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Content ArticleDr Chris Day has for the last ten years pursued a legal battle against Greenwich and Lewisham NHS Trust (GWT), claiming his whistleblowing action about unsafe staffing while working in ICU was used against him by the Trust and Health Education England. Following a 2022 employment tribunal involving Dr Day and GWT, consultancy firm KPMG was commissioned by the Trust to conduct an independent review of the Trust's governance and media strategy. In this LinkedIn blog, Dr Chris Day outlines the context of a Byline Times article that questions the independence of this review, due to director of corporate affairs at the Trust, Kate Anderson, being a former employee of KPMG.
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News ArticleWhistleblowers who first revealed a toxic environment at one of England's largest NHS trusts say they do not believe crucial changes will be made. In a letter, they said families who suffered due to management failings at University Hospitals Birmingham (UHB) "have every reason to feel let down". Investigations have been examining UHB after staff told the BBC a climate of fear put patients at risk. The letter was written by three doctors to the Labour MP For Birmingham Edgbaston, Preet Gill, who is heading a cross-party reference group on the trust. In their letter, the consultants raise concerns about the appointment from within the trust of new chief executive Jonathan Brotherton and feel the management team remains largely unchanged. "More than six months have elapsed since we spoke to you of the need to repay the debt owed to those UHB staff, patients and their families who have suffered as a result of the board's serious failings," they wrote. "They now have every reason to feel let down." Read full story Source: BBC News, 29 August 2023
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News ArticleMore than half of NHS staff believe bosses would ignore whistleblowers amid fresh concerns hospitals could be covering up potential scandals following the Lucy Letby case. New national figures seen by the The Independent reveal that in the majority of hospitals, most doctors and nurses do not believe their concerns would be acted upon if they were raised with senior managers. It comes after The Independent revealed that NHS bosses accused of ignoring complaints about Letby were the very same people later appointed to act on whistleblower concerns at the hospital where she murdered seven babies and tried to kill six more. Several doctors who worked alongside her during the killing spree say they attempted to raise the alarm with hospital managers – only to have their pleas ignored. They believe the lack of action by bosses resulted in more babies being killed, stating managers who failed to act were “grossly negligent” and “facilitated a mass murderer”. In nearly three-quarters of general hospitals – such as the Countess of Chester where Letby worked – fewer than half of staff believed their trust would act on a concern, according to results from the latest NHS staff survey. Read full story Source: The Independent, 27 August 2023
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News Article
NHS whistleblowers warn of 'unsafe' A&E staff shortages
Patient Safety Learning posted a news article in News
A group of senior doctors has accused NHS Grampian of ignoring their safety concerns about emergency departments. They told BBC Scotland News they were speaking out because they feel they cannot deliver a safe level of care. The medics said staff shortages meant Grampian's two A&Es have no senior registrars on shift to make key decisions about patients for the majority of weekend night shifts. Documents seen by the BBC News show medics have been raising concerns since 2021, both with NHS Grampian and the Scottish government, and in July this year submitted a formal whistleblowing complaint about the situation. One doctor said: "The staff are in an impossible situation. "We are witnessing ongoing harm with unacceptable delays to the assessment and treatment of patients. "There have been avoidable deaths and at other times there are too long delays getting to patients who may be suffering from a serious condition like stroke or sepsis." Read full story Source: BBC News, 23 August 2023- Posted
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Content ArticleIn this letter, Rob Behrens, the Parliamentary and Health Service Ombudsman, calls on the Secretary of State for Health and Social Care, Steve Barclay MP, to prioritise improving patient safety in the wake of the Lucy Letby trial.
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News ArticleA paediatric nurse who called in to LBC news during a discussion on Lucy Letby, says she can see how Letby was able to get away with her crimes as she herself was 'blacklisted' when she reported a colleague. Watch the video Source: LBC News, 19 August 2023
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Content ArticleOn 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this.
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Content ArticleWe now know that Lucy Letby is a murderer, responsible for the deaths of seven babies and the attempted murders of six more. But as unimaginable as her crimes were, this verdict raises as many questions as it answers. Letby was not working in a vacuum. Could the killings at the Countess of Chester Hospital NHS Foundation Trust have been stopped sooner? Did organisational failures cost the lives of babies who could have been protected? The timeline gives us a clue, writes Minh Alexander, a retired consultant psychiatrist and NHS whistleblower, in this Guardian opinion piece. In June 2016, Letby’s hospital trust commissioned a review of neonatal care by the Royal College of Paediatrics and Child Health after “concerns about increasing neonatal mortality”, which oddly did not feature a case-note review. This prevented detailed examination of the deaths, which should have been the prime objective. The college reported “extremely positive relationships” among staff but “remote” relationships with executives. Astonishingly, the college’s report seemingly did not explicitly acknowledge a possibility of deliberate harm. Nevertheless, the college raised concern that not all deaths were followed by postmortem investigations – as they should have been, according to guidelines – and that where postmortems did take place, they did not include systematic blood tests and toxicology. It noted concerns from obstetrics staff about four unexpected deaths. In the coming days, there will be many questions. Why did it take so long for the hospital to refer matters to the police? Were doctors pressured not to persist with their concerns about Letby? How many trust board members knew there was a possibility of deliberate harm but failed to act?
