Over the last few months The Doctors’ Association UK has been hearing from whistleblowers at West Suffolk Hospital who have spoken to us candidly of a “toxic culture” following a number of cases where patients had come to harm. They’ve described the “persecution” of whistleblowers and a “witch hunt” where the senior trust managers had sought fingerprints and handwriting analysis to identify the whistleblower. DAUK has commented widely on how this does not promote a free and open culture in healthcare, one which is fair and focuses on Learn Not Blame.
“A hospital obsessed with guarding its ‘outstanding’ status is accused of covering up errors that left one patient dead and another brain-damaged — and persecuting the whistleblower who tried to expose the scandal.”
The full story can be found in The Sunday Times
An excerpt of the article:
Just before the stroke of midnight on Monday December 11, 2017 Daniel Parsons’s heart stopped beating as he lay unconscious gasping for air in the West Suffolk Hospital in Bury St Edmunds. A healthy 47-year-old man, he had been suffering from nothing more than tonsillitis. Daniel, an engineer, had begun the day at home but had popped in to see his GP about a sore throat and a temperature. It was the start of a chain of events that resulted in the hospital accidentally killing him hours later.
His death was caused by an avoidable error in administering a drug that destroyed the functioning of his heart in a little over half an hour. It should have triggered an immediate patient safety investigation but the hospital was at first reluctant to admit fault.
There was a similar unwillingness to accept mistakes four months later when another avoidable error in the hospital left Paul Farmer, a former head teacher, blind and severely brain-damaged. Previously an accomplished pianist, he can no longer strike a single key.
Their families might not have known what had really happened if it had not been for Dr Patricia Mills, a consultant anaesthetist with 30 years’ experience, who was becoming increasingly concerned that summer about the way the hospital appeared to be sweeping patient safety issues under the carpet.
Mills had to intervene and contradict colleagues to ensure that both accidents were properly investigated and blew the whistle on another patient safety case that she believed was not being properly deal with.
Instead of addressing her concerns, the hospital’s executives placed her under disciplinary investigation for attempting to undermine colleagues. They also made her their chief suspect in an unprecedented internal inquiry that used National Health Service money to fingerprint and run handwriting checks on their own doctors.
The full story of the events in West Suffolk Hospital can now be told for the first time. It raises important questions about the way the management teams of NHS hospitals are prioritising the goal of gaining top marks in their annual inspections over the care of their own patients.
Doctors at the hospital have expressed disquiet and anger about the way they feel highly paid executives have been suppressing dissent and refusing to heed complaints. They allege that the maintenance of the hospital’s “outstanding” status in inspection reports has become more important than patient safety.
The story is even more pertinent because West Suffolk Hospital serves the constituents of the health secretary Matt Hancock, who has championed the cause of whistleblowers in the NHS.
He was alerted more than a year ago to the alleged culture of bullying in the hospital, yet for months he ignored the repeated appeals for help. He has now ordered an investigation.
There were question marks over the death of another patient, Susan Warby, who had undergone an operation for a perforated bowel. Susan had wrongly been given a glucose drip during her operation. The hospital owned up to the error, which was not ultimately the cause of her death.
However, a few weeks later Susan’s widower, Jon, was sent an anonymous letter alleging a “big cover-up” at the hospital. The letter claimed the glucose drip had been administered by an anaesthetist who “should never have been at work” as he had “injected himself with drugs before while in charge of a patient and it was all hushed up”. It was signed simply: “Operating Theatre Staff”.
Jon, a retired police officer, passed the letter on to his former colleagues in Bury St Edmunds CID, who carried out a brief investigation, taking fingerprints from the letter and its envelope.
However, the trust was determined to find out who sent the anonymous letter and Mills became top of their list of suspects. As a result, the hospital asked Mills and a small number of others to submit to handwriting and fingerprint tests. When she refused, Helen Beck, executive chief operating officer of the West Suffolk trust, wrote to Mills’s union representative at the British Medical Association demanding to know the “rationale” for her decision.
