Justice for Robert Henderson
By far the greatest harm caused by the NHS is not the mistakes that it makes, but the fact that they are so often denied, dismissed, improperly investigated or covered up so that patients, or more often relatives, spend decades seeking the truth, accountability and apology.
The never-ending nightmare of Will Powell, father of Robbie, is a good example (Eyes passim) He’s spent 23 years, and all his savings, trying to get the truth about how and why Robbie died. He was promised a public inquiry, which never materialised, although he did make it to the European Court of Human Rights in 2000, which judged that ‘doctors have no (legal) duty to give parents of a child who died as a result of their negligence a truthful account of the circumstances of the death, nor even to refrain from deliberately falsifying records.’
More recently, James Titcombe has spent 5 years trying to get to the truth about the death of his son Joshua at Morecombe Bay hospital in November 2008. The coroner in Newcastle refused to open an inquest because he said Joshua died of ‘natural causes’, the trust did an investigation without interviewing the staff, the critical records of Joshua’s care ‘disappeared’ and the testimony of both parents was ignored. The Local Supervisory Authority (LSA) eventually investigated but admitted two years later that their investigation was flawed. The Health and Safety Executive refused to investigate because they don’t apply HSE legislation to clinical situations. Monitor didn’t investigate because clinical issues were the job of the CQC. The Ombudsman took a year to ‘consider’ investigating but then refused to on the basis that it was the CQCs job. The CQC didn’t investigate on the basis that they misunderstood the Ombudsman’s decision not to investigate as a signal that they didn’t need to.
The Coroner was eventually pursued to open an inquest which was held in 2011 and exposed a cover up at the Trust. Monitor eventually investigated the Trust in 2011. The CQC eventually investigated the Trust in 2012. Grant Thornton was commissioned to investigate the CQC in 2013 and delivered a scathing verdict of another cover up. The Ombudsman is currently formally investigating the LSA and the Trust. The Police are formally investigating the Trust. The DoH have commissioned an independent inquiry led by Bill Kirkup to investigate the Trust, the LSA, the CQC and the Ombudsman. Still James waits to find out how and why his son died.
John Henderson, Emeritus physician at the Ottawa Hospital has been trying to get an independent investigation into his cousin’s death at Treliske Hospital in Cornwall for 14 years. Robert Henderson died on October 7, 1999. John has meticulously reviewed and analysed Robert’s medical records, which were then thoroughly reviewed by a panel of medico-legal experts (3 university professors and a coroner). Their conclusion may be summarized in two words: grave negligence. Henderson died shortly after perforating a duodenal ulcer, which may have been caused by his medication and certainly should have been investigated, diagnosed and operated on a lot sooner, given the amount of pain he was in, extreme tenderness on examination and the documented suspicions of a referring GP.
Despite the overwhelming evidence of avoidable harm, the Trust steadfastly refused to hold an independent inquiry, and appeals of the family to the Healthcare Commission and to the Parliamentary Ombudsman were dismissed on the grounds that local investigation had not been done. John Henderson’s last contact from the trust was from former medical director Dr Robert Pitcher, who on 13 March 2008, stated he had asked one of his colleagues to look into the matter with the involved clinicians, and he would “make sure that the outcome is sent to you.” It never was. Henderson won’t give up and will write to Ms Lezli Boswell, current Chief Executive of Royal Cornwall Hospital on the fourteenth anniversary of robert’s death, to ask for a proper investigation that will give Robert’s wife Marjorie, the justice and closure she deserves. The response will be a test of the new duty of candour that is sweeping the NHS after the Francis Inquiry. Or not. Either way, the Eye will print it. MD