⚡ A WAR on the WARDS 💥
💧 A Whistleblower’s Woes 💧
Whistleblower Reprisal: a very childish crime
Note: Though the core text of this account was written for my solicitor on the day I submitted my resignation, I have since added information of more general interest, as well as updates, emphasis & illustrations.
- March 1980: I joined 307 Field Ambulance RAMC, Territorial Army, subsequently training to Combat Medical Technician Class 1 at Duchess of Kent’s Military Hospital, Catterick and gaining the rank of Corporal.
- April 1987: I began 3 years Nurse Training to RGN level – Registered General Nurse.
- August 1990: I was registered with the Nursing & Midwifery Council as a General Nurse.
- September 1990: I began working as a Staff Nurse for Lancaster Health Authority, (latterly known as University Hospitals of Morecambe Bay Trust).
- 1991-98 I also worked part-time at a local private Nursing Home. I blew whistles there too.
- 1997: Our whole ward was moved to Ward 23 at Royal Lancaster Infirmary, a 24-bed both genders ward, becoming later the Acute Stroke Unit. We also saw Rheumatology, Medical Rehabilitation, and Acquired Brain Injury, as well as a wide variety of other medical conditions in patients aged between 13 & 103 years old.
🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌
I worked continuously as Full-Time Staff Nurse for Morecambe Bay Trust from 1990. In 1996 I was called up, by Army Medical Services, for 6 months Active Service as Combat Medic in the Civil War in The Former Yugoslavia. Attached to “23 Parachute Field Ambulance”, a unit of The Parachute Regiment, I was Medical Corporal-in-charge, under the MO, of a British Army Base Medical Centre, in the world’s most heavily-mined town, treating service personnel from a number of different nations as well as patients from the local civilian population.
“To endeavour to prevent destruction of life is by no means to encourage war, no more than to tend the sick & wounded in a field hospital is to encourage war.” – Florence Nightingale (1862).
Nightingale was an Army Nurse.
On my return to the ward, a Night Sister expressed her disapproval of me for taking so much
“Time off?” Dodging bullets in Bosnia…
I even blew a whistle or two in the Army!
🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑 🚑
- In Common Parlance: A firm belief in the reliability, truth, or ability of someone or something.
2. In Law: an arrangement whereby a person (a trustee) holds property as its nominal owner for the good of one or more beneficiaries.
3. In Fact: An evil empire which pays its bosses six-figure salaries to engage in obscuring & destroying evidence, as well as issuing disingenuous & misleading statements to Press, Public, Police, HM Coroner & Staff.
- a person who informs on a person or organization regarded as engaging in an unlawful or immoral activity.
- accuser, betrayer, blabbermouth, busybody, canary, double agent, fink, gossip, informer, judas, nark, rat, rumormonger, scandalmonger, snake in the grass, snitch, squeaker, squealer, stoolie, tabby, talebearer, taleteller, tattler, etc. etc.
- : the fact or action of being inadvertent.
- : a result of inattention, oversight. – ie. an inaccuracy or error, mismanagement, a careless mistake, miscalculation, misunderstanding, an act carried out without due diligence or attention, unintended, a blunder.
Incompetence, noun: inability to do something successfully; ineptitude.
It was never my ambition to become a “Whistleblower”. I wouldn’t have known what that meant. That role grew around me as experience of caring increased my awareness. A growing determination to have things done properly led me into conflict with some others.
It was bosses themselves that first termed me “whistleblower”, when they sent me a copy of their “Whistleblowing Policy”. I wasn’t familiar with the expression but, as it turned out, neither were they! They breached every clause!
Ever since being thus labelled, I’ve experienced exclusion, bullying, patronising & humiliating treatment from my “superiors”, as well as suspicion from others. I’ve even been accused of taking things too seriously! I beg your pardon? A neighbour told me that it had all been my own fault, “You shouldn’t have reported it!”
WARNING: I will try to keep this tale of misery as light-hearted as good taste can permit, but proud whistleblowers do love to tell it like it is. Expect to encounter some creepy 🤡 clowns, dreadful 🐉 dragons and dark 🕸️ dungeons 🕷️ as you journey on.
🕸️~~~~~✂️🩸~~~~~ 🦇 ~~~~~ 🐉~~~~~🚶🏼♂️~~~~~ 🤡 ~~~~~ 💀 ~~~~~ 😱 ~~~~~ 🕷️
The stories I tell here have some names anonymised. Patients are of course entitled to confidentiality. The others are ‘so-called’ nurses whose practices cried out to be made known to management. I’m content to allow them to remain *nameless here, if only because I’d like to draw attention more to the monumental mess & muddle that bosses made of my confidences. Bosses ought to be proud to hold accountable positions and quite unashamed to have their decisions held up for public admiration. They can make no legitimate claim to anonymity. If their standing in society depends so much upon subterfuge & silence, the party’s over.
*Those names were supplied to Morecambe Bay Investigation & Lancashire Police Major Crimes Unit.
Bosses’ skills lie chiefly in spinning well-crafted apologies & promises. Too arrogant to be informed (as that would imply that there might be something they don’t know), too remote to comprehend real-world clinical details (if they ever did work at the coalface, then it was long ago and not for long), too self-obsessed to even care (“my pension is safe”), they’ll believe only what other bosses tell them. In their company, integrity seems to get confused with pay grade. Is my credibility to be measured by how little you pay me?
To name shop-floor participants would make it too easy for bosses to play their customary cards. When bad news hits the headlines, they are always keen to blame “those tiresome workers who make life so difficult for us distinguished & dedicated managers.” I hope to demonstrate that not only do they not know what is happening under their lofty noses, but also that they don’t play the right cards when they’re handed information on a plate and even find it impossible to follow their own rules. I think we must all be forgiven for an occasional “inadvertence”, but to make a profession of it?
🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌
“Hospitals are only an intermediate stage of civilisation…” – Florence Nightingale
Nightingale’s wisdom is over 150 years old now. Modern nursing treats it all as outdated these days. I’ll throw in a few quotes from her occasionally. See what you think. This one’s a misquote really. She was expressing the hope that one day hospitals would be unnecessary because, as civilisation advanced, the sick would be nursed in their own homes. I misuse it here because it is so very appropriate in this context.
In early 2003, a colleague confided in me that an Auxiliary Nurse had told her that she needed some strong painkillers for her son, who had injured his hand in a fight. He had chosen not to seek medical help, for fear of the Police learning of his involvement. Over-the-counter analgesia being insufficient, she hoped to steal some stronger “Co-codamol 30/500” tablets, a Prescription-Only medicine, from the ward drugs cupboard. I counted the boxes of this drug in stock. Later that night, I found that one box had gone missing. I searched the woman’s bag and found the tablets there. I reported this to Night-Sister straightaway. The woman was given suspension on pay from work, while management “investigation” processes went endlessly on & on. At the long-awaited Disciplinary Hearing, held on completion of their inquiries, it emerged that bosses knew no more than what I’d told them at the outset! What on earth had they been investigating for 12 months? (Quite coincidentally of course, a long series of thefts of cash & belongings from staff changing-rooms ceased immediately the woman was suspended.)
It was over 12 months before the Trust held a knockabout-comedy hearing & dismissed the thief.
It became obvious that, somewhere along the course of management’s oft-reviewed “robust” procedures, confidentiality had inadvertently been breached. My informant colleague was childishly shunned and cruelly “sent to Coventry” by other staff, at work and elsewhere, receiving anonymous threats of violence & death by telephone at all hours. A Police call-recording tracing device was put on her phone-line. Objects were thrown into her garden at night. Despite the predictably damaging effect on staff morale & efficiency on the ward, bosses allowed this intolerable state of affairs to go on for over a year. She was forced to take time-off sick and still today feels disadvantaged at work, because of the part she took.
