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In the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell. The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that Addison's disease had been suspected. The referral letter was not typed until after Robbie had already died and was backdated to the day following the consultation. In a statement after Robbie's death this GP stated: "An Addisonian crisis is precipitated by an intercurrent illness and the stress it induces." Dyfed-Powys Police investigated Robbie's death between 1994 and 1996 but asserted, supported by the Crown prosecution Service in Wales, that there was no evidence of crimes committed by the GPs who, incidentally, were retained by this police force as police surgeons. Following a complaint by Will Powell (Robbie's father) in 1998 against the Deputy Chief Constable of Dyfed-Powys Police, regarding the inadequacies of the criminal investigation, a second criminal investigation was agreed, which commenced in January 1999. As with the first criminal investigation, there was a gross failure to adequately investigate the criminality of the doctors. This resulted in Will Powell making a formal complaint against the Chief Constable of Dyfed-Powys Police in late 1999. This complaint against the Chief Constable resulted in Dyfed-Powys Police appointing an outside police force to review Robbie's case in 2000. Detective Chief Inspector Robert Poole [DCI Poole] from West Midlands Police was appointed. DCI Poole’s investigation report, entitled 'Operation Radiance', which was based on the documents provided to Dyfed Powys Police in March 1994, by Will Powell and his solicitor, was submitted to CPS York in March 2002. This report put forward 35 suggested criminal charges against five GPs and their medical secretary. The listed charges were: gross negligence manslaughter forgery attempting to pervert the course of justice conspiracy to pervert the course of justice. DCI Poole's investigation also resulted in a disciplinary inquiry by Avon & Somerset Constabulary into Will Powell's allegations of misconduct against Dyfed-Powys Police officers with regards to their two inept criminal investigations between 1994 and 2000. Dyfed-Powys Police was found to have been 'institutionally incompetent' but no police officer was made accountable. In April 2003, Will Powell met representatives from the CPS in London, who accepted there was sufficient evidence to prosecute two GPs and their secretary for forgery and perverting the course of justice. However, they would not prosecuted because of (1) the passage of time, which was caused by a decade of cover ups between 1990 and the appointment of DCI Poole in 2000, (2) Dyfed Powys Police had provided the GPs with a letter of immunity, and (3) the available evidence had been initially overlooked by the police and the CPS, between 1994 and 2000, for a variety of reasons. Following a 2013 adjournment debate, in the House of Commons, the Director of Public Prosecutions subsequently agreed, in October 2014, that there would be an independent review of the decisions made by Crown Prosecution Service, in 2003, not to prosecute, when there was sufficient evidence to do so. The reviewing Queen's Counsels have been provided with a report, written by myself ( a healthcare IT professional, former head of IT in an NHS trust and clinician) on major anomalies in Robbie's Morriston Hospital computerised records, which were erased during the first criminal investigation between 1994 and 1996. The review has not been concluded six years on. The letter below (and also attached) from the English and Welsh Ombudsman was sent on 10 November 2020 sets out the case for a Public Inquiry.

Problems related to the care home and the company were known well before the Panorama expose in 2016. When the Panorama programme was aired it resulted in immediate closure of one home and all the homes which were operated by Morleigh being transferred to new operators. The Review includes reports of abuse against residents; residents being left to lie in wet urine-soaked bedsheets; concerns from relatives about their loved ones being neglected; reports of there being insufficient food for residents, no hot water and no heating; claims that dozens of residents were sharing one bathroom. Here's a summary of the report's findings: More than 100 residents had concerns raised more than once. More than 200 safeguarding alerts were made for individuals but only 16 went through to an individual adult safeguarding conference. More than 80 whistleblower or similar reports were made concerning issues that put residents at risk. 44 inspections were undertaken at Morleigh Group homes in the three-year period, the vast majority identifying breaches. There was a period of at least 12 months when four of the homes had no registered manager in place. During the three-year period reviewed the police received 130 reports relating to the care homes. A spokesperson for Cornwall Council said: “We have different procedures and policies in place and have invested time, money and staffing into making sure that we can respond better when concerns are raised.'' “One of the problems was that all the partners had their own policies and procedures but they weren’t integrated. That is probably one of the key issues that we have now addressed.” “The assessment is so different now and the organisations are working much more closely that it reduces the risk dramatically.'' This is an important and long-awaited review. This situation echoes other care home scandals across the UK. I urge everyone to read the full report and reflect on the real root causes of the problem, which I believe go well beyond failings in inter-agency policies and communication. What would your action plan be? How would you monitor it?

The Benchmarking Network is the in-house benchmarking service of the NHS. The Network is hosted by East London NHS Foundation Trust.

