Local MP calls for investigation into Baby P report
Posted on 10th Jun 2011 by Lynne Featherstone
Liberal Democrat MP for Hornsey and Wood Green, Lynne Featherstone, has called for an investigation into an alleged attempt to hide management failings following the death of Baby P.
Following the death of Peter Connelly (Baby P), Dr Jane Collins the Chief Executive of Great Ormond Street Hospital (GOSH) commissioned the Sibert Report to investigate both the doctor and the systems involved in child protection, run by GOSH in Haringey.
An addendum of the report was authored by Dr Jane Collins and submitted to the Serious Case Review. The full report has now been released to the BBC in response to an FOI request. It shows Dr Collins' addendum did not include the report's vital criticisms of the management and child protection practices.
In a letter to Jo Williams, Chair of the Care Quality Commission, Baroness Blackstone Chair of GOSH Board, Secretary of State for Education, Michael Gove and Secretary of State for Health, Andrew Lansley, Lynne Featherstone has called for an investigation into Dr Jane Collins' actions.
Speaking as Liberal Democrat MP for Hornsey and Wood Green, Lynne Featherstone said:
"There is now clear evidence that information was withheld from the serious case review into the death of Baby Peter. Key criticisms were edited out and it appears there was an attempt to cover-up the fact the situation was 'clinically risky'.
"The key person in charge in Haringey was dismissed from post. The key managers also lost their jobs. But the Chief Executive and the managers at GOSH who presided over this 'clinically risky situation' are still in post. Their roles and culpability have never faced proper scrutiny.
"This can be nothing other than a deliberate attempt to hide the management failings, and subvert the serious case review process.
"It is not possible to learn the right lessons unless all relevant and important information has been disclosed, whatever the potential impact on the hospitals and health trusts involved."
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0 thoughts on "Local MP calls for investigation into Baby P report"
Bradley Colmans on 10th Jun 2011 at 11:38 am said:
When you have done as much as Jane Collins and other doctors at Gt Ormond Street then you can comment. She as with others have devoted her professional life to looking after sick and dying children, whereas you are just a politician looking for an easy target. Stop trying to punish good hard working people. Look at your own self before criticising the people who actually help and support society
AM on 12th Jun 2011 at 12:10 pm said:
Obviously some people are determined to stop you succeeding here Lynne.
Anon on 13th Jun 2011 at 8:49 am said:
I think Lynne is right to demand for an investigation but it would be more helpful if appropriate steps are taken to change a culture of secrecy and fear as doctors, most often, don't speak up because of retaliation and only a few do raise concern and when they see Dr.Holt's ordeal, stop as they themselves are subjected to spurious complaints and referrals to the GMC who mainly listen to the NHS Managers and their complaints are taken as Stream 1 (most serious) and referred to Fitness to Practise (FtP)Hearing. Though the complaints are unfounded, the process of attending is daunting and a life long sentence as the doctor has to disclose it to all job applications.
Anyway, i believe its still hazardous to speak up unless there is guarantee of protection by law, employers and the regulatory bodies.
Steve on 19th Jun 2011 at 7:00 pm said:
Some Pressure groups are campaigning to abolish biased GMC and I am not sure if the DH/NHS who use regulatory bodies to silence and persecute genuine doctors will ever let it happen. GMC shows bias on almost every stage starting from investigation leading up to FtP decisions. For Caucasians in particular White British doctors, preferential treatment is given and if there is no strong written evidence, complaint will be perceived as vexatious especially if it is from a patient or member of the public. However NHS Medical Managers' concerns are taken as stream 1 (more serious) if the doctor is from ethnic minority and GMC take long time to conclude and for White British doctors, the case is either closed swiftly or brought to FtP panel in a few months with favourable outcome. A number of reports have shown that NHS Managers make false allegations against whistlebowers and complaints against White British doctors come to light only if the case is of Shipman or Kerr/Haslam level
http://www.nhsreformgroup.com/Kerr/Haslam-Inquiry/29.htm
as the NHS management support them and patients' concerns are ignored nor do the NHS staff dare to blow the whistle. By contrast, even a minor concern about ethnic minority doctors is taken seriously and reported to GMC and the NHS management use other staff members as witnesses and the ethnic minority doctors face prosecution by the GMC which is part of the mob culture. In nutshell, many experts in whistleblowing say, its wise to keep quiet and keep your head down.
