First published by Romy Cerratti January 24th 2022
A German doctor saved my life when I was just over a year old. A joyous first family Christmas in Germany ended in me catching an infection from my cousin, sepsis and ICU. The doctor gave my fragile young body the best possible chance and I owe him much. Sadly many of my subsequent encounters with doctors and nurses have been the opposite and it is these that have left their mark. I was assaulted by an NHS doctor when I was 14 and desperately unwell with a complex mental illness. However it’s never been as ‘straightforward’ as dealing with the one horrific incident. Many months of bullying and threats preceded that assault. In the years that followed I went through unnecessary incarceration in inpatient units and damaging treatment therein, intimidation, lies, misdiagnosis, catching life threatening hospital infections and plain old incompetence. I have more often survived despite and not because of medical ‘care’ and have added PTSD to an already complex set of mental and physical health conditions. It is a great source of pain to me that I now approach all medical professionals with distrust, even fear.
However the prevailing British view of ‘our NHS heroes’ and ‘our amazing NHS’ could not be further from mine. The reverence of many Brits for their healers knows no bounds and most won’t tolerate criticism of their modern day saints. This even extends to when their health or the health of a loved one has been mishandled and damaged, sometimes even when the result is death. Just recently I read a newspaper report of the tragic cancellation of vital scans, due to NHS Covid policy, for a 15 yr old boy with a brain tumour. It struck me that the mother did not blame the NHS for this or even the doctors for missing the clear symptoms of a brain tumour earlier on. Heartbreakingly this poor lady almost blamed herself for not being ‘pushy’ enough! My mother encounters this regularly in the course of her job as a vicar looking after 8 rural parishes. Even when an avoidable death has occurred, people are reluctant to complain about their medical treatment. ‘I’m sure they did there best,’ or ‘it’s a problem of the management and resources not the doctors and nurses’ are the predictable responses. Such pervasive NHS worship can also scare would be complainents and whistleblowers into silence. I am often contacted privately on social media by those who want to tell me their story of medical mistreatment. Telling me is ‘safe’ because they know I will accept and empathise rather than judge or dismiss their NHS heresy. It is a heartbreaking privilege. Recently a Twitter follower shared both her story of doctors covering up the failings in her treatment and a link to the ‘Oliver McGowan Mandatory Training in Learning Disability and Autism video’. Oliver’s brave mother eloquently tells the heartbreaking story of the catelogue of errors and mistreatment that lead to her son’s death. It somewhat shocked me that even in a case where there was clear blame to be ascribed to individual physicians, she said ‘It’s not about pointing fingers, it’s not about blame.’ But is it?
It’s actually quite rare for people to make an official complaint against the NHS, even if they do feel wronged in some way. The intrepid who do embark on the official complaints process find their path beset with obstacles that can feel designed to make you give up.
‘Scandalous and shameful. If you’re looking for an outcome and you’re emotionally stressed, don’t waste your time with these corrupt individuals.’
This is a Trust Pilot review of the Parliamentary and Health service Ombudsman, (PHSO), the final and highest arbitrator of complaints against the NHS and its employees. It is indicative of pretty much every single review. Undeniably people who have had bad experiences are more likely to leave online feedback. However this near universal unbridled fury and distress, summed up in one review as ‘The PHSO is a vehicle for injustice,’ suggests a fundamental problem.
