If you haven't had the chance to do the crossword yet, you can access it from the following links, in either PDF or Word formats.

Blank crossword and clues (pdf).pdfBlank crossword and clues (word).docx

The answers to each clue and the completed crossword can be found in the attachment below:

SOLUTION - Glimpses of NHS whistleblowing terrain.pdf

Notes on the answers can be downloaded from the following attachment:

Notes on the solution to the Crossword Counterpoint (glimpses of NHS whistleblowing terrain) w.i.p. 8.5.22 (2).pdf

A guide to the whistleblower's galaxy

This crossword is offered as a travel guide to help others navigate the complex and at times treacherous track trod by NHS staff who have suffered retaliation after speaking up. It can be a bewildering trek. Everybody's journey is different but there are common experiences. Travellers' tales suggest a pattern in milestones often encountered along the way.

Lonely planet

One of the cruellest manifestations of organisational hostility towards some NHS staff who have raised concerns about poor patient care is that they are propelled into orbit, pushed around on a procedural merry-go-round by alien and sometimes unseen forces, but excluded from professional circles in which they have built and practised their career. This isolation is often a deliberate intended consequence of actions taken by those who orchestrate reprisals against staff whose 'crime' is identifying areas where improvements are needed to improve patient care.

Isolation tactics include:

• suspending staff on some spurious pretext and instructing them not to speak to colleagues;
• denying them access to crucial documents or other information which supports their case;
• manipulating them into signing non-disclosure agreements – sometimes referred to as settlement agreements (formerly known as compromise agreements), confidentiality clauses or gagging clauses. Although such agreements are void and unenforceable under whistleblowing legislation in respect of protected disclosures they tend to inhibit communication nonetheless, and thus contribute to whistleblower isolation and exclusion. They also prevent true learning from whistleblowers' experiences.

Crossword aims

The aims of the crossword, this blog and others in this series,[1-5] are firstly to raise awareness of the realities of speaking up and, secondly, to support stakeholders who are trying to find a way through the morass. These stakeholders include policy-makers, legislators, leaders, campaigners and, last but not least, whistleblowers themselves. Their voices need to be heard.

There seems to be a shared view amongst stakeholders that the current situation is unsatisfactory. All concerned say that they want NHS staff to speak up if they are aware of poor practice affecting patient care. However, the latest NHS national staff survey results show that only 62% of staff said they feel safe to speak up about anything that concerns them in their organisation.[6]

This worrying statistic is an indication of the magnitude of the systemic problem which stakeholders are trying to solve, as well as being a reflection on the effectiveness of existing approaches. Effective problem-solving requires good analytical skills. It also requires knowledge and understanding of the true nature of the problem in question, and ability to challenge the status quo when necessary.

The problem for NHS organisations is that large numbers of their employees are afraid to speak up about poor patient care. Not speaking up and hostility towards those who do speak up are linked to an ongoing series of patient safety scandals.[7-21] The problem for many staff who have suffered retaliation after speaking up is that they have lost their careers, their livelihood and sometimes much more.

In such situations, NHS organisations tend to wash their hands of their responsibilities towards whistleblowers whose health and wellbeing they have harmed. This irresponsibility, and the culture which fosters it, has to change if leaders really want NHS staff to speak up when they are aware of sub-optimal and dangerous practices within their organisation.

The 62% staff survey statistic illustrates interconnected problems for organisations, patients and members of staff. It is a symptom of an underlying pathology that needs to be treated – the mistreatment of whistleblowers. As always in attempting a cure, it is important to treat the cause not the symptoms.

The aims of this contribution are to provide insight into the phenomenon of retaliation against healthcare professionals by their employers, and thus support effective action to address the root cause of these serious problems. It builds on foundations laid by many others.

Whilst the contents of this blog are to the best of my knowledge correct, for the avoidance of doubt this is not legal advice. Comments, feedback and discussion are welcome.