Matthew on 7th Jul 2011 at 8:13 pm said:
http://www.independent.co.uk/life-style/health-and-families/health-news/hung-out-to-dry-scandal-of-the-abandoned-nhs-whistleblowers-2306262.html
Hung out to dry: scandal of the abandoned
NHS whistleblowers
By Nina Lakhani
Sharmila Chowdhury faces losing her home
A parliamentary inquiry is to be held into the treatment of NHS whistleblowers amid growing
evidence of cover-ups which can destroy careers, waste millions of taxpayer pounds and endanger
patients by creating a culture of fear among health workers.
The Coalition Government faces a swell of anger among health professionals who are demanding
better protection for staff who speak out about substandard patient care and malpractice. Some
health services are being cut and tens of thousands of jobs lost as the NHS faces unprecedented
financial pressure over the next four years.
Stephen Dorrell, who was Health Secretary under John Major and is now the chairman of the
Commons Health Select Committee, last night promised to hold an inquiry into the treatment of
NHS whistleblowers after outrage over the latest case to emerge.
Sharmila Chowdhury, 52, a radiology manager at a London district general hospital, is likely to lose
her home after an inquiry found she was unfairly sacked after alleging that doctor colleagues were
wrongly claiming thousands of pounds of public money every month, which the doctors and trust
deny.
Ms Chowdhury, a radiographer with an unblemished 27-year NHS career, was marched off the
premises following an unfounded counter-allegation of fraud made against her by a junior whom
she had reported for breaching patient-safety procedures.
Ms Chowdhury's employer, Ealing Hospital NHS Trust, has spent hundreds of thousands of pounds
getting rid of her, leaving her depressed, unemployed and broke. After an employment tribunal
judge found in her favour, the trust has decided to make her redundant. Her "special severance"
must be approved by the Health and Treasury departments at a time when the NHS is cutting
thousands of jobs and slashing services in order to save £20bn. She is expected to lose her home
because of her inability to meet mortgage payments.
During the inquiry, MPs can expect to hear from an abundance of NHS whistleblowers – doctors,
nurses and even chief executives – who have been punished over the past decade while trying to
expose colleagues' wrongdoing or incompetence.
Mr Dorrell is likely to demand that professional regulators, such as the General Medical Council
(GMC) and the Nursing and Midwifery Council, come down harder on clinicians and managers
who are found to be complicit in wrongdoing through their silence.
Mr Dorrell told The Independent: "The committee will look into whistleblowers. It is every
professional's business to ensure that clinical care where they work is of a certain standard. Like Sir
Ian Kennedy said after the Bristol babies inquiry: 'It wasn't that nobody knew, it was that everybody
knew.' Every doctor and nurse has an obligation to act if they know there is a problem and those
who do nothing should be questioned by their regulator; it would soon stop this kind of thing."
On the subject of fraud, he added: "If doctors are dishonestly claiming public money then they, and
their medical managers, should be in front of the GMC."
Labour introduced the Public Interest Disclosure Act in 1998 following a series of industrial
accidents and health and financial scandals, introducing legal rights for employees who expose
corruption, safety breaches and fraud.
When in opposition, Andrew Lansley, now the Health Secretary, promised to beef up protection for
NHS whistleblowers amid growing evidence that the Act was failing to protect employees. The
Coalition agreement said: "We will introduce new protections for whistleblowers in the public
sector."
The Department of Health insists that it has "acted swiftly to deliver on this commitment" by
consulting on changes to the NHS constitution and by introducing a new contractual right for NHS
employees to raise public-interest concerns. However, patients and staff are unconvinced. Examples
continue to emerge from hospitals and care homes for vulnerable patients where whistleblowers
have been ignored.
Peter Walsh, the chief executive of patient-safety charity Action against Medical Accidents , said:
"The Government's approach to whistleblowers is totally inadequate. We have fine words and
guidance in abundance but NHS organisations have shown a consistent ability to work outside the
spirit of these well-intended measures, and regulators seem to stand by when organisations blatantly
flout them."
Case study: Legal bills – and no hope of employment
The radiology manager at Ealing Hospital NHS Trust reported in 2007 that two radiology
consultants appeared to be taking turns to work at a nearby private hospital every Monday while
they were being paid to see NHS patients. The NHS trust says it has found no wrongdoing.
