Here’s Dr Raj Mattu’s first disclosure on 1/7/2000 to chief executive David Loughton about the death of his patient on 21/12/1999 which he had raised concerns about but the Walsgrave board had ignored

Mattu 1

It got no response, despite its clear implication of patient harm and ongoing risk to patients. So he wrote again, on 27/4/2001. The letter makes extremely serious allegations requiring urgent investigation

Mattu 2

Again, Mattu gets no response. However, a cursory review is carried out two years later that doesn’t interview Dr Mattu or any of the staff. It is still damning of the trust.

Mattu 3

In 1999, whistleblowing surgeon Alban Barros D’Sa was suspended from the Walsgrave for raising concerns about high death rates for colorectal cancer surgery.

In 2001, the Walsgrave (now UHWC) was found to have the highest death rates in the NHS for heart bypass surgery, more than double the national average.

In 2001, the Walsgrave   received a damning ‘zero star’ inspection report from the Commission for Health Improvement, and was particularly critical of the practice of cramming 5 patients into 4- bedded bays.

Loughton resigned in 2002, was given a plumb job as CEO in Wolverhampton and a CBE for services to the NHS. Raj Mattu stayed in Coventry, tried to expose the cover up and patient harm, suffered appalling victimisation and will never work as a consultant again.

NHS cover-ups go right to the top

‘Patients’ lives are saved when courageous people speak up – openly and honestly – and when each of us takes personal accountability for putting things right.’ So said incoming chief of NHS England Simon Stevens on April 1^st. But the joke is that no one helps put things right for whistleblowers themselves, nor holds those to account who smear, ignore or black-ball them.

It is scandalous that whistleblowing Alder Hey surgeons Professor Ed Jesudason and Shiban Ahmed cannot operate in the NHS (Eyes passim) after making protected disclosures about patient safety. Ahmed also worked for the University Hospital of North Staffordshire (UHNS) and was suspended by them in 2009 on the grounds that he is as a mental health risk after a hotly disputed allegation by two Alder Hey surgeons – Matthew Jones and Colin Baillie – that he was suicidal, an allegation of which Ahmed was cleared by a subsequent investigation. Although Baillie and Jones accepted they were behind the suicide claim, this crucial evidence was withheld from Ahmed’s Employment Tribunal, and Alder Hey denied the claim had any role in his suspension. Ahmed’s insurers withdrew funding for his tribunal challenge due to the lack of evidence to support his case.

Jesudason discovered what Baillie and Jones had done to Ahmed, led the petition against Ahmed’s mistreatment and  unearthed material evidence of the unproven allegation and that Alder Hey withheld vital evidence from Ahmed’s ET. Alder Hey then wrote offering Jesudason a six figure pay off part of the deal being that he had to destroy this evidence.  He refused and was forced out after his High Court hearing collapsed (Eyes passim). During the hearing, the Eye was at one stage asked to destroy its damning evidence against Alder Hey because it was ‘the property of the court’, but this request was then rescinded. No attempt was made to examine the evidence, call witnesses or expose the mistreatment of Ahmed and the attempted silencing of Jesudason. MD has referred Simon Gorton QC – a barrister employed by Alder Hey and copiously funded by the public purse – to the Bar Standards Board, to investigate whether or not he played a role in misleading Ahmed’s ET, which  Gorton adamantly denies.. Ahmed and Jesudason’s patient safety concerns have never been properly investigated, but Alder Hey was recently classified as “potentially unsafe” after failing to meet four in five standards of quality and safety in an unannounced inspection by the Care Quality Commission (Eyes passim)

Equally shocking is the smearing of CQC board member Kay Sheldon. In 2012, Sheldon gave evidence to the Health Select Committee about her treatment after making very well founded and politically devastating accusations about incompetence and cover ups at the Care Quality Commission (Eyes passim). On November 28, 2011, Sheldon gave oral evidence to the Francis Inquiry which was publicly refuted through a message on the CQC website. Jo Williams, then CQC chair, wrote to Health Secretary Andrew Lansley the same day asking for her immediate suspension and replacement. Messages were also sent to CQC staff from chief executive Cynthia Bower and Williams undermining the evidence that whistle blowers gave to Francis.

Sheldon continued to attend board meetings but the atmosphere was so unpleasant it was hard for her to do her job properly and she experienced significant stress. She asked for an assessment with someone who understood her situation but was instead referred by Williams, without her knowledge or consent, to Medigold, a private occupational health company. On January 30, 2012, she spoke to the executive chair of Medigold, Dr. Mike Goldsmith, on the telephone for around 10 minutes saying there had been some crossed wires and that she didn’t need to see a doctor. They did not discuss any details about her health.  Following this conversation, and on the same day, Dr. Goldsmith wrote a three page letter to Williams. “My clinical view, based on a 20 minute telephone call, is that this lady is suffering from a mental health problem, which is likely to be one of the conditions that involve paranoia. The most common of which is paranoid schizophrenia and certainly some of the things that were said to me in a completely normal voice and without any emotion would fit with paranoid thinking” and “She may well be in denial, but I suspect she is actually suffering from significant paranoia at present”. He also suggested that her past history be obtained “in confidence” and that “if necessary, obtained a psychiatric opinion on her”. He said he would be happy to speak to the Chief Medical Officer about her. He also stated “I think it is really important that she is assessed or else removed from her position, because I think there are some serious issues here that need to be dealt with and not swept under the carpet”. Goldsmith also wrote a disturbing email stating he would be involved in her case “behind the scenes”.