References        

1. Wilkins H. What is a whistleblower? Patient Safety Learning, the hub, posted 2 February 2022.
2. Wilkins H. Crossword counterpoint: glimpses of NHS whistleblowing terrain. Patient Safety Learning, the hub, posted 16 March 2022.
3. Wilkins H. Organisational culture and patient safety (MPEC 2021). Patient Safety Learning, the hub, posted 14 October 2021.
4. Wilkins H. The right - and duty - of NHS staff to speak up. Patient Safety Learning, the hub, posted 22 June 2020.
5. Wilkins H. The mistreatment of NHS whistleblowers must stop (UKIO 2019). Patient Safety Learning, the hub/Learn/Culture/Whistleblowing, posted 17 March 2021.
6. NHS Staff Survey. 2021 National results briefing, March 2022, q21e, p27.
7. Kennedy I. The Bristol Royal Infirmary Inquiry. Learning from Bristol - the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995: 2001.
8. Smith J. The Shipman Inquiry (2002-2005), second report: the police investigation of March 1998: 2003.
9. Holt K. Great Ormond Street and 'Baby P': was there a cover-up? BMJ 2011; 343.
10. Francis R. The Mid Staffordshire NHS Foundation Trust Public Inquiry. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry volumes 1-3: 2013.
11. Clwyd A, Hart T. A review of the NHS hospitals complaints system: putting patients back in the picture, October 2013.
12. Dyer C. Whistleblower was unfairly dismissed in case lasting 12 years, tribunal rules. BMJ 2014; 348.
13. Kirkup B. The report of the Morecambe Bay investigation 2004-2013: 2015. 
14. Kirkup B. Report of the Liverpool Community Health Independent Review: 2018.      
15. James G. Report of the independent inquiry into the issues raised by Paterson: 2020.
16. Kirkup B. The life and death of Elizabeth Dixon: a catalyst for change - report of the independent investigation: 2020.
17. Cumberlege J. First Do No Harm: the report of the independent medicines and medical devices safety review: 2020. 
18. Outram C. West Suffolk Review: 2021.    
19. Care Quality Commission. Monitor. Monitor and CQC review into whistleblowing concerns at the Christie NHS Foundation Trust: 2022.
20. Ockenden Report. Findings, conclusions and essential actions from the Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust: 2022.
21. Dyer C. Whistleblowing: nephrologist who reported colleagues to GMC was unfairly dismissed. BMJ 2022; 376.

A recent blog I wrote for the hub, 'What is a whistleblower?', discusses different interpretations of 'whistleblowing'.[1] Broadly speaking, there is a divide between those who regard whistleblowers as good guys, and those who consider them to be treacherous villains. Hero or traitor?

In that blog I suggested that how you view whistleblowers depends on your viewpoint and the lens through which you view them.[1] An evidence-based lens combining personal experience and rigorous analysis may bring your image of whistleblowers into sharp focus. An opinion-based perspective prejudiced by hearsay and myth may create an inaccurate blurred image. Insight or groupthink?

The blog refers to definitions of whistleblowers from a number of referenced sources (read the definitions document here). Those in section A of the definitions document support the 'hero' interpretation. In contrast, references in section B are more aligned to the 'traitor' doctrine. A or B?

Revealing answers to 'Whistle-blower' crossword clue

By coincidence, shortly after that blog was submitted for publication on the hub, a leading newspaper published a crossword puzzle with 4 iterations of the same single word clue: 'Whistle-blower'.[3] Two of the answers (1 across and 22 across) were six-letter words; the other two (7 down and 11 down) were eight-letters.

As confirmed when the solution was published a week later, the respective answers for each clue are: 'Canary', 'Snitch', 'Telltale', and 'Betrayer'.[4] A revealing reminder that some people have very negative conceptions of whistleblowers. No sitting on the fence in the eyes of the compiler of the newspaper crossword – he/she clearly sees whistleblowers as 'traitors'!

Healthcare context

The 'What is a whistleblower?' blog pays particular attention to NHS healthcare professionals.[1] Registered healthcare professionals are required to report, and if necessary escalate, any concerns they have about the safety or care of patients.[5-7] It is ludicrous if they are then subjected to detriment by their employers, or if organisational culture causes staff to be afraid to speak up. Sadly there is evidence of both detriment and a climate of fear in parts of the NHS.[8-12] This needs to change.

In my experience healthcare professionals do not see themselves as whistleblowers when first speaking up – they are simply doing their job. It probably does not occur to them that in speaking up they may be putting their careers at risk. However, case after case show organisations responding by channelling 'whistleblowers' into protracted processes and employment disputes, with sanctions which may include career-ending dismissal. Those who have spoken up are wrongly seen as disloyal troublemakers. I am not the only one who believes that the 'whistleblower' term and related processes can be profoundly unhelpful.[1,8,13]

Healthcare professionals who raise patient safety concerns are not snitches!

It should be patently obvious that healthcare professionals who raise valid patient safety concerns are not 'snitches', 'telltales' or 'betrayers'. However, as illustrated by the recent newspaper crossword, that is how whistleblowers are seen by some people.[3,4] This is the reactionary 'section B definitions' view of whistleblowers[2], as promulgated for example in Roget's Thesaurus.[14] Fortunately there are others who have a more enlightened view of whistleblowers in general and in particular, for the purposes of this article, of staff who raise patient safety concerns.[15-17]

Does it matter?

Does any of this matter? Well, yes, it does. Words can be powerful in shaping attitudes, beliefs and behaviours, including negativity towards and retaliation against staff who raise concerns in the public interest. Orwell knew the power of language; 'Newspeak' is central to the setting of his book '1984'.[18,19] Similarly Burgess's 'Nadsat' in 'A Clockwork Orange'.[20] The term 'dogwhistle politics' refers to coded language described as a powerful form of speech enabling people to be manipulated, overtly or covertly, intentionally or unintentionally.[21] Negative perceptions of whistleblowers are a component of dysfunctional cultures that tolerate and enable reprisals against staff who speak up.

