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.
Suspension revoked
‘2. On a date between 7 and 11 September 2018 you:
a. added one or more retrospective entries into Patient A’s medical
records as set out in Schedule 1; Admitted and found proved in relation to 26 May 2016, 24 June 2016 and 20 October 2016
b. failed to make it clear that one or more of the entries referred to at
paragraph 2a were made retrospectively. Admitted and found proved in relation to 26 May 2016, 24 June 2016 and 20 October 2016
3. You knew that you should have made it clear within Patient A’s medical records that the entries referred to at paragraph 2a were made
retrospectively. Admitted and found proved
4. Your actions as described at paragraph 2 were designed to conceal the fact that you had not:
a. advised Patient A of one or more of the risks associated with the
procedures you had carried out as set out in Schedule 2; Determined
and found proved
b. recorded that you had advised Patient A of one or more of the risks
associated with the procedures you had carried out as set out in
Schedule 2. Determined and found proved
5. Your actions as described at paragraph 2 were dishonest by reason of paragraphs 3, 4a and 4b. Admitted and found proved in relation to paragraph 3
Determined and found proved in relation to paragraph 4a and 4b’
Click to access dr-vasudev-karri-02-sep-22.pdf
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Suspension revoked
‘4. …Dr Rahimtoola compounded his error by lying about it verbally and in writing to the patient and in writing to the patient’s General Practitioner. He denied making a surgical error, but suggested that he had always intended to explore the radial side of the patient’s wrist, because she had told him her ‘whole wrist’ was painful. At the time of the error, he only acknowledged a failure on his part to gain the patient’s consent to the additional procedure. ‘
Click to access dr-zulfiquar-rahimtoola-30-aug-22.pdf
Suspension, 6 months.
‘2. Dr Sarath Avula worked as a locum consultant in general surgery at the Cumberland Infirmary in August 2020. On 3 October 2020, Dr Avula made a self referral to the GMC in respect of an allegation of assault made by a patient (‘Patient A’). Patient A alleged that, on 16 August 2020, Dr Avula hit her on the side of her face.
4. Dr Avula pleaded Not Guilty on 23 March 2021 to the charge of assault by beating. He was subsequently found guilty and convicted of assault by beating contrary to Section 39 of the Criminal Justice Act 1988 at Cumbria Magistrates Court on 18 June 2021. Dr Avula was sentenced to an 18 month Community Order, which included unpaid work for 160 hours, a compensation payment of £200 and a payment of £400 costs to the Crown Prosecution Service.’
Click to access dr-sarath-kumar-avula-01-sep-22.pdf
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Restoration following disciplinary erasure
‘5. During its investigation, the NHS Counter Fraud team, identified that over the 2008 Easter weekend, 7606 entries were created in relation to 1703 patients. Many of these entries were backdated which gave the impression that the patients had been seen previously at the surgery. Following a series of interviews with witnesses, staff at the surgery,
staff members at the Trust, an NHS manager, an independent GP and Dr Sundaresan, a wide variety of anomalies were identified. At the conclusion of its investigation, the NHS Counter Fraud investigators passed the case to the Crown Prosecution Service (CPS).
8. On 17 March 2014, Dr Sundaresan was sentenced to 9 months imprisonment, suspended for 18 months, and ordered to pay a Contribution of £50,000 towards the costs of the prosecution.’
Click to access dr-thirumurugan-sundaresan-26-aug-22.pdf
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Suspension for 12 months
‘2. The First Tribunal found that Dr Blasco had made a number of bulk computer entries,in which he had entered diagnoses for a large number of patients when he had not examined the patient and knew that he had not done so. These included diagnoses for chronic conditions and asthma and medication reviews. The First Tribunal found this to be a failure to provide good clinical care and that the entering of bulk computer entries was dishonest. The First Tribunal was not satisfied that Dr Blasco fully understood the potential impact on patients, the effort needed to undo the bulk entries, or the dishonesty or lack of integrity involved. Dr Blasco’s fitness to practice was found to be impaired by reason of his misconduct.’
Click to access dr-inigo-iruskieta-blasco-11-jul-22.pdf
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Summary of outcome – Conditions revoked
‘5. The March 2017 Tribunal found that, by informing Patient A that Dr B had told Dr Pervez not to refer her to hospital, Dr Pervez had behaved dishonestly and his actions amounted to serious misconduct. The March 2017 Tribunal found that entering incorrect and misleading information in Patient A’s medical records was not only dishonest but had the potential to cause Patient A harm. The March 2017 Tribunal considered that Dr Pervez’s dishonesty in relation to Patient A departed from key principles in Good Medical Practice (‘GMP’) relating to probity and was a serious departure from the standards expected of a registered medical practitioner. It found that Dr Pervez’s fitness to practise was impaired by
reason of his misconduct.’
Click to access dr-sajid-pervez-06-jul-22.pdf
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BBC:
‘Detectives have launched a criminal investigation into medical procedures conducted by a former consultant gynaecologist.