During this lengthy ordeal, as I arrived home after dark, my neighbour warned me that a car had earlier driven into the yard at the side of my house. It spent 20 minutes parked there, engine still running, without the two occupants attempting to ring my doorbell, before driving off just a minute or two before I arrived. Living, as I do, in a remote farmhouse, she expected that I would have passed the vehicle, on the long driveway in. I realised that this was the car I’d just seen, being driven dangerously. I had halted at a junction, when a car, coming away from the farm at speed, braked suddenly as it passed me, mounting the kerb and skidding to a halt on the grass verge, some 100 yards beyond the junction. As I drove on away from the junction, I watched in the mirror as the car made a screeching U-turn in the road, furiously accelerating to follow me at speed, aggressively close behind almost bumper to bumper, for about 800 yards before falling back. My name had also been divulged and I was being targeted for intimidation. I logged the incident with Police next day, who assured me that the son was now in custody. A few days later, a newspaper told that the woman’s *son had been imprisoned for Grievous Bodily Harm in an assault on a female.
*A dangerously violent criminal, he went on, after release some years later, to be hunted down by armed Police after a two week search of the countryside not two miles from my home. Subsequently serving a seven-year prison sentence after being found guilty of wounding with intent, possession of class A drugs, arson and harassment in respect of three separate incidents, he was released on licence. Re-arrested to prison after breaching the terms of his licence, he was also charged in connection with reports of assault, criminal damage and threats to kill.
Breaches of whistleblower confidentiality can clearly result in very serious consequences.
I felt exposed, frightened and resentful, but knew nothing of Whistleblower protections at that time. Neither did management, it seems!
I received zero feedback from bosses regarding this matter. Then several weeks after the hearing, to add insult to injury, I was surprised to be rewarded with a “Formal Reprimand” from Nursing Director Mrs Sylvia Booth for not sharing the suspicions before the theft had taken place! Ludicrously, she instructed that I ought to make report to management whenever I suspected anything, a whisper of gossip or a rumour! She took the events “very seriously” because “someone has lost their job because of it!” Quite rightly too, in my view, and certainly not before time. (Staff who had suffered the losses of cash & belongings in the ward crime wave were not available to comment.)
Please Note: Mrs Booth here makes emphatic demand that management be informed of everything that I see, hear or suspect as I carry out my duties. That directive will be abandoned and utterly negated by Morecambe Bay bosses from here on.
I can deal with a wide variety of occurrences on a ward, but I was never taught Police work. I’m not a real detective, but maybe I don’t do so bad. If Booth would have had things done differently then perhaps she could have considered introducing training for staff sleuths, so that such events might be handled to her better satisfaction. I’d made a number of disclosures over the years. Not one had been gratefully received or handled well, but it was much later before I could firmly establish as proven fact that sharing suspicions, or indeed corroborated evidence, with management delivers no useful result at all. No acknowledgement, no investigation, no feedback, no effective remedial measures can be expected. They really don’t want to know what staff see or hear. From their quiet & airy carpeted offices, they gaze out over a veritable icon of healthcare, making its stately progress toward a distinguished future. Confusing reality with the public image they would like to portray, they fix, in their mind’s eye, a preposterously airbrushed, make-believe image of their squeaky-clean & well-ordered hospital. No untidy detail from the sweaty & clamorous front-line, however well-intended, can ever be permitted to disturb that. The real hospital beneath them must run itself; they have more important things with which to concern themselves. Without conceding the smallest degree of control to anyone below, they assume things will run smoothly just by insisting that they should do so. Staff are left to “cover themselves”, put up & shut up.
Although I felt that the “Reprimand” was incomprehensible and most unjust, I had no understanding at that time of the flimsy protection offered to whistleblowers by the Public Interest Disclosure Act (PIDA). This legislation describes the report I had made as a “Protected Disclosure”. Booth clearly had her own way of looking at it. If challenged over her decision today, I feel sure she would claim “inadvertence”. They all do. Booth may have felt satisfied that she had thus exhorted staff to keep bosses fully informed, but the message received was that sharing information would be punished. I would hear that same message again & again. The episode had writ LARGE that there is no appreciation for reporting wrongdoing in Morecambe Bay; neither thanks nor protection are offered to whistleblowers. Bosses, finding it easier to manage the fantasy hospital they hold in their imagination, extend no hospitality to harsh realities. When things are shown to have gone awry, they really do find it hard to believe. No-one can have told them all was not well, but they never ask themselves why they hear so little… sigh. Ah well. I’ll just have to get back to work and “put it all behind me”, …to coin a phrase.
“If you would like to break laws, cause harm & avoid hard work, the system will provide a safe space, cover up your schemes and silence anyone who tries to stop you. But if you want to see things done well, then you’re on your own, you dirty low-down, snake-in-the-grass, snitch. Just keep quiet, put it all behind you and get back to work!”
A pair of dangerously violent thugs had tried to silence me but failed, luckily without causing me any lasting harm. Later, a whole gang of well-dressed & uniformed bullies would undertake the same task. Again they ultimately failed, but they did me a great deal more damage.
An Unprotected Disclosure?
And so this is the life of a nurse?! Some ignorant people think it “Cissy” to be a nurse. It takes guts to do it properly. Which kind of nurse would you be?
A Cissy? ...cissies get promoted.
or a Whistleblower? …snitches get sacked.
with only the drugged or docile between them.
🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌
“So remember when you tell those little white lies
that the night has a thousand eyes…”
In 2004/5, working as Night Duty Staff Nurse on Ward 23 at Royal Lancaster Infirmary, I began to notice that an alarming number of “drips” ( Intravenous or Subcutaneous Fluid infusions ), which were prescribed to be given to very poorly and dependant patients, were being left in the closed position, ie. not being administered because the giving-set roller-clamp was locked OFF. In the normal course of events, one might expect, in a year, to find one or two such that had been left turned off by mistake. Now I was finding up to three in a single shift.
I had become accustomed to finding infusions that were running too slowly and well behind time, but this was a worrying new feature. Realising that something was very gravely amiss, I set about finding the cause. After a long while I began to notice a pattern emerging. I was forming suspicions, but needed some confirmation before I could decide what action to take.
One night, as I took over the ward, Staff Nurse A was giving me details of a particular patient, during “handover”. I became sceptical when she told me, in more detail than was usual from her, that “you might find that his infusion has run through. It was running behind (time), so I speeded it up.” She was well aware that I was diligent regarding patient hydration, but had perhaps not expected it was me coming on duty that night. Because I worked nights, I had become more aware than most that many of our patients were not adequately hydrated, as I completed the Fluid Balance Charts at midnight. I was always careful to emphasise the importance of this aspect of care in my hand-over reports. When she saw me arrive for work, I expect that Nurse A realised then that her particularly clumsy effort at depriving this patient was likely to be noticed and something of her demeanour alerted me.
I went straight-away to that patient and found that his infusion had been locked off at the roller-clamp at the very moment that the bag had emptied, but before the giving-set drip chamber had run right down. If her account had been true, the fluids would have run right through and the chamber would have been altogether empty. That it was not implied that whoever switched it off had been fully aware at that moment that the next fluids unit was required right away. If the unit had run through while she was busy or right at the end of her shift, she could simply have let me know that and no question would have arisen. However, I now had to form the view that S/N A had turned off the infusion much earlier and had not troubled to continue it, attempting to conceal her neglect by that incoherent deceit.
Betrayed by this tiny detail, her efforts to cover her tracks had only succeeded in drawing my attention to herself. I then came to recognise that all these similar incidents had been affecting only those patients cared for by her and were apparent to me only on those occasions when my shifts followed those on which A had been in charge of twelve of the ward’s patients.
