As we use the time of reflection gifted by the Covid-19 pandemic to imagine a better world, will any attention be given to the harm caused by the cover-up culture rampant in the NHS? The present system of accountability for all public services, not just the NHS, is not fit for purpose as so recently demonstrated by the Health Service Journal. Without accountability you get impunity.
Revealed: The serious care failings the NHS tried to keep secret
By Alison Moore25 June 2020
- Vast majority of safety reviews never made public, contrary to guidance
- 70 external reviews at 47 trusts over three years
- Regulator not given reports despite Kirkup ruling
The NHS has kept secret dozens of external reviews of failings in local services – covering possible premature deaths, unnecessary and harmful operations, and rows among doctors putting patients at risk – an HSJ investigation has found.
At least 70 external reviews by medical royal colleges were carried out from 2016 to 2019, across 47 trusts, according to information provided by NHS trusts.
More than 60 of these have never been published – contrary to national guidance – while several have not even been shared with the Care Quality Commission and other regulators. These include reviews which uncovered serious failings.
The reviews – generally known as royal college reviews or “invited reviews” – are commissioned by local trusts from national medical royal colleges for the relevant speciality, which receive a fee for the work.
It emerged in January that a 2016 report into East Kent hospitals’ maternity services — subsequently the subject of major national concerns — was not seen by the CQC until 2019, and was not published.
Bill Kirkup’s review into the Morecambe Bay scandal in 2015 recommended trusts should “report openly” all external investigations into clinical services, governance or other aspects of their operations, including notifying the CQC.
Since then the CQC has asked trusts for details of external reviews when it reviews evidence, and in July 2018 it began to ask for copies of their final reports.
But HSJ’s research suggests this does not always happen. Trusts were only able to confirm to us for 14 of the 70 reviews that they had been shared with the CQC. Many would not say or could not find evidence of whether they had done so. Several said they had informed the CQC but had not been asked to submit the final report.
James Titcombe, the patient safety campaigner whose son’s death led to the inquiry by Bill Kirkup into the Morecambe Bay maternity care scandal, said a review was now needed of whether its recommendations had been implemented.
“It is not acceptable that five years [on], there are still secretive royal college reports and patients are kept in the dark,” he said.
He said it was “really concerning that so little has happened” in ensuring the CQC was informed of findings. “Where are the patients in this? How are patients who are using these services meant to know about serious concerns which are being uncovered?”
Trusts which did not send review findings to the CQC included:
- The Royal Cornwall Hospitals Trust – the subject of four reviews in three years – said only two reviews were shared with the CQC, while the other two missed the timeframe for which the CQC had requested information.
- Kettering General Hospital Foundation Trust said there was not enough space to include a 2017 report into breast services in its CQC return, as only six documents could be submitted.
- Dartford and Gravesham Trust, which had commissioned three reports, two of which have been completed, said: “It would not be normal practice to inform CQC when commissioning reports.” It later added that it “has regular contact with its CQC nominated engagement lead where information, incidents of concern and progress on action plans is shared”.
- Rotherham FT said there was no “statutory requirement” to share a report into ophthalmology it commissioned in 2016. Its medical director said: “I can confirm that this report has not been included in any CQC [provider information requests]. The report was commissioned by my predecessor and we are unable to confirm if he made the CQC aware of this himself.”
Details of the reports have now been released to HSJ in response to Freedom of Information requests, although many were redacted.
The majority are what are known as “invited reviews” – where a trust has called in a royal college because of concerns about care problems in a particular service. In some cases, trusts may ask for a review of a particular medical consultant’s work or a review of options for a service’s future.
The CQC indicated trusts should share findings. Chief inspector of hospitals Professor Ted Baker said: “There has always been a clear expectation for trusts to be transparent where they know there are significant issues with the quality of their services…
“Our inspection teams are in regular communication with trusts outside of inspections and as part of that regular engagement we expect trusts be open and honest with us about any concerns or issues.
“Inviting an independent review is a proactive step towards improving care and we regard it as evidence that the trust is addressing quality concerns.”
The Academy of Medical Royal Colleges said its “operating principles” for “invited reviews” state that where there are care quality issues, the trust involved should make public a summary of the report and actions it plans to take. It also says that royal colleges have a responsibility for ensuring serious patient safety issues are shared with regulators either by trusts or by taking action themselves.
AOMRC chair Carrie MacEwen said: “It is important that organisations commissioning a review are aware of the framework and we expect that all involved in reviews would follow the principles in the document.”
Source
Information released to HSJ and other sources
Source Date
June 2020
Thanks for this. Cover ups ? Have sometimes considered a FOI query , re quantity of black ink used by NHS, redacting almost all of some patient records…
Several pages of my mother’s mental health & general records are more black than white…
As soon as we can – WFH currently more than full time –
, my analysis of major safeguarding failures concerning my mother’s care will be online, as an e-book – currently only in print…
The lack of communication between key agencies contributed to those failings -including disregard for the safety of a mental health patient. sectioned. with a condition identified as being especially vulnerable to exploitation and abuse. ( Care Cluster 12 ) .
