Dial M for Mistake

The ‘call 111 cock-up’  has shown why competitive tendering, outsourcing and the fragmentation it brings are hopeless for safe, coordinated emergency care. Many NHS staff, academics and government advisers predicted the risks, but the government ploughed on regardless.  It  has ‘delayed’ minimum pricing for alcohol and plain cigarette packaging to await ‘more robust evidence’, and yet rushed through massive, unmandated market reforms of the NHS that have no evidence base at all. And as MD pointed out (Eye 1340), out of hours care is high risk and dangerous, triaging calls is extremely complex and the system has to have experienced clinical staff on hand, have a clear safety net, agreed and enforced quality standards and be joined up with the rest of the NHS. Since when was rushed outsourcing on the cheap going to be the solution?

Health Minister Earl Howe told the Lords that contractors were offered ‘an extra six months to bed in NHS 111’ but only two took up the offer’. NHS England should have insisted on the 6 month delay to make the service safer. Howe now claims ‘the NHS 111 service is not unsafe ? it is a safe service. In the vast majority of the country it has been provided very well for patients’ – a statement that may well come back to haunt him. Where 111 is being run by ambulance and GP out of hours services, it seems working well. But evidence of safety is distinctly lacking.

Like the Liverpool Care pathway, the principle of 111 is sound – it’s the variable implementation by staff, some of whom have inadequate expertise and all under extreme time pressure, that’s the problem. The simplification of out of hours calls to two numbers – 999 and 111 – sounds reasonable but it’s never that simple. Patients are expected to be able to differentiate between life-threatening 999 emergencies, and urgent but not life-threatening 111 problems. Even experienced GPs who know a patient well have trouble separating the two over the phone, so what chance a call centre employee with no medical training, an algorithm and possibly the odd nurse to ask for help if he can attract her attention? Risk-averse call handlers are likely to refer to 999 to cover their backs, others may completely miss the cues of subtle, but life-threatening illness. Safer advice would be to try your GP first. You might get lucky – or you might get referred onto 111.

Labour came up with the idea  a national, three-digit number for out-of-hours healthcare services in 2007, but for once Hunt has decided not to blame them. Labour did not intend to replace NHS Direct, which was not perfect but was at least staffed by experienced nurses and had developed into a good service. Instead of building on that, Lansley decided to rip it all up and replace NHS Direct with 111

NHS Direct could still bid for the tenders and, in a panic, put in  ridiculously low bids despite knowing the complexity of the work it would be doing. Even worse, the Department of Health accepted the bids and awarded them 11 of the contracts. NHS Direct has now realised – as many callers have – that it can’t provide a safe, reliable service at such a low price and is pulling out of all 11 contracts, leaving NHS England scrabbling around for a ‘failure regime’ which will doubtless mean paying other companies over the odds to take on work they don’t have the capacity for. And patients with urgent health problems will just have to shop around in the out of hours market.

NHS Direct is at least tax-payer owned, so the government and NHS England can blame it without tarnishing private sector providers. But as Channel 4’s Dispatches showed, Harmoni is also struggling to deliver a safe, low cost service too. As one (secretly filmed) manager put it: ‘We had a very bad service. Still realistically on the weekends we still are unsafe. We don’t have the staff to deal with the calls that are coming in.’

NHS England now claims that 90% of 111 calls are answered within a minute, a simplistic target that says nothing about whether the advice is competent. Harmoni has a third of contracts, and will probably now mop up some more. It beat Care UK to the contracts, but Care UK retaliated by buying Harmoni and then recruiting, as its managing director, Jim Easton, who was lured from the Department of Health and then NHS England having … er … ‘overseen  the NHS 111 procurement process’.

Hunt Balls

Mr Justice Silber’s ruling that Jeremy Hunt’s decision to cut services at Lewisham hospital in south London was unlawful was spot on. Lewisham was being used as collateral damage in a battle  it had nothing to do with, namely to bail out nearby South London Healthcare NHS trust (SLHT) , which is losing £1m a week and will be £356m in debt by the end of the year. And a significant chunk of that debt is to service two ludicrously expensive PFI debts for Queen Elizabeth hospital in Woolwich and the Princess Royal hospital in Bromley.

