Flow Chart From the Minority Report describing an Emergency without EquipmentAs a whistleblower, it amazes me that the health service places the onus on you to come up with the data to establish the truthfulness of the whistleblowing incident. Real life of course is never that simple. For me, I was on Ward 87 for a every short time - probably about three weeks. The rota was very busy and all I had was the patient lists that I used during the ward rounds. Later these lists of patients would come to be criticised by Professor Griffiths as "disorganised", possibly because they were not on a typed sheet of paper. But then only those who never do clinical work have typed sheets of paper or have time to have these sheets of paper. I had oncalls to do, patients to take care of, I was working 110 hours a week and I didn't have time to eat or sleep never mind type up evidence. How does a whistleblower know that their concerns will not be taken seriously and that they will have to fight a decade to prove their innocence? I was what I term an accidental whistleblower. I did not consciously wake up one morning and say " Right, today is a sunny day, I have decided to whistleblow". My mind set was this " I was in an emergency, patients were dying, I needed equipment, patients needed care and if there was no one else to do it, I had to do it because it was my job" . I didn't think about the repurcussions of asking for more equipment. I thought it would simply be acknowledged and given. I didn't know the Trust would turn into a psychotic mongoose on acid and chase after me. I didn't even know that they would perceive it as a sin. To me, I was doing my job. The job I was paid to do - that was to ensure that on my shift no one died due to negligent care. Infact, I can safely say no one has died on my shift due to negligent care in the 10 years I have been in medicine.
I had a list of about 20-30 patients if that and my memory. Luckily, I also armed myself with a photocopy of one set of my writing in the patient notes. It occurred to me when I was with Joan signing the death certificates that a minor frenzy was developing that may explode into a small nuclear bomb. People were fizzing away and Joan told me I had to look after myself and have evidence of what had happened. That is what I did. I took the evidence and thankfully so. Joan the bereavement officer was a wise lady. The photocopy was done and slipped into my white coat pocket and it was that photocopy that has saved me through all these years. No one has been able to answer why there was no basic equipment, why there was no supervision, why there were no nurses on an acute ward. Later on in this blog, I shall also show the letter written by Professor Brenton who was critical of the care given by Ward 87. Later Professor Steve Bolsin was to support me.
I had made entries in other patient records about the negligent behaviour of the nursing staff but during the 2001 Report that verified my concerns, I realised that the nurses had doctored the material, removed incriminating observation charts and basically done what we call a " cover up job". I suspect it was important for these nurses [ who I shall name soon] to do a cover up job because that is the only way their gross neglect of patients would be concealed. Everyone knew these nurses were lazy, they were negligent and they were obtuse. Even worse, they had no insight into their failings. They lied so much that I am sure each of them had long noses at the end of every shift. It was a dysfunctional ward with dysfunctional people who thought it would be amusing to frame me for something I didn't do to save their own rotten skin. As women often do, they got together in a gaggle and lied in all the statements they gave to the Health and Safety Executive. Of course, lying together and effectively perverting the course of justice goes unnoticed. In the NHS lying together is equivalent to the truth. That is what they thought anyway. Have I forgiven them? Possibly not. Afterall, I believe in equality. For every action there is an equal and opposite reaction. Its physics simplified. As nurses, they should have known about physics before executing their plan of action.
The head of these nurses was Paula Wright. Paula Wright's name is all over the Report, all over the investigation charts and everyone knew she existed. When the NMC [ Nursing and Midwifery Council] asked North Staffordshire NHS Trust about her, the hospital pretended that they could find no record of her. Paula Wright and her negligent behaviour was supported by the head of nursing Mrs Boon. Mrs Boon of course was the lady that was amazed that I had asked for more nursing staff, more equipment and more care for the patients on that ward. That too because Paula Wright had asked me to contact Mrs Boon but later denied it. Mrs Boon had been outraged about this simple request and turned into such a huge fuss. In all honesty, had she just provided the nurses, the equipment and the basic care required in this third world ward, there would be no requirement for the media, for blogs like this nor would there have been a need for anything. We could have all gone our separate ways and led happy lives. Nevertheless, I am here to tell her that I was right and SHE was wrong. It may well have been many years down the line but its better late than never. All managers especially nursing management need to be accountable to the public.