I remembered that some time before, I had returned from days off to find a patient’s fluids infusion had been locked OFF at the roller-clamp, probably only minutes after I myself had started it at the end of my previous shift 4 days before! A macabre bedside decoration, an elaborate ornament displayed in the pretence that this patient was receiving professional attention, that same identifiable unit had been just hanging there uselessly for around 100 hours! I was shocked that while I’d been away, no-one had attempted to re-start it. At the very least, it ought to have come to the notice of the night Staff Nurse, as she completed the patient’s Fluid Balance Chart at midnight on each night. The Nurse-in-Charge on my nights off had been Staff Nurse B (…we’ll hear more of her later). I wrote a conspicuous note (IN RED INK CAPITAL LETTERS!!!) of this disgraceful neglect on the patient’s Prescription & Fluid balance Charts, as well as a full account in the patient’s Nursing Notes, and made emphatic reference to this occurrence when I “handed over” to the Day-Staff next morning.
Reputation Management: Keeping Up Appearances.
Downcast & disillusioned, I wondered what sort of nurses we had on this ward, until the Ward Sister demonstrated that it went further than that. Next evening, the Ward Manager, Sr. Paula Humphrey, challenged me about the eye-catching note and told me not to do such a thing again, because relatives had been alarmed, questioned her about it and put her in an embarrassing position. Now let us take careful note that it had taken relatives to draw it to her attention and that her disquiet lay primarily with avoiding complaints from relatives, …not with the dehydrated patient! I advised that she ought to take up her concerns with the staff whose negligence had brought it about.
I don’t believe she can have done that, because many such events kept occurring. In fact there was a period of several months, in which I could expect to find an unusually high number of empty fluid bags and cosmetic switched-off “drips” to be dealt with as I carried out my work on the ward. At best, I would have to find another qualified member of staff from elsewhere, to check & counter-sign a number of fresh fluid units for me, before I could “run-through” new giving-sets & re-start the infusions, as well as enter all the details & unique unit numbers on the Prescription & Fluid Balance Charts. Sometimes sorting these out could involve Heparin flushes to clear the cannulae, or even re-cannulating the patient. S/N A had clearly decided to relieve herself of the burden of infusions in the execution of her own “Lancaster Care Pathway”. Execution being an appropriate word here. Dehydration brings death.
By early June 2005, becoming more convinced now, I found an opportunity to talk to S/N A about these incidents. Believing we were not overheard, I tactfully asked her if she was having any difficulty with giving fluids, as I had found a number of “drips” turned off. I expected a denial or at least any of a number of possible fabrications. However, I was shocked to hear her say, “Well, he’s terminally ill. What are you doing when you give these patients fluids? You’re just killing them slowly, aren’t you?”
Wow! Is it our job to kill them quickly?
At that moment, another nurse, Staff Nurse B, having heard the exchange, emerged from the Treatment Room close by, and walked past, saying to me, “Well, she’s right, isn’t she?”
It matters not that S/N A should offer her own assessment of this man’s “terminal” condition. The fact remains that a Doctor had taken the decision to prescribe fluids and her clear duty was to carry out those instructions. Her view appeared to be that, as these patients might well die in any case, we should save ourselves the considerable effort of trying to prevent it by “permitting” them to die more quickly. She may have considered that “mercy”, but, as I understand it, the law applies an entirely different term.
“That which you do unto the least of these, you do unto me.”
We may all hold our own personal views on the vexed subject of “Dignity in Dying”. Opinions do differ, but only chaos can flow from us each implementing our own little individual care plans. When I put it to “A” that some theorists believe that dehydration can bring about unpleasant hallucinations for the patient, she countered by proposing that the patient in discussion was “demented” so that wouldn’t matter! Do I really have to say that his dementia does not diminish that patient’s value as a human being/husband/father/grandad? His Doctor clearly shared this opinion and the fluids ought to have been given as prescribed. I walked away thinking that some nurses may also be demented.
“Management must be informed”, Mrs Booth had said.
So next evening, on 4th June 2005, I told a Sister about my discovery. She told me “Russell, I can’t do anything about that unless you put it in writing!” I most reluctantly felt obliged to make a hand-written report during the following night and handed it to that Sister next morning, 5th June 2005. Feeling very uncomfortable, I was careful not to use any strong terms, certainly the word “MURDER” did not feature, but I did make it perfectly clear that there were cogent reasons for urgent concern. I’m not accustomed to accusing colleagues of such serious criminal offences and was anxious to avoid, if I possibly could, the sort of aftermath I had endured from earlier disclosures. As I started work one night, Ward Manager, Sr. Humphrey told me “I read your letter. I’m sure it was happening, but A has resigned.” I assured her that it was indeed happening. She said nothing more on the subject. Nevertheless, I expected that Management, or even Police, would at least, want to discuss the report with me, if not take further details; but I would not be contacted again concerning this matter, until the report itself became the subject of my second Grievance dated 31.11.2008. In the public interest, the Trust ought to have passed my report to Police. I feel certain that, under questioning, Nurse A would have confessed to her convictions that doctors were merely prolonging their patients’ sufferings. She had readily revealed that much to me, after only one simple exploration of her conduct. Instead they allowed her to leave, carrying with her a Nurse Registration that would comfortably allow her to find work elsewhere, if she so chose. Our ward’s long-standing serious difficulties with fluids administration noticeably improved straight-away.
Licenced to Kill?
If Police had been invited to investigate this at the time, I would have felt obliged to mention to them in addition my disquiet over another occurrence. A patient, in her forties, had suffered an unexpected “Respiratory Arrest” while alone with Nurse A in an ambulance, a year or two earlier. Having thus incurred major hypoxic brain damage, that patient died early the next morning, on my night shift. I was very upset by the tragic passing of such a relatively young woman, made yet more distressing because her two tearful young children witnessed it all at the bedside. At handover that morning, I shared my feelings with the oncoming staff. Nurse A was, shall I say, a little over-dramatic in an exhibition of sympathy for me. Her performance disturbed me. It felt feigned & quite unlike her. She was trying, I thought, to shift my overall view of the outcome away from tragedy to one of “Well, her death was the best result all round.” I did have a degree of unease about that “Arrest” at the time but kept it to myself. At that stage I was still naively confident that hospital authorities would look into it. However, after I’d become aware of A’s professed perspective on death & dying in general, that suspiciously unwitnessed incident took on a more sinister aspect. I had, by then, no recollection of the patient’s name or the date, but there were staff still on the ward at that time who might have been able to help with those details. While the Trust wasted so much time ignoring & archiving all my concerns, I became increasingly convinced that nothing would ever be done about my unsupported doubts anyway. Who would believe that a nurse might do such a thing? That so few would want to believe it may be the very essence of the problem. Look, I’m no more comfortable with this stuff than you are, but, I’m sorry, we do have to allow ourselves to consider such distasteful possibilities. The Trust’s response would probably be, “That cannot have happened because things like that just don’t happen.” Well, I’m afraid they do. (Google “nurse smothered patient” to get an idea of how often). Safeguarding must involve consideration of all possible risks. I did warn you that it would be creepy in here.
Nurse A’s sudden disappearance from the ward, together with the absence of any management feedback, ill-foundedly raised my faith in Trust Management for a while. I mistakenly hoped that some cloak of confidentiality had been thrown around the issues, that the continuing silence about Nurse A’s practice could only mean that investigations and criminal proceedings were underway. How wrong I was! Nothing at all had been done. (Years later, I learned that A had in fact resigned rather than face a disciplinary procedure on quite separate patient abuse charges that I had not known about. She was never even told about my evidence, of a much more serious nature. But more of this later…)
https://sharmilachowdhury.com/2014/12/14/ignoredwhistleblowers-claim-of-nurse-who-killed-slowly/ – The Sunday Times, Martyn Halle, 14 December 2014
🛏️ 🛌 🛌 🛌 🛌 🛏️ 🛌 🛌 🛌 🛌 🛌 🛏️ 🛏️ 🛌 🛌 🛌 🛌 🛌 🛏️ 🛌 🛌 🛌 🛌 🛏️
On 23rd September 2006, I was on night duty on Ward 23 RLI. As I began work on the ward, a patient, Mr.”Alpha”, a young man who was suffering confusion and difficulty with communication as a result of a serious head injury, repeatedly tried to gain access to the locked Controlled Drugs, “CD”, cupboard. He had a history of drug abuse. I could not understand what he was trying to tell me and was unable to persuade him to desist. Time after time, I was forced to return to the Treatment Room to ask him to leave. He became very animated and his speech more confused on each occasion. As I was busy, giving out medications to the rest of the 24 patients, I was unable to afford him the considerable length of time it might have taken to explore his motives.