The reporting reveals a legal and medical system that sometimes struggles to differentiate accidental injuries from abuse, particularly in cases involving children too young to describe what happened to them. Physicians intent on protecting the most vulnerable in some instances have overstated the reliability of their findings, using terms such as “100 percent” and “certain” to describe conclusions that usually cannot be proven with absolute confidence. Child welfare workers, overworked and untrained in complex medical issues, are not always sure how to proceed when the primary evidence against a caregiver comes in the form of a doctor’s note. Under this system, children are sometimes taken from seemingly caring parents, while others are left in situations that, in rare cases, turn out to be deadly. Parents managed to regain custody in most of the cases reviewed by reporters, in some instances after additional medical findings or reports from outside experts raised doubts about the initial abuse determination. Nevertheless, some parents lost jobs or faced financial ruin as the result of their fights with Child Protective Services, and a few children emerged from foster care suffering from depression or other health issues. In a few instances, caregivers were charged criminally or had their parental rights permanently terminated, despite questions about the doctors’ findings in their cases.

Recommendations from the report There should be a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data, for example, how many times a consultant has performed a particular procedure and how recently. This should be accessible and understandable to the public. It should be mandated for use by managers and healthcare professionals in both the NHS and independent sector It should be standard practice that consultants in both the NHS and the independent sector should write to patients, outlining their condition and treatment, in simple language, and copy this letter to the patient’s GP, rather than writing to the GP and sending a copy to the patient. Differences between how the care of patients in the independent sector is organised and the care of patients in the NHS is organised, should be explained clearly to patients who choose to be treated privately, or whose treatment is provided in the independent sector but funded by the NHS. This should include 219 Recommendations clarification of how consultants are engaged at the private hospital, including the use of practising privileges and indemnity, and the arrangements for emergency provision and intensive care. There should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and treatment options. We recommend that the GMC monitors this as part of ‘Good Medical Practice’ The CQC, as a matter of urgency, should assure itself that all hospital providers are complying effectively with up-to-date national guidance on MDT meetings, including in breast cancer care, and that patients are not at risk of harm due to non-compliance in this area. Information about the means to escalate a complaint to an independent body is communicated more effectively in both the NHS and independent sector. All private patients should have the right to mandatory independent resolution of their complaint. The University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen. We recommend that Spire should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen, and that they should check that they have been given an ongoing treatment plan in the same way that has been provided for patients in the NHS. A national framework or protocol, with guidance, is developed about how recall of patients should be managed and communicated. This framework or protocol should specify that the process is centred around the patient’s needs, provide advice on how recall decisions are made, and advise what resource is required and how this might be provided. This should apply to both the independent sector and the NHS. The Government should, as a matter of urgency, reform the current regulation of indemnity products for healthcare professionals, in light of the serious shortcomings identified by the Inquiry, and introduce a nationwide safety net to ensure patients are not disadvantaged. The Government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of the system identified in this Inquiry. If, when a hospital investigates a healthcare professional’s behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional. If the healthcare professional also works at another provider, any concerns about them should be communicated to that provider. The Government addresses, as a matter of urgency, this gap in responsibility and liability.

Colour is a hallmark of Autumn across the US. A more spectacular set of colours, in a variety of shapes and sizes, paint the sky at daybreak every October in New Mexico. The Albuquerque International Balloon Fiesta is the largest gathering of its kind. In 2019, its 48th year, the fiesta hosted 550 hot air balloons, 650 pilots and entertained close to 900,000 visitors. The event holds a place on the bucket lists of travellers around the world. It is hard to describe the feeling of glee standing amid a mass ascension until you’ve been there amongst the early morning crowds. You might think it’s all fun, funnel cakes and floating but—like any aviation activity—ballooning entails risk. Make no mistake, the balloonists and their teams, the organisers, law enforcement, and even participants play a role in the safety of the event. Before sunrise each day, the “dawn patrol” of 8–10 hot air balloonists lift off. These experienced pilots gage the safety of the sky prior to the authorities giving the signal for the assent to begin. Only after that, does the wave after wave of multiple balloons unpack, gear up, inflate and take off from the field. Crews mull about, patiently navigating their designated space amongst onlookers and their cameras to get ready for flight. They implement standard procedures to safely gear-up for flight. Healthcare, too, prepares teams for complex situations to ensure safety through standardisation and practice. The US healthcare accreditation agency, the Joint Commission, shared insights on reducing maternal harm due to postpartum haemorrhaging that summarises best practices centered on readiness, recognition, response and reporting to support systems learning. Stanford Medicine in California recently held a series of “dress rehearsals” prior to opening a new hospital. The test of the space gave clinicians, administrators and patient advisors a chance to make sure conditions were right for a safe opening day. The fiesta organisers also deploy tactics to learn from what doesn’t go well. They use technology to gather input from crews and the public to identify areas for improvement. Traffic into the 360-acre launch site creates ineffective and potentially dangerous situations given the swell of people arriving in town. Attendees almost double the size of the city for the 10-day event. Public input gathered online helped planners to redesign this year’s park and ride shuttle system after it failed in 2018 to reliably get people to the festival. Hospitals also use information technology to learn how to improve the safety of the care experience. Researchers in Washington State developed a 4-step model built on inpatient experiences with undesirable events. They used patient and family knowledge to design informatics solutions that engage patients as contributors to safety. The model supports raising awareness of problems, encouraging prevention actions, managing emotional harms and reducing barriers to reporting .A rare situation stalled the festival this year: fog. Yes, fog is not something New Mexican’s encounter often but it shut down opening day morning—none of the balloonists could take off. This unique occurrence would have been all the more problematic had teams not heeded safety advice in this less-than-ideal situation. Practices and protocols keep patients safe too but only if they are followed. A unique set of circumstances led to the death of a patient awaiting care in a Pennsylvania emergency department. Protocols weren’t followed limiting situation awareness, communication and process completion. Balls were dropped and the results were tragic. Complex systems can manifest unintended consequences from strategies designed to protect people. Balloon fiesta has its share of mishaps. Pilots end up in the Rio Grande, drift into powerlines, bones get broken and, rarely, lives are lost. The expert crews mean well but failures happen. A nurse in Tennessee who made a medication mistake that resulted in patient death was charged criminally. While lawmakers may feel this is a just approach, it is a threat to healthcare transparency. A series of incidents involving misdiagnosis of child abuse is raising concerns in the US. While specialised paediatricians can readily identify patient conditions that indicate abuse, sometimes those judgements are made in error. The decisions made to protect children instead accuse innocent parents or family members of harm. The safe flight of those families then tumbles to the ground. The pace is back to normal in Albuquerque. Balloons still float above us in the morning and afternoon—'tis the season. They brighten the clear blue skies with the Sandia mountains as a backdrop. But you can bet that what did go wrong this year will be folded into the event planning so all that participate in the 2020 festival will be as safe as possible.

