Putting patients first? Another example of the unaccountable NHS serving its own interests

The BBC is reporting that a hospital where a girl bled to death has refused to publish the findings of its inquiry for fear of “endangering the mental health” of staff.

Kettering General Hospital conducted a serious incident investigation following the death of 17-year-old Victoria Harrison, who bled to death on a ward after an appendix operation in 2012, but has said it will not be making the full report public despite an FoI request.

The trust has undertaken a public interest test with regard to providing a chronology of events.

It believes that Section 38 (1) (a) should be engaged as it is likely to endanger the mental health of individuals [staff] linked to the events leading up to the tragic death of Victoria Harrison, should the information be in the public domain.

The reason for this is due to the risk of colleagues and peers being able to identify the individuals [staff] involved in the incident, and placing the individuals concerned under additional stress and pressure in addition to that already experienced during the investigation and inquest.

Having made this response, Kettering General refused to say how many staff had been disciplined, or their rank, claiming individuals would be identified, but it did reveal that no staff were dismissed.

An artery had been damaged during surgery, with the surgeon rectifying the issue, but not all nursing staff had been told about the bleeding and a number of nurses – incredibly – did not routinely read medical notes of the patients, or when they did could not always decipher surgeons’ handwriting, the inquest was told.

The last written formal observations were taken nine hours before Miss Harrison was found dead by nursing staff.  It is staggering that Miss Harrison had texted her boyfriend to say she was in pain and bleeding, yet staff apparently did not know about it.  No surprise therefore to hear that the coroner said:

Windows of opportunity to treat Victoria were lost – had these been acted upon the outcome may have been different.

I believe her chances of survival would have significantly increased.

Yet despite these failings, the hospital is telling the public they have no right to know how the failings leading to a preventable death have been addressed.

How are residents, forced to rely on the ‘care’ provided at Kettering General, supposed to have confidence in how they will be treated and subsequently looked after?

The interests of the hospital staff are being put first.  This is another example of the public sector, the servant of the public, acting more like the public’s master in refusing to be held to account.  We are just expected to provide the funding and take pot luck when it comes to putting our lives in their hands.

21 Responses to “Putting patients first? Another example of the unaccountable NHS serving its own interests”

  1. 1 Barrie Singleton 21/01/2014 at 1:22 pm

    That’s fair. Three and a half years of making democratic challenge to Westminste has certainly ‘done my ‘ed in. Go to my website. It will do yours in as well. ‘D’ MOCK CRASS Y?

  2. 2 Ted Treen 21/01/2014 at 2:51 pm

    Pournelle’s Iron Law of Bureaucracy:-

    In any bureaucracy, the people devoted to the benefit of the bureaucracy itself always get in control and those dedicated to the goals the bureaucracy is supposed to accomplish have less and less influence, and sometimes are eliminated entirely.

  3. 3 lostleonardo 21/01/2014 at 3:02 pm

    Maybe I am being too absolutist, but seeing as we own the NHS (and the rest of the government – and, if someone wants to tell me that we don’t, the toerags in Parliament can start by giving me my money back) should not all NHS/government commissioned reports be made available to the British public as a matter of course?

    I suspect that there may be exceptions, but cannot think of them myself, and find it often helps to ask a direct question.

  4. 4 Barrie Singleton 21/01/2014 at 3:16 pm

    Newbury Berkshire will be key. I shall stand under SPOIL PARTY GAMES’.
    A couple of elections ago Newbury was LibDem. Labour are eclipsed here.
    My countdown is well underway (see website) the forces of evil must come to me in Newbury with their balloons, their placards, their hand-shaking and smiles, and their ‘D MOCK CRASS Y? I shall be more than ready.
    You do toerags a disservice; these upstarts have no discernable function.

  5. 5 Autonomous Mind 21/01/2014 at 10:17 pm

    Barrie, while I welcome your contributions, please will you stop using the comments as continual plugs for your site? If you want to advertise I’m sure we can agree a fair rate.