The Lewisham campaign was evidence-based,  united clinicians and patients, and was funded by donations via 38 Degrees. There was no rational case for downsizing such a high performing and popular hospital, and neighbouring trusts would not be able to take on the extra work without patients suffering. The decision does not, alas, solve the looming disaster of PFI debt (Eyes passim ad nauseum). As MD observed back in 1997, PFI is ‘political diktat triumphing over common sense, open debate and the will of the people.’ (Eye June 20) 21 PFI NHS trusts now have debts of  £130 million between them, and the total bill for repayments has risen by £200 million (18%) in 2 years. The government seems desperate to keep PFI shareholders sweet, but the contracts either have to be renegotiated or the debt spread right across the NHS rather than punishing nearby hospitals.

Spare a thought also for Mid Staffordshire NHS Trust, which has greatly improved its care, come in the top 10 for the Friends and Family test in its A&E department and achieved a glowing CQC report. The Trust Special Administrator has recommended that it doesn’t open its A&E overnight again, and that it loses its maternity and paediatrics services, which have never been criticised. Local campaigners may well appeal this, just as Jeremy Hunt may appeal the Lewisham decision. The issue for the government is that is simply isn’t trusted. It promised to protect hospitals or departments from closure in opposition, and an end to top down reorganisation. It then foists a massive market-driven  structural reorganisation on the NHS, and further service reorganisations – even if clinically rational – are seen as another ‘top down’ betrayal. The biggest winners, as ever, are likely to be lawyers.

Medicine Balls Eye 1345  July 26

Keogh Facts

Sir Bruce Keogh’s review into the quality of care and treatment provided by 14 NHS trusts with high death rates was shrewd and thorough, but his proposals for proper NHS inspections lead by doctors are nothing new. In 2000, MD endorsed the idea of an independent medical inspectorate in his evidence to the Bristol Inquiry and the Eye (Feb 3?), based on the work of Dr William Pickering.

“Shipman got away with it for so long was because he knew that in the NHS, and in general practice in particular, doctors can do more or less what they like. They call it ‘clinical freedom’ and cherish it. No one (except the law) can meaningfully challenge their actions, and then only if they are found out. Medical ethics do not include commenting on another doctor’s practice, nor do they insist upon an open mentality. The ‘self-regulation’ of doctors is, therefore, equivalent to no regulation.”

‘Most medical disasters start with single errors or near misses, and yet they only come to light much further down the line when many more mistakes have been allowed to occur. Even then, it needs the strident clamour of patients or the press to get near the truth. So-called regulators have been of singular irrelevance; had it been left to them, many recent disasters would be continuing yet.”

“The only way to exact such basic clinical standards is to have a person in each district of the country undisguisedly looking for sub-optimal clinical practice, working within an Independent Medical Inspectorate. Each Inspector should be informed (a doctor) and impartial (paid from outside the NHS). The Inspectorate will glean its information for any source, including whistle blowers and patient complaints. All clinical complaints, plus a copy of the written response and explanation to the patient from the doctor, will pass across the Inspectorate’s desk. This will press medical personnel into prompt, open and accurate explanations. If indicated, the Inspectorate would examine the medical records and if sub-standard clinical practice is evident, it will swiftly inform the doctor and the regulatory bodies. It’s very presence will force all clinical staff to examine their practice. Clinical standards may be expected to quickly rise. Expensive legal defence costs and awards are likely to drop. Above all, patients can be sure that their doctors are, at last, meaningfully clinically accountable.”

13 years and many disasters later, Keogh and Mike Richards, the new chief inspector of hospitals, have reached the same conclusions, adding in patient assessors too. It remains to be seen how many clinical staff and patients volunteer to be inspectors (MD will), and whether they will be completely independent, properly funded and able to speak the truth to power without getting bullied, ostracised and silenced  as has happened to those who raise concerns in the past (Eyes passim ad nauseum). By calling Mike Richards the whistleblower in chief, Jeremy Hunt has at least given the appearance of getting the importance of whistleblowing. Whether he remains so enthusiastic as failures in NHS care under his watch emerge near election time remains to be seen.