A stain on the reputation of the NHS – ongoing implications for patient safety

I am not fundamentally opposed to the 'whistleblower' word. Some who have experienced retaliation after reporting wrongdoing embrace it. But it can create misleading prejudice, which is particularly concerning from a patient safety perspective in the context of healthcare staff raising valid concerns. The pejorative connotations associated with a 'section B' interpretation (in which the whistleblower is portrayed as a 'sneak', 'snitch', 'rat', 'telltale', 'betrayer' and other derogatory terms [2,14]) has serious adverse consequences: for the individual concerned, workforce morale and patient safety.[8-11]

The House of Commons Health Committee reported as long ago as 2015 that:

"The treatment of whistleblowers remains a stain on the reputation of the NHS and has led to unwarranted and inexcusable pain for a number of individuals. The treatment of those whistleblowers has not only caused them direct harm but has also undermined the willingness of others to come forward and this has ongoing implications for patient safety".[22]

That statement is as true now as it was then.

Crossword: Glimpses of NHS Whistleblowing terrain

In an attempt to convey a more accurate understanding of the whistleblowing landscape, particularly in respect of the NHS, I have compiled a new crossword: Glimpses of NHS Whistleblowing terrain.[23] It can be accessed from the following links, in either PDF or Word formats.

Glimpses_of_NHS_Whistleblowing (blank crossword and clues).pdfCROSSWORD (Glimpses of NHS Whistleblowing Terrain) questions.docx

(Click the above links to download the crossword. The PDF option is best  for writing the answers by hand on printed sheet. Try the Word file if you prefer to enter answers electronically.)

This crossword is offered in a spirit of education and learning (though of course it is not legal advice). I appreciate that it is as susceptible to author's bias as any publication but I have tried to be fair, and have supported my views with authoritative sources of reference where possible. It is an attempt to redress the balance that sometimes operates against healthcare professionals who raise concerns in the public interest. This imbalance also has adverse consequences for patients, taxpayers and organisational culture.

I hope the crossword provides some light-hearted entertainment, and contributes to better understanding of these issues.

The solution, with explanatory comments and accompanying blog, are now available on the hub here.

References

1. Wilkins H. What is a whistleblower? Patient Safety Learning; 2 February 2022.
2. Wilkins H. What is a whistleblower? Definitions document. Patient Safety Learning, the hub; 2 February 2022.
3. CONCISE CROSSWORD 1767. The Sunday Times; 30 January 2022: p.28
4. CrosswordGiant, Crossword Puzzle Clues and Answers: CONCISE CROSSWORD 1767. The Sunday Times; 6 February 2022: p. 27.
5. Health and Care Professions Council. Standards of conduct, performance and ethics; 2016. 
6. Nursing and Midwifery Council. The Code; 2015.
7. General Medical Council. Ethical guidance for doctors. Raising and acting on concerns about patient safety; 2012.
8. Robert Francis. Report of the 'Freedom to speak up' review; 2015.
9. Holt K. Whistleblowing in the NHS. BMJ 2015; 350: h2300.
10. Outram C. West Suffolk Review; December 2021.
11. NHS Improvement and Care Quality Commission. Monitor and CQC review into whistleblowing concerns at the Christie NHS Foundation Trust; 2022.
12. BBC News. Hinchingbrooke Hospital patient sent 'whistleblower' letters; 8 March 2022.
13. National Guardian's Office. What is speaking up?
14. Roget's 21st Century Thesaurus, third edition. Whistleblower synonyms.
15. Gov.uk website. Whistleblowing for employees.
16. UNDOC. United Nations Convention against Corruption: Resource guide on good practices in the protection of reporting persons; 2015. 
17. UNODC. Speak up for health! Guidelines to enable whistle-blower protection in the health-care sector; 2021.
18. Orwell G. Politics and the English Language. Horizon No. 76, April 1946. The Orwell Foundation.
19. Cliffs Notes study guide: Critical Essays. The Purpose of Newspeak: Orwell (1949). Nineteen eighty-four; Appendix. 
20. The International Anthony Burgess Foundation. A Clockwork Orange and Nadsat.
21. Saul J. Dogwhistles, political manipulation, and philosophy of language. In New Work on Speech Acts, chapter 13. Oxford Scholarship Online; 2018.
22.  House of Commons Health Committee (2015). Complaints and Raising Concerns, chapter 5 (Treatment of staff raising concerns). 
23. Wilkins H. Glimpses of NHS whistleblowing terrain (blank crossword: PDF format, Word format). Patient Safety Learning; March 2022.

The word 'whistleblower' conjures up different emotional reactions in the minds of different people. Hero or villain? It probably depends on your perspective, which in turn may be shaped by your experience. In this article I hope to encourage reflection on terminology associated with the phenomenon of employer hostility towards healthcare staff who raise patient safety and related concerns while doing their job.

Reprisals against healthcare staff who raise patient safety concerns

Retaliation against whistleblowers is a problem in many industries. In this article I want to focus on healthcare staff whose careers suffer after raising concerns. In 2013, a report on a research project[1] that studied the experiences of 1,000 employees who had sought advice from the UK whistleblowing charity Public Concern at Work (now Protect) found:

• Patient safety – an issue essentially confined to health and social care – is one of the top five concerns in this large sample of whistleblowers from many sectors (also including education, charities, local government, financial services and other industries). The other four of the top five issues reported in this study (ethical, financial malpractice, work safety and public safety concerns) are not industry specific.
• The study found that whistleblowers who had raised a patient safety concern were more likely to suffer formal reprisal than those who had spoken up about other matters. The most likely management reprisal against health sector whistleblowers was dismissal on their first attempt at speaking up, with the more senior the worker the higher the risk of dismissal.

