Steve Turner

In 2015 the Government introduced a Freedom to Speak Up Guardian and a system of Local Speak Up Guardians in response to the recommendations made by Sir Robert Frances following the scandal at Mid Staffordshire. From the outset, this system has attracted significant criticism and the APPG has heard from whistleblowers who have been failed by local guardians sharing their experiences that included the disclosure of their identity to hospital management and boards – resulting in retaliation. The APPG has also heard from Local Guardians who were not supported and themselves the target of retaliation after supporting whistleblowers. Local Guardians in East Kent were described as, “dishonest” and that the Guardian system had failed in every case that had been investigated throughout the UK. Further evidence was provided of a tick box approach to the Duty of Candour introduced by the former Secretary of State for Health. The APPG was told that both the Guardian and Duty of Candour systems are beyond resurrection and that across the NHS there is no ownership of problems. All attempts to encourage speaking up have been hindered by a failure to introduce an effective and safe whistleblowing regime across the NHS, resulting in the NHS being unsafe for whistleblowers, making it unsafe for patients. The APPG were told that, in over 50 years of investigation experience, little has changed, and that “these issues are not new, nor are they confined to a small number of rogue hospitals”. That league table results are inaccurate because of a flawed regulatory system with no ownership of the problems and where the regulators are “caught up in the fraud”. The APPG was provided with a series of examples of what were described as “deep seated problems” relating to teamwork and culture, which resulted in the failure to join up clinical and ethical responsibilities. These responsibilities were described as being on separate tracks and a failure by the regulatory regime to identify or report on the impact of this has significant consequences for patients, whistleblowers and the future of the NHS, as demonstrated by the case of the Bristol Children’s Heart scandal brought to light by Dr Steve Bolsin 30 years ago. Dr Bolsin was shunned for exposing the failures that resulted in the death of so many babies because funding the unit was more of a priority that the lives of the babies (he has since made a successful career in Australia). In every case, a failure to listen to whistleblowers, followed by attempts to discredit the whistleblowers, and a deliberate cover up has proved in many cases fatal for patients. What has been proved time and time again is that The Public Interest Disclosure Act (PIDA) has made little or no difference to this failure to protect patients or whistleblowers or to learn and improve our NHS. Evidence provided to the APPG is of a lack of system-wide action and an absence of commitment to speaking up beyond excellent PR. It is unclear who, if anyone, is responsible for the monitoring and reporting on recommendations contained in investigation reports. In addition, there is no coherent process for triggering high-level independent reviews of major patient safety failings. This causes confusion, suffering and leads to missed opportunities. Mary Robinson MP, chair of the APPG for Whistleblowing, said: “We have a duty to support and protect whistleblowers because without them we cannot prevent more deaths like those in East Kent. My APPG is committed to making whistleblowing safe and will continue to press the Government to introduce the Whistleblowing Bill which will incentivise and normalise speaking up. I encourage everyone to write to their MPs and ask them to join the APPG and support the Whistleblowing Bill.” The Right Hon. Baroness Susan Kramer, said: “Doing nothing is not an option that we can afford. It’s time to put an end to ‘tick box culture’ and turning a blind eye to whistleblowers. Whistleblowing law must be meaningful, easily understandable and enforceable. The Whistleblowing Bill will do this and in doing so will save lives and protect our NHS.” Wendy Morden MP, member of the APPG for Whistleblowing, said: “I hear about problems when I am at the hairdresser because people are too afraid to speak up in their place of work. The Office of the Whistleblower will be the catalyst for meaningful change.” Dr Bill Kirkup, author of Reading the Signals Report, said: “I support the proposals set out in the Whistleblowing Bill because the NHS urgently needs an effective early warning system.”

These four vlogs are edited versions of vlogs originally commissioned by the NHS. They are all fully referenced based on UK National Institute for Health and Care Excellence (NICE) guidelines and on the Royal Pharmaceutical Society Prescribing Competency Framework for all prescribers (see the video description) and contain links to useful sources of further information. Shared decision making - 'It's my decision', which covers the latest NICE Guideline on shared decision making. 'Too much information' - Dealing with information overload on medicines & prescribing, which includes some of the work of the former UK National Prescribing Centre on information mastery. The way numerical data presentation influences decisions and treatments. Key components of taking a past medical history and a thorough medicines history when prescribing, which is a refresher on what was covered in the Independent Prescribing Course.

Everyone who works in health and social care should listen to this podcast in full. I've followed Will's search for justice and I am proud to know Will. A man of great integrity who is campaigning for an individual #dutyofcandour in #healthcare, for the benefit of us all. I remain shocked, when I teach on this, how few know Robbie's story. There has been so much lost learning, a failure of accountability, and a failure to deliver an effective statutory duty of candour. For me, this appalling story of failure and cover up highlights clearly why we have to recognise the value of whistleblowers in #healthcare. When staff don't/can't speak out, or are ignored and bullied, it falls to patients or relatives to do this, at huge cost. #Robbieslaw Related post: English and Welsh Ombudsman set out the case for '... a proper public inquiry into the tragic death of Robbie Powell'