Hunt’s Commons response to Keogh was a dangerous game of trying to hole Andy Burnham below the waterline and damage Labour’s credibility as saviours of the NHS. Where Keogh had wisely avoided blame and sensationalism, and focused on the complexities of providing safe NHS care in a cash-strapped service in parts of the country that find staff recruitment tough, Hunt and Cameron went straight for the Labour jugular. MD repeatedly exposed Labour’s  missed opportunity of using all the extra funding to  rebuild the NHS around quality and safety, the woeful variations in standards of care, toothless regulators fearful of government and appalling treatment of staff, patients and relatives who try to raise concerns. But this has continued under the government’s watch and divisive, political point scoring is ludicrous, particularly given that all political parties have  endorsed Sir David Nicholson as NHS leader, despite overseeing such an unsafe and bullying culture. Hunt started off not blaming Labour, but in changing horses while keeping the same jockey, he is setting himself up for a fall. Politicians need to unite around what’s best for the NHS, and the best way to encourage clinical leadership is to have a wise clinical leader. The sooner Keogh unseats Nicholson, the better.

The Truth About Death Rates

The Hospital Standardised Mortality Ratio represents the number by which the deaths in a hospital exceeds the number that would have occurred if the hospital had had the national death rate for each age, sex, diagnostic group etc for which adjustments are made. It is a statistical estimate, and so can’t be used to determine precise numbers of deaths or whether any individual death might have been avoided with better care. It is however, an excellent warning alarm to go and dig deeper. All fourteen trusts targeted by Keogh because of high death rates turned out to have serious safety problems.

The media habit of attributing a precise number of avoidable deaths to HSMRs is nonsense, but it has been used by Labour and its activists to discredit both Sir Brian Jarman and his methodology, and to cover up the fact that hospitals with high HSMRs were either not investigated by Labour, or reported to an incompetent regulator set up by Labour to perform an inadequate investigation. Labour’s booing of Jarman during the Keogh debate is just another example of shooting the messenger. As Keogh himself said to the Mid Staffs inquiry: ‘I am reasonably confident that the process which is now in place would have picked up the situation at the trust before it was granted Foundation Trust status. The HSMR information and the question in the staff survey about whether the member of staff would be happy for someone in their family to be treated at the hospital are two examples of where the problems at the Trust would have been identified by the current position’. No one method is perfect at picking up avoidable harm. But to avoid the warning signs is unforgiveable.

Medicine Balls Eye 1344 July 12

Trust and Transparency

The BMA’s vote of no confidence in health secretary Jeremy Hunt, a year after the same outcome for Andrew Lansley, is no surprise. The government promised an end to structural reform of the NHS and then landed it with the largest structural reform in its history. Lansley, and now Hunt, also promised a new era of transparency whilst simultaneously refusing to publish the ‘risk register’ for such absurdly complex and unnecessary legislation. And most NHS staff believe that increasing private competition will lead to fragmentation and cherry picking more than integration and improved services.

Lansley even predicted an end to political interference in the NHS, leaving  the running of the NHS to chief executive Sir David Nicholson and his ‘people’. But a succession of scandals and cover-ups on Nicholson’s watch has given the ambitious Hunt an open invitation to interfere. Hunt is keen to deflect blame, and so Mid Staffs was a good opportunity to claim there was too much mediocrity in NHS care and too many hospitals were “coasting”.

The out-of-hours service 111, introduced on Hunt’s watch without proper safety standards and despite repeated warnings from clinical staff that it was dangerous, has resulted in at least 3 deaths and queues in accident and emergency, both of which Hunt tried to blame on a 9 year-old GP contract. The Mid Staffs and Morecambe Bay scandals are in Hunt’s view Labour’s fault, even though the government has stuck the same NHS leadership and the cover-up by the CQC happened in March 2012, two years after the coalition took office. In the new transparent NHS, this high level meeting wasn’t minuted and has no audit trail nor evidence to show who in the DH was aware of the scandal and its suppression. As Kay Sheldon, the CQC whistleblower put it: ‘The CQC was not fit for purpose and patients’ lives were at risk. But the only thing the Department of Health and the CQC cared about was maintaining the illusion that the system was working.’