Derbyshire Police said the inquiry into Daniel Hay followed reports a number of women allegedly suffered harm under his care.
The force says the “complex” investigation is in its early stages.’
https://www.bbc.com/news/uk-england-derbyshire-62831397
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PSA appeal – ERASURE
PSA successfully appealed an MPT decision to suspend Dr Hannah Isabel Austin who ‘acted dishonestly, misled her employer and as a result had carried on practising as a doctor when she ought to have been suspended…
[9] The allegations were that she misrepresented to supervisors the volume of work that she had carried out on projects while on attachment and, separately, she had misled colleagues and supervisors as to the status of a journal article.
[18] The GMC sought to have Dr Austin’s name erased from the medical register.’
https://scotcourts.gov.uk/docs/default-source/cos-general-docs/pdf-docs-for-opinions/2022csih37.pdf?sfvrsn=22366bf8_1
Scottish Legal News:
‘This case is a useful reminder of the approach the court takes towards dishonesty in professional discipline cases.’
https://www.scottishlegal.com/articles/douglas-waddell-professional-standards-authority-successfully-appeals-medical-practitioners-tribunal-decision
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The Guardian:
‘Trust the doctors,’ the nurse told me. It turned out to be the worst advice I will receive in my whole life…Martha died in part because of inflated egos.”
https://www.theguardian.com/lifeandstyle/2022/sep/03/13-year-old-daughter-dead-in-five-weeks-hospital-mistakes
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‘The director of communications at Nottingham University Hospitals Trust has been suspended after blocking the Twitter accounts of parents whose babies died in its care.
Tiffany Jones, who has worked in NHS communications for 20 years, sparked outrage this week for preventing several of the parents involved in an ongoing maternity review from accessing her social media account.’
https://www.dailymail.co.uk/news/article-11131959/NHS-trusts-communications-director-suspended-blocking-bereaved-parents-Twitter.html
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Suspension revoked – not impaired
‘4. The January 2022 Tribunal found that Dr Eftimie, in dishonestly falsifying records to show he had prescribed medication for Patient A, had sought to divert any blame for Patient A’s death that could be attributed to him. The January 2022 Tribunal determined that Dr Eftimie’s dishonest conduct fell so far short of the standards of conduct reasonably to be expected of a doctor as to amount to misconduct.’
Click to access dr-adrian-george-eftimie-02-aug-22.pdf
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Conditions for 9 months -Review hearing directed
‘2. 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
3. On 28 January 2021, Dr Isima was directed to undergo an assessment of his performance…Dr Isima did not undertake a performance assessment.’
Click to access dr-michael-isima-29-jul-22.pdf
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BBC:
‘Staff at a mental health trust falsified records that they had checked on a vulnerable patient the night he died, an inquest has heard.
Eliot Harris was found dead in his room at Northgate Hospital in Great Yarmouth, Norfolk, in April 2020.
…
Det Sgt Appleton listed 19 instances in which the observation record was signed by a staff member that night, indicating Mr Harris had been checked, but was not backed up by the CCTV record.
He identified a number of “points of concern” in his evidence in which falsifying logs was “normal” and “standard practice” on wards.’
https://www.bbc.com/news/uk-england-norfolk-62352962
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Falsifying records standard practice. Don’t tell the ombudsman.
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‘Three members of staff at a mental health trust have been sacked after falsifying observation records on the night a patient died, it has emerged.
An inquest jury found the practices at Northgate Hospital in Great Yarmouth were “encouraged” by managers.’
https://www.bbc.com/news/uk-england-norfolk-62466894
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Words fail me.
‘Doctor who falsely diagnosed children with cancer to scare their parents into paying for scans and tests at HIS private healthcare firm is struck off’
https://www.dailymail.co.uk/news/article-11050219/Doctor-falsely-diagnosed-children-cancer-scare-parents-paying-tests-struck-off.html
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BBC:
‘Failures by hospital staff to diagnose a woman’s ruptured appendix led to her death, a watchdog report has concluded.
The 49-year-old died from sepsis but that could have been avoided, the public services ombudsman said.
Her family said they had been “robbed” of a “loved woman” by doctors “found incompetent of doing the basic things.”‘
https://www.bbc.com/news/uk-wales-62206678
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Suspension, 8 months.
‘1. On 28 April 2017 you carried out Septoplasty and Bilateral Antral Washout (‘BAWO’) on Patient A …
156. The Tribunal identified the following aggravating factors:
• The catastrophic injury caused to Patient B, which had a serious impact on her life.
• Patient B’s injury could have been identified at an earlier stage if it was not for Dr Farboud’s failings/dishonesty.
• Dr Farboud’s lack of insight into the clinical failings, in the absence of reflection.
• Dr Farboud had shown no insight into the dishonesty, whilst the Tribunal accepted that Dr Farboud’s denial of dishonesty did not amount to lack of insight.