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Content ArticleBabies would have survived if hospital executives had acted earlier on concerns about the nurse Lucy Letby, a senior doctor who raised the alarm has said. In an exclusive Guardian interview, Dr Stephen Brearey accused the Countess of Chester hospital trust of being “negligent” and failing to properly address concerns he and other doctors raised about Letby as she carried out her killings. Brearey was the first to alert a hospital executive to the fact that Letby was present at unusual deaths and collapses of babies in June 2015. The paediatrician and his consultant colleagues raised concerns multiple times over months before Letby, then 26, was finally removed from the neonatal unit in July 2016. The police were contacted almost a year later, in May 2017. Speaking publicly for the first time, Brearey told the Guardian that executives should have contacted the police in February 2016 when he escalated concerns about Letby and asked for an urgent meeting.
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News ArticleAn award-winning hospital consultant says he has been “hunted” out of the NHS after 43 years for flagging patient safety failings. Peter Duffy, 61, performed his final surgical procedure, supervising a bladder cancer removal, earlier this month at Noble’s Hospital on the Isle of Man. He said he had “been looking forward to a good few more years of full-time work — another five, at least”. But the cumulative toll of a long-running whistleblowing dispute with his former employer, Morecambe Bay NHS Trust (UHMBT), instead pushed him into “an abrupt, even savage termination of my calling”. The General Medical Council watchdog recently dropped a 30-month probe into Duffy prompted by emails that he alleges were falsified. The emails, which were apparently sent by Duffy in December 2014 but did not surface until 2020, appeared to implicate him in the string of clinical errors that led to the death of Peter Read, a 76-year-old man from Morecambe. The GMC concluded that it could not attach weight to the emails as evidence. However, Duffy says the ordeal of “having the responsibility for an avoidable death I’d reported being flipped and of having the finger pointed back at me” drove him to contemplate suicide. Read full story (paywalled) Source: The Times, 24 July 2023
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Event
Scottish Speak Up Conference
Sam posted an event in Community Calendar
This conference is for staff involved in managing concerns in NHS Scotland, including the promotion, delivery, and use of the Whistleblowing Standards. The Independent National Whistleblowing Office are supporting the event. It will explore the legislative requirements around whistleblowing and the benefits of effective management of concerns. The programme concludes with a focus on what a healthy speak up culture looks like and how that can be delivered. The day will be chaired by John Sturrock, KC, and include a keynote presentation from Rosemary Agnew, the Independent National Whistleblowing Officer. It also brings together expert speakers from NHS Scotland, Scottish Government, trade union and academia with expertise in speaking up, culture change, quality, safety and candour. The programme will consider the Whistleblowing Standards since their launch in April 2021, as they approach their anticipated 3-year review. It offers an opportunity to share good practice, support ongoing improvements and promote an effective Speak Up culture that works from the bedside to the boardroom. Programme Register- Posted
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Content ArticleNHS England commissioned a limited scope independent review into patient safety concerns and governance processes related to the North East Ambulance Service. Chaired by Dame Marianne Griffiths DBE, the review considered the facts surrounding a number of individual cases, reviewed the processes surrounding coronial investigations and reviewed the seven previous investigations and reviews undertaken by the ambulance service to determine if they were sufficient to fully understand and resolve issues.