This National Partnership Agreement sets out: the defined roles of the five partners the commitment to working together and sharing accountability for delivery through the linked governance structures core objectives and our priorities for 2018-21, and a link to the workplans that provide the details of the activities to deliver priorities how they are working together to improve data and evidence so that they can better understand the health needs of people in custody and the quality of health and social care services delivered to people in prisons.

This report is not simply a story about a rogue surgeon. It would be tragic enough if that was the case, given the thousands of people whom Ian Paterson treated. But it is far worse. It is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again. This video report was streamed live on ITV News on 4th February 2020.

The Government’s response and action needed The Government’s response to the publication of the Inquiry’s report advised that they would look at these recommendations and report back ”in three to four months’ time”.[3] When doing this it is vital that these recommendations are considered holistically as part of the wider change that is needed, where patient safety is treated as a strategic purpose of healthcare. Patient safety is currently treated as one of many priorities to be weighed against each other. We think it is wrong that safety is negotiable. Patient safety must be core to the purpose of healthcare, reflected in everything that it does. We look forward to the Government’s response to the Inquiry recommendations. This must include action for change, including: Culture change Creating a culture in healthcare where staff feel safe and secure in reporting patient safety concerns, knowing their concerns will be actively welcomed, listened to and acted upon. Healthcare organisations should regularly and independently assess their organisational culture and have programmes of action to ensure a just and learning culture is in place. Staff reporting concerns An open and learning culture clearly signposting staff on how to raise concerns and that these concerns are acted upon. Harmed patients are supported Patients receive the support they need when things go wrong. ‘Harmed patient care pathways’ outline the provision of advice, guidance, practical and psychological support to patients and families. Learning from complaints All private patients have the right to mandatory independent resolution of their complaint. Patient safety applies to all, irrespective of whether care is provided for in the NHS or independent sector. #Share4Safety Organisations develop systems and measurements to improve patient safety, collecting data on patient safety and sharing learning. We strongly support the recommendation made by the Inquiry that where a healthcare professional is suspended with a perceived risk to patient safety, these concerns should be communicated to other providers that they work for. Leading and owning patient safety A new model for leadership and governance for patient safety that operates in both the NHS and independent sector. There should be high standards and behaviours set for our leaders and they should be supported by specialist patient safety experts in executive and non-executive board roles. Organisations need clear and published goals for patient safety with board focus and effectively oversight on reducing patient harm. The healthcare system operates as one coordinated system with patient safety as a core purpose. If action isn’t taken, then the Paterson Inquiry will become yet another report of unsafe care where sympathetic noises are made but no real learning and change occurs. If Government and leaders say that ‘lessons have been learned’ then they need to tell us what those lessons are, what actions they are taking, and publish updated reports on their progress and share these publicly. Without having these measures in place, how can the public and patients be assured that there won’t be future reports of unsafe care? As the Inquiry Chair said, “it is wishful thinking that this could not happen again”. References The Guardian. Ian Paterson inquiry: more than 1,000 patients had needless operations. 4 February 2020. The Right Reverend Graham Jones. Report of the Independent Inquiry into the Issues raised by Paterson, February 2020. House of Commons Debate, Paterson Inquiry, 4 February 2020, Volume 671.