These findings are truly disturbing from a patient safety perspective (not to mention other negative aspects of such retaliation).

Devastating consequences of negativity towards whistleblowers

I am ambivalent about the whistleblower term. I am aware of its pejorative connotation in the eyes of some and think that this hinders understanding and learning. Negative attitudes towards people who identify areas where healthcare improvements are needed can lead to failure to listen and respond properly to what they are saying – with devastating consequences for patients, staff and the organisation concerned.

Many NHS staff feel insecure about speaking up – even about unsafe clinical practice

Eight years after publication in 2013 of the 'Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry',[2] which documented abysmally poor response to numerous concerns raised by patients, families and staff, the 2021 West Suffolk Review[3] showed how poor the response of NHS organisations could still be to NHS staff who speak up. Results of the then most recent national staff survey, whilst the covid pandemic was ongoing, implied that about 330,00 workers (27.5%)[4] of the NHS England workforce of about 1.2 million people[5]) would not feel secure raising concerns about unsafe clinical practice. The latest (2025) survey showed that 28.9% of the workforce would not feel secure about raising concerns about unsafe clinical practice.[6] These statistics indicate a worsening situation and underline that there is still a long way to go before staff can be confident that it is safe for them to speak up about unsafe patient care.

Better understanding of how whistleblowers are perceived is needed

Whilst there are many facets to the complex issue of why some managers and leaders retaliate against staff who are simply doing their job in reporting problems, the way that whistleblowers are perceived within organisations and wider society is an important factor, which needs to be better understood if there is to be real progress in this area. Bias, conscious or unconscious, favourable or unfavourable, can cloud judgments in whistleblowing cases. Objectivity is required to recognise, and hopefully eliminate, any prejudice which may exist. This is important so that the concerns raised, the motivation of those who report them and organisational responses to such reports can each be assessed on their merits.

Prejudice against whistleblowers and hostility towards them is a patient safety issue

Referees in many sports carry a whistle which they can blow to call a halt and ensure fair play. The whistle blown by workers when speaking up is metaphorical rather than physical but raising a concern is analogous to referees blowing the whistle, in that both are attempts to rectify contravention of the rules. Illustrating the influence of bias, it is well known that football fans' opinions about the ref may be highly dependent on which team they support.

In a similar way, prejudicial bias against whistleblowers in general may carry over to workplace settings when organisations handle whistleblowing cases. All too often the organisational reflex is to focus attention onto the person who has spoken up, not on the concerns they have raised. Numerous cases and reports provide evidence of this being seriously detrimental to patients and staff – and to the organisations themselves. Hostility towards healthcare professionals who raise concerns is a patient safety issue.

Stages of whistleblowing

There are substantially different interpretations of what constitutes 'whistleblowing' and what a 'whistleblower' is, which colour perceptions as to whether whistleblowers are seen in a positive or negative light. In this respect, it is important to distinguish between:

• internal reporting within an organisation;
• external reporting to a person or body, such as an MP or regulator;
• public disclosure, e.g. via social media, mainstream media or writing a book.

In my experience, healthcare professionals who inadvertently joined the community of harmed whistleblowers invariably started their journey by internal reporting. In all innocence they reported patient safety and related concerns through appropriate internal channels.

In so doing they were doing their job, in line with their professional codes of conduct. They surely had a right to expect a professional response (in line with organisational policy, though they may not have consulted the whistleblowing policy at that stage - they probably did not then see themselves as whistleblowers). I think it needs to be stressed that they were simply doing their job and were probably unprepared for the hostility with which their concerns were received by their employers.

Whistleblowing is usually a process, rarely a single event. In healthcare organisations, internal reporting typically involves a succession of reports, to higher and higher levels in the local organisational hierarchy if the whistleblower believes that the issue has not been properly addressed.[7] In such cases, in line with NHS whistleblowing policy, they may escalate matters by external reporting to a 'prescribed person'.[8, 9] Increasing numbers of harmed whistleblowers, having exhausted internal reporting and perhaps also external reporting stages, put their stories into the public domain. I do not know of any healthcare professional who has made a public disclosure without having first gone through at least the internal reporting stage. I think this is often overlooked, but is very important in understanding the realities of whistleblowing, particularly in the healthcare context.

Whistleblowers – heroes or villains?

As suggested above, perception of whistleblowers is an important aspect of how they are treated. Perceptions about them generally fall into one of two groups. On the one hand, it seems to be increasingly recognised that they are a force for good in society. On the other hand, there are those who still regard whistleblowers in a very poor light. This simple binary model is complicated by virtue-signalling from some who profess support for whistleblowers in concept, whilst in real life being instrumental in detrimental action taken against them. It is further complicated by others who claim to be whistleblowers in an attempt to extricate themselves from unrelated disciplinary action.