Of course, for Mrs Boon her own incompetence shone through. Paula Wright was a weak ineffective nurse manager. I have no idea whether her little blonde crop had anything to do with it. A mentally vacant lady who was in too deep but didn't know what was right or wrong. They all had tea with the consultant of the ward Dr Spitieri, a doctor with very little in the way of communication skills. She was a short tubby little thing who was more concerned that there was so much litigation on the ward to worry about patient care. On our induction day, that is what she had told us - we had an induction on all the litigation that was present on the ward and why we should record all blood test results in the book because " The last junior forgot and resulted in litigation".
Mrs Boon, Dr Spitieri and Paula Wright were really a trio. As women they talked too much and didn't do enough work. It was of course ironic that Dr Monica SPITieri was head of a Respiratory Ward. The important thing about these three women is that they should have been housewives and not been given the role of taking care of so many sick people. More sick people died than lived on Ward 87. We all knew that. They were of course the three who mismanaged the entire situation and were later criticised heavily for it. They were also prone to lying. Lying is an interesting phenomenon. People do it when they are in a bit of a position. They also do it because they can get away with it. As a young doctor, I never realised how well and convincingly people could lie. The trio had then turned me into their problem. The problem with turning me into a problem is that people tend to defend themselves. I suspect that is not what they had expected. Afterall, they had ruined the lives of a number of junior doctors before me - all gleefully of course. I am positive they could not help their behavioural tendencies. It was the culture in North Staffordshire NHS Trust at the time. A culture of frenzy and madness where the distinction between the truth and lies was blurred for all of them.
There has never been any broader data study done on the Ward. It was on the strength of my small amount of data that I managed to stuff into my bag/pocket on the day I left the hospital that has provided me with the armoury to fight. It is of course amazing that so many problems were found on minority data which begs the question, how bad were the problems on wider data? Attempting to get North Staffordshire NHS Trust or anyone else to open the files of North Staffordshire NHS Trust is a major task. Infact, in 10 years I have not managed it. I shall list the organisations as follows
In summary, all these reports were done on Minority Data. No Majority Data was ever considered or used. Overall, there has never been a wider investigation on the ward. There never will be.
1. North Staffordshire NHS Trust
1999 Review of Ward 87 Plus 2001 Creamer Report. Done on minority data. No wider data was never examined.
2. Health Commission
Advised that whistleblowers cannot raise concerns. Only relatives of the ward can. No wider data study was never done.
3. Health Ombudsman
Advised that the time frame was too long and it is not in the public interest to do any wider data study.
4. Coroner
Whistleblowers cannot raise concerns because they are not termed as the " interested party".
5. General Medical Council
Did not understand the concept of "wider data" and refused to instigate or obtain any documentation from North Staffordshire NHS Trust
6. NMC
Still contemplating
7. Police
The police had amusingly contacted the hospital and said " Is there any Crime". The Hospital rang the police back and said " No". [they admitted to this in the 2001 report]. The police shut the file down.
I then met Ken Raper of Staffordshire Police refused to inform any of the relatives as he said it was not in the public interest to do so. There are some amusing tape recordings with the police which I must put up online just for entertainment value. Ken Raper was not allowed to see the hard copy of the records of death. The hospital supplied him with some figures and glossed over the fact that they were not " death rates" and statistically their figures meant nothing.
Raper though refused to obtain a full unredacted copy of the report and did not question the hospital. The flaws within his investigation had been pointed out but Staffordshire Police still have not responded to the letter after a year or more. No finding was made from the investigation if we can call it that. Ken Raper refused to look into one patient's medical notes, refused to check her death certificate and basically refused to do anything that resembled hard work. What he decided to do was tell me all about David Southall. Ken Raper is though a nice man instructed by the top powers that be to shut down any investigation. Infact, there was no investigation apart from what Ken thought would keep me quiet. For a police man, on occasion he isn't very astute but always amused me as a man trying to keep all sides happy but not quite balancing the issues of public interest. His charm of sympathising with me and talking about how badly whistleblowers were treated just didn't wash with me. I needed the files in North Staffordshire NHS Trust as a wider data study to be opened. There was a case for Corporate Manslaughter here but no one wanted to investigate it.