• Whilst the dishonest misconduct was not sustained, the Tribunal was of the view that Dr Farboud had maintained the dishonesty…’
Click to access dr-amir-farboud-21-jun-22.pdf
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Suspension, 12 months
‘2. The allegation that led to Dr Gill’s hearing could be summarised as follows: it was alleged that in October 2019 Dr Gill submitted at least 41 Patient Satisfaction Questionnaires (‘PSQs’) as part of her training portfolio, knowing that one or more were completed by her and that they were not completed by patients and that her actions in doing so were dishonest.
29. The Tribunal considered that even though the misconduct was conducted on 14 October 2019, it involved falsifying a large number of PSQs and Dr Gill made deliberate attempts to cover up her actions while completing the forms and misled and minimised the seriousness of her actions afterwards. It was only when it became obvious that she could not hide her actions that she made her first admissions. The Tribunal considered that Dr Gill’s actions undermined the trust of her colleagues at the Practice.’ (p19)
https://www.mpts-uk.org/hearings-and-decisions/medical-practitioners-tribunals/dr-rajvinder-gill-jun-22
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Suspension, 4 months, no immediate order, no IOT to revoke
‘4. In May 2019, the GMC received a referral from South Tees Trust in relation to Patient C. Patient C, who was then four-months old, underwent a CT scan of the brain on 19 June 2018 which was reported by Dr Volle. The clinical history provided to Dr Volle was that Patient C had multiple seizure episodes, presented with abnormal posturing, a high pitched cry, and eyes rolling. Patient C’s head circumference was noted as over the 99.6th centile. Dr Volle failed to identify that extra cerebral fluid collections on the scan were not of CSF density, but were clearly subdural, and that there was local mass effect with effacement of sulci overlying the cerebral convexities…
60. The Tribunal was of the view that Dr Volle’s conduct in relation to Patient C was serious misconduct in two regards…’
Click to access dr-eckhard-volle-14-jun-22.pdf
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BBC:
“A hospital trust is to be prosecuted over the death of a baby who died 23 minutes after being born.
Wynter Andrews was delivered by Caesarean section on 15 September 2019 at Nottingham’s Queen’s Medical Centre.
Nottingham Coroner’s Court heard Wynter’s death was “a clear and obvious case of neglect”.
The Care Quality Commission (CQC) said Nottingham University Hospital NHS Trust would be prosecuted over “failure to provide safe care and treatment”.”
https://www.bbc.com/news/uk-england-nottinghamshire-62164300
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How awful.
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Suspension to expire (not impaired)
’10. In relation to Dr Das’ inappropriate and dishonest use of Dr B’s name when ordering prescriptions, conducting investigations and completing discharge summaries, the previous Tribunal considered that this clearly amounted to misconduct. The previous Tribunal concluded that Dr Das’ actions in this regard fell far below the standard to be expected from a medical practitioner, that public confidence in the medical profession would be undermined, and there would be a failure to uphold professional standards if a finding of impairment were not made.
2. The previous Tribunal determined to suspend Dr Das’ registration for a period of four months. It concluded that this period would be sufficient to mark the seriousness of Dr Das’ misconduct and would send a declaratory message to the medical profession and to the wider public that her misconduct was not acceptable.’
Click to access dr-priya-das-16-jun-22.pdf
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12 months suspension
‘A response was received from Mr B, LAGeSO,* dated 01 March 2019 in which he advised,
“…we are not allowed to fully respond to your enquiry in case of Mr Mlangeni for reasons related to German data protection law.
We’re just allowed to mention, that Mr Mlangeni was revoked his license to practise medicine by administration notice dated 9th January, 2017.
Meanwhile, the judgement is final and legally binding. Mr Mlangeni is therefore permanent not entitled to practise as a doctor in Germany.
For further questions or details of why the doctor is subject to disciplinary sanctions… please contact Mr Mlangeni personally to consult…. ”
35. Having considered the evidence provided to it, the panel found that Dr Mlangeni has not engaged in any way with the GMC since the 28 May 2021 Tribunal. It found that he had not provided the information that led to his disciplinary and subsequent prohibition of his practice in Germany.
36. Accordingly, the Tribunal determined that Dr Mlangeni has continued to fail to comply with the direction of 28 May 2021 to provide the GMC with this information.’
Click to access dr-foster-mlangeni-16-jun-22.pdf
* Regional office for Health and Social Affairs – Landesamt für Gesundheit und Soziales Berlin
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Conditions revoked (Not Impaired)
‘9. The 2014 Panel considered that Dr Nergui had created a situation which exposed vulnerable patients to significant risk of harm. It was satisfied that Dr Nergui’s misconduct had damaged the public interest, in that his work purported to offer the services of a psychiatrist without appropriate safeguards to patients. The 2014 Panel considered that Dr Nergui had not shown any convincing evidence of remediation. It considered that there was an ongoing risk to patient safety which required a finding of impaired fitness to practise and that public confidence in the profession, as well as in the regulatory process, would be undermined if a finding of impaired fitness to practise were not made.’