Sheldon was bullied and branded mentally ill for exposing the CQC, and threatened with dismissal by Lansley although he backed down after the counter-threat of legal action. Lansley was also well aware, but seemingly unable to help, Dr Hilary Cass, the whistle-blowing paediatrician and now president of the Royal College of Paediatrics and Child Health, who was gagged by Great Ormond Street Hospital in 2010 and warned that support for her palliative care training would be withdrawn if she spoke out (Eye last).

Ministers seldom, if ever, get involved in individual cases and the promise of NHS England boss David Nicholson to support any whistleblower who contacts him does not appear to be bearing fruit. Instead it’s left to Hunt to profess to be outraged, shocked and disgusted by each new scandal, when a properly briefed health secretary would be anything but surprised. But Hunt is just a caretaker health secretary with no intention of staying in the job after the next election. As such, he’ll happily play ignorance for as long as he can get away with it. He landed one of the most complex jobs in the cabinet after claiming, as culture secretary, he had no idea that his hand-picked special adviser was passing confidential and market-sensitive information to BskyB.

The government’s best chance of restoring both transparency and trust in the NHS is to accurately measure standards and experiences of care, and publish them. The friends and family test, and the release of named-surgeon data, could prove how good the bulk of NHS care is, and show where it needs to be improved. But staff  have to trust the government and NHS England to do this fairly and sensibly, without politicisation, victimisation and press histrionics. Many doctors don’t trust Hunt or Nicholson and until they do, even the best intentioned stab at transparency could fail. But patients will happily provide feedback on their care when asked, and the early results are very encouraging for the NHS.¹

¹http://neilbacon.wordpress.com/2013/06/20/total-massive-huge-success-story-in-the-nhs/

Medicine Balls Eye 1343 June 28 2013

How High Can You Gag?

Private Eye has finally got Great Ormond Street Hospital (GOSH) to release details of its gagging settlement with Dr Hilary Cass, a consultant in disability and the current President of the Royal College of Paediatrics and Child Health. GOSH told Cass that if she didn’t accept a gag, her palliative care training for terminally ill children would be withdrawn. Bullied and wary of the consequences for children,  Cass agreed to judicial mediation and an ‘off the book’ payment of £35,000 in settlement of her claim for constructive dismissal.

In the compromise agreement, drawn up by Beachcrofts, Dr Cass must “warrant” that she has talked to nobody but her immediate family, and “must not disclose in future to anyone the circumstances of your termination of employment” and “must not directly or indirectly make any statements derogatory of GOSH”. Dr Cass could still be sued today if she makes a true statement about GOSH that is deemed “derogatory” by them. So why was GOSH so keen to shut her up?

On January 11^th 2007 Dr Cass, as Deputy Medical Director at GOSH, heard a grievance from Dr Kim Holt (Eyes passim), who had raised safety concerns about the Haringey clinic where the abuse of Baby Peter Connelly was subsequently missed.  Dr Holt was put on special leave by GOSH and made allegations of widespread bullying and harassment by managers. Dr Cass found in favour of Dr Holt, but was asked by senior management make substantial changes, including a statement that Dr Holt’s grievance was not upheld. This was seen as crucial to GOSH’s business plan to take over the management of children’s services in Haringey. Cass did not accept the outcome should be changed, but agreed some amendments to the outcome letter.