Context and motivation are important. There is a world of difference between people speaking up in good faith in the public interest (e.g. healthcare professionals seeking to improve patient safety) and individuals claiming whistleblower status for other reasons. These groups deserve to be regarded and treated differently.

I am of course not suggesting that healthcare professionals raising concerns about patient care are the only whistleblowers acting in the public interest. Nor am I suggesting that all whistleblowers are subjected to retaliation. Many people in all walks of life raise concerns every day and are thanked by organisations who recognise and welcome the opportunity to make improvements. But far too often this this does not happen, with organisations reacting with inappropriate and sometimes brutal aggression against the whistleblower, distracting attention away from the concerns themselves.

The attached document, which can can be downloaded by clicking below, contains a number of definitions that have been proposed for whistleblowing and whistleblower. It also contains other alternative terms sometimes used instead of whistleblower, whistleblowing and concern.

Whistleblowerdefinitiondocument - update March 2026 (1).pdf

Acting in the public's interest

I have explored the lexicon of whistleblowing (see attachment above), with a particular focus on healthcare professionals raising concerns about patient safety in the course of doing their job. I highlight that whistleblowing can be a very loaded term, evoking bias and adversely affecting attitudes towards whistleblowers.[25-27] However, 'whistleblowing' and 'whistleblower' have the merit of being single words, which can be beneficial in concise communication.

United Nations guidance on good practice in the protection of reporting persons states that:

"A public awareness campaign is one way to promote cultural perceptions of whistleblowers as people acting for the public good and out of loyalty to their organization, profession and to society, rather than as traitors or informers."[27]

Greater awareness that whistleblowers acting in the public interest are doing so out of loyalty to their organisation, profession and society is certainly needed.

Those judging the actions of staff who raise valid concerns about patient safety should reflect on whether or not they are acting in the public interest (a rhetorical question, surely). They should also reflect on the fact that healthcare staff who speak up are probably acting in accordance with organisational policies and, where relevant, professional codes of conduct.

Discordance between policy and practice

A message on the Gov.uk website ends with the exhortation "don't ever stop speaking truth unto power".[29] However, speaking up is just part of what needs to happen. Those in power need to listen to what staff are telling them, however uncomfortable that may be. Problems arise if organisational power dynamics prevent concerns being heard by leaders.[30]

Evidence suggests that discrepancies between policy and practice in responses to healthcare staff who speak up exist in many healthcare organisations.[1,4,8,15,22-25,30]

Organisational leaders should be alert to the possibility of conscious or unconscious bias prejudicing the handling of whistleblowing cases. They should exert due diligence in ensuring that policies that allow personnel to raise concerns freely without fear of retaliation are not only created but, crucially, are also implemented.[30] There is compelling evidence of discordance between policy and practice in this respect.[1-3,8,15-19,22-23,30]

In considering whether or not reports of wrongdoing, breaches, violations or poor practice are in the public interest, it may be helpful to start by considering whether or not the concern relates to any of the following: criminal offence; failure to comply with a legal obligation; miscarriage of justice; danger to health or safety; environmental damage; cover up.[16,17] Did the so-called 'whistleblower' report their concerns internally at the outset, in line with organisational policies? If so, how can reprisals against them be defensible in an organisation seeking to support its workforce in delivering compassionate care?

I suspect that careful analysis of the concerns raised by most healthcare professionals whose careers have been wrecked after speaking up would show that they meet the criteria for being both qualifying disclosures and protected disclosures.[16-19] Should they be seen as troublemakers? Of course not.

Healthcare professionals have a professional duty to raise patient safety and related concerns if they are aware of poor practice. It is totally wrong for any worker to be at risk of retaliation from their employers for doing their job. Protection of healthcare staff who speak up is a patient safety issue.

This article is not legal advice. However, it contains information in the public domain about legislation,[16-18] authoritative guidance,[9,14] and policy.[8,24] Until there is a substantial change of culture within the NHS, UK healthcare professionals must decide for themselves how to balance risks of speaking up about poor practice and risks of keeping silent – and how they can best do this to protect patients and themselves.

Conclusions

I have focused on healthcare professionals who have suffered detriment after identifying areas for improvement in healthcare provision. The 2015 Freedom To Speak Up review confirmed the existence of serious problems in this area in the NHS.[15] It is clear from NHS staff survey results,[4,6], Annual reports from the National Guardian's Office[23] and what was, in December 2021, then but the latest in a continuing series of reports of retaliation against whistleblowers[3] that many staff are still, with good reason, far from confident that they will be safe if they speak up about poor patient care.

My aim in writing this article is to improve understanding of what motivates healthcare staff to speak up and the risks they run in doing so. I have emphasised the crucial public interest aspect of whistleblowing and drawn attention to the need for whistleblowers acting in the public interest to be recognised as loyal members of the team, not regarded as troublemakers. I hope it contributes to learning and the culture change in this area that is widely acknowledged as being needed. I would be delighted if it supports rehabilitation of the reputation and career of anybody who has experienced reprisals after raising concerns in the public interest. They should be thanked, not vilified.