At about 21.45hrs, I saw him enter a six-bedded female area. I followed and found him begging aggressively for cigarettes from a frightened female patient. I asked him to leave and followed him out. He turned suddenly and furiously threw himself at me, head-butting me in the face, scattering and damaging my glasses, and bringing his knee upwards into my groin with great force. His face twisted in an expression of frustration & deep loathing, he continued lashing out at me as I struggled to comprehend what the hell was happening, while punches & kicks landed in my face, abdomen and legs. In my attempts to restrain him, I had to remain mindful that he was missing a part of his skull, having had a craniotomy. A bone-flap had been surgically removed to relieve pressure to his brain. I took care not to involve further injury to his head during the confrontation, but it cost me dear. I got a right good hiding for my consideration. After a considerable effort while receiving dozens of frenzied kicks & punches, I wrestled him to the floor, having to sit on his chest to restrain him. I was unable to call other staff for help as I was shocked and out of breath. I suffered a split upper lip, a laceration to my right forearm and bruised painful goolies, as well as general bruising, aches and pains from the barrage of blows I’d received. “Alpha” was thankfully uninjured.
At 06.30hrs on the following morning, 24th September 2006, Mr “Alpha” came out from his bedroom and immediately ran at me throwing punches. I wrestled him to the ground and held him there until other staff came on the scene. During this assault, I received painful exacerbation of a previous neck injury, which resulted in time off work and required physiotherapy treatment. The patient was again uninjured. I found out later that “Alpha” had been told that his own tobacco had been locked in the CD cupboard for safekeeping. No-one had informed me of this arrangement and “Alpha” had been quite unable to explain to me.
I did suffer a prolonged degree of distress following the assaults, the episode being the more regrettable, because it could have been so easily avoided. In my opinion that upset arose more from the anguish of being forced to treat my poor patient with such violence, as the situation dictated, while trying to remain in the role of nurse, than from the violence done to me. It took me several days to settle my mixed feelings, even though I might have congratulated myself for successfully restraining him without causing him any injury. Of course, I had to conclude that circumstances had compelled me to behave in a wholly uncharacteristic manner. I did notice that I was being guarded & distrustful with my other patients for a month or two afterwards. I regretted that very much but I simply couldn’t help it. The Independent Consultant, engaged by the Trust to explore my first Grievance, was trained & experienced in Mental Health Nursing, being one-time CEO of Ashworth High-Security Hospital. He diagnosed my symptoms as PTSD (Post-Traumatic Stress Disorder). HR’s John Barstow found cause to snigger and decry this when the Consultant declared his opinion in the Grievance Hearing, yet the HR Director would later choose to attribute all of my ensuing troubles to this assault. He, of course, would prefer to believe that, rather than accept that the Trust’s mismanagement of all that followed could possibly be blamed.
Apparently, as in all things, the omniscient Trust knows best how to deal with violent assaults. They listed me for “Restraint Training”, but the course was endlessly unavailable and I never did get trained. What intrigued me was the selection process. I was listed only because I’d been assaulted. Staff members who had not yet been beaten senseless were not being summoned for training. It looks then that you have to get battered before any preventative action will be taken! Such is the Corporate way with stable doors. Should authorities inquire what steps the Trust have taken on the topic of “Violence Towards Staff”, they can always point to the “temporarily” unavailable training. “Oh yes, of course, we’ve fully supported Russell through these distressing events. We’ve booked him on a course.” Bosses don’t get beaten up; they keep well away from patients.
I came in for criticism from Senior Nurse Hulme over my handling of this incident due to a misunderstanding on the part of the Night Sister. She had asked me if she ought to call Police. Hulme had formed the view that I had refused Police involvement.
Now let’s be perfectly clear. Involving Police does not fall within my duties as Staff Nurse. I was very sternly instructed NOT to call cops, following an incident when I’d made a 999 call to inform that a stolen car was being driven at tyre-burning speed around the hospital car-park. Police did make arrests as a result. On that occasion, I was advised that I ought to seek permission from bosses before involving Police! Why would the Trust be so afraid of cops? (The registered keeper of the vehicle taken without consent was not available to comment.)
Accordingly, when I was asked, “Should I call Police?”, I had not the slightest notion that I was being asked for consent. I took it that Night Sister was seeking my advice. My reply took into account that my patient had serious cognitive difficulties and was unlikely to recognise police uniform, let alone heed legal counsel. I answered, “I can’t see what good that will do”, just those words alone. The poor chap could not reasonably be held responsible for his actions, in the condition in which he found himself. He was clearly frustrated & upset, had already apologised, gone to bed in his room and turned out the light. The idea that Police Officers could in any way improve on that outcome seemed absurd. Sister had simply recorded that I’d “refused” to involve Police! Hulme, in turn, had inadvertently taken Night Sister’s brief notes of her own involvement as the definitively reliable account of events, (pay-grade prioritising?), without asking me for further & better particulars, and failed later to better inform himself by reading only the 4-page Summary of the 120-page Grievance Investigation Report.
Spreading virally, it seems everyone has caught the “Bay Plague” : Inadvertence. noun: a misunderstanding…
The way in which these incidents were handled by management received comprehensive criticism later, in the Independent Consultant’s report, “The Trust should review its arrangements for dealing with violence towards staff without delay.” He noted, “It is not acceptable to allow traumatised staff to decide whether or not Police ought to be involved.” Hulme’s ignorance of this recommendation, (which did appear in the 4-page Summary he claims to have read), exposed that my Senior Nurse had not taken a great deal of trouble to learn from the investigation.
When later, to obtain the means to have my glasses replaced, I claimed Criminal Injuries Compensation over this attack, Hulme wrote from his exalted comfy chair to the CICA authority claiming an authoritative overview of the occurrence, though plainly not from any reading of my Grievance Investigation Report. He asserted with confident certainty that I had “requested” that Police should not be involved. Waffling on, he claimed that “Incidents of this type are reviewed on a case-by-case basis where the patient’s mental health & capacity are considered together with any other relevant circumstances.” I hope you’ll agree that is exactly what I’d already done in response to Night Sister’s ambiguous question. Unhindered, Hulme continued, “In this circumstance, I would suggest that Police indeed should have been contacted regardless of the above request.” Well, there never was such a request, Hulme. If Police “should have been contacted”, then why did the Senior Nurse not do that, at the very moment he read copy of my Clinical Incident Report & Sister’s notes? Might I suggest that, since he felt so strongly, having analysed the incident using his rose-tinted “case-by-case” criteria, he ought to have picked up a nearby phone himself? He could even have asked me to explain my “request”. But no, this sage had no need of first-hand eye-witness testimony before passing his august judgment.
My CICA claim was initially turned down on the sole basis of Hulme’s guesswork review. Nevertheless, it was later upheld on appeal when I explained my thinking to the Tribunal, submitting copies of the Grievance Investigation Report and producing evidence of the large numbers of assaults made on Morecambe Bay staff in the relevant period, revealing that Police were only rarely brought in. The panel then agreed with me that I had met the requirements of Criminal Injuries legislation by making report to the Trust, as a “Responsible Authority”! Clearly they can’t know that authority as well as I do.
I believe these events were continuing to have effect upon my motivation, when I met with my Ward Manager Sr. Humphrey for Appraisal on 8th November 2006. She recorded that “This was probably the worst appraisal I have ever participated in. Russ has now reached his lowest ebb and now seriously questions his continuation within the nursing profession… Russell is a very hard-working staff nurse who has always been valued as part of Ward 23 team. He has a considerable amount of input to the day to day working of the ward. I will support him in any way I can.”