When a CQC report on a care home identified seven major failings, the place was allowed to continue operating on condition that the failings were remedied. At the same time, the home was facing prosecution, following the death of a resident -( not my mother. .)
Conviction and sentencing followed, CQC apparently unaware of the ongoing prosecution by HSE.
My other key concern is direct police access to patients’ NHS records, from staff, not via medical legal, and without DP , in circumstances which don’t involve child protection or immediate danger to the public. – no terrorism, no gunshot wounds
Hospital central to my complaint stated direct release to the police is normal practice, NDG office directed me to the official position, so did the GMC. PHSO accepted and upheld the trust’s position, rejected my complaint.
Police clearly did not understand opthalmology data released to them by a registrar – data which identifies the patient as blind.
Complicated case, involving three public authorities – NHS, Social Services and the Police.
CEO of the Trust acknowledged that the opthalmology data identifies blindness – indicated that correcting CID was my problem….
best wishes
Rosamund Ridley
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I have been to court 3 times to try and obtain records for a claim made against NHS and they find a way through the most expensive lawyers to avoid giving evidence. This can be supported by judge , I will pursue this corruption through internet/social media to expose deception . I have been trying to get repayment for care fees since 2013!
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The court is too often just another tool of the state unfortunately.
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Business as usual, hopefully one day the government etc. will see the error of these ways and deal with stuff, less hassle and I am sure less costly to all concerned. Been doing a short course on making compliated decision making and one part referred to ‘lock ins’ where it is usual to stay with the same way of thinking, lacking the ability to change direction – relating mostly to consumerism, but applies to so much I feel, especially including the awful cover-up locked in way of managing.
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Once you start covering up I guess it’s difficult to stop.
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I wonder what the Patients Association will say about this. Maybe they will express their ‘shock’ yet again.
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The PA could help by getting behind the families (more than 1,000) affected by the Shrewsbury and Telford Hospital NHS Trust baby deaths scandal. West Mercia Police has today announced that it is looking into th matter:
‘West Mercia Police said it was investigating whether there is “evidence to support a criminal case either against the trust or any individuals involved”.’
https://www.bbc.co.uk/news/uk-england-shropshire-53241946
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I doubt the PA will do more than express shock.
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It seems like they aren’t even prepared to do that!
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Sadly, PA, once the champion of the people is no more. That’s what happens when ex NHS staff, who never did understand Patient safety, take over. Sadly gives too many good NHS staff a bad deal.
Lucy, it might have been better if you had simply retired.
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Should investigate BSMHFT as well. Lied to me lied to Coroner lied to PHSO for 10 years. Cover ups still alive on later deaths from negligence at that place.
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Some might like to read this recent MPT decision that reveals how a doctor can go rogue. I suspect, however, that most delinquent medics never get caught. In this case the GP is having her suspension revoked, but here is what she did:
“3. Dr Rudling was found by the tribunal to have made a retrospective entry on 10 December 2012 (after being notified of Patient A’s death) of her discussion with Patient A’s mother on 7 December 2012 without recording that the entry was retrospective. She was also found to have failed to record being told that Patient A’s genitalia had turned black and that this action was dishonest and undertaken to avoid criticism of her care and treatment of Patient A. The tribunal found that Dr Rudling on 13 November 2013 provided a statement to the police, supported by a statement of truth, but had dishonestly and incorrectly claimed that she had seen “a summary of the notes made and the advice given but not the full detailed note”before speaking to Patient A’s mother on 7 December 2012.”
Just a matter of time before those caught and suspended can see patients again.
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Thanks for sharing this Jeff. I can recall being at a GMC conference and an assessor said “I always start from the premise good doctor – bad day” and couldn’t see anything wrong with that.
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An awful lot could be swept under the carpet with that attitude.
In truth, doctors do not intend to do harm, but when they do it’s important that incidents are properly recorded and investigated. I think a significant number of mistakes happen because of overwork. In this example (dishonesty relating to timesheets) the Tribunal indicated the hours it thought acceptable for a doctor to work:
‘The Tribunal did not consider working 35 hours in a 44 hour period to be inherently unsafe.’ (page 18 [para 95])
Seeing the doctor at the 35th hour could have serious consequences.
Requirements for lorry drivers:
‘Driving hours
The main EU rules on driving hours are that you must not drive more than:
9 hours in a day – this can be extended to 10 hours twice a week
56 hours in a week
90 hours in any 2 consecutive weeks’
https://www.gov.uk/drivers-hours/eu-rules
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Good point. Of course the lessons are never learnt when everything is covered up.
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