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
phsothetruestory 
Excellent website, which I’ve only just come across.
I have to say though, most reviews aren’t reviews, they’re investigations. ‘Review’ is a weasel word – NHS exec-speak to try to make investigations appear less important than in fact they usually are, to put a gloss on them. My mother made a complaint to the PHSO, it was upheld in full, and the Chair of the provider which failed, annoyingly and insultingly always referred to it as a review. While helping my mum with letters I corrected him several times, but he disingenuously kept on using the word.
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The NHS complaint process is corrupt and with the PHSO who only find in favour of the NHS. In my case I did get a partial uphold which should have been a full uphold it took 2.5 years. I was misdiagnosed with a serious condition and treated with powerful drugs for that condition. I found out nearly 3 years later that the Consultant didn’t believe he had done anything wrong despite his actions not following clinical guidelines. Obviously in with the boys because he was Clinical Director.
I live with irreversible side effects from this misdiagnosis and the treatment given. The Consultant only lives with the knowledge he made a mistake. The GMC did nothing and are as corrupt as the PHSO. They refer back to the responsible officer which is not doubt a chat over a cup of coffee and don’t do it again.
I did manage to force an audit of the Consultant’s work against the Clinical Guidelines and a random audit of patients with the same condition to see if the biospies that weren’t done in my case were being done as part of the diagnostic work up. The Trust concerned never even logged an incident and whitewashed an external investigation. I did find a solicitor who took on my case and even got the top man in the country to give an opinion. He shafted me big time by going against the very guidelines he wrote saying that my care had been correct. I lived under the cloud of this condition for 12 months before biopsies found I never had the condition.
The systems are stacked against truth coming out due to toxic cultures and standards that are so poor they are now the norm. Oh and NHS do like to lie big time to get themselves off the hook. It is a case of defend, deny and discredit. My advice is don’t go there with even a complaint, avoid the PHSO like the plague and give the GMC a swerve too. This is why there continue to be scandals because nothing changes and the quangos who could enforce change don’t. Oh and the PA are a waste of air. My trust in Doctors has been destroyed and will never be regained.
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I went to PALS, now my records are a work of fiction. They are refusing to treat. I had not seen panorama hospital secrets uncovered, in which a patient cannot reveal his identity otherwise he said they would refuse to treat, until afterwards. So I agree there seems no point in a complaint.
I wanted to ask you how you got other biopsies, was this at another hospital or private? As I don’t know who to approach and am thinking of going abroad. As I read online “they stick together like glue”, so I don’t know who will test me and give me an honest opinion. As you say my trust in Doctors has now been destroyed. But I still need treatment.
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You may need to pay privately for biopsies or try not to reveal the reason you would like them done. It is very rare for any doctor to criticise another doctor even when it is obvious that a mistake has been made.
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Biopsies were done because another test showed the medication wasn’t working. It wasn’t working because I didn’t have the condition it was prescribed for!
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At the same hospital. Whatever doubts the Consultant had he never shared them with me which meant I wasn’t giving informed consent. The Trust never forgave me for forcing them to be scrutinised by external agencies with an action plan. They never took this seriously and needed 3 action plans to get things right.
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Yes, they are all in it together no matter which way you turn. Clear breaches in guidelines turn out to be nothing more than oversight and a slap on the wrist is the most any guilty party will receive.
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Another falsifier. I lost count of the number of times the word ‘dishonest’ appears alongside his name. His name was erased from the medical register, but doctors who are erased can get back on it.
Dr Ramon MARTOS MARTINEZ GMC ref. no. 4298135
Click to access dr-ramon-martos-martinez-14-jun-21.pdf
‘8. You knew:
a. the copy letter had been falsified, as described in paragraph 7; Admitted and found proved ‘(page 17)
’21. The Tribunal considered that Dr Martos Martinez’s dishonesty was for his own personal gain. It concluded that he was dishonest in his application form to STNT and used post nominals he was not entitled to so people would view him more favourably. Dr Martos Martinez’s repeatedly acted dishonestly for his own interests. These instances of dishonesty amounted to misconduct both individually and collectively. Dr Martos Martinez has breached GMP as set out above.’ (page 22)
’24. The Allegation found proved relates to three separate categories of dishonesty over a period of almost five years and was not restricted purely to the period of time spent at BHFT.’ (page 27).
