Bristol and the Francis Report

On Tuesday 21st January 2014 Ms Alison Moon (Director of Transformation and Quality, Bristol Clinical Commissioning Group) and Ms Lindsey Scott (Director of Nursing and Quality at NHS England Bristol, North Somerset and South Gloucestershire Local Area Team) were scheduled to attend a meeting of Bristol City Council’s Health, Wellbeing and Adult Social Care Scrutiny Commission to present the responses of the following NHS organisations to recommendations of the Mid Staffordshire Public Inquiry

  • Avon and Wiltshire Mental Health Partnership Trust
  • Bristol Community Health
  • North Bristol NHS Trust
  • University Hospitals Bristol NHS Foundation Trust

Ms Moon’s and Ms Scott’s chutzpah does not distract attention from their evasion of public accountability for the following failings:

1. Ms Moon was Chief Nurse at University Hospitals Bristol NHS Foundation Trust when it was served a warning notice by the Care Quality Commission in October 2012 in respect of failure to meet essential standards of care on Ward 32 of the Bristol Royal Hospital for Children.

2. In December 2011, during Ms Moon’s tenure as Chief Nurse, the Trust received a report written by one of its senior paediatric nurse leaders, Judith Hernandez which said that:

There are children who require high dependency care for general paediatric/surgical conditions, in addition to specialist services who because of the lack of appropriate facilities are admitted to the Paediatric Intensive Care Unit, the only area within the hospital where such care can be currently provided safely.”

Despite this warning, Ms Moon allowed the Trust to try to provide care for children with High Dependency (HD) needs on its Ward 32. Two boys who required HD care, Luke Jenkins and Sean Turner died on Ward 32 in early 2012.

3. Ms Lindsey Scott was Chief Nurse of University Hospitals Bristol NHS Trust and its Clinical Governance Lead from 1997 to 2009. She left the Trust a few months before Dr Phil Hammond exposed misdiagnosis allegations in Private Eye about paediatric pathology and adult histopathology. It seems that Ms Scott did not volunteer to give evidence to the Inquiry appointed in 2009 to review the allegations to explain why, under her clinical governance leadership, University Hospitals Bristol had, according to the Department of Health’s Professional Standards Unit, a problem in the diagnostic quality of its service. Inquiry Chair, barrister Jane Mishcon said “we have our doubts as to whether many lessons have been learned since the Kennedy Inquiry.” Ms Scott set out the lessons which should have been learned in “Hearing the Alarm”, but refuses to publicly explain why they were not learned under her clinical governance leadership. 

Hearing the Alarm

Maybe NHS organisations in other cities have learned lessons from the Francis Report. There is no evidence that the brazen boards of NHS organisations in Bristol have learned any lessons. Nor is there any evidence that the Nursing and Midwifery Council (NMC) has applied any lessons from Francis to Bristol. It has been informed of concerns about the professional conduct of Ms Moon and Ms Scott and refused to investigate them.

Therefore it is left to Professor Stephen Bolsin, referring to Sean Turner’s death, to state the facts about Bristol which former Chief Nurses Moon and Scott and the NMC refuse to face:

 I would like to apologise on behalf of the medical profession for the poor care that Sean received and his subsequent tragic death. Having been in the same situation and seen so many similar, needless deaths before, at Bristol, in the 1980s – 90s, I find the fact that the same organisation has failed to learn from its mistakes particularly galling.”

Sadly the lives of the 171 children who died in Bristol then, but might have survived elsewhere, have not helped bring about permanent change for the better.”

SWWHAG deplores the refusal of University Hospitals Bristol NHS Foundation Trust and other NHS organisations to learn from Bristol’s mistakes.

© South West Whistleblowers Health Action Group 2014 





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