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News Article
Ambulance service apologises to families
Patient Safety Learning posted a news article in News
An ambulance service has apologised to families following a review into claims it covered up errors by paramedics and withheld evidence from coroners. The families of a teenager and a 62-year-old man were not told paramedics' responses were being investigated by North East Ambulance Service (NEAS). The deaths, in 2018 and 2019, were raised by a whistleblower last year. Among the findings of the independent review carried out by Dame Marianne Griffiths, were inaccuracies in information provided to the coroner, employees who were "fearful of speaking up" and "poor behaviour by senior staff". The study, commissioned by the former health secretary Sajid Javid in August, examined four of the five cases that were highlighted by the whistleblower, initially in The Sunday Times. It found two bereaved families were left in the dark about investigations into the response of paramedics called to help their loved ones. Read full story Source: BBC News, 12 July 2023- Posted
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News Article
‘Beginnings of safety culture’ emerging at ‘cover-up’ trust
Patient Safety Learning posted a news article in News
An ambulance trust at the centre of an inquiry into alleged cover-ups has shown signs of improvement, according to the Care Quality Commission (CQC). North East Ambulance Service Foundation Trust has been accused of withholding information from coroners. An ongoing inquiry chaired by former acute trust chief executive Dame Marianne Griffiths is looking at how it deals with serious incidents, whistleblowers’ concerns and whether the trust complies with the “duty of candour” as well as its processes around inquests. The CQC report suggests it has made progress on many of these areas since inspections last year – which triggered a warning notice – and has raised the rating for its emergency and urgent care division from “inadequate” to “requires improvement”. The inspectors said it was a “mixed picture” but they had seen “the beginnings of a safety culture emerging within the trust”. Read full story Source: HSJ, 7 July 2023- Posted
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News ArticleNHS whistleblowers need stronger legal protection to prevent hospitals using unfair disciplinary procedures to force out doctors who flag problems, the British Medical Association has said. Doctors are being “actively vilified” for speaking out, which has resulted in threats to patient safety, including unnecessary deaths, according to the council chair of the doctors’ union, Phil Banfield. Despite a series of scandals in recent years, it is becoming more common for hospitals to use legal tactics and “phoney investigations” to undermine or force out whistleblowers rather than address their concerns, he warned. Banfield said: “Someone who raises concerns is automatically labelled a troublemaker. We have an NHS that operates in a culture of fear and blame. That has to stop because we should be welcoming concerns, we should be investigating when things are not right. “Whistleblowers are pilloried because some NHS organisations believe the reputational hit is more dangerous than unsafe care,” he added. “Whereas the safety culture in aviation took off after some high-profile airplane crashes in the 70s, the difference is that the aviation industry embraced the need to put things right and understand the systems that led to the disaster – the NHS has not invested in solving the system, it’s been bogged down in blaming the individual instead of the mistake.” Read full story Source: The Guardian, 2 July 2023
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Report finds West Midlands ambulance whistleblowers stifled
Patient Safety Learning posted a news article in News
Ambulance staff in the West Midlands have had their ability to speak up as whistleblowers stifled for many years, an independent inquiry has found. The investigation, commissioned by NHS England, also identified failings in financial governance at West Midlands Ambulance Service (WMAS). Five senior and former members of staff spoke out to NHS England. WMAS accepts it has learning to do, but says the report expresses confidence in the service's ability to address the issues raised. The whistleblowers included a finance director, medical, operations and quality control staff. They raised issues through the Freedom to Speak Up scheme with the National NHS England Team. The inquiry, led by Carole Taylor Brown, had terms of reference which included "Governance, probity, the difficulty of speaking up about these issues and the alleged behaviour of some senior leaders". Read full story Source: BBC News, 28 June 2023- Posted
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Content ArticleAre whistleblower reward programmes a charter for malicious complaints, as some claim, or are they a genuine incentive providing a safety net against retaliation? How successful are these programmes in recovering fraud and other proceeds of crime and serious organised crime? This paper aims to answer these questions—it was produced by WhistleblowersUK in collaboration with US lawyers who contributed to the development and improvement of US reward programmes. It aims to address questions about the legislation around US reward programmes, dispel some of the myths and look at some of the objections attributed to British attitudes about rewarding whistleblowers.
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Content ArticleAn article from Roger Kline on the failure of many NHS organisations to create a climate where it is safe for staff to speak up. Roger reflects on the recent report published by the National Guardian’s office which summarises the results from the NHS staff survey completed by over 600,000 staff and highlights the story of a senior manager who tried to speak up and the consequences that followed. Further reading: Still not safe to speak up: NHS Staff Survey Results 2022 (Patient Safety Learning blog)
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News Article
Fresh review into ‘doctors being bullied with regulatory referrals’
Patient Safety Learning posted a news article in News
Investigators have begun a further review of how a major trust handles disciplinary and professional standards cases, including allegations leaders had targeted some doctors with referrals to the medical regulator, HSJ has learned. The claims were part of a raft of concerns raised about University Hospitals Birmingham Foundation Trust over recent months, including BBC Newsnight reporting that a large number of General Medical Council referrals had led to no action; and claims of whistleblowing doctors “being bullied… by the threat of referrals to the GMC”. One external review of UHB, whose report was published in March, already examined the issue, and said it had identified 17 cases which contradicted Newsnight’s claim, with two referrals resulting in criminal conviction and removal from the medical register. It said there was “nothing exceptional” about the referral numbers or types at UHB, or their outcomes, but also noted that medical staff told the review about “dysfunctional processes for maintaining higher professional standards”, and “expressed a perception that there was a rather rapid process to escalate to a GMC referral”. Read full story (paywalled) Source: HSJ, 21 June 2023- Posted
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Content ArticleThe Right Honourable Sir Anthony Hooper was asked by the General Medical Council (GMC) on 5 September 2014 to conduct an independent review of how the GMC engage with individuals who regard themselves as whistleblowers. The terms of reference were: “To conduct a review of how the General Medical Council handles cases involving individuals who regard themselves as whistleblowers and who have appropriately raised concerns in the public interest. These are individuals: whose fitness to practise is being investigated or determined under the General Medical Council (Fitness to Practise) Rules 2004; or who have reported such a concern to the GMC.” This is the report by the Right Honourable Sir Anthony Hooper to the GMC presented on the 19th March 2015.