I received no support of any kind. Her touching praise would not inhibit her attempts to discredit me later, in her responses to the Grievance Investigator. Nor would they prevent her from turning away her face to ignore my greeting, as a result of learning, via Matron’s confidentiality breach, that her “valued team player” had made “protected” disclosures. She actually wrote later to the Investigator to complain that her responses to questioning would have been different, had it been made clear that I would see them in his report! Her honesty seems then to depend upon who might be listening, offering a cosmetically retouched version tailored to suit each recipient. The truth shouldn’t be like that. Such uneasiness with truth is not uncommon in Trust employees.
“Russ has now reached his lowest ebb”– but worse was yet to come!
🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌
On 11th January 2007, I arrived at Ward 23 for the night-shift to learn that we would again be short-staffed. The Staff Nurse who had been in charge during the afternoon, S/N B, stated that she was willing to continue working until 04.00hrs to “help you guys out”. I instantly recognised that her choice of leaving-time owed more to her personal preferences than any thought of ward requirements, but nonetheless appreciated her immediate assistance. The more usual offer of help from a member of Day Staff would have been to stay on until, say, midnight, leaving after patients had been settled and medicated. Night Sister was informed of the arrangement when she visited the ward during the evening and suggested that it would be unnecessary for B to continue after 02.00hrs, as she herself would be in a position to give assistance after that time. This clearly did not please B, but she agreed. At 02.00hrs, Night Sister came to the ward and told S/N B that she was free to leave. B remained on the ward chatting about inconsequential matters until asking me to watch her cross the car park to her car at 02.35hrs. I could see that she was not happy at being told to leave in advance of her planned time. Had she been allowed to continue until 04.00hrs, she would have been able to claim a whole shift off during that week without incurring any time owed. Regardless of the above, and that she was contracted to work 30 hours per week; she actually worked only 27 hours during that week, yet still saw fit to claim 6 and a half hour’s night enhancement, for a night on which she was on night duty for only 5 hours. No adjustment for the shortfall was entered in the Time Owing Book to this effect. I made copies of the Duty Roster for that week, as well as S/N B’s Time-sheet submitted by her at month end. I contacted Internal Audit Department to report this after I saw that the pay claim had been authorised by Sister Humphrey.
”Tell-tale tit, your tongue shall be slit…”
On 5th February 2007, I met a Trust Fraud Investigator in the Internal Audit Dept. to provide her with my evidence. I gave her copies of the documents and made a statement to her about the above events. Aiming to provide some context in addition, I related a brief history of S/N B’s past misconduct, making it clear that this was history. B was known for such things as stealing bottles of milk to take home, helping herself to medicines etc. etc. but I didn’t bring those into it. The incidents I mentioned had all been reported and “dealt with”, in Trust fashion, earlier. The Fraud Investigator inadvertently took the impression that I was making a first report of those events, which had all occurred years earlier. While she then busied herself with investigating the allegation of fraud, she referred the clinical incidents first to the Head of Medicine Directorate, who passed the matter to the Director of Nursing, from whom it passed in turn to the Modern Matron. Invitations to the party were going out all over.
“… and all the dogs in the town… “
Promised an independent and confidential investigation, I was already becoming alarmed at the growing number of participants, when, on 19th February, I received an email requesting evidence, from Matron Gill Bentley, which had been “inadvertently” copied to my Ward Manager, Sr. Humphrey, breaching confidentiality! Matron wrote her emails to me entitled: “Re Ongoing Investigation”. Over 12 months after my initial report, I learned that no investigation had ever been commenced!
“… shall have a little bit.”
Inadvertence has a big part to play in affairs at Morecambe Bay. Matron would later plead in her defence, to the investigator of my first Grievance, that her confidentiality breach was “inadvertent” and that she had not had adequate support from senior management. I do believe though that her inadvertence was in choosing the wrong word to describe her failure. “Inadvertence” describes “an accident, an error”. “An inability to successfully complete a task unsupported” is better termed “Incompetence”. My first Grievance Report recommended, among many other things, that “Staff should be trained in Investigation Skills before they undertake investigations.” The Trust, of course, will have “reviewed their procedures” as they always do. They don’t trouble to follow their procedures, but they do very often feel the need to “review” them.
The Trust Fraud Investigator had quickly concluded that “although it was possible that a minimal amount of time had been claimed and possibly not worked, the allegations could not be proved and the investigation costs would totally outweigh the possible gains.”! She did all this without reference to the ward’s Time Owing Book and wasted no time on my suggestions to examine other weeks’ records for shortfalls that were not adjusted in the Time Owing Book. There were several such easily identifiable examples of similar fraud. In a workplace that frequently warns of “Instant Dismissal” for pilfering milk or an apple, I considered this attitude to at least one misappropriation of over £35 quite bewildering. Sr. Humphrey maintained that “B did not falsify her timesheet. In fact when I investigated I found she had in fact claimed for half an hour less than she worked.” This view puts her at odds with the “Counter-Fraud Specialist” of Internal Audit, who agreed that S/N B had apparently worked only 27 of 30 hours during the week in question. In her testimony to the investigator, Humphrey talks of a “flexible arrangement” with S/N B’s working hours. She “understands” that “it may have been difficult for (me) to appreciate the whole picture”. I would put it that, as she had no way of knowing when S/N B was relieved of duties that night, it carries no weight that she carried out her own investigation. In effect, all she is telling us is that she merely checked B’s pay-claims against what B said she had worked. Unsurprisingly, they (almost) matched!
🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌
“It may seem a strange principle to enunciate as the very first requirement in a hospital is that it should do the sick no harm” Florence Nightingale.
Then four days after making my report to Internal Audit, I witnessed yet another instance of clinical misconduct by S/N B.
On the evening of 9th February 2007, I listened to Staff Nurse B as she “handed over” her patients to me. Dealing with one patient, “Mr. Beta”, she proudly told me that she had qualified that week to pass naso-gastric (NG) feeding tubes on patients with swallowing difficulties (common in Stroke patients) and had been looking for a patient to practice on. Inserted skilfully via a nostril, the tube is intended to carry fluids into the patient’s stomach. Glowing with self-satisfaction, she told me to “be sure to let Paula (Sister Humphrey) know” that she had successfully demonstrated her new skill on Mr.Beta. She admitted, “I shouldn’t have really. He’s already had four inserted and pulled them all out”. The Clinical Protocol, as it was understood at the time on Ward 23, recommended that patients should be tried with NG tubes on no more than three occasions, because, if they show a tendency to remove tubing, there will exist a risk that a tube only partially removed might allow fluid to pass into the lung(s), resulting in life-threatening Aspiration Pneumonia. (It did emerge later that no Clinical Protocol applicable to the use of NG tubes in 2007 could be found. Local practice had been guided only by local hearsay! But such was the only guidance available on Ward 23.)
“A Strange Principle to Enunciate…”
Though I felt concerned, I made no comment at this point, but lowered my glasses to stare over them in a mixture of disbelief and disapproval. Revealing that she was aware that there might be misgivings, she hurriedly defended her action by saying that the relatives had been “pressing for it” and that, in any case, she had “got a Dietician to authorise it”. So that makes it alright then? Neither excuse can justify her selfish motives. Consent for one procedure should not be taken as open-ended; it must be renewed for each subsequent procedure. Dieticians may authorise a plan for feeding via NG tube, but it is the individual clinician’s responsibility to justify the insertion.
When I reached “Mr. Beta”, I saw that he was slumped down in the bed, very flushed, and hyperventilating. The tube had been dislodged, but by no more than about 2 or 3 inches, (adhesive tape applied to secure it to the patient’s nose was now detached but still marking the point at which the tube was intended to be fixed). As we lifted him up the bed he vomited, so I asked a colleague to switch off the feed pump as I removed the NG tube. His temperature was in excess of 39 degrees. I immediately administered oxygen at a high rate (10litres/min) and called a doctor, who diagnosed Aspiration Pneumonia, prescribing high doses of two intravenous antibiotics.