When Baby Peter died on August 3, 2007, GOSH’s huge error in not investigating Dr Holt’s safety and bullying allegations became apparent. As the reputational clean-up operation kicked in, Holt was offered, but refused, a gag. In October 2007, Cass raised concerns that cuts in junior doctor staffing were putting patients at risk and was swiftly removed from her educational post by chief executive Dr Jane Collins. Cass later filed a grievance against Collins, claiming she had breached her managerial code of conduct. Cass also wrote to London Strategic Health Authority in June 2009, blowing the whistle on the bullying conduct of GOSH senior management and their failure to address the safety concerns. Nothing happened. In June 2010, Cass sent her concerns to the Care Quality Commission. Again, nothing happened.

In 2009, Cass secured a new post at Guy’s and Thomas Hospital which did not have a specialist palliative care service for children. GOSH allowed Cass to train in palliative care in order to set up the service at her new hospital, but made the training conditional on her silence. In a statement, GOSH said: “The Trust recognises that some clauses in the agreement could be interpreted as restricting what Dr Cass could speak about publicly. In hindsight those clauses should not have been included. No clauses of this nature will be included in any future agreements.’ GOSH could not recall who put the threat of palliative care training withdrawal into the gagging agreement, as papers relating to early drafts of the agreement had ‘gone missing’.  Dr Jane Collins has since deregistered from the GMC and now works as the head of Marie Curie, a charity responsible for…  palliative care. On 30.9.2011, the Eye referred consultant Dr David Elliman to the GMC for not acting on the concerns of Dr Holt. Nearly 2 years later, the GMC is still sitting on the case. Meanwhile, MP Stephen Barclay has unearthed 50 such ‘off the book’ payments to silence NHS whistleblowers at a cost to the taxpayer of £2 million.

Times Thunderer Column, 21.6.13

‘Those currently in power in the NHS don’t listen to the truth’

David Cameron and Jeremy Hunt profess to be “shocked” by the latest appalling NHS scandal, this time in Morecambe Bay, but they shouldn’t be. A regulator that failed so miserably in one hospital, Mid Staffs, is likely to have failed in others, along with the managers, clinical staff and commissioners who either failed to spot the scandal or colluded in the cover-up. What is shocking is that the Government decided to stick with the same leader of the NHS, Sir David Nicholson.

When the fish is rotting from the head, you need to remove it. Instead Mr Cameron and Mr Hunt fully support him as the only man to lead the NHS into this new era of openness and transparency, where we no longer cover up our mistakes. Sir David has finally agreed to retire next March, but his legacy is not just one of fear and bullying in the NHS, where too many in the chain of command kiss up, denying appalling care beneath them and delivering only good news to Downing Street. He has also ensured that many in key positions of power in the NHS are “David’s people”. As such, it is difficult for them to speak truth to power, as Cynthia Bower, the former chief executive of the Care Quality Commission, found to her cost.

It seems inconceivable that high- level CQC discussions about serious failings at Morecambe Bay would not reach the ears of Sir David and others in the Department of Health. But as Robert Francis found in his report into Mid Staffs, it’s fiendishly difficult to pin down the evidence linking scandal to the centre. Sir David may also outlast Mr Hunt, who is playing a very dangerous game of pass the buck. Many senior doctors and nurses warned of the dangers of rushing in to the new 111 out-of-hours service, but the Government went ahead anyway, and three fatalities at least are alleged to have occurred. Mr Hunt’s response has been to blame a nine-year-old GP contract. It shows that those currently in power in the NHS still don’t listen to truth, even if you dare speak it to them.

It might be more prudent for Mr Hunt to have one large truth and reconciliation hearing, rather than a series of public inquiries. Above all, we need people like the Morecambe Bay parent James Titcombe, who are unafraid to speak the truth. Mr Titcombe is modest but unrelenting. He works in the nuclear industry and has been staggered by the slack, defensive safety culture in the NHS. I would trust the CQC far more if people like him were on its board. Give the power to those who’ve earned it.

