Category Archives: Uncategorized

Last Post

This is the last post on this blog. It was set up in the aftermath of the Bristol Histopathology Inquiry. 

Bristol’s histopathology services are part of the cellular pathology service which is now managed by North Bristol NHS Trust. Thus the key recommendation from the Histopathology Inquiry – one cellular pathology service for Bristol – has been achieved. 

We are not in a position to comment on the quality and safety of the merged service because no outcomes data for it is publicly available.

Patients requiring cellular pathology services may wish to ask their doctors for outcomes data to enable them to provide informed consent for cellular pathology investigations.

A Citizen Whistleblower’s evidence for the IPSIS Expert Advisory Group

The background to the call for evidence is here:

https://www.gov.uk/government/groups/independent-patient-safety-investigation-service-ipsis-expert-advisory-group

Here is the covering letter:

IPSIS EAG – Evidence

The evidence includes two case studies as examples of how not to conduct investigations.

First Case Study and Supporting Documents:

Histopathology Inquiry Case Study

Histopath Attachment 1    An opportunity cost of a £734k inquiry

Histopath Attachment 2   A Case Study Review Analysis

Histopath Attachment 3   A clinician blows the whistle to former South West SHA Medical Director, Dr Mike Durkin (Chair of the IPSIS EAG)

Histopath Attachment 4   Dr Durkin’s, Dr Chris Burton’s, Mr Julian Brookes’  and Mr Andrew Millward’s handling of a Freedom of Information Request.

Histopath Attachment 5   Julian Brookes’ (formerly of the South West SHA and now a member of the IPSIS EAG) briefing to Sir Ian Carruthers on Statistical Sampling.

Second Case Study and Supporting Documents:

Risk Summit Case Study

Risk Summit Attachment 1  Risk Summit minutes 29th October 2012

Risk Summit Attachment 2  provides insight into an NHS Chief Executive’s response to a Risk Summit hosted by the Care Quality Commission (CQC). It includes the Chief Executive’s accusations to the CQC that it was biased in favour of bereaved parents.

Here’s a question for whistleblowers. Why bother to try to make the world a better place? Perhaps this is one answer:

“Albert Camus, a great humanist and existentialist voice, pointed out that to commit to a just cause with no hope of success is absurd. But then, he also noted that not committing to a just cause is equally absurd. But only one choice offers the possibility for dignity. And dignity matters. Dignity matters.

Stripped of all platitude and illusion, Camus was saying we still have to fight. So for God’s sake, fight. And get angry if you need to get angry. A little anger is a good thing if it isn’t on your own behalf, if it’s for others deserving of your anger, your empathy. And if you see the wrong around you getting bigger and uglier, then speak up, and call that wrong by its true name. Learn to refuse, to dissent. And in demanding something more from yourself and from your society, you may be surprised to find that you are not entirely alone. That other voices are saying the same things, that others want the same things.” (David Simon)

http://articles.baltimoresun.com/2012-05-25/news/bs-ed-simon-20120525_1_new-century-woody-allen-commencement/2

Bristol CCG – Defence and Denial

Bristol Clinical Commissioning Group’s Freedom of Information and Complaints Manager is Kathryn Tucker.

When holding the same position at NHS Bristol Primary Care Trust (PCT), Ms Tucker provided this advice to a colleague, Lindsey Scott (1) regarding a request to the Information Commissioner (ICO) for a review of the PCT’s decision that a Freedom of Information (FOI) Request (2) was “vexatious” under Section 14 of the Freedom of Information Act 2000:

“The requester is only able to request a review of each individual response, whereas when providing our supporting evidence we are able to provide evidence of previous requests and other correspondence as examples of context.”

In other words Ms Tucker advised Ms Scott that the ICO treated FOI requesters and public authorities differently when reviewing an authority’s decision to deem an FOI request “vexatious”.

This seems odd and unfair to requesters so I asked the ICO for its policy (3). The ICO eventually confirmed that no such policy was held and that “The public authority’s statement is inaccurate.”

The ICO also stated that “although we consider all FOIA complaints on a case by case basis, this doesn’t mean that we won’t take the requester’s view of the public authority’s previous behaviour into account when looking at cases involving section 14.”

Members of the public whose FOI requests have been deemed “vexatious” by public authorities can judge how often the ICO genuinely takes into account the requester’s view (and evidence) of a public authority’s previous behaviour.

I provided all the above information in a document to the CCG at its public question time held on 28th July 2015 and raised the question of whether Ms Tucker knowingly misrepresented the facts to Ms Scott or whether she simply did not check them. Either way I asked what specific action the CCG would take to ensure that the public will be protected from such inappropriate behaviour in response to FOI requests in future and I invited the CCG to contact me if it wished to meet me to discuss the matter.