  6. 6 Barrie Singleton 21/01/2014 at 11:01 pm

    Never intended as such, sad that you so construe. The site is always in my details so I can see no – logical – harm. My intent is to offer amplification without repetition. I seem to have failed. Ironically, your rebuke is all this sitehas yielded . . . Thanks for the welcome. (:o)

  7. 7 avoncliffnorthmill 22/01/2014 at 12:36 am

    Having seen copious NHS training notes relating to medical accidents and worse (mostly worse) accidentally exposed on the early ‘net – this does not surprise me at all.

    It is a tortured subject – as almost everybody who expires under the care of the NHS has somebody close who wants “a reason” (read someone to blame) that person died – and they can be quite (totally bloody) irrational for varying lengths of time – death does that to some people and the impulse to protect workers from this sort of thing is a genuine reason to resist dealing with their every demand.

    The thing is though – that a genuine intent to do the best thing has been perverted – and there were stunning and quite shameless tactics detailed in the training material I saw which extended to deliberately withholding documentation and plainly calling the witnesses liars – all hung on an “attrition calendar” of tactics designed to obstruct exposure of incompetence or worse and the application of an effective remedy.

    I did that long ago ‘net research as a result of a relative’s appalling (non)treatment and demise at a local A&E – the calendar was ruthlessly adhered to.

    The mindset that produces such handbooks will think the “endangering the mental health” of perpetrators thing quite a wizard wheeze – of that I am certain. .

  8. 8 Dave H 22/01/2014 at 3:28 am

    Part of the problem is that prevailing lynch mob attitude of “Someone is to blame and must be punished”. Yes, there are cases where there is demonstrable criminal negligence, but in most cases it is the system to blame.

    Compare the medical profession with the aviation industry (and indeed, the former is starting to learn from the latter) – both have highly trained professionals who, with a single, often quite small, mistake, can cause death or injury. Many years ago, the aviation industry decided that overall, people would be best served by a culture of openness, accepting that mistakes can happen and that admitting a mistake or near-mistake would allow others to learn and possibly save lives. Incidents were accepted to be largely due to the system, not individuals, and mostly came about because of a sequence of errors, rarely due to a single mistake. Even when an individual can be identified as the person committing the critical error, there’s usually a trail of skipped checks and incorrect and inadequate training or maintenance leading to that point, without which it would not have been critical. Names are not normally used in air accident reports, but the industry tends to know who was flying or fixing an aircraft.

    This appears to be what has happened in the hospital – a clear series of failures, and unless the sequence of events is made public, it can, and will happen again. You can be sure that those involved will have learned the lesson the hard way, it is important that their colleagues should be able to benefit from that and not have to repeat the lesson.

  9. 9 David Jones 22/01/2014 at 7:01 am

    Dave H

    True. Have you read this book – “The Checklist Manifesto: How To Get Things Right”? It’s fascinating. It’s mainly about the development of medical checklists but tells how aeroplane checklists came about.

    The book also tells of “… an intensive care checklist protocol that during an 18-month period saved 1500 lives and $100 million in the State of Michigan” – http://en.wikipedia.org/wiki/Keystone_Initiative

    It’s basically washing hands and obeying the rules that everyone knows (but most ignore). Crucially nurses are given the right to halt proceedings if any rules are broken.

  10. 10 Mark B 22/01/2014 at 7:14 am

    And what of the mental health of the family concerned ? Are not their needs for justice taken into account ?

  11. 11 Andrew Duffin 22/01/2014 at 8:29 am

    “…the risk of colleagues and peers being able to identify the individuals [staff] involved in the incident…”

    What utter stuff. The colleagues and peers will already know EXACTLY who was involved in this.

  12. 12 Andrew Duffin 22/01/2014 at 8:32 am

    “Compare the medical profession with the aviation industry ”


    Or look at the admirably impartial reports published (and I mean published: no hiding behind FoI quibbles for them!) by the Marine Accident Investigation Board. No blame, no finger-pointing, just a calm assessment of the facts and the causes.

    But then, of course, the maritime industries are not in the public sector.