She reported others for making duplicate claims and for claiming hours they hadn't worked. She
also reported her discovery of discs containing reports and scans from about 100 patients with
conditions including kidney cancer which a junior radiographer had failed to upload on to the
imaging system for six months.
In 2009 Ms Chowdhury was interviewed by the internal fraud officer; days later she was suspended
and marched off the premises. She was sacked, but pending a full hearing an employment tribunal
ordered the trust to reinstate her full pay after concluding that "she would probably win".
Following this, and an independent investigation which found no evidence to support her dismissal,
the trust wants to make her redundant. She will be left with less than a year's salary after paying her
£100,000 legal bill. Like many whistleblowers, she cannot get another job.
Medics who dared to speak out
* Dr Steve Boslin, the anaesthetist who finally exposed paediatric heart surgeons in the Bristol
babies scandal in 1995, moved to Australia after being ostracised by the NHS.
* Margaret Haywood was struck off the nursing register after she went undercover for a BBC
documentary, exposing poor standards of care for elderly patients at a Sussex hospital. Five years
later she was reinstated by the Court of Appeal.
* Dr Kim Holt repeatedly warned Great Ormond Street Hospital that its Haringey clinic was unsafe
because of staff shortages and inadequate training. Baby Peter Connelly's life-threatening injuries
were missed at the same clinic, two days before he died. Dr Holt remains on "special leave".
* John Watkinson was sacked as chief executive of the Royal Cornwall Hospital NHS Trust in 2007
after he refused to remove cancer services without first consulting local people. An employment
tribunal awarded him nearly £900,000 in compensation; he has been unable to find another job.
* Dr Ramon Niekrash, a urological surgeon, was suspended after he refused to stop highlighting
patient-safety problems caused by cost-cutting measures at Queen Elizabeth Hospital in south-east
London. He was awarded £17,000 by an employment tribunal, but was left with a £180,000 legal
bill.
John on 14th Feb 2012 at 9:52 am said:
http://www.dailymail.co.uk/health/article-2097389/Why-soft-dodgy-doctors-There-thousands-complaints-single-year–just-ELEVEN-struck-off.html#ixzz1ljlJp8VO
Why are we so soft on dodgy doctors? There are thousands of complaints about them in a single year – yet just ELEVEN are struck off
By Jane Feinmann
Last updated at 2:56 PM on 9th February 2012
•	Comments (92)
Doreen Williams had a chest infection — it wasn't serious but her GP thought it best to admit the 71-year-old to hospital so that she could have stronger, intravenous antibiotics.
Seven days later, Mrs Williams was dead as a result of a pulmonary embolism — a blood clot on the lungs which had developed while she was in hospital.
Her death was entirely needless, says her daughter Karen Rutland.
Karen Rutland's mother Doreen Williams was admitted to hospital for a chest infection. Neither the doctors nor nurses intervened to save her life
'My mother was a busy retired teacher who had visited Wales and Cornwall in the two months before her death,' she explains.
'She had chronic obstructive pulmonary disease, a long-term lung condition, but it never seriously affected her daily life.
'It just meant she had to be careful to get proper treatment for chest infections.'
Mrs Rutland, 56, has no doubt what was to blame for her mother's untimely death.
'She was not given the intravenous antibiotics or standard blood tests until five days after she was admitted to hospital.
'And although she was at high risk of a blood clot because of her age and her lung condition, she was never given the blood-thinning medication that would have prevented it.'
The doctor in charge also issued a 'do not resuscitate' order — without discussing it with the family.
So, as Mrs Williams lay dying, neither the doctors nor nurses intervened to save her life.
Shocked and distressed by this betrayal of her mother, Mrs Rutland, a former management consultant from Cornwall, did what most people would do. She tried to complain. She got nowhere.
The doctor denied any responsibility for her mother's death. And Luton and Dunstable Hospital Trust, where Mrs Williams spent her last days, refused to accept any wrongdoing.
There were 7,000 complaints to the General Medical Council (GMC) last year. Only 17 per cent of those by patients were investigated
Perhaps most frustrating, however, was the response of the General Medical Council.
This is the only medical regulatory body in the UK with the power to suspend or strike off doctors in the interests of patient safety.
Initially, the GMC's senior investigating team recommended the doctor in charge of Mrs Williams's care should face a Fitness to Practise hearing.