On 12th August 2015, the CCG’s Chair, Dr Martin Jones replied to the document saying “what was stated was factually accurate”. He did not clarify which statement made by whom he regarded as factually accurate. He also seemed to suggest that Ms Tucker’s actions when Freedom of Information Manager for Bristol PCT have no bearing on her ability to perform the same role for Bristol CCG.

I replied to Dr Jones pointing out that when a person is discovered to have made an error, it is normal to apologise and take action to reduce the risk of recurrence. I reminded Dr Jones that I had provided the CCG with documentary evidence that its Freedom of Information Manager, Kathryn Tucker misrepresented facts in advice she gave to a senior NHS manager regarding a Freedom of Information appeal; and I made the obvious point that such behaviour undermines public confidence in her ability to perform that role as the CCG’s FOI Manager because it poses a risk to the CCG’s ability to respond appropriately to FOI requests.

The point is lost on Dr Jones because Bristol CCG’s leaders (4) remain embedded in the dysfunctional culture which lives on in many parts of the NHS – defend, deny and never apologise, even when staff have been found to have spread misinformation in their role as a Freedom of Information Manager.

Dr Jones’ response is not surprising. Bristol CCG’s attitude to the public it serves is already well known (5).

Daphne Havercroft

SWWHAG

(1) https://swwhag.wordpress.com/2014/01/21/bristol-and-the-francis-report/
(2)  https://www.whatdotheyknow.com/request/director_of_commissionings_induc#outgoing-169937
(3) https://www.whatdotheyknow.com/request/ico_policy#incoming-680894
(4) https://www.bristolccg.nhs.uk/about-us/our-people/our-governing-body/
(5) https://protectournhs.wordpress.com/2014/06/13/when-will-bristol-ccg-stop-this-farce-chapter-two-in-the-continuing-story-of-a-misleading-press-release/

Opportunity Cost of the £734,000 spent by University Hospitals Bristol NHS Foundation Trust on a Histopathology Inquiry

This is how the £734,000 cost to the public (confirmed by the National Audit Office), of a Histopathology Inquiry (1) commissioned by the Trust could have been used to improve the care of patients, in this example children with congenital heart disease, by reducing the risk of harm caused by too few skilled nurses at the Bristol Royal Hospital for Children.

A Department of Health Briefing (2) cleared by Sir Bruce Keogh, was issued following the CQC’s 2012 inspection of Ward 32 at the Bristol Royal Hospital for Children.

Paragraph 18 says:

“The major issue of concern is that there are no step down facilities e.g. a High Dependency Unit (HDU) between the Paediatric Intensive Care Unit (PICU) and the ward. The CQC consider that, given the complex case load, there should be such a facility as there are too many children with complex needs being treated by too few nurses who are not sufficiently skilled”

The first paragraph of the Histopathology Inquiry Report, published in December 2010, acknowledges that the cost of the Inquiry need never have been incurred if the Trust had ensured that concerns were properly investigated when managers first knew about them.

“An Inquiry of this nature, scope and cost would never have been necessary or probably even contemplated had concerns been thoroughly and promptly investigated when and whenever they were raised and the results of those investigations made clear to those who had made the allegations.”

The £734,000 of public money spent on the Histopathology Inquiry whose report fails to explain why senior doctors and NHS managers who knew about the concerns for years failed to adequately investigate them, could have paid for 23 Grade 5 staff nurses for a year (3). With appropriate skills, these nurses could have alleviated some of the staffing problems on Ward 32 which presented a risk to the safe care of children.

(1) http://drphilhammond.com/blog/2011/01/21/private-eye/medicine-balls-private-eye-issue-1280/

(2) https://www.whatdotheyknow.com/request/169406/response/419243/attach/3/796181.pdf

(3) https://www.nice.org.uk/guidance/sg1/documents/safe-staffing-guideline-consultation9

Table 2 page 18 – £734,000 divided by total cost of a band 5 staff nurse, £31,867 would pay for 23 band 5 staff nurses for a year, or 18 band 6 charge nurses or 15 band 7 sisters/ward managers.

© South West Whistleblowers Health Action Group 2015

Dame Julie Mellor, “The Morecambe Bay Stance” & Bristol

These blog posts are relevant to our post:

http://www.morecambebayinquiry.co.uk/index.php/blog

http://phsothetruestory.com/2015/03/08/does-dame-julie-mellor-meet-the-fit-and-proper-person-test/

https://patientsafetyfirst.wordpress.com/2015/03/07/phsos-capability-questioned-after-morecambe-bay-report/

Open Letter to Dame Julie Mellor, the Parliamentary and Health Service Ombudsman – 8th March 2015

Dear Dame Julie,

Complaints Reference EN-145676

The purpose of this letter is to give you and your organisation feedback on your handling of the above complaints and propose an action for you and your board of directors. The background and timeline of the complaint handling are here:

PHSO Background and Timeline

In our opinion the way in which you and some individuals in your organisation have handled this complaint is a case study in maladministration, misuse of public money and immoral, unethical and unprofessional conduct.