Click to access dr-anatta-nergui-24-jun-22.pdf
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ERASURE
‘168. The Tribunal concluded that, on the balance of probabilities, it was more likely than ot that Dr Shoukri’s actions in submitting falsified documentation as part of the Application was because he knew that he did not meet the criteria. It did not consider any other explanation for the numerous acts of falsification and dishonesty to be likely or convincing. (P30)
21. The Tribunal first considered the aggravating factors:
• Dr Shoukri’s dishonesty was persistent and maintained and there was no evidence that the deception would not have continued had it not been discovered by the GMC;
• Dr Shoukri’s dishonesty was an attempt to deceive his regulator and as such could have undermined the integrity of the regulatory system and potentially put patients at risk of harm; and
• Dr Shoukri had not demonstrated any insight into his actions and there was no recognition of the nature and extent of his misconduct’. (P42)
Click to access dr-michael-ashak-soliman-shoukri-23-june-2022.pdf
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Suspension, 12 months
‘5. Dr McClelland was referred to the GMC in 2011 following a police caution for false representation for presenting a prescription at a pharmacy XXX. He was offered undertakings by the GMC in 2012 which he accepted. These undertakings remained in place until October 2015.
8. In 2017 concerns were raised about Dr McClelland’s behaviour at work XXX. As a result, an enquiry was made, and a clinical audit noted that there had been an 11-minute short session on the EMIS system, in which time Dr McClelland had generated five prescriptions which had been issued and logged. Two prescriptions appeared troublesome,
17. On 10 October 2019, Dr McClelland was made subject of an order for conditional discharge for a period of two years in respect of dishonestly making a false representation to an employee of Lloyd’s Pharmacy, Ballymena on 17 August 2018, to which he pleaded guilty.’
Click to access dr-john-mclelland-21-jun-22.pdf
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ERASURE (patient died)
‘312. Although the Tribunal acknowledges that there may have been system failures within the Hospital, it determined that Dr Taylor’s individual failures before and during surgery were so serious that they amounted to misconduct.
313. In relation to Dr Taylor’s evidence to the Inquest, the Tribunal considered its findings on facts. Although the Tribunal did not find Dr Taylor to have acted dishonestly, it was of the view that Dr Taylor still had a duty to disclose highly relevant information to the Coroner. The Inquest was held six months after Patient A’s surgery and death. At the time he gave evidence, Dr Taylor had available to him substantial and significant information in relation to Patient A’s medical history and care, including the evidence of experts. Dr Taylor should therefore have appreciated that he had a duty to disclose relevant information to the Coroner’s Inquest.
316. In relation to Dr Taylor’s statement to the Inquiry and his interview with PSNI, the Tribunal considered its findings on facts. It found that Dr Taylor had acted dishonestly on four occasions…’
Click to access dr-robert-taylor-21-jun-22.pdf
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Suspension, 2 months.
’13. On 14 June 2018, Dr Rault was convicted at Jersey Magistrates’ Court of wilfully making a false representation that she had examined a deceased person and signed and uttered a false certificate in that regard with a view to procuring the cremation of a deceased person contrary to Article 5(2) Cremation (Jersey) Law 1953. She was sentenced to pay a fine of £2,500. It is alleged that the offence, if committed in England and Wales, would constitute a criminal offence.
84. The Tribunal identified the following aggravating factors:
• Dr Rault lied to a number of people involved in the death certification process;
• She compounded those lies, during the period of investigation, by telling untruths to those looking into concerns. She persuaded those looking into concerns there had been a ‘misunderstanding’;
• Her further lies resulted in enquiries being made of other people and further evidence being obtained to establish her dishonesty. Doubt was cast on the motives of Dr B for initially raising concerns. ‘
Click to access dr-sian-rault-17-jun-22.pdf
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Conditions, 6 months (not impaired)
’12. The 2021 Tribunal considered whether Dr Tejura’s actions brought the medical profession into disrepute. The 2021 Tribunal had regard to the sentence imposed on Dr Tejura at Cardiff Crown Court, namely, a 12 month community order and a £1000 fine. In his sentencing remarks, the judge referred to the issue of thirty fraudulent prescriptions and the theft of both Class A and Class C controlled drugs from his employer, which he hid inside a locked filing cabinet. In doing so, he circumvented the Company’s systems for strict control and audit of controlled medication.’
Click to access dr-harsit-tejura-18-jun-22.pdf
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BBC:
‘A mother was killed at her hospital appointment by a doctor who botched a routine procedure, a court has heard.
Dr Isyaka Mamman, 85, was responsible for a series of critical incidents before the fatal appointment, Manchester Crown Court heard.
Mamman, who admitted gross negligence manslaughter, had already been sacked by medical watchdogs for lying about his age but was re-employed by the Royal Oldham Hospital.