Phil Hammond is a GP turned hospital doctor and Private Eye’s medical correspondent

CQC in the Dock

NHS England has confirmed there will an ‘inquiry in public’ into the serious systemic failures at University Hospitals of Morecambe Bay Foundation Trust (UHMBFT). But will it have the balls to expose yet more failings in the regulation and leadership of the NHS? The inquiry was sparked by the avoidable death of baby Joshua Titcombe at Furness General Hospital in November 2008.  Joshua had a low temperature due to lung infection that would have been easily treatable had it been diagnosed. Sadly, it wasn’t. Joshua’s crucial observation chart disappeared soon after his death, despite ‘extensive’ searches, leading the coroner to deduce,  32 months later, it may have been ‘deliberately destroyed.’ He concluded there was a ‘very worrying mark of suspicion hanging over the maternity unit at Furness General Hospital (part of UHMBFT)’ and identified ten serious failures. A previous review into the service had also found serious failings. So why did the Care Quality Commission not investigate?

Whistleblowing CQC board member Kay Sheldon recently accused the CQC of registering failing hospitals as safe to avoid another public scandal such as Mid Staffordshire.  ‘It seems to me that CQC gave assurance about the Trust that wasn’t actually accurate…It was a very shocking thing to find, thinking that an organisation that’s there to protect patients had effectively given what amounted to false assurance and that meant that problems in the Trust carried on unacknowledged and unaddressed.’

James Titcombe, Joshua’s father, works in the nuclear industry and knows a thing or two about safety: ‘The idea that any regulator could deliberately give false reassurances about the safety of vulnerable people is deeply shocking. Could you imagine the Civil Aviation Authority knowing about significant safety issues in a type of passenger jet, but then deliberately suppressing the concerns?  What would happen in these circumstances if a plane subsequently crashed and hundreds of people died as a consequence?’

At Morecambe Bay, following the ‘all clear’ registration of the Trust by the CQC’, the Dr Foster unit at Imperial College London calculates that 415 excess deaths may have occurred (up to and including 2012). In 2011, the statistical estimate was more than 257 excess deaths (the highest mortality rate of any Trust in the country).

Titcombe has meticulously and courageously unearthed documents which unequivocally show the serious concerns CQC had about Morecambe Bay as far back as September 2009. At this time, the Health Service Ombudsman was considering undertaking her own investigation into concerns regarding the Trust’s maternity services, including the death of Joshua. During this process, a discussion took place between the deputy Ombudsman (Kathryn Hudson) and the regional director of the CQC (Alan Jefferson). Ms Hudson recorded details of the conversation which she forwarded to the Ombudsman, Ann Abraham. It revealed clear evidence of systematic failure in maternity services across the Trust, and serious concerns about how the entire Trust operated¹. And yet in February 2010, Abraham refused to investigate, saying it was the CQC’s job to address failures,  and  two months later, CQC registered Morecambe Bay ‘without conditions and with no planned investigations’.

The scandal also implicates Mike Farrar, who was CEO of the North West Strategic Health Authority between July 2006 to October 2011, and is in the running to succeed Sir David ‘No Accountability’ Nicholson as chief exec of  NHS England. Farrar’s partner, Rosamond Roughton, is the Director of Commissioning Development at NHS England. That shouldn’t obstruct a thorough ‘inquiry in public’.

1 www.morecombebayinquiry.co.uk

A Law Unto Themselves

The success of Robert Francis QC in stopping the NHS from covering up the harm it causes is crucially dependent on the behaviour of his own profession. At the time of the Mid Staffordshire scandal, there was unequivocal guidance for NHS trusts, managers and clinical staff to be open and transparent when patients may have been harmed by their care, but lawyers tend to focus their attention on the law, and who’s paying their fees. Hence the solicitors’ code of conduct – to act in the best interests of the client – invariably trumps any wider ethical guidance to the NHS, particularly when it comes to admitting anything that might expose a hospital to bad press, litigation and financial loss. Francis’ solution – to make non-disclosure of harm a criminal offence –is as big a shift in the culture of medical law as it is to the NHS.