Critical thinking, good analytical skills and wisdom are needed in judging the extent to which organisational policies supporting the rights and responsibilities of personnel to raise safety concerns are borne out in practice. Whistleblower voices need to be heard and welcomed. If all healthcare leaders were to respond positively to employees who, in good faith, raise genuine concerns, and not tolerate harassment, intimidation, retaliation or discrimination for raising concerns, I have no doubt that this would lead to substantial improvements in staff engagement, organisational culture, quality of care and patient safety.

References

1.  Vandekerckhove W, West C. Public Concern at Work / University of Greenwich. Whistleblowing: the inside story - a study of the experiences of 1,000 whistleblowers, 2013. https://gala.gre.ac.uk/id/eprint/10296/ 
2.  Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013). https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry
3. Outram C.West Suffolk Review, December 2021. https://www.england.nhs.uk/east-of-england/wp-content/uploads/sites/47/2021/12/west-suffolk-review-081221.pdf 
4.  NHS Staff Survey 2020 National results briefing (March 2021) p.35 q17b. https://www.nhsstaffsurveys.com/static/afb76a44d16ee5bbc764b6382efa1dc8/ST20-national-briefing-doc.pdf
5. Full Fact (2017). How many NHS employees are there? https://fullfact.org/health/how-many-nhs-employees-are-there/
6. NHS Staff Survey 2025 National results briefing (March 2026) p.23 q20a. https://www.nhsstaffsurveys.com/results/national-results/
7.  Vandekerckhove W and Phillips A. Whistleblowing as a protracted process: A study of UK whistleblower journeys. Journal of Business Ethics Issue 1 2019; 159(2):1-19. https://www.springerprofessional.de/en/whistleblowing-as-a-protracted-process-a-study-of-uk-whistleblow/15192750
8. NHS England (2022, updated March 2026). External freedom to speak up policy for NHS workers. NHS England » External freedom to speak up policy for NHS workers
9. NHS England (2022). Freedom to Speak Up policy for the NHS ver 2, June 2022 (accessed 27.3.26 from NHS England » The national speak up policy
10.  Department for Business, Energy and Industrial Strategy. Whistleblowing: list of prescribed people and bodies. https://www.gov.uk/government/publications/blowing-the-whistle-list-of-prescribed-people-and-bodies--2/whistleblowing-list-of-prescribed-people-and-bodies 
11. Rodulson V, Marshall R, Bleakly A. Whistleblowing in medicine and in Homer's Iliad. Medical Humanities 2015;41:95-101. https://mh.bmj.com/content/41/2/95 
12. Nader R, Petkas P, Blackwell K. Whistle Blowing: the Report of the Conference on Professional Responsibility held in Washington DC, September 1972. ISBN-10: 0670762253. https://searchworks.stanford.edu/view/685302 
13. Miceli M, Near J. Characteristics of Organizational Climate and Perceived Wrongdoing Associated with Whistle-Blowing Decisions. Personnel Psychology, 1985; 38(3), 525-544. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1744-6570.1985.tb00558.x 
14. International Standards Organization (2021). Whistleblowing management systems - Guidelines: ISO 37002:2021. https://www.iso.org/standard/65035.html
15. Gov.uk website. Whistleblowing for employees. https://www.gov.uk/whistleblowing
16. Robert Francis QC. Report of the 'Freedom to speak up' review, 2015. http://freedomtospeakup.org.uk/
17. Employment Rights Act 1996. https://www.legislation.gov.uk/ukpga/1996/18/contents
18. Public Interest Disclosure Act 1998. https://www.legislation.gov.uk/ukpga/1998/23/contents
19.  Enterprise and Regulatory Reform Act 2013. https://www.legislation.gov.uk/ukpga/2013/24/contents
20. Sprack J. Blackstone's Employment Tribunal Handbook 2014-2015. https://global.oup.com/academic/product/blackstones-employment-tribunals-handbook-2014-15-9780198719427?cc=gb&lang=en& 
21. Directive (EU) 2019/1937 of the European Parliament and of the Council of 23 October 2019 on the protection of persons who report breaches of Union law. https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32019L1937
22. National Guardian's Office. What is speaking up? https://nationalguardian.org.uk/speaking-up/what-is-speaking-up/
23. National Guardian's Office. Listen Up training for all managers launched (2021). https://nationalguardian.org.uk/2021/01/26/listen-up-training/
24. National Guardian's Office annual reports - Collection (all 5 NGO annual reports, including last report (2024 to 2025) before abolition of NGO in June 2026) National Guardian's Office annual reports - GOV.UK
25. United Nations Office on Drugs and Crime (UNODC, 2021). Speak up for health! Guidelines to enable whistle-blower protection in the health-care sector. https://www.unodc.org/documents/corruption/Publications/2021/Speak_up_for_Health_-_Guidelines_to_Enable_Whistle-Blower_Protection_in_the_Health-Care_Sector_EN.pdf
26. Roget's 21st Century Thesaurus, third edition. Whistleblower synonyms. https://www.thesaurus.com/browse/whistleblower
27. UNODC (2013). An Anti-Corruption Ethics and Compliance Programme for Business: A practical guide. https://www.unodc.org/documents/corruption/Publications/2013/13-84498_Ebook.pdf
28. UNODC (2015). United Nations Convention against Corruption: Resource guide on good practices in the protection of reporting persons. https://www.unodc.org/documents/corruption/Publications/2015/15-04741_Person_Guide_eBook.pdf
29. Gov.uk website (2014). Speak truth unto power. https://www.gov.uk/government/news/speak-truth-unto-power (accessed 1.1.22)
30.  Reitz M, Higgins J. Speaking truth to power: why leaders cannot hear what they need to hear. BMJ Leader 2021;5:270–273. https://bmjleader.bmj.com/content/5/4/270
31. International Atomic Energy Agency (IAEA, 2020). A Harmonized Safety Culture Model. https:/www.iaea.org/sites/default/files/20/05/harmonization_05_05_2020-final_002.pdf