“First Do No Harm”
I noted that the Dietician had advised that the feed should have been given during the “Daytime Only” by clearly annotating the chart accordingly. It ought not to have been started as it was, during the late evening, set to run for 15 hours overnight, during which period the patient would not be as aware as he might, along with a decreased level of surveillance from reduced staff numbers. It had become customary on Ward 23 to totally ignore Dieticians’ instructions in this way, day-staff preferring to shift all responsibility for NG feeding onto night-staff. In any case, Mr. Beta was receiving vital hydration via IV infusion and had been recommended for imminent insertion of a PEG Tube, (a flexible feeding tube surgically placed through the abdominal wall into the stomach), by which he would have been fed. So, ultimately, there was no urgent requirement, nor indeed convincing justification, for Mr Beta to undergo NG insertion beyond B’s desire to practice her new skill and impress Sr. Humphrey.
To put it bluntly, in his extremely vulnerable condition, alone and unable to fully understand, resist or even speak to withhold consent, he was criminally assaulted & forced to suffer an unnecessary & unpleasant invasive procedure, at the hands of a nurse he might have hoped he could trust, solely to fulfil her own personal ambitions, …followed by its distressing & deadly consequences, suffering needlessly for twelve days.
Patients, not playthings. Patients.
If you can’t help them, …leave them alone.
I reported this Clinical Incident to Sr. Humphrey, when she came on duty in the morning. She looked immediately shocked and concerned, remarking “I don’t know how she can justify passing another NG on him.” She would later tell the Independent Investigator when questioned, “I haven’t seen anything in writing about this. I recall the incident but not the allegation. I wish I had written something down about this at the time.” Clearly, she saw no reason to pass on her immediate concerns to management herself at the time. I did not myself complete a written Clinical Incident Report, as the reporting system involved making a signed entry in a book, kept on the Nurses Station desk for all to read. I considered this to be a most effective way of obliging anyone making a report to conveniently breach their own confidentiality, (thus relieving Matron of the bother), …and I already had enough on my plate! Neither did Humphrey, despite her initial outward display of concern.
Despite my recounting the events and producing documentary evidence to Modern Matron Gill Bentley at a meeting on 24th May 2007, investigation of this incident had still not been commenced when my Grievance was reported on in April 2008. The incident was described by the Independent Investigator as “gross misconduct, as by failing to follow clinical protocol a patient’s life was put at risk.” Staff Nurse B had unexpectedly resigned after going on Sick Leave (claiming a “bad back”) only days after the patient’s death, well before my Grievance Investigator began his work, and so could not be interviewed. I suspect that she must have heard of my allegations on the ward grapevine as a result of Matron’s breach of confidentiality. She quickly recovered however and found a position at a NHS Hospital in London, able to continue her career with unblemished record – “No restrictions on practice” – so no mentions of scissors, naso-gastric tubes, fraudulent pay-claims and the rest. I believe that she, at least, had glimpsed the enormity of what she’d done, even if no-one else was prepared to admit it had happened or do much about it.
L👀king, without wishing to see.
Mr Beta’s Death Certificate listed two primary causes: 1a. Aspiration Pneumonia & 1b. CVA (Stroke). An internal review by the Trust of the death was carried out in 2014, a full 7 years Post-Mortem, again without informing relatives, the whole sorry business seems to have nothing to do with them. Mr Beta seems to have become the sole property of the Trust. It revealed that, original notes having been destroyed, the microfilmed page of notes referring to the NG Incident had somehow, inadvertently, become illegible on microfilming …just that one page, the very one! sigh… The Chief Nurse carried out this review, tentatively suggesting, in the absence of much evidence, that the patient “may” already have had Aspiration Pneumonia on admission. If that were the case, it had gone surprisingly undiagnosed & untreated by Medical Staff throughout! The term pneumonia and the extreme symptoms of that condition only appeared in his notes after that questionable fifth NG insertion. The Review had been kept from me, the only person to have expressed any interest, for two years, until I was provided a copy only after I complained to the Chief Executive. I did write to the Chief Nurse offering that, as I was one of few that had actually read the original notes, I might be able to help decipher & interpret the blurred image. In typical corporate style, she did not acknowledge my offer.
How very convenient. Inadvertence, noun: a careless mistake, not as was intended?
🚔 🚔 🚔 🚔 🚔 🚔 🚔 🚔 🚔 🚔 🚔 🚔 🚔
An Inspector Calls
“Nothing Occurred. Nothing to see here at all. Let’s move on and put it all behind us.”
“Cake or a biscuit for you, Superintendent? Will that be one sugar or two?”
While giving evidence to the Morecambe Bay Investigation in 2015, I was asked by the Chair, Dr. Kirkup, if it had crossed my mind to inform Police of the serious events I witnessed. I told him that, though I did see them as very serious, I had hoped that informing management, a “responsible authority”, would be sufficient to have appropriate action taken. Reflecting later on Kirkup’s questioning, I decided that Police should most certainly have been told. So I wrote to Lancashire’s Chief Constable and was duly cross-examined intensively at my home by Detective Superintendent Thistlethwaite, Head of Lancashire’s Major Crime Unit, & Detective Sgt. Lawless for over three and a half hours. They apologised for the ordeal they had put me through, but explained that the process was understandably necessary to establish that I was telling the truth. I didn’t mind, I like telling the truth. Satisfied now that I was indeed truthful, they went off to put some questions to the Trust.
Morecambe Bay assigned their trusty HR Director to fend off the inquisitive cops. The HR Director, Mr David Wilkinson is a human resource manager who cannot to be reproached for his inadvertence over clinical knowledge, because he ought not to be expected to have any at all. He was an excellent choice for the task of baffling Police because he always speaks with ebullient confidence and, moreover, should he be found to err in his interpretation of clinical details, well who could blame him? He is, after all, only a humble personnel manager doing his best to co-operate.
As you read on, bear firmly in mind that my original concerns were for “a patient injured by an unjustified procedure without proper consent”. Until I saw the Police account of this interview, I was not even aware that the patient had not survived.
Now gather round children. Watch closely as the Trust’s Top Spin-Doctor cleverly conjures the focus entirely onto whether the NG led to death. Our concerns will suddenly vanish!
Wilkinson assured Police “there was nothing to suggest that this death was in any way affected by the alleged procedure carried out by (Nurse B)“. Nothing at all to even suggest it? This was far from the truth, but the cops simply took his well-dressed word for it. As every defendant in a court knows well, a shirt & tie does a lot for one’s credibility. So do cake & biscuits. 🍰 ☕ 🍪
On closer look, what he told Superintendent Thistlethwaite was misleading in every way. To state as fact that “there was nothing to suggest …” does imply that he’d made some sort of scrutiny of it all, despite possessing only a layman’s acquaintance with matters medical. Knowing, as he must have done, that an experienced Staff Nurse had raised emphatic concerns, that no investigation had been conducted for years afterwards and further cognisant that the primary Cause of Death in this patient was, after all, Aspiration Pneumonia, then his assertion comes close to risking a criminal charge of Obstruction. In testimony to a Murder Squad top cop that must have taken courage, but Wilkinson is audacious. Or perhaps he really is just as naively innocent as he appears. Ladies & Gentlemen of the Jury, I leave it to you to make up your own minds.
Professional inadvertence: A carefully planned “mistake” deliberately designed to achieve a desired objective.