I then asked these 6 organisations to tell the relatives about the 1999 and 2001 Reports that verified my concerns. The Trust and ALL organisations unanimously refused to inform any relatives of the issues at stake.
Following this refusal, I decided to ask the Sentinel to advertise a version of the online report. The Sentinel and Tim Berrisford refused. No reason was given of course.
More people died on this Ward than the Bristol Inquiry. The difference is of course that these were young and elderly patients. They do not command the same heart strings effect on the media has say children's hearts. Steve Bolsin told me that and he was right. The excuse the Trust would use is that they would have died anyway.
My question is " Would they have died?". In the minority report, those who had been neglected could have survived. The problem though with patient deaths on a ward is that life moves on much like a factory. The reports to the coroner are dependant on the RMO and if that RMO wants to cover the issue up then there is no other option. In the one patient that the coroner considered, Dr Spitieri had not reported her death. Of course, by law it was her responsibility. The Coroner though did not wish to criticise her or anyone within the hospital for their lack of reporting these incidents.
In the end, the documentation etc was obtained because I was curious to find out whether the Bristol Inquiry or the Shipman Inquiry had changed anything in the NHS. This material comes parallel between the two and occurred during the two high profile cases. It also shows us that as a whisteblower, you have very little rights and there is no procedure to effectively raise your concerns so that a full investigation is done. As a whistleblower, the NHS does not even entitle you to the Report that establishes the concerns.
The onus was left to me to collect the mass data which is impossible to obtain once you do not work there anymore. Amusingly, more investigations have been done on me over the years by the GMC [on my written work] than the matters I whistleblew on. It is also a case that shows that the whistleblower cannot and should not report their concerns because on every occasion their personality, their credibility and their evidence is attacked and undermined. In the end, you end up not only fighting for justice for a group of patients [ who don't even know you are fighting] but fighting to regain back your own credibility. By then, the authorities have spread so many untrue rumours that it is impossible to fight through the thick fog.
No medical whistleblower currently survives in the UK. Most have quietened down and stopped raising issues and concerns. The BMA Conference in the year 2000 showed the impact of whistleblowing on the lives of doctors. My case happened by accident. I didn't even realise that asking for more equipment was whistleblowing. It just goes to show how one spur of the moment decision to ask for more equipment can suddenly spiral out of control. Nothing is therefore ever certain in life.
Ward 87 was shut in 2005 on the same year the Trust squealed about releasing the redacted 2001 Report to me. To them all, shutting the ward would make the problem go away. Infact, we can apply that to any ward in the NHS with a high death rate - get rid of the evidence and no one will find out how many people really died. That is what happened on Ward 87.
I had a list of about 20-30 patients if that and my memory. Luckily, I also armed myself with a photocopy of one set of my writing in the patient notes. It occurred to me when I was with Joan signing the death certificates that a minor frenzy was developing that may explode into a small nuclear bomb. People were fizzing away and Joan told me I had to look after myself and have evidence of what had happened. That is what I did. I took the evidence and thankfully so. Joan the bereavement officer was a wise lady. The photocopy was done and slipped into my white coat pocket and it was that photocopy that has saved me through all these years. No one has been able to answer why there was no basic equipment, why there was no supervision, why there were no nurses on an acute ward. Later on in this blog, I shall also show the letter written by Professor Brenton who was critical of the care given by Ward 87. Later Professor Steve Bolsin was to support me.
I had made entries in other patient records about the negligent behaviour of the nursing staff but during the 2001 Report that verified my concerns, I realised that the nurses had doctored the material, removed incriminating observation charts and basically done what we call a " cover up job". I suspect it was important for these nurses [ who I shall name soon] to do a cover up job because that is the only way their gross neglect of patients would be concealed. Everyone knew these nurses were lazy, they were negligent and they were obtuse. Even worse, they had no insight into their failings. They lied so much that I am sure each of them had long noses at the end of every shift. It was a dysfunctional ward with dysfunctional people who thought it would be amusing to frame me for something I didn't do to save their own rotten skin. As women often do, they got together in a gaggle and lied in all the statements they gave to the Health and Safety Executive. Of course, lying together and effectively perverting the course of justice goes unnoticed. In the NHS lying together is equivalent to the truth. That is what they thought anyway. Have I forgiven them? Possibly not. Afterall, I believe in equality. For every action there is an equal and opposite reaction. Its physics simplified. As nurses, they should have known about physics before executing their plan of action.
