An anaesthetist who raised concerns about a colleague who was self-medicating was subject to a battery of complaints by a hospital management that went on to order fingerprinting of a whistleblower letter, a long-awaited inquiry has found.
The behaviour of senior managers at the West Suffolk NHS Foundation Trust was “intimidating, flawed and not fit for purpose,” according to an external review.
The Trust was forced to order a review after a whistleblower wrote to the family of a dead patient, revealing she was treated by an anaesthetist who was self-medicating.
Its first response to the anonymous letter was to order fingerprinting and handwriting analysis.
Adverse publicity then led it to commission Christine Outram, chair of the Christie Hospital, Manchester, to conduct a review. Yesterday the 200-page long review revealed that a female colleague of the self-medical anaesthetist had raised concerns some time before.
She was then accused of “divisive conduct”, undermining the executive of the trust and an “attempted coup” against the department’s clinical leadership.
Ms Outram says the concerns about the self-medicating doctor were well-founded, but the allegations lodged against the whistleblowing colleague were not.
She goes on to say that there was “inadequate” handling of the serious incident in 2018 that led to the anonymous letter, the death of a patient after receiving the wrong solution in an arterial line.
The medical director decided not to take action about the self-medicating anaesthetist after concluding the doctor was not responsible for the incident. Ms Outram says this showed insufficient regard for patient safety and the doctor’s wellbeing.
The review reveals several senior clinical staff raised concerns about the self-medicating anaesthetist and adds it was “extraordinary” this was ignored and rejected. The female colleague then wrote to the chair of the trust, who simply passed her letter to the chief executive, Steve Dunn, the review reveals.
The findings and an apology issued by the current management of the Trust were welcomed by the Doctors’ Association.
Chair Dr Jenny Vaughan said: “We hope that this long-awaited report provides some answers for the family of Susan Warby. It’s absolutely crucial that staff feel able to raise concerns without feeling bullied or intimidated as that’s much safer for patients. Unfortunately, what happened here was the opposite.
“There is no place for this in healthcare, and the Doctors’ Association looks forward to real cultural learning in future which means this does not happen again.”
Georgina Halford-Hall, chief executive of WhistleblowersUK, said: “This report must be a call to action by every member of the NHS from Board down, it sends a clear message that whistleblowers are essential to the NHS – their actions really can save lives.
“It is our experience that too many staff are forced to look the other way because they fear the consequences of retribution by colleagues – this culture must stop.”