  13. 13 Furor Teutonicus 22/01/2014 at 10:07 am

    XX It is staggering that Miss Harrison had texted her boyfriend to say she was in pain and bleeding, yet staff apparently did not know about it.XX

    If she was well enough to send shite by text, she was well enough to press the red button and kick the nursing staffs arses into gear. Dumb bitch.

  14. 14 Autonomous Mind 22/01/2014 at 11:23 am

    The point being made is that she probably did tell the nurses about it, but nothing was done because getting the arses of nursing staff into gear is a major problem in the NHS.

  15. 15 Autonomous Mind 22/01/2014 at 11:32 am

    Furor, article about it says this:

    “However, Miss Harrison had later texted her boyfriend from her hospital bed to say she was in pain and bleeding, and later that a nurse was “sorting it”.”


  16. 16 Furor Teutonicus 22/01/2014 at 11:44 am

    O.K. Point taken.

    I know here, the nursing staff would be getting interviewed by the police, and possibly even sitting in remand cells. (Nachlassung and Gefährliche Körperverletzung. Basically “neglect of duty,” and “causing injury,” even when, as in this case, by neglect.)

    There it seems to be taken as “Na ja, things happen, so what?”

  17. 17 Sceptical Steve 22/01/2014 at 11:44 am

    The richest irony is that it was the BBC that made the FoI request, the organisation that is always allowed to avoid its own responsibilities in this field. It would hardly put them in a strong position when it comes to challenging any decision made by the Information Commissioner!

  18. 18 qed 22/01/2014 at 8:29 pm

    I’m shocked to read about this in the aftermath of Robert Francis’ report last year. It seems only criminal sanctions will force the NHS to change.

    Robert Francis QC made many important recommendations in the report concluding the Mid Staffs NHS inquiry, including:

    Hospitals should agree lists of ‘fundamental standards’ about patient safety, effectiveness and basic care…. To cause death or serious harm to a patient by non-compliance should be a criminal office…. A ‘duty of candour’ should be imposed, by law, and deliberate obstruction of this duty should be made a criminal offence.

    Professor Brian Edwards (former Dean of the School for Health and Related Research at Sheffield University and a former senior NHS manager) states unequivocally that senior managers, professionals and boards, must be held criminally liable for a breach of the NHS Constitution resulting in harm to a patient:

    “A breach in any of the Constitution’s fundamental standards that results in serious harm to patients should lead to criminal liability. One can only assume that the criminal liability will lie with both senior managers and professionals and in some circumstances with a whole Board. There is a clear parallel with the obligations on employers under the Health and Safety Acts not to tolerate dangerous working practices.”

    NHS constitution:

  19. 19 lostleonardo 22/01/2014 at 8:54 pm

    Excellent points by David H. A “culture of openess” would be a very good idea indeed. Systemic failure is a risk that needs to be discussed and even highly skilled individuals make mistakes. Oddly enough, our much despised Conservative-led government, in the shape of Mr Jeremy Hunt, tried to very gently raise the point about the “blame culture” a couple of months ago, with talk of protection for “whistleblowers” within the NHS. (How can this have deteriorated that far? What kind of a country is this?)

    What is being done about it, I do not know. But, as ever with this government, it was a shame to see a legitimate point being made only for them to then back away from it when the Labour attack dogs started barking. Personally, politically speaking, I would have been inclined to get right up in Andy Burnham’s face and shove any report right down his throat. But, then, that is probably why these people are in Government and I am not. If that was a good idea politically speaking, I suspect they would have done it. After all, nobody in British politics can say anything to criticise the saintly NHS – and therein lies the problem.

  20. 20 John 22/01/2014 at 10:26 pm

    After MidStaffs, Morecambe Bay & Bristol why would one be surprised?
    We have allowed the staff to colonise OUR public services.
    Being heavily unionised the last thing they want to be troubled by is the paying customers
    The bigger question is around whether Public Service provision is FFP in 21st Century Britain

  21. 21 Flyinthesky 23/01/2014 at 12:05 pm

    We have allowed the NHS to evolve into the NHA mainly for its own benefit.
    It no longer serves but directs.

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