In 2016, after a scandal provoked a change of Ombudsman , chief executive at the Patients Association, Katherine Murphy said patients had ‘been failed by the PHSO for too long.’ However, the statistics, as well as patient feedback, suggest nothing has improved. In 2018/19 it was found that the PHSO upheld just 2.4% of all the complaints submitted. (It must be added that if resolution without investigation is taken into account this figure rises to 20% but also that ‘resolution’ is most often no more than a simple apology). This is a decline from the already paltry 3% in 2016/17 and even further from 4.7% 2015/16. The Ombudsman is theoretically held to account and monitored through the submission of annual reports to the Public Administration and Constitutional Affairs Committee, (PACAC), a parliamentary committee made up of cross-party members. However PACAC can’t review individual complainants cases and the Ombudsman’s verdicts can’t be challenged. Therefore the Ombudsman is not accountable in any meaningful sense. The only recourse available to a complainant is Judicial Review, a path that precious few citizens have the means to make use of. One rare example of a successful High Court challenge in the High Court was brought by two GPs in 2018. In the ‘Miller & Anor V Health Service Commissioner for England’, the judgement criticised all aspects of the investigation process including failure to consider all the evidence and an inadequate review process. Importantly it also highlighted the ‘lottery’ of the ‘clinical advisor’ selected for each case. When the PHSO investigates and scrutinises a case it uses but a single clinical advisor whose words are Holy Writ. Therefore one person’s opinion is basically all that matters and it is an NHS doctor reviewing one of their fellows. The NHS arguably acts as its own judge and jury.
‘It doesn’t matter what I say or what evidence I present you will simply stick to your narrative that bears no relation to the truth. I am powerless.’
This time these are my own words, taken from my response to the PHSO’s final report on one of my two complaints I submitted in late 2018. I had already gone through a long mentally draining process to get to this stage of utter despair. That involved having to first complain to the hospital and the NHS Trusts, several labyrinthine forms and some rather interrogatory face to face meetings. This smorgasbord was completed by a random, intimidating phone call from someone at the relevant NHS Trust trying to dissuade me from taking things further. Both complaints centred around the absence of psychiatric assessment, misdiagnosis and serious negligence in both psychiatric and physical healthcare. The consequences of the way I was treated have been profound and I am living with the terrible consequences daily. But those wounds were actually deepened by the complaints process I had hoped would bring some healing closure and justice. The fact that my records were lost, my complaints muddled up resulting in huge delay and my caseworker frequently went AWOL almost feels inconsequential to me now in the light of the whole process being a whitewash. The first question asked of the PSHO’s clinical adviser assigned to my case was:
‘Is there any evidence that Ms Cerratti should have been assessed by a psychiatrist during her admission/time as an inpatient?’
The Ombudsman actually questioned whether it is essential for someone with severe psychiatric problems to be assessed by a psychiatrist whilst in hospital. This gives a fair impression of the whole tortuous coverup of an ‘investigation’. I was left staring at a page of my medical records, on which was written a few notes of my medical history, dictated to a nurse by my mother, but on which the PHSO insisted was recorded a psychiatric assessment. One by one family members stared at the same page and we all started to wonder whether we’d fallen ‘through the looking glass’. Indeed my whole encounter with the PHSO had the bewildering feel of being in a shape shifting bonkers Wonderland.
‘“When I use a word,” Humpty Dumpty said in rather a scornful tone, “it means just what I choose it to mean — neither more nor less.”’
They were in control and could weave whatever bizarre fiction they chose irrespective of what most would understand to be reality.
I have nothing but admiration for the amazing Mrs McGowan, the architect of the much needed Oliver McGowan Mandatory Training in Learning Disability and Autism programme. She has achieved more regarding NHS reform than I am ever likely to. I also respect her emphasis on improving the education of NHS staff. However improved training, although vital, can not alone solve the problem of NHS malpractice. In order to stop the rot we must get rid of rotten apples and that very much involves both blame and pointing the finger. It must involve holding individual medics to account, even criminally, and certainly striking off the worst offenders. In Oliver’s tragic case no amount of extra training could have prevented the arrogant disregard of his medical notes and ignoring his family’s and indeed his own wishes. In my friend’s NHS story, it was not ‘lack of training’ that made doctors falsify her medical notes to conceal their bad practice. In my own case there was an invisible psychiatric assessment, disregard of my previous trauma and the unwillingness to believe me or even listen to me, none of which was down to a lack of training.