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So what happened to him?
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Just can’t practice as a doctor… until another MPT finds that he can. Will have to show remorse and remediation, though. He probably couldn’t get a job with the PHSO either. But disciplinary cases can take years to be heard, so a doctor facing allegations subsequently found proved could possibly work for the PHSO up until the date of the MPT decision. I am not sure whether the PHSO would allow a doctor facing disciplinary proceedings to work for it, or whether it contacts the GMC to verify claims made by potential clinical advisors. Some stuff on MPT outcomes:
Click to access Analysis_of_cases_resulting_in_doctors_being_suspended_or_erased_from_the_medical_register_FINAL_REPORT_Oct_2015.pdf_63534317.pdf
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Another case of a doctor falsifying records. Suspended for only 2 months.
Dr Nishat AHMED GMC ref. no. 7469945
https://www.mpts-uk.org/hearings-and-decisions/medical-practitioners-tribunals/dr-nishat-ahmed-may-21
‘7. The Trust carried out an initial informal investigation in relation to both cases and at that time decided not to take any formal action against Dr Ahmed…
…
(4) You recorded information in Patient A’s clinical notes which:
a. was untrue; Admitted and found proved
b. you knew to be untrue. Admitted and found proved’
One wonders how many similar cases (i) never come to light and (ii) how many cases that do come to the notice of trusts result in no formal action.
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Here’s a case that had no evidence to suggest any clinical failings on the part of the doctor; however, it shows what patients might consider a ‘red card’ offence to be something treated as minor:
Dr Natasha WATERS GMC ref. no. 6116264:
file:///C:/Users/HP/Desktop/MPTS/Dr%20Natasha%20WATERS%2023%20Feb%2021.pdf
‘9. Following her review with Patient A, Dr Waters altered Patient A’s Consent Form by adding ‘haemorrhage’, ‘return to theatre’, and ‘repair of injury’; and Clinical Notes, by adding ‘pre op’, ‘previous 5x [sic] did not relief pain at all’ and ‘aware of risks of haemorrhage, infections infancy [sic], return to theatre’.
10. Dr Waters knew that any retrospective changes to Patient A’s Consent Form and Clinical notes should have been clearly indicated but they were not.’
Conditions previously imposed were revoked – not impaired.
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I once went to a GMC meeting and a woman who carries out these reviews said ‘I always assume good doctor, bad day’.
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Another example of a dishonest doctor who altered a patient’s records being restored to the medical register:
12. The 2015 Panel determined that Dr Jenyo made additions to, and deleted parts of, Patient A’s clinical notes. The 2015 Panel concluded that the deletions were particularly serious, as they were intended to show symptoms in different areas to those reported by Patient A. For example, in the deletion of the term “mid-back pain” (entry 26 February 2007, amended 27 May 2010), to remove reference to such pain early on in Patient A’s records, and the deletion of a note of a chest examination (entry 17 January 2007, amended 27 May 2010), to fit in with the clinical picture that Dr Jenyo wanted to present.
13.The 2015 Panel determined that Dr Jenyo’s dishonesty was not a single isolated incident, but behaviour repeated over a long period of time. Further, the 2015 Panel determined that Dr Jenyo’s conduct was calculated…
Dr Robert JENYO 5193333
Click to access jenyo-may-2021.pdf
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They are all crooks Jeff who hound out the honest NHS whistleblowers while protecting the criminal actions of others.
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Only a 12-month suspension for Dr Ojo (GMC ref 6050894):
21. The Tribunal found that, in the course of the proceedings, Dr Ojo made false representations in his 2017 witness statement, which he knew to be untrue and dishonest. The Tribunal were of the view that by making false representations in his witness statement, to cover up his clinical failings, Dr Ojo was intentionally dishonest. Furthermore, Dr Ojo had maintained the falsehoods on oath at the Coroner’s Inquest. The Tribunal determined DrOjo’s actions amounted to serious misconduct. (page 24)
29. However, the Tribunal also took into account the number of testimonials submitted in support of Dr Ojo’s behalf. He is well regarded otherwise. Those who knew him and worked with him were “shocked” by allegations of dishonesty. (page 25)
Click to access dr-anthony-ojo-30-mar-21.pdf
Lord Phillips made a great point about testimonials in the case of Dr Haris that I previously mentioned:
https://www.bailii.org/ew/cases/EWCA/Civ/2021/763.html
’39. To take an illustration given by my Lord, Phillips LJ, in the course of the hearing, if X is found as a fact to have loaded a gun, held it against someone’s head and pulled the trigger, and the issue is whether when he did those things he intended to cause that person really serious injury or death, the fact-finding tribunal might well hear and accept entirely credible evidence from X himself and from X’s family and friends that he has been a lifelong pacifist, is kind to children and animals, and abhors violence. However, that information will not assist the tribunal in determining what inference can be drawn as to his intention when he held the gun to the victim’s head, let alone point to a positive conclusion that it is more likely than not that he had no intention to kill or seriously injure. Such a conclusion would be perverse.’