He is due to be sentenced on Tuesday.’
https://www.bbc.com/news/uk-england-manchester-62039156
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Jailed for three years.
https://www.dailymail.co.uk/news/article-10983833/Doctor-killed-mother-three-48-pierced-heart-jailed-three-years.html
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Daily Mail:
“‘Shocked’ coroner blames NHS neglect for 14-year-old schoolgirl’s death after she disappeared from her family home and was found hanged in park”
https://www.dailymail.co.uk/news/article-10964519/Shocked-coroner-blames-NHS-neglect-14-year-old-schoolgirls-death-hanged.html
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Coroner’s Verdicts: It’s so sad and too frequent an occurrence due to previous coverups played out through corrupt complaints system with no accountability. But (a) a Coroner cannot blame anyone – it’s not their job in establishing mode of death; (b) subsequent Services’ denials out-trump what Coroner thinks – then yr getting into PHSO agenda to assist cover-ups at whatever cost to nation and repeated negligence. PHSO don’t even read Coroners verdicts, and are not trained in any way to understand outcomes (…or anything, for that matter).
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You are right Colin. PHSO staff are only trained in finding ways to close complaints.
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Suspension to expire (NOT IMPAIRED)
‘4. The facts found proved at the 2021 hearing can be summarised as follows: on 8 June 2020, at Caernarfon Magistrates’ Court, he was convicted of possessing three extreme pornographic images (XXX), which were grossly offensive, disgusting or otherwise of an obscene character and possession of an indecent image, namely a Category A photograph of a child, between 16 October 2018 and 28 January 2019. On 7 July 2020 Dr Anwar was sentenced to a Community Order to carry out unpaid work for 300 hours within 12 months in respect of each charge and to register with the police in accordance with the Sexual Offences Act 2003 for five years.
13. The 2021 Tribunal determined to suspend Dr Anwar for a period of 12 months.
35. The Tribunal considered that Dr Anwar has now developed an appropriate level of insight into the very damaging impact that images of this kind have upon the children and others involved, and indeed, on the animals concerned.
44. To put the matter in another way, the Tribunal does not consider that, in the particular circumstances of this case, the fact that Dr Anwar will be obliged to sign the Sex Offenders Register until 2025 is of itself a matter that dictates a finding of impairment on public interest grounds.’
Click to access dr-mohsan-anwar-01-june-2022.pdf
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Trust me, I’m a cheaper physician associate.
“An undercover BBC investigation has shone a light into the ‘unbelievable’ workings at Britain’s biggest chain of GP practices.
Operose Health, which runs 70 NHS surgeries across England, is accused of hiring cut-price staff to replace doctors.
…
Responding to the footage Professor Sir Sam Everington, a senior GP in London, said he was ‘horrified’ and described it as inexcusable.
He said: ‘You’ve got 20,000 patients and not a single doctor seeing patients? That’s unbelievable and completely unsafe.'”
https://www.dailymail.co.uk/health/article-10914577/Undercover-busy-GP-chain-days-NO-doctors-available.html
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ERASURE
“2. …Dr Metwally was sentenced to 14 years and six months’ imprisonment…
17. …He then noted the trial judge’s comments:
‘…You repeatedly visited acutely dangerous acts upon Miss A which placed her in hospital twice and nearly killed her on 4th July 2019. I have every reason to believe you harbour ingrained and perverted attitudes which would lead you to act in exactly the same way as you behaved towards Miss A. This would expose others to a high level of risk of serious injury in the future. History could easily repeat itself if you are given the chance to do as you did in this case in the future.'” (PAGE 14)
Click to access dr-hossam-metwally-31-may-22.pdf
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No action (warning not considered)
Medical notes that have ‘gone missing’ might sometimes prove a complainant’s case. But in this case, the GMC alleged that no notes ever existed.
This case is a good example of the difficulties faced by the GMC in establishing misconduct.
’52. The GMC position was that there had never been in existence any records relating to the relevant consultation and care of Patient A. However, Dr Oluwajobi and Mr C contended that the records had been made and subsequently went missing.
53. …The Tribunal recognised that the evidence that Patient A was being prepped for surgery on 21 June 2018 supported the assertion that there must have been circumstances and consultations to which the records did not attest, including notes from the relevant nursing team. In the absence of any written note for 21 June 2018 the Tribunal considered it more likely than not that the notes for this particular day had gone missing from Patient A’s file.’
Would the tribunal have reached the same conclusion had only Dr Oluwajobi contended that records had been made?
‘ 99. The Tribunal was of the view that Dr Oluwajobi may have made all of the comments and statements that Patient A has described in his witness statement. However, it took the circumstances into account, namely that Patient A was in pain, on medication, had hardly slept over the previous weekend, and was frustrated.’