The medical abuse I have suffered hasn’t just left me with a distrust of medics, it’s given me a deep rooted distrust of life. Ironically the process I hoped would help ease that, the NHS complaints process, actually reinforced it. I can only speak out to encourage other victims to do likewise and in the hope that our suffering will be acknowledged and provoke reform of the NHS, it’s culture and its complaints process.
phsothetruestory 
Nurse erased:
‘6. The patient’s grandson, a registered paramedic, arrived to visit his grandfather at 3am that night. On arrival, he found the door to the side room locked. Despite knocking repeatedly, there was no answer. He sought assistance from the sister in charge at the time. After several more minutes of knocking, the door was opened by the Nurse who
then closed it again. When she re-opened the door a few minutes later, it appeared to both witnesses that she had just woken up because of her appearance and because the room was in virtual darkness. Blankets were seen rolled into pillows and there were other blankets on the chairs which gave the impression that the Nurse had been sleeping on a makeshift bed.
7. When the light was turned on, Patient A was found to be unresponsive on the bed with his head lowered down below his legs, and his legs bent but elevated at a 45-degree angle…’
Click to access 1230.pdf
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Shocking
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ERASURE
‘2. The allegation that has led to Dr Mamman-Aka’aba’s hearing can be summarised as that on 20 May 2022 at Manchester Crown Court, he was convicted of gross negligence manslaughter and on 5 July 2022 he was sentenced to three years’ imprisonment
11. The Trust commenced an investigation following the matter being reported on the day of Patient A’s death as concerns were raised by Mr B that Dr Mamman-Aka’aba had not stopped when Patient A had cried out in pain and he had been asked to stop.’
Click to access dr-isyaka-mamman-akaaba-06-apr-23.pdf
Suspension, 6 months
‘2. It is alleged that on 11 May 2021, whilst sitting Paper 1 of the Membership of the Royal College of Physicians (UK) Part 1 online written examination (‘the Examination’), Dr Ip used his mobile phone to check or amend answers, knowing that he was not permitted to do so, and that by this dishonest conduct, he sought to obtain an unfair advantage in the Examination.
At the outset of these proceedings, Dr Ip made admissions to the whole of the Allegation…
97. The Tribunal considered the following to be aggravating factors in Dr Ip’s case:
• In the documentary evidence, Dr Ip had sought to minimise his conduct, describing his cheating as ‘impulsive’;
• Dr Ip only admitted to planning to cheat before going into the Examination when questioned by the Tribunal; and
• Dr Ip demonstrated a lack of candour about the degree of his preplanning.’
Click to access dr-chak-ip-6-apr-23.pdf
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Suspension, 12 months
’97. The Tribunal concluded that by directing Patient B’s support should be decreased, whilst knowing that taking the BMs post-feed would manipulate the plan to continue weaning, Dr Derbyshire put the health of the patient at risk. Dr Derbyshire’s direction, therefore, was inappropriate.
143. …In this statement Dr Derbyshire accused the Trust of scapegoating her, calling them “psychopathic criminals”. Dr Derbyshire wrote (referring to the telephone call with Dr C on 8 May 2017), “If they had not seen what they were looking for within this phone call, I have no doubt they would have next taken steps to kill a patient for purpose of framing me for manslaughter as the consultant old boys’ network (OBN) did to poor Dr Bawa Garba. Now they thought at last they had the opportunity to establish I had made an error of judgement.”’
Click to access dr-debbie-derbyshire-29-mar-23.pdf
Suspension for 12 months
‘1. …The fitness to practise concerns were initially brought to the attention of the GMC in April 2020 by Dr Isima’s Responsible Officer, who advised that Dr Isima was involved in a Serious Incident in 2019 which resulted in a neonatal death.
The GMC case examiner subsequently summarised the concerns as follows:
• poor communication skills,
• poor record keeping,
• acting outside the limits of his competence,
• failure to make decisions on management plans,
• no sense of urgency when asked to review patients
• delaying procedures inappropriately
• ignoring colleague advice,
• an inability to explain how he kept his professional portfolio up to date as a locum
• a general lack of insight into his clinical performance. ‘
Click to access dr-michael-isima-26-april-23.pdf
ERASURE
“228. The Tribunal found that Dr Donnelly had acted dishonestly in his professional practice, when he submitted applications for various roles on the basis of false information, as set out at paragraph 125 of the SG:
‘125 Examples of dishonesty in professional practice could include:
…
d inaccurate or misleading information on a CV
e failing to take reasonable steps to make sure that statements made in formal documents are accurate.’