The head of these nurses was Paula Wright. Paula Wright's name is all over the Report, all over the investigation charts and everyone knew she existed. When the NMC [ Nursing and Midwifery Council] asked North Staffordshire NHS Trust about her, the hospital pretended that they could find no record of her. Paula Wright and her negligent behaviour was supported by the head of nursing Mrs Boon. Mrs Boon of course was the lady that was amazed that I had asked for more nursing staff, more equipment and more care for the patients on that ward. That too because Paula Wright had asked me to contact Mrs Boon but later denied it. Mrs Boon had been outraged about this simple request and turned into such a huge fuss. In all honesty, had she just provided the nurses, the equipment and the basic care required in this third world ward, there would be no requirement for the media, for blogs like this nor would there have been a need for anything. We could have all gone our separate ways and led happy lives. Nevertheless, I am here to tell her that I was right and SHE was wrong. It may well have been many years down the line but its better late than never. All managers especially nursing management need to be accountable to the public.
Of course, for Mrs Boon her own incompetence shone through. Paula Wright was a weak ineffective nurse manager. I have no idea whether her little blonde crop had anything to do with it. A mentally vacant lady who was in too deep but didn't know what was right or wrong. They all had tea with the consultant of the ward Dr Spitieri, a doctor with very little in the way of communication skills. She was a short tubby little thing who was more concerned that there was so much litigation on the ward to worry about patient care. On our induction day, that is what she had told us - we had an induction on all the litigation that was present on the ward and why we should record all blood test results in the book because " The last junior forgot and resulted in litigation".
Mrs Boon, Dr Spitieri and Paula Wright were really a trio. As women they talked too much and didn't do enough work. It was of course ironic that Dr Monica SPITieri was head of a Respiratory Ward. The important thing about these three women is that they should have been housewives and not been given the role of taking care of so many sick people. More sick people died than lived on Ward 87. We all knew that. They were of course the three who mismanaged the entire situation and were later criticised heavily for it. They were also prone to lying. Lying is an interesting phenomenon. People do it when they are in a bit of a position. They also do it because they can get away with it. As a young doctor, I never realised how well and convincingly people could lie. The trio had then turned me into their problem. The problem with turning me into a problem is that people tend to defend themselves. I suspect that is not what they had expected. Afterall, they had ruined the lives of a number of junior doctors before me - all gleefully of course. I am positive they could not help their behavioural tendencies. It was the culture in North Staffordshire NHS Trust at the time. A culture of frenzy and madness where the distinction between the truth and lies was blurred for all of them.
There has never been any broader data study done on the Ward. It was on the strength of my small amount of data that I managed to stuff into my bag/pocket on the day I left the hospital that has provided me with the armoury to fight. It is of course amazing that so many problems were found on minority data which begs the question, how bad were the problems on wider data? Attempting to get North Staffordshire NHS Trust or anyone else to open the files of North Staffordshire NHS Trust is a major task. Infact, in 10 years I have not managed it. I shall list the organisations as follows
In summary, all these reports were done on Minority Data. No Majority Data was ever considered or used. Overall, there has never been a wider investigation on the ward. There never will be.
1. North Staffordshire NHS Trust
1999 Review of Ward 87 Plus 2001 Creamer Report. Done on minority data. No wider data was never examined.
2. Health Commission
Advised that whistleblowers cannot raise concerns. Only relatives of the ward can. No wider data study was never done.
3. Health Ombudsman
Advised that the time frame was too long and it is not in the public interest to do any wider data study.
4. Coroner
Whistleblowers cannot raise concerns because they are not termed as the " interested party".
5. General Medical Council
Did not understand the concept of "wider data" and refused to instigate or obtain any documentation from North Staffordshire NHS Trust
6. NMC
Still contemplating
7. Police
The police had amusingly contacted the hospital and said " Is there any Crime". The Hospital rang the police back and said " No". [they admitted to this in the 2001 report]. The police shut the file down.