The timeline reveals that one of your staff explained to your Managing Director, Mick Martin that the PHSO had not investigated our complaints because:

“we decided that one of the regulatory bodies was dealing with the matter – it has very broad similarities to the stance we took in the Morecambe Bay complaint….”

The Morecambe Bay Inquiry Report reveals the immense damage caused by this stance. Similar damage has been inflicted on Bristol which is still haunted by past and present NHS failings.

Our timeline also reveals that the PHSO’s decisions as to whether or not to investigate a complaint can be improperly influenced by the NHS organisations against which complaints have been made. This is what one of your investigation managers said about our request for review of the PHSO’s refusal to investigate our complaints:

“if we uphold the complaint about us and re-investigate there is a risk to our relationship with the bodies that are subject to the complaint (some of which believe that the matters are not for the Ombudsman to investigate).” (PHSO Investigation Manager, Morgan Phillips 6th October 2014) (1)

This shameful statement was made six months ago and belies the plethora of PHSO spin that it can be trusted to handled complaints fairly. The PHSO’s investigation remit is governed by Parliamentary Statute, not the whims of the NHS. The PHSO is not answerable to unelected NHS officers, some of whom want to avoid accountability for their misconduct and continue to bully and suppress staff and citizen whistleblowers. The PHSO is accountable to Parliament, which is answerable to the citizens of Britain.

We agree with the Patients Association’s November 2014 analysis of the PHSO. It is the final and fatal mix of the toxic culture which repeatedly fails those who raise complaints about the Health Service.

We call on you and your board of executive and non executive directors to resign before you cause any more damage to people who entrust their complaints to your organisation.

Yours sincerely,

South West Whistleblowers Health Action Group.

(1) 8th July 2015, PHSO Managing Director Mick Martin says that the comment was made by Suzannah Beazley, then Head of the Review Team. We don’t care who at the PHSO made it. It’s shameful.

A former BMA solicitor decides, but is it justice?

In April 2013 three members of SWWHAG appealed against the Information Commissioner’s decision to uphold as “vexatious” a Freedom of Information (FOI) Request made to NHS Bristol Primary Care Trust for the same information that its Director of Commissioning, Louise Tranmer had requested of North Bristol NHS Trust.

Unlike most other exemptions to the Freedom of Information Act 2000, the vexatious exemption is not subject to a public interest test. That is why some public bodies and their officers seize it to unscrupulously conceal information of public interest, as NHS Bristol did in this case.

The Information Commissioner and NHS Bristol declined to be represented at the First Tier Tribunal Hearing. The Tribunal Panel was chaired by Christopher Hughes, former solicitor to the BMA (British Medical Association), and included two lay people, Suzanne Cosgrave and Jacqueline Blake. The role of the Information Tribunal Panel is simply to determine whether the Information Commissioner’s Office has applied the Freedom of Information Act lawfully. However this Tribunal Panel upheld the Information Commissioner’s decision by way of this curiously intemperate ruling:

http://goo.gl/7N94P4

We decided not to appeal to the Upper Tribunal against the First Tier Tribunal decision because the chances of success were low. Our experience is that Tribunals regard litigants in person (people who have  no legal representation), as pests, to be swatted away. For the record here is our response to the Tribunal’s ruling that the FOI request was a “gross misuse” of the act. It did not reply:

https://www.dropbox.com/s/pkxosgsf048jvkr/Response%20to%20Tribunal.pdf?dl=0

Our recollection of Panel member Jacqueline Blake’s participation in the hearing was that she yawned once and asked one unmemorable question. Suzanne Cosgrave asked why we had resorted to the Freedom of Information Act instead of relying on normal mechanisms of accountability. When we explained that normal mechanisms don’t work with the NHS, she moved on quickly.

Christopher Hughes seemed disinterested when we pointed out that the bundle submitted by the Information Commissioner contained documents which were prima facie evidence of breach of the Data Protection Act and Freedom of Information Act by NHS Bristol.