Eye readers will be well aware of the extent the NHS uses publically-funded lawyers to suppress whistleblowers. The case of John Moore-Robinson at Mid Staffs illustrates how such a defensive – but entirely legal –  culture obstructs parents from understanding how their son died. Moore-Robinson, a previously fit young man, was examined in A&E at the Trust on 1 April 2006 following an accident on his mountain bike. He was examined by a junior doctor and, in spite of the protests of friends who were with him, discharged – in a wheelchair as he could not walk – with advice to take an analgesic. He was still being sick as he left A&E. He died the following day at another hospital. It was later found he was suffering from a ruptured spleen, a lethal injury unless diagnosed and treated promptly. He was showing signs and symptoms which were indicative of this as a possible diagnosis and he should not have been discharged. It is likely that his life could have been saved had he been kept in hospital for a thorough investigation and treatment.

The Trust received a request from the Coroner for information in relation to the death. The junior doctor had left the Trust, so Mr Ivan Phair, the senior A&E Consultant, was asked by the Trust’s legal team  for a “report addressed to the Coroner for use in the inquest.” Phair concluded that the junior doctor should have interpreted that Mr Moore-Robinson could have been suffering from some form of bleeding. ‘I cannot find enough evidence which would lead me to conclude that a thorough abdominal examination was carried out… I would therefore raise the possibility that his unfortunate, untimely death may have been avoided, had he been more properly assessed on his initial attendance to the A&E department.’

On May 25, 2006, Kate Levy, the Trust’s in house solicitor, wrote to Mr Phair saying his report had not been forwarded to the coroner. ‘Whilst it would be entirely appropriate as a report in respect of a clinical negligence claim it goes beyond the issues which concern the Coroner. The Coroner is undertaking a fact finding exercise and does not concern himself with matters of blame or potential negligence. I would therefore like to suggest that the section of your report headed “Conclusion” with the exception of the final para be removed’

When Mr Phair refused, she wrote: ‘As reports are generally read out in full at the Inquest and the press and family will be present, with a view to avoiding further distress to the family and adverse publicity, I would wish to avoid stressing possible failures on the part of the Trust.’ She suggested removing the two paragraphs of the conclusion. ‘I feel such a concluding statement may add to the family’s distress and is not one which I would wish to see quoted in the press.’

Mr Phair amended his report but it still contained his grave concern, his opinion about the ‘brief an incomplete’ abdominal examination and the possible cause of death. Levy decided not disclose either version to the coroner or Moore-Robinson’s parents, and neither did fellow solicitor Stuart Knowles. When the failure to disclose Phair’s report was discovered by the Francis Inquiry, Levy was dismissed from the Trust in 2010 but won her case for unfair dismissal and was awarded £103,000 in damages. Capsticks solicitors advised the Trust that it was normal to exclude issues of blame and potential negligence from a coroner’s inquest. The Solicitors Regulatory Authority and the Bar Standards Board agreed Levy had acted entirely professionally in line with her employment contract and solicitors’ code of conduct, and there was no case to answer.

Meanwhile, Knowles – who was also the deputy coroner – privately advised the NHS Litigation Authority that ‘it would not be unreasonable to view the matter as indefensible’. In October 2007, the claim was settled for £15,000, a step Mr Knowles said was “eminently sensible” but “slightly overpriced”. The Trust stressed in a press statement that ‘liability was not admitted.’ Chief executive Martin Yeates wrote to John’s parents in an attempt to apologise. ‘While I understand that nothing can compensate for the loss of a loved one I hope that the fact that matters have been resolved speedily will go some way to enable you to put this matter behind you and move on.’

Knowles was flummoxed at the family’s anger and wrote: ‘The apology was the standard NHSLA affair and it was approved by someone … This family have been going on about this and they appeared on telly recently … we settled very quickly even though there might have been issues that could merit further investigation. I take the view that we treated the family very well … Who is causing a problem and what are they trying to achieve? … Anyway hopefully we can sort this out soon but I suspect the family are having issues (quite understandably) with grief etc… it is indeed unfortunate that what appears to have been a rapid and well-handled [settlement] by the NHS does not appear to have been appreciated by the family and that they have taken this unfortunate line.’ Seven years later, John’s parents are still campaigning for an independent inquiry into his death. If lawyers can’t be trusted to give patients and relatives the truth, there needs to be a law against it.