Meeting with Dr Bill Kirkup CBE and the APPG for Whistleblowing
This month the APPG for Whistleblowing heard evidence on the state of the NHS following the recent report on the avoidable deaths and life changing injuries caused to mothers and babies at the East Kent Trust3. The culture at this hospital was described as one where “everyone knew the problems” and where whistleblowers were “thrown to the lions”. A culture attributed to 45 of the 65 baby deaths reviewed.
Parliamentarians heard that at East Kent, “The onus was on patients to raise concerns” because the culture of fear prevented whistleblowers from speaking out. “In every case staff were aware of serious mistakes or wrongdoing but they were unaware of how to raise concerns because those who tried were subjected to peer pressure to be silent and everyone was afraid of the [personal] consequences.” These consequences were exemplified by the experience of the nursing director who was told that speaking up would harm her career.
In 2015 The Government introduced a Freedom to Speak Up Guardian and a system of Local Speak Up Guardians in response to the scandal at Mid Staff’s following the recommendation of Sir Robert Frances.
From the outset this system has attracted significant criticism and the APPG have heard from whistleblowers who have been failed by local guardians sharing their experiences that included the disclosure of their identity to hospital management and boards - resulting in retaliation. The APPG has also heard from Local Guardians who were not supported and themselves the target of retaliation after supporting whistleblowers.
From left to right: Mary Robinson MP, chair APPG for whistleblowing, Dr Bill Kirkup, Georgina Halford-Hall, Steve Turner, co-chair WhistleblowersUK health focus group
Local Guardians in East Kent were described as, “Dishonest” and that the guardian system had failed in every case that had been investigated throughout the UK. Further evidence was provided of a tick box approach to the Duty of Candour introduced by the former SoS for Health. The APPG was told that both the Guardian and Duty of Candour systems are beyond resurrection and that across the NHS there is no ownership of problems. All attempts to encourage speaking up have been hindered by a failure to introduce an effective and safe whistleblowing regime across the result being that the NHS is unsafe for whistleblowers, making it unsafe for patients.
The APPG were told that in over 50 years of investigation experience little has changed, that “these issues are not new, nor are they confined to a small number of rogue Hospitals”. That league table results are inaccurate because of a flawed regulatory system with no ownership of the problems and where the regulators are “caught up in the fraud”.
The APPG was provided with a series of examples of what were described as “deep seated problems” relating to teamwork and culture resulting in the failure to join up clinical and ethical responsibilities. These responsibilities were described as being on separate tracks and a failure by the regulatory regime to identify or report on the impact of this has significant consequences for patients, whistleblowers and the future of the NHS as demonstrated by the case of the Bristol Children’s Heart scandal brought to light by Dr Steve Bolsin 30 years ago. Dr Bolsin was shunned for exposing the failures that resulted in the death of so many babies because funding the unit was more of a priority that the lives of the babies he has since made a successful career in Australia.4
In every case a failure to listen to whistleblowers, followed by attempts to discredit the whistleblowers, and a deliberate cover up has proved in many cases fatal for patients.
What has been proved time and time again is that The Public Interest Disclosure Act [PIDA], has made little or no difference to this failure to protect patients or whistleblowers or to learn and improve our NHS. Evidence provided to the APPG is of a lack of system wide action and an absence of commitment to speaking up beyond excellent PR. It is unclear who if anyone is responsible for the monitoring and reporting on recommendations contained in investigation reports. In addition, there is no coherent process for triggering high-level independent reviews of major patient safety failings. This causes confusion, suffering and leads to missed opportunities.
Mary Robinson MP chair of the APPG for Whistleblowing, “We have a duty to support and protect whistleblowers because without them we cannot prevent more deaths like those in East Kent. My APPG is committed to making whistleblowing safe and will continue to press the Government to introduce the Whistleblowing Bill which will incentivise and normalise speaking up. I encourage everyone to write to their MP’s and ask them to join the APPG and support the Whistleblowing Bill.”
The Right Hon. Baroness Susan Kramer, “Doing nothing is not an option that we can afford. It’s time to put an end to ‘tick box culture’ and turning a blind eye to whistleblowers. Whistleblowing law must be meaningful, easily understandable and enforceable. The Whistleblowing Bill will do this and in doing so will save lives and protect our NHS.”
Wendy Morden MP, member of the APPG for Whistleblowing, “I hear about problems when I am at the hairdresser because people are too afraid to speak up in their place of work. The Office of the Whistleblower will be the catalyst for meaningful change.”
Dr Bill Kirkup author Reading the Signals Report, “I support the proposals set out in the Whistleblowing Bill because the NHS urgently needs an effective early warning system.”
Steve Turner, ‘For decades now patients have been put at risk and lost their lives because of repeated failures to listen to genuine healthcare whistleblowers
whether they are workers or anyone else. Patient safety failings are routinely covered up and lessons are not learned. Regulators and professional bodies have been unable to tackle this issue because the law simply does not allow them to. We must use this opportunity to save the NHS and save lives by introducing the Whistleblowing Bill because patient safety improvements is not an employment issue.’
Steve Turner is a retired Senior Mental Health Professional, WhistleblowersUK Health spokesperson, and co-chair of the WBUK Healthcare Whistleblowing Focus Group
For more information contact: secretary@wbuk.org
07860 963947
References:
Kirkup B, (2015) The Report of the Morecombe Bay Investigation WWW: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf (accessed 28.11.2022)
Ockenden D (2022) Final findings, conclusions and essential actions from the Ockenden review of maternity services at Shrewsbury and Telford Hospital NHS Trust WWW: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1064302/Final-Ockenden-Report-web-accessible.pdf (accessed 28.11.2022)
Kirkup B (2022) Reading the signals: maternity and neonatal services in East Kent – the report of the independent investigation WWW: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1111993/reading-the-signals-maternity-and-neonatal-services-in-east-kent_the-report-of-the-independent-investigation_web-accessible.pdf (accessed 28.11.2022)
https://www.independent.co.uk/news/uk/crime/whistleblower-s-tears-for-heartop-victims-739691.html