Click to access dr-oluwaseun-oluwajobi-27-may-22.pdf
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Belfast Telegraph:
‘Public confidence is being jeopardised by terminating fitness to practice proceedings and granting a Belfast neurologist voluntary removal from the medical register, the High Court has heard.
Counsel for an oversight body also claimed it will be “neutered” if blocked from challenging a decision to accept the application by Dr Michael Watt.
In October last year, the Medical Practitioners Tribunal Service (MPTS) allowed the former consultant at the Royal Victoria Hospital to be voluntarily erased from the register.
It meant the neurologist at the centre of Northern Ireland’s biggest ever patient recall would not face a public hearing into concerns about his work.’
https://www.belfasttelegraph.co.uk/news/northern-ireland/public-confidence-being-jeopardised-by-granting-belfast-neurologist-voluntary-removal-from-medical-register-high-court-hears-41741140.html
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BBC:
‘The Professional Standards Authority cannot legally challenge a Belfast neurologist’s voluntarily removal from the medical register, the High Court has ruled.
It held that the legislation does not allow the oversight body to challenge a decision to accept Dr Michael Watt’s application.’
https://www.bbc.co.uk/news/uk-northern-ireland-61797499
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Daily Mail:
“Mrs Hart suffered multiple cardiac arrests and would not have died if it were not for the uterine inversion, the inquest found.
The inquest also found that the mismanagement of her ongoing hemorrhage also contributed to her death, with regular checks not undertaken in the hours leading up to her death.
…
Dr Didcock criticised the hospital’s trust for a report written after the incident and given to medical bodies, which she said did not include any recommendations or analysis from the expert who provided an independent review into what happened.
Dr Didcock told the inquest: ‘Serious omissions has led to insufficient learning and no acceptance that this had caused serious distress to the family.”
https://www.dailymail.co.uk/news/article-10882213/Mother-33-died-just-hours-giving-birth-hospital-medics-exceptionally-bad-decisions.html
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BBC:
“Health and social care leadership in England will be overhauled after a review found evidence of bullying and blame cultures, Sajid Javid has said.
Following a series of damaging scandals at NHS trusts, the government said the report found “institutional inadequacy” in how managers are trained and valued.
The health secretary said the findings – to be published in full later – were “stark”.”
https://www.bbc.co.uk/news/health-61727258
The article also includes a covertly recorded video of an A&E nurse telling patients that the wait time to see a doctor is 7.5 hours.
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Just another step towards privatisation of the NHS.
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Conditions, 18 months
“69. The Tribunal considered the sentencing remarks of HHJ M Lucraft QC dated 10 January 2020:
‘Despite professing to be an expert she was not able easily to explain what diminished responsibility amounts to, did not know where the burden of proof lay, and did not appear to know that it could only be a partial defence to murder.’
1. In November 2017, you acted as an expert witness for the Prosecution in the case of Patient A and you:
a. copied sections of Dr C’s expert report; Admitted and found proved
b. submitted the report as if it was all your own work; To be determined
c. knew that sections of the report were not your own work. Admitted
and found proved
29. Accordingly, the Tribunal found Paragraph 1(b) of the Allegation proved.
2. Your actions as described at paragraph 1a and 1b were dishonest by reason of paragraph 1c. To be determined
34. …the Tribunal found Paragraph 2 of the Allegation proved. ”
Click to access dr-seshni-moodliar-20-may-22.pdf
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Warning
‘d. you prescribed medications:
i. in inappropriately large quantities; Admitted and found proved
ii. without adequate knowledge of:
1. what they were for; Admitted and found proved
2. their indications; Admitted and found proved
3. the monitoring arrangements they required; Admitted and
found proved
4. their value; Admitted and found proved
5. who was collecting them; Admitted and found proved
6. where they were being sent; Admitted and found proved
iii. in an irresponsible and unsafe manner; Admitted and found proved
e. your issuing of the Prescriptions could have led to patient:
i. harm; Admitted and found proved
ii. death. Admitted and found proved’
Click to access dr-sundeep-kaul-17-may-22.pdf
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Daily Mail:
‘Concluding the hearing at Shropshire Coroner’s Court, Mr Ellery said: ‘Based on all the evidence, the conclusion of this inquest is that Mr Dingle’s death was an avoidable accident.’
At Telford Magistrates’ Court on May 18, a judge imposed an £800,000 fine on one of two charges relating to the death of dialysis patient Mohammed Ismael Zaman, 31.
He also fined the Shrewsbury trust £533,334 over a charge brought in relation to Mr Dingle’s death.’
https://www.dailymail.co.uk/news/article-10870827/Death-retired-policeman-head-trapped-hospital-bed-avoidable-accident.html
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BBC:
‘The couple had gone to University Hospital Lewisham’s A&E department after Laura had a late miscarriage at home.
But they were advised there was nowhere safe to store the baby’s remains, and they felt their only option was to take their baby home.