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An example of a doctor’s notes not reflecting the truth:
26. ‘Dr Haris’s handwritten records of the examination of Patient B were not all made immediately afterwards; some parts were written 2-3 hours later. He had conducted other consultations at the hospital that day after seeing Patient B. The MPT found that the handwritten records contained inaccuracies, including allegations relating to Patient B’s mental health which were not borne out by her historic medical records. The notes specifically recorded that Dr Haris had not conducted an intimate examination nor a breast examination.’
https://www.bailii.org/ew/cases/EWCA/Civ/2021/763.html
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The truth is whatever they want it to be.
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I’m not aware of any links – I have just seen tweets about the case.
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I have seen tweets on PHSOthefacts concerning the death of the young girl Claire Roberts in 1996 from hyponatraemia.
The Chief Scientific Advisor to the Department of Health (NI), Professor Young, has recently had a judicial review dismissed. The process by which allegations were brought against him by the GMC was found to be lawful:
Click to access 534.pdf
’20. O’Hara J was satisfied that a “cover-up” of the cause of death was attempted by Dr Steen and to some extent by Dr Webb…
’49. “3.280 In the light of this evidence, I am of the view that Professor Young shifted from his initial independent role advising Dr McBride to one of protecting the hospital and its doctors.”’
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Is there a link from this to PHSO?
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The MPT goes light on delinquent doctors. Consider the case of Dr David Henry Dighton.
He was suspended for excessively prescribing drugs amongst other things (see para. 8 of the appeal).
The PSA appealed the decision on the basis that the sanction was insufficient:
http://www.bailii.org/ew/cases/EWHC/Admin/2020/3122.html
Mrs Justice Farbey heard the appeal and concluded:
“43. I have considered whether I should order the erasure of the second respondent or whether his voluntary erasure would be adequate. Ms Morris emphasised the three elements of the public interest which I must consider: the protection of patients; the maintenance of standards; and public confidence in the profession. In my judgment, public confidence in the medical profession means not only that the flawed decision of the MPT cannot be permitted to stand but that the court should order erasure.”.
How can the public have confidence in the MPT? What’s not getting to the High Court? If things are looking bad for a doctor it seems that voluntary erasure is the way they can stop an MPT panel from deciding on their alleged conduct.
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Thanks for sharing.
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Sometimes things are covered up in plain sight!
Consider Dr Blasco (GMC ref. 3503135) who:
“6. made a number of bulk computer entries, in which he had entered diagnoses for large numbers of patients when he had not examined the patients and knew that he had not done so. These included diagnoses for patients with chronic kidney disease, obesity and depression.It also found that Dr Blasco had inputted asthma reviews and medication reviews when he had not seen the patients. The 2018 Tribunal found that Dr Blasco failed to provide good clinical care to a number of these patients and had acted dishonestly in relation to the bulk computer entries.”
Click to access dr-inigo-iruskieta-blasco-31-jul-20.pdf
Seems like a clear case of erasure from the medical register in my opinion. But no. Merely suspended. Perhaps the next time his case is reviewed he will have developed ‘full insight and remediate[d] his dishonesty’, thereby paving the way for his return to medicine.
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In plain sight indeed.
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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])
Click to access dr-ali-ismail-14-feb-2020.pdf
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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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.”
Click to access dr-joanne-rudling-26-jun-20.pdf
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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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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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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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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I wonder what the Patients Association will say about this. Maybe they will express their ‘shock’ yet again.
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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 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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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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