229. Further, the Tribunal considered that it has found that Dr Donnelly’s dishonesty was persistent, not only regarding the three applications made in 2020, but over the span of his career, taking into account that he was erased for near-identical allegations of dishonesty in 2003.”
Click to access dr-michael-donnelly-28-apr-23.pdf
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Suspension revoked
‘4. Dr Jones’s substantive hearing concluded in October 2021 (‘the 2021 Tribunal’). The initial concerns had been raised with the GMC by Dr Jones, who referred himself to the GMC following his arrest on 26 March 2019.
5. The matters which were the subject of the hearing were as follows: on 12 January 2021, Dr Jones was convicted on two counts of fraud, the total value of which amounted to £67,420.26.
6. In relation to count 1, Dr Jones made false locum payment claims on 271 occasions to various health boards in Wales between 15 April 2016 and 1 August 2019, which amounted to £34,184.86’.
Click to access dr-aled-jones-24-mar-23.pdf
Suspension to expire
‘Curriculum Vitae
17. In September 2018 you provided your CV to the panel investigating concerns about your research conduct (‘the Panel’) and you falsely listed the paper referred to at paragraph 1b as being ‘accepted and pending publication’. Admitted and found proved
18. When you submitted your CV to the Panel you knew the paper referred to at paragraph 1b was not ‘accepted and pending publication’.
Determined and found proved
19. Your actions as described at paragraph 17 were dishonest by reason of paragraph 18. Determined and found proved’
Click to access dr-abul-siddiky-24-mar-23.pdf
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Daily Record 9/4/23:
‘A catalogue of failures led to the death of Jade McGrath, 19, when she was admitted to New Craigs Hospital in Inverness, which has now also formally apologised to her mother. Jade, who had threatened to take her own life, walked out of the hospital unchallenged.
Disinterested staff failed to report her missing for over 45 minutes. They also failed to tell police she was a suicide risk. It was 11 days before her body was found by children playing less than a kilometre from the ward.’
https://www.dailyrecord.co.uk/news/scottish-news/family-tragic-jade-mcgrath-given-29664184
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ERASURE (includes many more allegations found proved)
1a. answered ‘No’ to the question ‘Have you ever been removed from the register, or have conditions or sanctions been placed on your registration or have you been issued with a warning by a regulatory or licensing body in the UK or in any other country?’ To be determined
28. Therefore, the Tribunal found paragraph 1(a) of the Allegation proved.
Click to access dr-luigi-angelini-15-feb-23.pdf
Suspension revoked
6. At the tribunal which sat from 21 November 2022 – 1 December 2022, it was found proved that Dr Varghese amended the hospital copy of the consent form after Patient A had signed it, knowing that he had not discussed this particular risk with Patient A and knowing that the amendment was not included on the copy given to her. It was found proved that in doing so, Dr Varghese acted dishonestly
Click to access dr-jibu-varghese-22-feb-23.pdf
Order revoked
4. On 26 January 2018 Mr Andrews carried out a right Exeter Unitrax Cemented Hemiarthroplasty (the ‘Surgery’) on Patient A and failed to report to his line manager and/or clinical team that there was no hip fracture when he operated; and failed explain to Patient A’s relatives that there was no hip fracture when he operated. Mr Andrews also failed to record that there was no hip fracture in the operation notes and the rationale for proceeding with the hip replacement in the operation notes.
5. The failures as described above where an attempt to conceal that the Surgery was unnecessary and to avoid an investigation into his treatment of Patient A.