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News Article
My surgeon experimented on me and ruined my life
Patient Safety Learning posted a news article in News
Leann Sutherland was 21 and suffering from chronic migraines when one of Scotland's top surgeons offered to operate. She was told she would be in hospital for a few days and had a 60% chance of improvement. Instead she was in for months while Sam Eljamel operated on her seven times. "He had free rein on my body. He was playing god with my body and the NHS handed him the scalpel, seven times," says Leann. When Leann tried to raise concerns with staff she was told that Mr Eljamel had saved her life. She was not told that he was under investigation, nor that he had been later forced to step down. It was only after seeing recent BBC coverage she realised she was not alone. The BBC can reveal her surgeon - the former head of neurosurgery at NHS Tayside - was harming patients and putting them at risk for years but the health board let him carry on regardless. BBC Scotland has spoken to three surgeons who worked under Mr Eljamel at Tayside. All three said he was a bully who was allowed to get away with harming patients. All three said there was a lack of accountability in the department and that Mr Eljamel was allowed to behave as if he were a "god" - partly because of the research funding he brought to the department. Read full story Source: BBC News, 16 June 2023- Posted
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Whistleblowing surgeon quits profession over fear of being “hunted” by NHS
Patient Safety Learning posted a news article in News
A campaigning whistleblowing surgeon who wrote two books about his experiences has decided to leave the medical profession out of fear that he is being “hunted” by the NHS. Peter Duffy, a consultant urologist, is quitting work several years earlier than planned and intends to remove his name from the medical register. After a two year investigation the General Medical Council has decided to take no action against him. But he told The BMJ that he is worried that, after several investigations into his conduct, he remains vulnerable as long as he stays on the register. Duffy, 61, who blew the whistle on patient safety issues at University Hospitals of Morecambe Bay NHS Foundation Trust’s urology department, left the NHS nearly seven years ago. He claimed he was forced to resign from the trust for his own protection and won a claim for unfair constructive dismissal in 2018, when the trust was ordered to pay him £102 000 in compensation. Read full story (paywalled) Source: BMJ, 12 June 2023- Posted
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Content ArticleAn NHS consultant who was sacked after whistleblowing says it was because he raised concerns that “normal birth” ideology was putting the lives of women and babies at risk. Martyn Pitman, a respected obstetrician and gynaecologist, became a whistleblower to prevent “avoidable disasters” in NHS maternity care, but it cost him his career. Pitman lost his job last month after more than 20 years as a consultant at Royal Hampshire County Hospital in Winchester. His bosses cited an “irretrievable breakdown in his relationship with management”. His dismissal caused outrage from hundreds of former patients and doctors’ leaders, who say it highlights an NHS culture of “punishing those who dare to speak out”.
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News ArticlePolice are investigating about 40 hospital deaths over allegations of medical negligence made by two consultant surgeons who lost their jobs after blowing the whistle about patient safety. The allegedly botched operations took place at Royal Sussex County hospital (RSCH) in Brighton, part of University hospital Sussex NHS trust, when it was run by a management team hailed by Jeremy Hunt as the best in the NHS. Last week, detectives from Sussex police wrote to the trust’s chief executive, George Findlay, confirming they had launched a formal investigation into “a number of deaths” at the RSCH. They were investigating allegations of “criminal culpability through medical negligence” made by “two separate clinical consultants” at the trust, the letter said. It is understood about 40 deaths occurred between 2015 and 2020 after alleged errors in general surgery and neurosurgery departments. Both whistleblowers alleged the trust failed to properly investigate the deaths and learn from the mistakes made. Read full story Source: The Guardian, 9 June 2023
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Content ArticleBackground to the independent review by Lewisham and Greenwich into Dr Chris Day's whistleblowing case.
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