Further reading on the hub:

• Speaking up for patient safety: A new interview series about raising concerns and whistleblowing

1840588231_ThemistreatmentofNHSstaffwhoraisevalidconcernsmuststop(banner)(1).pdf

• Disposable gowns are being reused by keeping them in a room and then reusing after 3 days.
   
• There were no fit tests. Staff were informed by management that "one size fits all, no testers or kits available and no other trusts are doing it anyway". Only when the Health and Safety Executive (HSE) announced recently that fit tests were a legal requirement, then fit tests were given. I queried about fit checks only to discover that it was not part of the training and, therefore, staff were wearing masks without seals for three months before fit tests were introduced and even after fit tests! I taught my colleagues how to do fit checks via telephone.
   
• There was no processes in place at the hospital to aid staff navigation through the pandemic (no red or green areas, no donning or doffing stations, no system for ordering PPE if it ran out); it was very much carry on as normal. A hospital pathway was made one week ago, unsigned and not referenced by governance, and with no instructions on how to don and doff. 

• Guidelines from the Association for Perioperative Practice (AFPP) and Public Health England (PHE) for induction and extubation are not being followed – only 5 minutes instead of 20 minutes. Guidelines state 5 minutes is only for laminar flow theatres. None of the theatres in this hospital have laminar flow.
   
• One of my colleagues said she was not happy to cover an ENT list because she is BAME and at moderate/high risk with underlying conditions. She had not been risk assessed and she felt that someone with lower or no risk could do the list. She was removed from the ENT list, told she would be reprimanded on return to work and asked to write a report on her unwillingness to help in treating patients. The list had delays and she was told if she had done the list it would not have suffered from delays. Just goes to show, management only care about the work and not the staff. It was only after the list, she was then risk assessed.
   
• Diathermy smoke evacuation is not being used as recommended. Diathermy is a surgical technique which uses heat from an electric current to cut tissue or seal bleeding vessels.  Diathermy emissions can contain numerous toxic gases, particles and vapours and are usually invisible to the naked eye. Inhalation can adversely affect surgeons’ and theatre staff’s respiratory system. 

If staff get COVID-19 and die, they become a statistic and work goes on as usual. The examples listed above are all safety issues for patients and staff but, like me, my colleagues are being ignored and informed "it's a business!" when these safety concerns are raised at the hospital.  The only difference is they are permanent staff and their shifts cannot be blocked whereas I was a locum nurse who found my shifts blocked after I spoke up.

• Why has it been allowed to carry on? 
• Why is there no Freedom To Speak Up Guardian at the hospital?
• Why has nothing been done?

We can all learn from each other and we all have a voice. Sir Francis said we need to "Speak Up For Change", but management continues to be reactive when we try to be proactive and initiate change. This has to stop!

Actions needed

• We need unannounced inspections from the Care Quality Commission (CQC) and HSE when we make reports to them.
• Every private hospital must have an infection control team and Freedom To Speak Up Guardian in post.

Prerana recently retweeted a message from NHS England and NHS Improvement that "It's so important (for NHS staff) to feel able to speak up about anything which gets in the way of patient care and their own wellbeing".[1],[2]

She is absolutely right... in principle. She is right to point out that NHS staff have both the right and the duty to speak up about problems like this, as is spelt out in the NHS Constitution[3] and professional codes of conduct for healthcare professionals.[4],[5],[6]

The problem is that in practice, as an unknown but substantial number of NHS staff have discovered to their cost, their careers may be at risk if they do speak up as is evident from almost all the replies to both tweets.[1],[2] There is a sad pattern of disciplinary action being taken against staff who have, in good faith, raised concerns in the public interest. Even though their motivation in speaking up in the first place is to improve patient care, they discover to their astonishment that they are considered to be troublemakers for having done so. A depressing cycle of suspension, isolation, unfair dismissal, denigration and blacklisting of the person who has spoken up is often played out, whilst the original concerns and their validity are covered up. What a waste of valuable resources.