6. On 8th March 2022 the tribunal found Mr Andrews’ fitness to practice to be impaired by reason of his misconduct.
Click to access mr-christopher-andrews-23-feb-23.pdf
ERASURE (more than 700 paragraphs)
2. The Allegation faced by Dr Latif can be summarised as follows.
Between 9 March 2006 and 5 June 2018 as the sole doctor working at the Clinic, Dr Latif knew that controlled drugs for weight loss were being distributed and issued to one or more patients by non-medically qualified and/or untrained staff at the Clinic (‘the Staff’). It is alleged that he permitted the distribution and issue of controlled drugs for weight loss by the Staff to the patients of the Clinic. Other allegations include failure to ensure that the controlled drugs, Phentermine and Diethylpropion, were stored appropriately and that Dr Latif had insufficient training in the area of weight management
43. Accordingly, the Tribunal found paragraph 1.a of the Allegation proved save that the Tribunal does not find proved that Dr Latif was the “only doctor” at the Clinic.
Click to access dr-mufti-latif-27-feb-23.pdf
ERASURE
1b. without consulting with Patient A, you altered the signed Consent form for the Procedure dated 11 June 2019 (‘the Consent Form’), in that you:
i. crossed out the word ‘Mirena’; To be determined.
ii. inserted the word ‘copper’. To be determined
46. The Tribunal had regard to the Consent Form retained by the Trust, dated 11 June 2019, which was signed by Dr Macfoy and Patient A. It noted that this copy of the Consent Form had been altered and under the heading proposed procedure or course of treatment the word mirena had been struck through and replaced underneath with the word ‘copper’.
47. The Tribunal noted from Patient A’s statement that she was clear that she had not seen the altered Consent Form and had not been consulted with by Dr Macfoy about it. She exhibited the original Consent Form which had been signed by her and Dr Macfoy on the morning of the 11 June 2019. On it, she had consented to a procedure whereby she would have her Mirena coil removed and replaced by another Mirena coil. Patient A maintained that she only saw the amended Consent Form, with the word Mirena crossed out in favour of copper, after the Procedure. She stated that she was shown the altered form by nursing staff and it was not altered in her presence nor did she agree to it being altered.
62. Accordingly, the Tribunal found Paragraph 1 (b)(i) and (ii) determined and found proved.
Click to access dr-donald-macfoy-28-feb-23.pdf
ERASURE
12. The Allegations before the Tribunal relate to Dr Khan’s application to join the MPL [Medical Performers List] in Wales; her applications to work for Malpas Brook Health Centre in Ireland and St Paul’s Clinic in Newport; her application to work as a locum GP with ID Medical, based in England (a recruitment agency); her applications to join the MPL in London, the MPL in England and the MPL in Northern Ireland. All these applications are alleged to have been fraudulently made. There are further allegations that she made false statements in emails to a doctor when seeking a reference from him and that she sent emails to recruitment consultants which were inappropriate and threatening.
32. Therefore, the Tribunal found paragraphs 1a, 1b and 1c of the Allegation proved
Click to access dr-seamina-khan-02-mar-23.pdf
Suspension, 12 months
5. The allegation that has led to Dr Gall’s initial hearing in February 2022 can be summarised as follows: Dr Gall failed to contact the General Practitioners (‘GP’) of patients A, B, C, D, E and F, or obtain adequate information from the patients’ medical records before issuing prescriptions to the patients. She inappropriately prescribed excessive amounts of medication, and also failed to share relevant information with the patients GPs in relation to the prescriptions for medication.
Click to access dr-diana-gall-02-march-23.pdf
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BBC:
‘Former patients of a surgeon who has been struck off say their lives have been ruined by his misconduct.
The number of people harmed by Jeremy Parker is unknown but at least 123 are taking legal action.
Their lawyer said the scale of harm caused by his malpractice “could be huge”.
Mr Parker, who left East Suffolk and North Essex NHS Trust in 2019, declined to comment when contacted by the BBC via the Medical Protection Society.’
https://www.bbc.com/news/uk-england-essex-64705442
(See comment of 5/3/23 for link to MPT decision.)
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