The Tribunal’s decision obsesses about SWWHAG’s relationship with NHS organisations and its views on the Bristol Histopathology Inquiry, managed by management consultants, Verita.

https://swwhag.wordpress.com/2013/03/03/beware-nhs-independent-inquiries/

The Tribunal’s narrative about the co-chair of a Pathology Lay Reference Group, Mr Malcolm Watson (Page 13) is “illuminating” because it relies solely on Mr Watson’s own words and ignores these facts:

https://swwhag.wordpress.com/2012/08/10/winterbourne-view-have-cqc-and-south-gloucestershire-learned-anything/

and this:

The specific bit that riled me was the apparent quote cited on page 11, which states “The exhaustive inquiry found no evidence to suggest that the histopathology department at University Hospitals Bristol provides anything other than a safe service.” (Sentence is in bold in the middle of a paragraph!). This made me angry……… For a start it is taken out of context.  Secondly it is cherry-picking one of the few non-negative comments about UHB histo in the whole report.” (South Gloucestershire Local Involvement Network Chair Malcolm Watson, commenting on University Hospitals Bristol’s Quality Account 2010/11 on 10th May 2011).

The Histopathology Inquiry covered up the extent and seriousness of the histopathology problems and senior doctors, including a former president of the Royal College of Pathologists, have not been held accountable for the part they played in this.

https://www.dropbox.com/s/hmat4w7gcaccrz0/Case%20reviews.pdf?dl=0

At first sight, it’s difficult to understand why the Information Tribunal Panel thought our opinions about the Inquiry were relevant to an appeal against an FOI request which simply asked for the same information about service quality that NHS Bristol’s Director of Commissioning had tried to obtain from North Bristol NHS Trust; until you consider this:

Suzanne Cosgrave’s career includes the following:

  • General Pharmaceutical Council, Fitness to Practise lay member (reserve)
  • Council member, General Dental Council
  • Chief Executive, Worthing Priority Care NHS Trust
  • General Manager – Operations, Medical Defence Union

Christopher Hughes’ career includes:

  • Interim Company Secretary and Consultant – £400M NHS Body.
  • Interim Head of Legal Services NHSU (National Health Service University)
  • Consultant Solicitor Central Government – including Department of Health
  • Ten years as Solicitor to the British Medical Association (BMA)

as Dr Phil Hammond says, with friends like the BMA……….

http://drphilhammond.com/blog/2015/02/21/private-eye/private-eye-issue-1385/

It all falls into place. Christopher Hughes and Suzanne Cosgrave should have recused themselves from hearing the appeal due to potential conflicts of interest and lack of impartiality through their professional association with the NHS, Department of Health and Health Profession defence/trade unions.

With these undeclared and unresolved conflicts of interest, it is not surprising that this Tribunal Panel got uppity that Citizen Whistleblowers dared to criticise the Verita managed Histopathology Inquiry that cost £734,000 of public money and betrayed whistleblowers.

© South West Whistleblowers Health Action Group 2015

Emersons Green Independent Sector Treatment Centre

Latest news on this blog post about South Gloucestershire Healthwatch and the Health and Wellbeing Board.

https://swwhag.wordpress.com/2014/08/02/accountability-healthwatch/

Mona Van Wyk, Head of Nursing and Clinical Services at Care UK’s Emersons Green Hospital eventually resigned as a Healthwatch Volunteer.

Read the open letter from Bristol GPs about the £7m of public money squandered on the contract with Care UK for services which weren’t provided.

https://protectournhs.wordpress.com/2015/02/03/64-bristol-gps-go-public-on-the-7m-lost-to-care-uk-at-the-emersons-green-treatment-centre/

Yet even when she stood down from Healthwatch, Ms Van Wyk refused to admit that she had a conflict of interest and apologise to patients and the public for purporting to represent their views.

The Emersons Green Independent Sector Treatment Centre was spawned from the South West NHS culture of abusing the principles of fair and lawful public and patient consultation which continues to this day:

http://www.leighday.co.uk/News/Archive/2007/July-2007/Positive-judgment-for-Rebecca-Fudge-regarding-Fren

http://healthpolicyinsight.com/?q=node/502

https://petitions.southglos.gov.uk/petitions.ti/savefrenchaycommunityhospital

http://www.leighday.co.uk/News/2014/June-2014/Bristol-CCG-told-to-retract-‘misleading’-statement

http://www.bristolpost.co.uk/StruggleHospital-campaigners-plan-new-rally/story-25874251-detail/story.html

South West NHS organisations don’t seem to understand that patients and the public won’t kiss up if they are kicked down. They will kick back.

If something isn’t working, intelligent NHS managers would try something different to win the trust of patients and the public in service changes, but perhaps it’s unrealistic to expect any sense from people who are probably being kicked.

http://www.telegraph.co.uk/news/nhs/11432976/Bullying-in-the-NHS-is-getting-worse-annual-survey-shows.html

© South West Whistleblowers Health Action Group 2015