Sheldon remains a vital member of the CQC board and has shown no signs of paranoid schizophrenia. Williams and Bowyer both resigned from the CQC when all of Sheldon’s allegations were proved correct. Dr Goldsmith was reported to the GMC and no action was taken, despite the inadvisability of suggesting a diagnosis of paranoid schizophrenia when you are not a psychiatrist, based on a short phone call that did not discuss health matters and did not gain patient consent.

The business of covert assessments, and other occupational health work, appears to very profitable.  Dr Goldsmith’s company – Medigold – paid him £256,676 in 2012 with much of the money paid as fees for the Medigold trademark meaning it may well be very tax efficient.  When asked about the tax efficiency, Dr Goldsmith’s son, a former City banker and now finance director of the company replied, “So what?”

But why did the CQC engage a private family occupational health company to do a secret psychiatric assessment? The answer was revealed as Sheldon gave evidence to the Public Accounts Committee last month. Medigold was recommended to the CQC by the Permanent Secretary of the Department of Health, Una O’Brien. So the DH was instrumental in organising the inappropriate, secret and erroneous psychiatric assessment of hugely embarrassing whistleblower by a private occupational health doctor based on a short phone call where health was not discussed.

Una O’Brien remains the most senior civil servant at the Department of Health and one wonders how many other secret mental health assessments have been conducted under her leadership. O’Brien refused to comment personally, but claimed, “The Department suggested Medigold, with which the Department holds a contract for the provision of occupational health services.” If Stevens really wants to support whistleblowers, and reverse the culture of his predecessor David Nicholson, he needs to shine the light at the top of the NHS

Patients First Letter to Jeremy Hunt

The Anguished Death of Thomas Milner

Thomas Milner, a kind and gentle man, was 76 when he was diagnosed with myelodysplasia in June 2005. By October 2005 this had developed into leukaemia and he began weekly blood transfusions.  On 7th January 2006 he suffered a large gut haemorrhage and was losing blood from the rectum. He was admitted to the A & E at Sheffield’s Northern General Hospital where he was given IV fluids. There was a ‘Do Not Resuscitate’ notice in his medical records.

Once rehydrated, it was confirmed that Mr Milner was dying and he was given morphine on demand by injections, when his family noticed his distress.  On January 9^th, on the Medical Assessment Unit (MAU) a morphine syringe driver was set up and he was transferred to the MacMillan Palliative Care Unit (MPCU).  This involved wheeling him 500 metres outside in the cold wearing only his pyjamas, to sit in a wheelchair for 4 hours whilst administrative forms were filled in.  Once on MCPU he needed two extra morphine doses as he was very agitated, cold and frightened. .

On 10th January, staff on the MPCU started refusing to give morphine, writing that his family were giving him ‘dandelion and burdock’ which ‘settled’ him. For 15 hours on Thomas’s penultimate day he received no morphine and by the time night staff came on duty he was very agitated and lying  in his own blood and urine (a scene his daughter describes as heartbreaking and pitiful). The day staff  failed to wash and toilet him, and failed to dress a huge sacral bedsore.  By the morning of the 11th January Thomas Milner was pulling at the bed sheets with tears rolling down his face. The family called staff and two junior nurses attended saying that they could not give him anything and that the doctors would attend on their morning round.  In desperation Thomas’s daughter called the family GP, who summoned a junior doctor who finally administered morphine at 9.00am. Thomas died at 10.40am.

A complaint was made to the hospital and for the next 6 years the family sought answers from the hospital, the Nursing and Midwifery Council, the General Medical Council, the Healthcare and Care Quality Commissions and the Healthcare Ombudsman. The answers became more absurd and contradictory as to why Thomas had suffered so much, why he was denied morphine and why his family had to resort to calling their GP for help. The NHS Regulators took no action.

Thomas’s story was highlighted by the Patients Association in their 2009 Report ‘Patients not numbers, People not statistics’. 4 years after Thomas’s death the family obtained copies of the controlled drug register and other drug charts that the hospital had originally said did not exist and found that they had been altered. His family believe that instead of logging the intervention of the GP and reporting a ‘significant untoward incident’ on the day Thomas died, which would trigger an investigation, the matter was covered up.

The family alleges that the syringe driver was initially set up at the wrong rate on MAU, and that the MPCU staff failed to correct this mistake and did not refill it correctly or take into account the extra injections of  morphine that had been needed. On Thomas’s last night staff failed to refill the morphine syringe driver at all. They also believe that unqualified staff had handled and administered morphine to Thomas, the details of which were later altered, perhaps to make it appear the syringe driver on his last night had been refilled

The hospital has confirmed that there were no MacMillan or Palliative Care nurses on duty the two nights that Thomas was on at the MPCU, just very junior nurses. The trust  apologised in 2010 for lack of attendance to hygiene and the long wait in the wheelchair but not the lack of pain relief. In March 2012 South Yorkshire Police began an investigation to ascertain whether any controlled drugs were unaccounted for, whether there had been deliberate cover up of failings in care following the complaint and whether there had been any genuine errors in record keeping. This investigation is still ongoing, over 8 years after Thomas Milner’s anguished death.  As with other NHS failings, the suffering may well have been prevented had there been enough specialist nurses on the ward.