I then met Ken Raper of Staffordshire Police refused to inform any of the relatives as he said it was not in the public interest to do so. There are some amusing tape recordings with the police which I must put up online just for entertainment value. Ken Raper was not allowed to see the hard copy of the records of death. The hospital supplied him with some figures and glossed over the fact that they were not " death rates" and statistically their figures meant nothing.
Raper though refused to obtain a full unredacted copy of the report and did not question the hospital. The flaws within his investigation had been pointed out but Staffordshire Police still have not responded to the letter after a year or more. No finding was made from the investigation if we can call it that. Ken Raper refused to look into one patient's medical notes, refused to check her death certificate and basically refused to do anything that resembled hard work. What he decided to do was tell me all about David Southall. Ken Raper is though a nice man instructed by the top powers that be to shut down any investigation. Infact, there was no investigation apart from what Ken thought would keep me quiet. For a police man, on occasion he isn't very astute but always amused me as a man trying to keep all sides happy but not quite balancing the issues of public interest. His charm of sympathising with me and talking about how badly whistleblowers were treated just didn't wash with me. I needed the files in North Staffordshire NHS Trust as a wider data study to be opened. There was a case for Corporate Manslaughter here but no one wanted to investigate it.
I then asked these 6 organisations to tell the relatives about the 1999 and 2001 Reports that verified my concerns. The Trust and ALL organisations unanimously refused to inform any relatives of the issues at stake.
Following this refusal, I decided to ask the Sentinel to advertise a version of the online report. The Sentinel and Tim Berrisford refused. No reason was given of course.
The summary of the above is this, I was of course right about my concerns on Ward 87 but no one wanted to look at the wider data. As time has moved on, the excuse made was that it was"too long ago". Effectively, we observe a mass shut down and silencing of any concerns or subsequent accountability. The managers are responsible but the senior doctors followed much like sheep. This is of course the reason why no doctor should ever whistleblow. There was never any accountability for the management who caused the deaths of these patients. The managers consisted of doctors as well as lay people.
More people died on this Ward than the Bristol Inquiry. The difference is of course that these were young and elderly patients. They do not command the same heart strings effect on the media has say children's hearts. Steve Bolsin told me that and he was right. The excuse the Trust would use is that they would have died anyway.
My question is " Would they have died?". In the minority report, those who had been neglected could have survived. The problem though with patient deaths on a ward is that life moves on much like a factory. The reports to the coroner are dependant on the RMO and if that RMO wants to cover the issue up then there is no other option. In the one patient that the coroner considered, Dr Spitieri had not reported her death. Of course, by law it was her responsibility. The Coroner though did not wish to criticise her or anyone within the hospital for their lack of reporting these incidents.
In the end, the documentation etc was obtained because I was curious to find out whether the Bristol Inquiry or the Shipman Inquiry had changed anything in the NHS. This material comes parallel between the two and occurred during the two high profile cases. It also shows us that as a whisteblower, you have very little rights and there is no procedure to effectively raise your concerns so that a full investigation is done. As a whistleblower, the NHS does not even entitle you to the Report that establishes the concerns.
The onus was left to me to collect the mass data which is impossible to obtain once you do not work there anymore. Amusingly, more investigations have been done on me over the years by the GMC [on my written work] than the matters I whistleblew on. It is also a case that shows that the whistleblower cannot and should not report their concerns because on every occasion their personality, their credibility and their evidence is attacked and undermined. In the end, you end up not only fighting for justice for a group of patients [ who don't even know you are fighting] but fighting to regain back your own credibility. By then, the authorities have spread so many untrue rumours that it is impossible to fight through the thick fog.
No medical whistleblower currently survives in the UK. Most have quietened down and stopped raising issues and concerns. The BMA Conference in the year 2000 showed the impact of whistleblowing on the lives of doctors. My case happened by accident. I didn't even realise that asking for more equipment was whistleblowing. It just goes to show how one spur of the moment decision to ask for more equipment can suddenly spiral out of control. Nothing is therefore ever certain in life.
Ward 87 was shut in 2005 on the same year the Trust squealed about releasing the redacted 2001 Report to me. To them all, shutting the ward would make the problem go away. Infact, we can apply that to any ward in the NHS with a high death rate - get rid of the evidence and no one will find out how many people really died. That is what happened on Ward 87.