But the hearing was cancelled — twice — because the GMC's medical advisors said there was 'an insufficient case to answer'.
However, the coroner who later examined the case said he found it 'inconceivable that vital steps were not taken to follow up' particular warning signs that something was seriously wrong.
'There was every reason to believe that after a short stay in hospital, Mrs Williams should have been well enough to return home,' he said.
So why didn't the GMC take action? It is a question being asked in an increasing number of cases of alleged medical negligence.
The concern is that the GMC, which is funded by the doctors it regulates, is biased in their favour and shields those it is supposed to discipline.
Furthermore, it is accused of treating whistleblowers who try to expose malpractice as pariahs.
Five years ago Sir Liam Donaldson, who was then the government's Chief Medical Officer, described the GMC as 'secretive, tolerant of sub-standard practice and dominated by professional interest rather than that of the patient'.
It's a criticism that won't go away.
Last year, the Parliamentary Health Select Committee described the GMC in a highly critical report as 'overly lenient' to doctors — while just a few months ago, the chair of the Patients' Association, Dr Mike Smith, accused the organisation of 'clearly under-investigating complaints submitted by patients'.
The statistics speak for themselves. There were 7,000 complaints to the GMC last year. Only 17 per cent of those by patients were investigated — with only 11 doctors struck off as a result of these patient complaints. It is worth noting that once the GMC makes a decision, there is no right of appeal from the complainant.
Even when decisions do go against doctors, the criticism is that the disciplinary process takes far too long, allowing incompetent doctors to continue putting the public at risk.
It took 12 years after the first complaints were made about Dr Jane Barton for the GMC to initiate the investigation
In January 2010, Dr Jane Barton was found guilty of serious misconduct after a GMC investigation found she'd given painkillers at six times the recommended dose to 12 elderly patients, causing their death at two wards she ran at the Gosport War Memorial Hospital in Hampshire.
Yet it took 12 years after the first complaints were made for the GMC to initiate the investigation.
'If Dr Barton had been suspended by the GMC in 1998 when her actions were first questioned, then many of these patients would have been saved, including my mother,' says Ann Reeves, 57, whose mother Elsie Devine died aged 88 of a 'substantial overdose' of opiates administered by Dr Barton in 1999.
Incredibly, despite finally finding Dr Barton guilty of serious misconduct, a Fitness to Practise panel — who are appointed by the GMC — still allowed her to continue working as a GP (she has since retired).
Indeed, in 2010, 39 other doctors were permitted by panels to remain on the medical register even though the GMC's own investigators recommended they be struck off.
One of these was general surgeon Gideon Lauffer, who was found guilty of serious misconduct after a series of botched operations that caused the death of two patients and injured 18 more.
Yet a Fitness to Practise panel ignored the advice and imposed a six-month suspension allowing him to return to work 'under supervision'. By November 2011, he was back at work.
Karen Rutland had little idea of the failings of the GMC when she decided to complain to the organisation about her mother's death in 2006. While Doreen Williams was in hospital, her husband Ralph had become increasingly worried.
Mrs Rutland recalls: 'He told me the consultant in charge of my mother, Dr Tariq Mirza Rehman, hadn't started her on the intravenous antibiotics.'
So, the next day, the concerned father and daughter spoke to Dr Rehman. 'He told us in a reassuring voice how very seriously he was taking our mother's care.'
But after her mother's death, Mrs Rutland learned that from the moment Mrs Williams was admitted, Dr Rehman was responsible for a series of glaring omissions in her care. The full extent of neglect was revealed at an inquest in January 2011 — five years after Mrs Williams's death.
The inquest heard that not only did Dr Rehman fail to prescribe Mrs Williams antibiotics, but he didn't give her medication routinely prescribed to hospital patients of her age and health background to prevent the blood clot.
There were other more serious failings too. The level of oxygen in Mrs Williams's blood dropped — a warning sign of a pulmonary embolism — and fell further on the day of her death, which should have resulted in her emergency transfer to intensive care.
At 3pm on Mrs Williams's final day, Dr Rehman issued a 'do not resuscitate' order, a step that is supposed to be taken by doctors at the end of a terminally ill person's life to stop resuscitation in the event of a cardiac arrest — thereby preventing unnecessary suffering.