Greenwich and Lewisham NHS Trust says a full investigation is under way. But the case has raised wider concerns about miscarriage care in the UK. ‘
https://www.bbc.com/news/health-61576787
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‘An ambulance trust has been accused of acting like a “criminal gang” and lying to dead patients’ families by an employee who repeatedly warned about paramedics’ mistakes being covered up.
Paul Calvert, a coroner’s officer whose job was to produce reports on deaths, tried to raise concerns about managers at the North East Ambulance Service (NEAS) for three years before walking out last year on the verge of a breakdown.’
https://www.thetimes.co.uk/article/fed33942-decb-11ec-a8e5-0e2d1d181260?shareToken=5f9e062ee464ae3c927a5228773e1563
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BBC:
‘A mother whose baby died after mistakes by staff said she felt like she “was dying”, on the day the NHS trust responsible is ordered to improve its maternity services.
The units at Nottingham University Hospitals trust – under review after dozens of baby deaths – have been rated inadequate by the health watchdog.’
https://www.bbc.com/news/uk-england-nottinghamshire-61581128
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The Guardian:
‘Overall, 203 women on whom Anthony Dixon performed procedures between 2007 and 2017 came to harm, according to a review by the North Bristol NHS trust (NBT). Dixon, who for years was Britain’s most influential pelvic surgeon, worked for both the trust and the private Spire hospital in the city.’
https://www.theguardian.com/society/2022/may/26/surgeon-harms-203-women-with-unnecessary-operation
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Suspension 12 months
Click to access dr-shreelata-datta-11-may-22.pdf
Daily Mail:
‘Over a five-month period in 2019, Datta, a consultant obstetrician and gynaecologist and former chair of the BMA’s Junior Doctors Committee, ignored warnings from a senior colleague not to undertake private work.
She carried out three caesarian deliveries, several biopsies and one hysterectomy during 99 days of private patient work at the Lister and Portland Hospitals in London and the Guthrie clinic in Kings College Hospital, a tribunal heard.
The General Medical Council had called for Datta to be struck off the medical register due to her ‘brazen and persistent’ dishonesty.
Datta also undertook procedures privately during a phased return to work, while simultaneously claiming she needed help to do the same work in her NHS practice.
Typically 30 minute private medical consultations in London can cost £280 with a caesarian delivery costing £6,040.
At the Medical Practitioners Tribunal Service, she admitted a string of misconduct charges and was suspended from medical practice for 12 months.’
https://www.dailymail.co.uk/news/article-10852613/Gynaecologist-42-accused-NHS-lethal-failings-conditions-caught-moonlighting.html
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Here is an example of a doctor making an ‘innocent mistake’:
No action (warning not considered)
‘1. Between 31 October 2018 and 1 November 2018, you consulted with Patient A and you stated to Patient A’s son that Patient A’s:
a. blood results were ‘absolutely fine’, or words to that effect; Admitted and found proved
b. international normalised ratio blood level was ‘2.5’, or words to that
effect. Admitted and found proved
21. The Tribunal also considered it possible that Dr Jegatheesvaran mistakenly looked at the results for the wrong patient. A further possibility is that he wrote down results on his job sheet of several patients and mistakenly gave the result of a different patient to Mr E when asked. There is corroborative evidence from Mr E that Dr Jegatheesvaran had read a result from his clipboard.
22. The possibility that Dr Jegatheesvaran made an innocent mistake is all the more plausible upon consideration of the work environment prevailing at the time.’
Click to access dr-pradeeba-jegatheesvaran-11-may-2022.pdf
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ERASURE
‘2. … As a result of the concerns raised, the Trust reviewed 15% of Dr Srivatsa’s cases to ascertain whether there were any ongoing performance issues and decided to analyse eight of Dr Srivatsa’s telephone consultations using a Royal College of General Practitioners (‘RCGP’) modified template. The minimum acceptable score for record keeping is 16, and Dr Srivatsa’s score, based on the cases examined, was 11.38. As a result, the Trust decided to terminate his contract as a locum GP.
28. The Tribunal should bear in mind that the word “failed” in this context does not simply mean that Dr Srivatsa did not do something, it means that Dr Srivatsa had a duty or obligation to act in a particular way and that he failed to carry out that duty or obligation. In deciding if he failed in his duty to provide good care to a patient, the Tribunal should assess this against the standard of a reasonably competent GP working in an OOH service .
