegations against whistleblowers

UHMBT has made use of Capsticks’ legal services, including representing the trust against whistleblowers and the drafting of settlement agreements with whistleblowers:

Morecambe and wise counsel

In 2012 UHMBT entered into a highly questionable agreement with a midwife who was accused of cover ups, where redundancy with 14 months pay was agreed on the basis that she would not be investigated for maternity care failures:

“Following discussions between the employee and the trust, the employee has opted to take early redundancy and as a result the employer has agreed not to commence an internal investigation into the employee’s performance as maternity risk manager.” 

Morecambe: All that glisters…

However, in 2018, it was reported by the Nursing and Midwifery Council that the midwife admitted many of the allegations against her:

“Grace Hansen, acting for the NMC, said: ‘’Jeanette Parkinson was a maternity risk manager at Morecambe Bay Hospitals Trust from 2004 to 2012.

She was also appointed as a supervisor of midwives by the Local Supervising Authority from November 2002.

‘’In 2008 two maternity and three neonatal deaths occurred at Furness General. The charges brought by the NMC relate to Miss Parkinson’s investigation of these these tragic events on behalf of the trust and the LSA.

‘’She has admitted many of the charges and accepts they amount to misconduct and her fitness to practice has been impaired by reasons of that misconduct.

‘’The parties agree the only appropriate and proportionate action is a striking off order. This is the most serious sanction the NMC can impose.”

Midwife at centre of baby death scandal faces being struck off after 11 babies died during her time at trust