Such a step was 'entirely inappropriate and unwarranted', according to Dr Vincent Mak, a respiratory medicine and intensive care consultant at Central Middlesex Hospital, North West London, and an independent expert witness at the inquest.
He noted Mrs Williams's health prior to admission was 'of reasonable quality', adding that 'she had recently had an echocardiogram that showed her heart was working well'.
By issuing the 'do not resuscitate' order, Dr Rehman breached two sets of legally binding guidelines, including failing to record the reason for taking this drastic step — which is mandatory.
Nor did he consult with Mrs Williams, later insisting that she did not have mental capacity — another claim denounced as untrue by the coroner.
It is also mandatory for doctors to notify a coroner if a death is unexpected —Dr Rehman did not do this. Instead, he allowed Mrs Williams's death certificate to carry the cause of death as septicaemia and pneumonia.
Dr Mak said Dr Rehman presided over a regime of 'suboptimal care that led to (Mrs Williams's) death'.
The coroner summed up his concerns as Dr Rehman stood in the witness box as: 'You failed to pay attention and treat the patient in front of you'.
Despite these findings, the hospital trust supported Dr Rehman and denied any wrongdoing.
So Mrs Rutland turned to the GMC for help.
'We saw it as our duty to ensure no other family would suffer as we have,' she says.
Dr Kim Holt was suspended by Great Ormond Street Hospital after blowing the whistle on staff shortages and a 'chaotic' appointment system at the clinic
Yet in 2008, the Fitness to Practise panel, a group of medical and non-medical volunteers, appointed to investigate Dr Rehman's behaviour, was cancelled — because an independent medical expert claimed 'none of the points in respect of medical management reflect either incompetence or malpractice'.
Astonishingly, the same thing happened a year later when a second hearing was set up following a complaint from the Rutlands.
Despite the coroner's unusually critical verdict last January, the GMC insists its own rules prevent it from 'reviewing a decision to cancel a hearing'.
Chief executive Niall Dickson recently defended the organisation's record, claiming problems often lie with flawed perceptions of the GMC's responsibilities.
'Our job is not to punish doctors but to protect patients by taking action against a failing doctor,' he said.
'We look closely at every complaint to see if the doctor's fitness to practise could be impaired but will only take a case forward if the complaint indicates serious concerns about the doctor. In the majority of cases where a doctor has made a single mistake, this is not indicative of a bad doctor, however catastrophic the consequences.'
So what exactly does a doctor have to do in order to provoke 'serious concerns' by the GMC? The worrying answer may be to tell the truth — there is growing concern that doctors who try to blow the whistle on unsafe practice could can end up facing disciplinary action themselves.
Two weeks ago, the GMC issued new guidance reminding doctors they have a duty to raise concerns about poor patient care.
Yet it's an empty warning for Dr Kim Holt, a consultant community paediatrician at Haringey Primary Care Trust.
In 2006, Dr Holt was excluded by Great Ormond Street Hospital, the trust that then employed her, after blowing the whistle on staff shortages and a 'chaotic' appointment system at the clinic where, months later, Baby P (Peter Connelly) was treated days before his death.
'It didn't ever get to the stage of a complaint to the GMC. But there was an attempt to discredit me, to force me out of medicine as a damage limitation exercise,' she recalls.
'I was lucky in that I've now been reinstated in my job. But I've met several doctors who have been reported to the GMC by their trusts after they became whistleblowers, and a handful who have even been struck off the medical register.
'Hospitals use threats of referral and actual referral to the GMC as a means of ensuring silence from medical staff.'
Brian Jarman, professor of primary health care at Imperial College, London, agrees changes are needed.
'There is precious little evidence the GMC supports doctors who speak out when they see failing practice. Why doesn't the GMC have a confidential helpline for people who see problems at their hospitals? That would be a start.'
Later this year, the GMC will supervise the launch of a revalidation scheme under which doctors' performances will be evaluated every five years.
Katherine Murphy, of The Patients' Association, is not impressed.
'Unfortunately the GMC's record on managing complaints makes you wonder how revalidation will work — and whether it's going to be friends revalidating friends,' she says.
'We have many experiences of good care and unsung heroes in the NHS,' adds Mrs Rutland.
'But there has to be a way of taking action against the bad ones — otherwise standards slipping and people dying unnecessarily becomes acceptable.'