No Surprises at Alder Hey and Morecombe Bay
Alder Hey Children’s Hospital in Liverpool as “potentially unsafe” after failing to meet four in five standards of quality and safety in an unannounced inspection by the Care Quality Commission will come as no surprise to readers of the Eye. The CQC acted after it was contacted by operating theatre staff, and found failures to report serious adverse incidents, near misses, very worrying staff shortages, and problems with essential equipment.
Alder Hey, which now has the highest risk rating the CQC can award, also had a low rate of reporting safety incidents, and its staff were uncertain which types of incidents to report, airways monitoring equipment was not in place and the emergency call alarm system in the day surgery theatre was faulty. The theatre department had a high staff sickness level, staff sometimes had to work long hours and operation schedules often overran, with ‘potentially unsafe’ staffing of the recovery area. An internal review by the trust’s own director of nursing that found “shortcuts being made to safety processes that have created high risk activity.”
The safety concerns are very similar to those outlined by the trust psychologist Dr Alan Phillips in November 2010, which were only made public after the Eye forced the trust to disclose his report by successfully appealing to the Information Tribunal. (Eyes passim) Two well-respected surgical consultants, Shiban Ahmed and Edwin Jesudason, blew the whistle on unsafe care at Alder Hey and have paid a heavy price. Ahmed remains suspended, accused of inappropriately accessing patient data when the Trust deputy Chair asked him to compile details of patient harm as part of his whistleblowing disclosure. Jesudason, who supported Ahmed and raised concerns about unethical and unsafe surgical practices, resigned last year and has been unable to find work since.
The tactics used against Ahmed have been particularly unpleasant. The Eye has seen a letter dated 5 September 2010 from surgeon Colin Baillie which reads: “Shiban mentioned he had considered suicide. I have no doubt this was what was said because I asked him to repeat himself. I shared this with the clinical director Matthew Jones.” Ahmed knew nothing of this. The claim was made behind his back when a proper response to a genuinely suicidal colleague would have been to arrange an urgent mental health assessment. He was however suspended pending an investigation which cleared him of being any risk to himself or his patients. Yet he is still not back at work, and other charges have been made against him to keep him away at huge cost to the taxpayer.
A review by the Royal College of Surgeons found Ahmed and Jesudason are regarded as extremely gifted surgeons, which makes their senseless and expensive exclusion from the NHS all the more tragic. Alder Hey has never satisfactorily responded to the allegations made by Ahmed and Jesudason about unsafe care, and the CQC’s highest risk rating for the current service leaves little grounds for optimism. The Royal College, the CQC, NHS England and the Department of Health has no appetite for supporting individual whistleblowers, particularly if they are not white, and they are just thrown on the NHS scrapheap. Meanwhile Jeremy Hunt’s pledge that there will be no more NHS cover ups looks ludicrously hollow.
The abuse of NHS whistleblowers needs to become culturally unacceptable in the NHS. At present, there are trusts who are serial offenders, where whistleblowers are regularly persecuted and bullied for speaking up for patients, and the harm they suffer is because they rocked the boat and therefore got what they deserved. At every level, from student nurses who don’t get their training signed off because they raised safety concerns, to senior consultants who face multiple referrals to the GMC on concocted charges for embarrassing their employer, the NHS simply isn’t a safe place to tell the truth about poor care. As the commentator Roy Lilley puts it; ‘In what sort of organization is lying about patient harm seen as preferable to sorting it out?’ Answer? The worst parts of the NHS.
No surprises at Morecombe Bay either
More than 5 years after the death of baby Joshua Titcombe, the Health Service Ombudsman this week published at scathing report which stated the trust responsible for his death failed to investigate it openly and honestly. This however, is not full story. More than 3 years earlier, the same organisation refused to investigate Joshua’s death stating that they were ‘pleased’ with the way the trust responded. The Ombudsman have now apologised to the Titcombe family for their original decision; probably a wise decision given that events at Morecambe Bay are now subject to an independent investigation by Bill Kirkup, who played a key role in the Hillsborough inquiry. One has to wonder how many other decisions not to investigate serious NHS complaints the Ombudsman has got wrong in the past?