The existence of such hostility to staff who have spoken up is evidenced in the 2015 report of the Freedom To Speak Up (FTSU) Review: "an independent review into creating an honest and open reporting culture in the NHS".[7] The press release which accompanied its publication announced that the review "identifies an ongoing problem in the NHS, where staff are deterred from speaking up when they have concerns and can face shocking consequences when they do. The review heard stories of staff that have faced isolation, bullying and counter-allegations when they’ve raised concerns.  In some extreme cases when staff have been brave enough to speak up, their lives have been ruined".[8]

The FTSU report calls for "an overhaul of NHS policies so that they don’t stand in the way of people raising concerns with those who can take action about them" and sets out "20 Principles and Actions which aim to create the right conditions for NHS staff to speak up". The principles are divided into five categories: the need for culture change; improved handling of cases; measures to support good practice; particular measures for vulnerable groups; and extending the legal protection.[7] 

In theory the law protects whistleblowers, but in practice, as a procession of disillusioned NHS staff who have experienced reprisals from their employers after speaking up have discovered the hard way, it does not. Employment tribunals are an alien environment for most healthcare staff. Case after case has shown that they are woefully ill-equipped to deal with precipitating patient care issues, in which tribunals appear to have little interest.

Even when NHS staff are, against massive odds, found to have been unfairly dismissed after raising concerns in the public interest, the so-called remedy they receive almost invariably amounts merely to paltry financial 'compensation'. These are monetary awards that generally come nowhere near compensating for the full financial consequences. The adverse impact of this lack of protection for whistleblowers is not only on the individual but also includes the chilling effect of deterring other staff from raising concerns and the consequences of cover ups. True overall costs to the NHS, patients, whistleblowers and taxpayers of retaliation against staff who speak up are very much greater than financial costs alone.

Staff surveys show that nearly 30% of NHS staff would not feel secure raising concerns about unsafe clinical practice.[9] Over 40% would not be confident that their organisation would address their concern if they do speak up.[10] There is still a lot to do in this area, as has been brought to the fore by recent reports of hostile responses by some NHS organisations to staff who have raised serious personal protective equipment (PPE) concerns affecting patient safety and health of themselves and their families.

To be fair, serial staff surveys show a marginal improvement in the percentage of NHS staff who agreed they would feel secure raising concerns about unsafe clinical practice, up from a disturbingly low 68.3% in 2015 to 71.6% in 2019.[9] And a further tiny improvement in the percentage confident that their organisation would address their concern, up from an even lower 56.2% in 2015 to 59.8% in 2019. 

Viewed from the perspective of NHS whistleblowers whose careers have been wrecked after speaking up these are painfully slow rates of improvement. Bearing in mind widespread reports of PPE shortages, and warnings to NHS staff not to make a fuss about this, it will be interesting to see whether this glacial pace of change in speaking up culture is maintained when the results of the 2020 survey are available. Based on experience in the last two years, we can expect another prolonged FTSU publicity campaign in the month preceding the annual autumn NHS staff survey.

The NHS Interim People Plan, published in June 2019, refers to development of a focus on whistleblowing and speaking up. It highlights the need for inclusive and compassionate leadership so that all staff are listened to, understood and supported, and the need to do more to nurture leadership and management skills of middle managers.[11] The original aim was to publish a full, costed NHS People Plan by Christmas 2019,[12] building on the interim plan, but this was delayed by unforeseen events, including a change of government, general election, Brexit ramifications and now the coronavirus pandemic. The interim plan makes clear the need to embed culture changes and leadership capability in order to achieve the aim of making the NHS "the best place to work".

There is much to do, and I wish well to those who want to make it safe for staff to speak up, but they must be under no illusion – there is a long way to go – and this will take more than an overhaul of NHS policies. I hope to develop these themes in future postings to the hub. Comments welcome.

References

1. NHS England and NHS Improvement tweet, @NHSEngland, 15 May 2020, 6:35pm. 
2. Prerana Issar tweet, @Prerana_Issar, 15 May 2020, 6:47pm.
3. The NHS Constitution for England. Updated 14 October 2015. 
4. Nursing and Midwifery Council (NMC). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates, 2015, updated 2018. 
5. General Medical Council (GMC). Good medical practice: The duties of a doctor registered with the GMC. 2013, last update 2019. 
6. Health and Care Professions (HCPC). Standards of conduct, performance and ethics: The ethical framework within which our registrants must work, 2016. 
7. Freedom to speak up: An independent review into creating an open and honest reporting culture in the NHS. Report by Sir Robert Francis QC, 11 February 2015. 
8. Press release: Sir Robert Francis publishes his report on whistleblowing in the NHS, 11 February 2015.
9. NHS Staff Survey 2019. q18b: % of staff agreeing or strongly agreeing with the statement that: 'I would feel secure raising concerns about unsafe clinical practice'. 
10. NHS Staff Survey 2019 q18c: % of staff agreeing or strongly agreeing with the statement that: 'I am confident that my organisation would address my concern'.
11. Interim NHS People Plan, June 2019. https://www.longtermplan.nhs.uk/publication/interim-nhs-people-plan/
12. NHS People Plan overview, 2019.