When will we ever learn?

On March 3, Dr Bill Kirkup published his report on the failures in maternity care at Furness General Hospital (FGH) between 2004 and 2013 (Eyes passim ad nauseum). It received scant media attention, possibly because repeated serious NHS failings have lost their ability to shock. The investigation found 20 instances of significant or major failures of care at the hospital which could have contributed to the deaths of 3 mothers and 16 babies. The report concluded that one mother and 11 babies could have been prevented from dying if they had been given different clinical care.

The report found serious failures at every level of the NHS from the trust to the Care Quality Commission (CQC), Monitor, the Department of Health and the Parliamentary and Health Service Ombudsman (PHSO). Kirkup uncovered a ‘lethal mix’ of factors that led not just to avoidable deaths but a culture where midwives at FGH and the trust itself to cover up what happened. Unsurprisingly, the lessons from previous deaths went unlearned and the harm repeated itself. The report found that following serious incidents there had been ‘instances of distortion of the truth’, ‘distortion of the process underlying an inquest’

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Blow the whistle if you Dare

Dr Hayley Dare, a highly regarded NHS clinical psychologist, has been raising concerns for some years in the country’s biggest mental health trust, West London Mental Health NHS Trust (WLMHT). She spoke out about poor patient care and staff welfare. For example, in August 2012, the Trust’s Forensic Director closed a ward on the Women’s mental health unit without warning. This led to a 72-year-old woman having to sleep in a windowless, isolated padded room because there was no normal bed for her; she died a fortnight later. The Trust’s investigation into Dr Dare’s allegations was never published but Dr Dare’s concerns were subsequently upheld in court.

Dr Dare raised her concerns through the appropriate channels but was subjected to a campaign of bullying from senior management. This included a poison-pen letter threatening her and her children and accusations about her mental health. Dr Dare has an unblemished 20-year career in the NHS. As a specialist in women’s forensic care, she provided therapy to severely psychologically unwell women with long histories of abuse who had become a danger to themselves and to others.

Following an unexpected reorganisation, Dr. Dare’s post was put at risk

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Bill passed away on 5 February 2015 after a brief illness.

Dr Bill Pickering was a huge influence on my thinking over 15 years, and along with the Bristol whistleblower Steve Bolsin and Bristol parent Maria Shortis (now Maria Von Hilldebrand), he was the most lucid thinker about patient safety that I was privileged to meet. Steve demonstrated the urgent need for NHS staff to be able to speak up about NHS failings without fear of persecution, and the duty of managers and regulators to act on this. Maria lost her baby at Bristol and yet started a wonderful charity called Constructive Dialogue for Clinical Accountability, whose focus was on culture change in the NHS towards an honest, open and trusting relationship between users and staff that was truly accountable. But it was Bill who had the best idea on how to achieve this.

I supported his vision for an independent medical Inspectorate as far back as 1999 in Private Eye. Having a local and independent body in every region, free from the NHS brotherhood yet staffed by clinicians, who would swiftly investigate all serious clinical concerns arising from patients, carers and staff – and could go in and access

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With friends like the BMA….

“The freedom to raise concerns without fear of reprisal is vitally important for patient safety.” So trumpets the British Medical Association in response to Sir Robert Francis’s Freedom to Speak Up Review. So why is the BMA suing whistleblowing surgeon Ed Jesudason for legal costs of up to £250,000 resulting from the collapse of a High Court battle? If successful, it will bankrupt him. Jesudason’s ‘crime’ was to refuse to sign a compromise agreement brokered by the BMA’s appointed solicitors that demanded he destroy documents including letters which exposed false claims that another whistleblowing surgeon at Alder Hey, Shiban Ahmed, was suicidal. The documents also exposed how poor the representation of Mr Ahmed was by the BMA. Instead of taking the gag, Jesudason shared this evidence with the Care Quality Commission, Mr Ahmed and the campaign group Patients First, of which MD is a patron. MD was so appalled by the treatment of Jesudason and Ahmed, and the failure to thoroughly investigate their patient safety concerns,that he wrote about it repeatedly in the Eye.

Jesudason also made protected disclosures about the surgery department at Alder Hey Children’s Hospital Foundation Trust in 2009, and says the

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