“Any refusal to provide a rationale . . . could have a relevance to the fact-finding investigation,” Beck wrote. “This is because it could be considered evidence that implicates your member as being involved in the writing of the letter to Patient W’s [Warby’s] husband.”
Mills changed her mind and the hospital sent an example of her handwriting to an expert for comparison with the Warby letter with samples from four other medical staff. The results were all negative apart from the Mills sample.
In October last year the expert found “a number of similarities” with the sample of Mills’s writing sent by the hospital. In turn, Mills hired her own handwriting expert, who concluded that she was certainly not the author of the letter. A number of staff also consented to having their fingerprints taken but Mills continued to refuse. By now matters were getting out of hand and the medical staff committee meetings expressed anger about how the doctors who had raised patient safety concerns were being singled out.
Hancock initiated a Department of Health inquiry into the treatment of whistleblowers in the hospital. The move was announced after he had held a private meeting with Mills. The CQC downgraded the hospital to “requires improvement” last month. It criticised the executive leadership for not fostering an “open and empowering culture” and found that safety concerns were not identified or addressed quickly enough.
The West Suffolk NHS Foundation Trust said:
“We strive to provide high-quality, safe and attentive care for all our patients. Regrettably, we don’t get it right every time, and on the rare occasion something goes wrong we always endeavour to investigate thoroughly, honestly and transparently.
“We remain incredibly sorry to the families involved in these cases for the mistakes made, and are committed to continue learning, improving and changing our processes.”
Do hospitals try to dupe the inspectors?
Several doctors have complained about hospitals trying to pull the wool over inspectors’ eyes.
A medic who worked at a hospital in west London said ambulances were diverted away from the casualty department during an inspection, to make it look less busy.
One doctor claimed staff secretly “moved all the electronically adjustable beds back and forth” between two hospitals in Sussex in an attempt to try to impress inspectors by ensuring they never saw a non-electronic bed.
Another clinician added: “Two places I have worked in Surrey have had booklets printed essentially telling us what to say [to inspectors].”
Is there a cover-up culture in the NHS?
There is a widespread problem of NHS hospitals prioritising public image over patient safety, according to the Doctors Association UK.
The group says it is being contacted by growing numbers of whistleblowers who have been “persecuted” by bosses for speaking up.
The group said it had experienced hospital’s “going into lockdown when concerns have been made public, with staff being intimidated and hushed up”.
Have other whistleblowers been targeted?
There have been several examples of NHS doctors being victimised after speaking out. Recent high-profile cases have included a doctor who lost his job after airing understaffing concerns at an intensive care unit in Woolwich and a surgeon who was forced to resign after raising the alarm over baby deaths at a hospital in Liverpool.
Other doctors are said to have been discouraged by the publicity from speaking out. However, many health workers are still taking whistleblowing cases to employment tribunals.
Matt Hancock, the health secretary, has always been quick to praise the hospital that serves his constituents as “one of the best in the country”.
He is also a big fan of the West Suffolk NHS Foundation Trust’s chief executive, Dr Stephen Dunn, who was appointed a CBE for services to health and patient safety in the 2019 new year honours.
Hancock was gushing after the award, making reference to West Suffolk Hospital’s recently acquired “outstanding” status.
He said: “A brilliant leader, and how typical he calls it a team effort. It is, of course, a team effort, but outstanding teams need outstanding leaders.”
Part of that team is Dr Nick Jenkins, the medical director, who was ultimately responsible for patient safety investigations in the hospital and was described as a health service “rising star”.
West Suffolk Hospital alleges that Dr Patricia Mills, the whistleblower, undermined his clinical judgment over the mistakes that led to the death of Daniel Parsons and left Paul Farmer blind with serious brain injuries.
Hancock was alerted more than a year ago to the allegations that doctors who were trying to speak out were being bullied, but for months failed to respond to repeated appeals for help, including from Mills herself.
His department announced an inquiry into whistleblowing at the hospital in Bury St Edmunds after Hancock held a private meeting with Mills.