141. The Tribunal identified the following aggravating factors in the case of Dr Srivatsa:
• Lack of insight which was evidenced by his refusal to accept his failings, his refusal to engage meaningfully with the regulatory process, and his assertion that the GMC had no right to investigate his performance
• A failure to work collaboratively with colleagues
142. The Tribunal was unable to identify any mitigating factors’
Click to access dr-kadiyali-srivatsa-29-april-2022.pdf
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No warning (Not Impaired)
’41. Whilst the Tribunal notes that Dr Ali would document ‘jailing’ or sub-total occlusion, it considered that by not recording any complication at the time, as he should have, this amounted to misconduct. However, in itself, it did not amount to serious misconduct…
The Tribunal acknowledged that this was the first time Dr Ali had experience of such a complication, but that did not detract from his duty to treat it appropriately. The Tribunal noted Dr Ali inflated the balloon for 27 seconds at an inappropriate pressure when the guidance suggests that the balloon should be inflated for ten minutes or more at a low pressure… p.94
53. The Tribunal found, as it did in respect of paragraph 3(c) above, that Dr Ali failed to treat Patient B in accordance with the relevant guidance. It was incumbent upon him to have arranged for an emergency echocardiogram to be carried out when he became aware one had not been done. The Tribunal found Dr Ali’s failure amounted to misconduct which is serious.’ p95
Click to access dr-omar-ali-29-april-2022.pdf
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Conditions, 12 months.
‘5. The 2021 Tribunal found that Dr Vadher’s two courses of admitted dishonesty and his producing 21 false prescriptions over 11 months, were sufficiently serious departures from what is expected of doctors as to amount to misconduct. The 2021 Tribunal found that fellow practitioners and members of the public would find such conduct deplorable. In respect of Patient B, the 2021 Tribunal found that Dr Vadher’s attempt to ‘cover his tracks’ by encouraging Patient B to lie on his behalf may have been an act of desperation, but was nevertheless inexcusable. It concluded that he had placed improper pressure upon Patient B and distressed her. The 2021 Tribunal considered that Dr Vadher’s conduct in advising what Patient B should say if anyone at the hospital asked her about the prescriptions demonstrated a degree of pre-planning which members of the profession and public would find deplorable.’
Click to access dr-nilesh-vadher-14-apr-22.pdf
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ERASURE
‘135. The Tribunal considered that Dr Palouki’s actions in not gaining informed consent from Patient A, and, further, ignoring Patient A’s explanation as to why she did not give consent, were concerning. The Tribunal noted that Dr Palouki persisted with her actions in the face of Patient A explaining why the procedure would not work. It also considered that not estimating Patient A’s blood loss and continuing to pull the umbilical cord was inappropriate and could have had a serious impact on Patient A’s health. It was mindful that Patient A needed a surgical procedure after this incident, and that she had been put in a potentially dangerous position because Dr Palouki had not assessed her blood pressure or estimated her blood loss.
147. The Tribunal next considered Dr Palouki’s actions in attending a professional meeting under the influence of alcohol and asking a colleague, via text, to say that she was not under the influence. The Tribunal was mindful that, until this hearing, Dr Palouki had denied attending the meeting under the influence of alcohol. XXX. ‘
Click to access dr-panagiota-palouki–27-april-2022.pdf
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The charity ‘Rethink Mental Illness’ is named to give the impression that they ‘rethink’ mental illness, they think differently, out of the box, they break the mould. Nothing could be further from the truth. They work in partnership with the NHS and have absorbed the theology that it is beyond reproach. They absolutely will not hear any patient who yries to present them with clear evidence of ill-treatment and wilful neglect by their partners and would much rather see that patient perish as a consequence, much rather be wilfully negligent themselves. Again I have the clear proof of this.
CALM and MIND are no better. It is devastating to find this out when turning to them in distress and despair. All others I’ve tried too. They recoil when aproblem with NHS healthcare is mentioned/broached.
Anyone doubting me can try it for themselves. How about Victim Support for example. Victim Support, the charity that provides victim support for victims of all crime, whether reported to the police or not, so they say…
But call them or webchat with them. See how their attitude changes when you tell them that those that have done you harm, committed the crime or crimes against you are individuals and/ or departments within the NHS.
So we can all quickly establish for ourselves that there is no justice at all for those wronged by the NHS. None. Why, why WHY is the general public so deluded?? It was Julie Bailey who pointed out to me that in the aftermath of the Mid Staffs scandal, the NHS was likened to the Mafia by and in the media. Julie also stated nothing has changed.
We (public) have been told time and time again but we’re not listening. I had a police officer at my door yesterday. I could tell that he was a nice bloke and I’ve met him before. I briefly described, tried to impress upon him my plight. I mentioned the Mid Staffs Scandal. He hadn’t heard of it (this is Wolverhampton, Staffordshire). Molly Russell: hadn’t heard of her. Genuinely hadn’t heard of her. He wasn’t being a ***** just to wind me up, which police officers often do and indeed are very good at being so. What else? C’mon Clive IMG there was so much he had no idea… He had heard of the wrongly convicted sub postmasters but everything else…a community police officer
How on Earth…? My recording and those two police officers at Wolverhampton police station. Before and during the formal interview… I mention mysogyny in the Met and all forces throughout the UK. I don’t think those two female police officers knew the meaning of the word.
I’m tired!
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There’s a quote by Martin Luther King, Jr which features at the top of Peter Duffy’s Twitter profile:
“The ultimate tragedy is not the oppression and cruelty by the bad people but the silence over that by the good people.”
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