To some small extent, the Chief Nurse’s Review of the death may bear a little of the weight of his firm assurance, inasmuch as he could always plead from the dock that he’d relied on her superior Clinical Knowledge, but had perhaps inadvertently misinterpreted it. Nevertheless, her review had been frustrated by poor film copy of the notes, as well as gaps & inaccuracies in the recorded details of events. For reasons unexplained, she had not seen cause to invite me, as a prime eye-witness, to better inform her study. Instead, she ignored my offer of support in interpreting unclear details. It is not uncommon among management circles to find that if a thing is not recorded in the written word, then it can be regarded as negligible. In this court, only the written word endures; professional eye-witness sworn testimony can bear no significance. Her unconfirmed speculations, she conceded, had to rely heavily on supposition & educated guesswork; she expressed her own doubts and uncertainties throughout. She even admits that she is “not qualified to provide a medical opinion on the cause or time that the patient acquired pneumonia”. In truth, she brought forward nothing to suggest that the death could NOT be related to the procedure. She carefully avoided the indisputable fact that repeatedly inserting NG tubes brings with it an unavoidably increased risk of pneumonia. If we don’t manage to cause that injury the first time, we can keep on putting them in until we do!
But let’s not be drawn too far down the path chosen for us by Wilkinson; we’re still waiting for any mention of “Consent”, or even possibly “Criminal Assault”. Naturally enough, the Chief Nurse offered little mention of this aspect because the relative page of notes was now so lamentably illegible. Wilkinson chose not to be hampered by any missing pages, nor all the expressed ambivalence, relying instead on cherry-picking the more appealing samples from her hypothetical assumptions.
It was, at the very least, quite mistaken & misleading to assert that there could be any degree of certainty, beyond all reasonable doubt, that there was “nothing to suggest…” That would be to extend the Chief Nurse’s tentative theories well beyond what she could have intended. But Wilkinson boldly goes the distance anyway. There HAD BEEN every reason to suggest … Why else would the Trust Chief Nurse have taken all that tardy trouble? Could her touchingly-loyal but thinly-evidenced work of corporate hand-washing have erased all those reasons?
But, hang on, we’re still being dragged along behind Wilkinson’s dubious deductions. Be all that as it may, Wilkinson has only ushered us carefully to the highly debatable dismissal of a suggestion that was all his own invention. If it cannot be said that the patient definitely died from it, why should we worry about what happened to him? Ipso fatso.🤣
Meanwhile my original concern, that of “a patient injured by a procedure without legitimate justification and/or proper consent“, has mysteriously slipped from our sight.
Now that’s magic, boys & girls! Where can it have gone?
Trust Internal Reviews are notoriously unreliable and attract condemnatory criticism. As The Morecambe Bay Investigation of 2015 had observed, in Chapter 7.6 of its Report, “A pattern emerged of a Trust that has undertaken reviews, produced action plans and provided assurance to commissioners and regulators that appropriate action is in hand. However, on numerous previous occasions this assurance has proved false.”
The patient’s medical notes had been flagrantly, (or should I say inadvertently?), destroyed after some customary period, in utter disregard that the Trust was well aware that I had raised concerns around this patient’s treatment and that, as they ought to have learned from the Grievance Report, an investigation of those concerns had never been commenced. The careless film copying & destruction obliged their dedicated Chief Nurse to dream up a work of fiction, based on supposition and a balance of probability, in review of the historic death.
It was Mr Wilkinson too who crafted the Trust PR statement to Press about my disclosures. On that occasion he had regretted, “Unfortunately, the lack of detailed evidence available to us… means we are unable, so many years later, to substantiate the issues he raised”, failing to admit in addition that those “many years” had been wasted by the Trust itself. He found no difficulty in firmly “substantiating” to Police the tenuous & speculative musings of the Chief Nurse, whose frustrated & belated Review had suffered from the same lack of detail and long passage of time. So now what I actually witnessed had thus been officially discounted in favour of what Chief Nurse couldn’t read and wasn’t qualified to interpret! See what I mean about Spin? 🌀 Whichever way the wind blows, skilled sorcery can always turn it a fair wind for the Trust.
To further defend his Trust’s good name, Wilkinson went beyond proper call of duty again to convince Police that no continuing danger to the public existed, stating “Neither ‘Nurse A’ nor ‘Nurse B’ are still registered with the Nursing & Midwifery Council (NMC)”. This was conspicuously untruthful. Nurse B has been continuously Registered and working for a NHS Hospital in London ever since. It was another highly risky deceit too, the NMC Register being easily accessed by anyone. But Wilkinson does dare go that extra mile for his loyalty.
I did tip-off the Superintendent that they’d been treated to a fairy story, but Police were just grateful for the opportunity to leave the corpse where it lay, draped insecurely across Wilkinson’s broad shoulders. I still have the Detective’s letter detailing what he’d been told by Wilkinson. I was disappointed that he hadn’t been as aggressive & thorough in his questioning of the Trust as he’d been with me, but then D/S Thistlethwaite is exceedingly fond of cake & biscuits.
The Doctor scribbled some notes, but no-one read them. The nurse made complaints, but no-one looked into them. Someone snapped a hasty photo, then someone burned the notes. Chief Nurse wasn’t qualified and couldn’t read it, …but the Director was *confident*. The cops were relieved and dipped their biscuits, …and then they all lived happily ever after. (The late Mr Beta & relatives were not available to comment. Perhaps it’s not too late to approach them? Now that would set a cat among the pigeons.)
Now gather round children. I want you to whisper to each other a story about a poorly patient. Keep passing it on, from one to the next, until we can end with a story of how he retired happily to a villa in Spain. He might even send us a postcard expressing his gratitude! Keep it going and no cheating. Any child who mentions “Consent” will have to go and stand outside.
Clinical Protocol. The Chief Nurse Review of the patient’s death did reveal that, although the Trust was engaged in training nurses to perform NG insertions in 2007, no formal Trust Protocol for the procedure could be found to have been circulated at that time. Certainly, we on Ward 23 had been left in the dark as to what was involved and an utterly bogus word-of-mouth version of protocol had been allowed to become commonly held as authentic. Care Quality Commission later included Misplaced Naso-Gastric Tubes among their list of “NEVER EVENTS” – incidents with the potential to cause serious patient harm or death that are wholly preventable. The Trust’s interpretation might be “An incident that should NEVER EVER be investigated”. This one was not investigated until 7 years later and then only after evidence had been destroyed. The review, such as it was, explored only the “Potential to Cause Death” aspect of the “Never Event”, carefully avoiding the more relevant “Serious Harm” angle and leaving out entirely all consideration of the obvious avoidability.
The absence of a proper “Clinical Protocol” may well indeed stand right at the heart of Trust reluctance to investigate the death. An investigation might have exposed some embarrassing details about the sort of inadvertent management that patients & staff endure at Morecambe Bay. There was no apparent validated Trust Clinical Protocol in circulation for the procedure, (staff were left to asking each other what the policies might be), and a resulting death exposed weakness in the hospital’s training programme. Not only had this particular fledgling novice, with her learning still fresh in her memory, managed to inadvertently get it so spectacularly wrong, she had clearly been given no effective acquaintance with the substantial & compelling ethical considerations applying to it. Carrying out such a procedure without justification, as well as without the patient’s fully-informed consent, would constitute a Criminal Assault. I doubt very much that relatives were consulted for their consent on his behalf. Certainly no mention of them, or indeed the very subject of “Consent”, was made in the Chief Nurse’s “Review”. 🤫 “Don’t let relatives know. Put it all behind us.”
🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛏️
“Not concerned about competence.”
Cutting through the c**p! 💩
Previous incidents concerning S/N B’s clinical practice had been made known to Sr. Humphrey in the past. On one occasion, while helping an elderly lady to bed, a pair of sharp-ended scissors had protruded through a hole in B’s uniform pocket and inadvertently stabbed the patient in the leg. The leg became very badly infected and swollen requiring treatment with IV antibiotics; the patient being very poorly, confused and agitated for several weeks. This was common knowledge at the time and must have been documented in the patient’s paperwork. In addition, of course, the Ward Sister will have insisted on a “Clinical Incident Report” being completed, to detail the occurrence, …perhaps. Yet Humphrey did not know of “any specific incidents that led (her) to be concerned about B’s competence”. I regarded this “accident” as criminally negligent, especially when, some weeks afterwards, I saw B with unprotected scissors still poking menacingly from the same hole in her pocket.
🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 ✂️🛏️ 🛏️ 🛏️ 🛏️
On one unforgettable night shift, I found myself short-staffed again and was sent a very young and inexperienced Auxiliary Bank Nurse to help me. At one point she told me that a dressing on the sacral area of one patient had become detached. I asked her to lay the patient on his side for the meantime and I would tend to him when I had finished giving out medications. Later, I asked the young nurse to help me and she watched as I cleaned a dressings trolley and loaded it with the sterile stores and antiseptic the procedure would require.
She asked me why I was doing all this, so I began explaining the need to avoid cross-infection. Halting me in the middle of my lecture, she explained that she had only asked because, on the previous night, she had worked Ward 23 with another Staff Nurse, when the same dressing had fallen off. On that occasion, she had watched the Staff Nurse use her scissors to poke the packing from the old dressing back into the patient’s wound; then replace the scissors into her pocket, without even cleaning them!
I should point out now that this practice is not acceptable under any circumstances, before taking into account that the patient in question was known to suffer from Hepatitis C. This is a transmissible, incurable and deadly blood-borne virus. People infected with Hepatitis C virus often show no symptoms initially, but long term effects can include liver damage and cancer. The virus is transmitted by infected bodily fluids, and needle sharers are at particular risk. Scissor sharers can probably be included as well. It should come as no surprise to the reader to learn that the previous night’s Staff Nurse was B.
Of course, I related that observant young lady’s story (*she had indicated her willingness to bear witness) to Sr. Humphrey on the following morning. She told me “Well, B has identified dressings as one of her weaknesses in Appraisal.” I hold that such recklessness constitutes much more than “weakness” in an experienced Staff Nurse. Within days, I was hearing, from my colleagues, that S/N B had been questioning them about my smoking habits, trying to discover whether I was in breach of Trust anti-smoking policy. I realised that, in all probability, Humphrey had spoken to her about her wound-care, and, in so doing had breached confidentiality, provoking B’s desperate attempts at retaliation.
* I never did see that promising young Bank Nurse again and can now readily believe that she was excluded from Ward 23 by its jealous Ward Manager for her whistleblowing. I sincerely hope that she went on to better things elsewhere.
When questioned about this incident by the Independent Grievance Investigator in March 2008, the unretentive Humphrey told him, “I do not remember being told about this”, (so just who exactly had told Staff Nurse B?), and therefore felt able to maintain, in writing to the Grievance Investigator, that she did not know of “any specific incidents that led me to be concerned about B’s competence”.
From late February 2007, after learning of Matron Bentley’s breach of confidentiality, I realised that I was ill. I had difficulty sleeping and went over & over the events endlessly in my thoughts. I could concentrate on little else, could hardly remember what I had done the day before and lost interest in my usual pursuits, including socialising. In fact, I became very withdrawn, wanting to talk only about NHS and rudely dismissive of any other subject. Friends had begun dropping out of contact, people can only tolerate so much of this stuff. I felt unwilling properly to tend to the daily necessities of living. I told my GP who signed me off sick suffering from Stress Anxiety. I remember protesting “I’m not stressed, I’m just worried, that’s all!”
During April and May 2007, I attended Counselling sessions at the Occupational Health Dept. with no resulting improvement in my sleep pattern. If it did any good at all, it was solely because, at last, there was someone at the Trust who was prepared to listen to me, albeit paid to do so. Laughably, when I failed to turn up for a session because I’d been unable to sleep, the whole treatment course was cancelled! Later I was persuaded by Occ. Health to undergo a course of Cognitive Behaviour Therapy. I agreed, principally to pass the time while waiting agonisingly for completion of the Grievance Investigation. The notes of these “Confidential” sessions were subsequently, quite inadvertently of course, submitted in evidence by the Trust to Employment Tribunal, …evidence of what was never revealed.
It’s cropping up all over – Inadvertence, noun: a blunder.
The Defective Detective 🔎
Russell wasn’t comfortable that Matron would be handling the investigation.
But he had no idea that she would never even begin it!
On 24th May 2007, I attended a meeting with Matron Gill Bentley and a Human Resource Officer. I explained the details of the above incidents and produced photos of some documents in support. Matron emphasised that “These are VERY SERIOUS ALLEGATIONS, Russell”, ominously *implying dire consequences to be heaped upon me for my raising them, but then took a great deal of time later to do exactly nothing whatsoever about them. Zilch! That’s how VERY SERIOUSLY she took them. * FYI Matron: Intimidation of a witness is a criminal offence.
Matron, prompted by Sister Humphrey’s suggestions, insisted that these VERY SERIOUS ALLEGATIONS were the result of “personal” differences. I denied that. Now I wouldn’t like to sound too much like a former US President or Royal Personage, when I point out that I did not have a personal relationship with that woman, (nor would I). We had a professional relationship and my reports concerned entirely professional matters. I don’t throw serious allegations around unless they are very serious. I had been obliged to make five reports of serious malpractice in as many years only because they were so very serious. I really don’t enjoy this sort of thing, I can assure you. Though fiercely protective of patients, I was always reliably supportive of other staff when that was appropriate. Indeed, in making my original report, I harboured no sneaky secret ambition that Nurse B should face punitive discipline, rather my most optimistic hope was only that she might be sternly “spoken to” on the subject of professional standards. Punishment is for others to inflict; I looked only for remedy. Though I determined to have “something” done now, her devil-may-care rashness had not struck me as so very far outside the parameters of “normal” practice on the anything-goes Ward 23. Even the Ward Manager was perturbed by the NG insertion for only a few minutes and then forgot all about it. Forgot, that is, until she made an inadvertent mistake, referring to it as an “Incident” in her response to the Independent Consultant: “I recall the incident but not the allegation.” No, it can’t have been an “Incident”, of course it wasn’t. If it had been, then she would naturally have filed an Incident Report. It was just some tiny thing that she surprisingly did remember happening. My expectations of other staff and their management had been brought very low by this time.
Q: “When is an incident not an incident?” A: “When it happens to someone else who is not important to you. e.g. A patient”
Just in case you should also treat the allegation of “personal difference” as a likelihood, I ought to say more. Nurse “B” and I were so poles apart in our approach to patient care that there was no chance that I could ever take a personal liking to her, but it is essential to efficiency that some degree of professional co-operation is maintained.
“Conceit & Nursing cannot exist in the same person any more than new patches on an old garment.“ – Florence Nightingale
Fresh from qualifying as Staff Nurse from the Enrolled Nurse Conversion Course, B turned up for her first shift, sporting new blue epaulettes, the insignia of her elevated rank. A cheeky Auxiliary Nurse (HCA) passed by carrying a bed-pan and, “pulling her leg”, asked if our new Staff Nurse would help her toilet a patient. Nurse “B” rounded angrily, “I’m a Staff Nurse now. I don’t do bums anymore!” I’d been Staff for 12 years by then and I’d cheerfully “do” anything I could for my patients, everything from headlice to gangrenous toes, whatever.
She styled herself as the nurse who could get through “the work” quickly. Get through “the work”? I think she refers to “caring for patients”. I certainly hope she does, but I’m sure there’s some ideological dissonance there. But she was much quicker than me, though I couldn’t help but notice some of the expedients she adopted to get her through “the work” sooner.
I would always ask my patients if they would like any of their “PRN” medications. These are prescribed not to be taken on a schedule, but only if required. There might be such things as painkillers, sleeping tablets, inhalers, aperients or antacids on that prescription. Of course, if you don’t even ask the patients, you can be home & dried much more quickly. You can save a lot of time too when patients “refuse” to take their regular medications. You can just mark the relevant place on the chart with “R”. Nurse B was very quick.
She even managed to record patients’ temperatures on successive nights when the ward didn’t possess a functioning thermometer! We only had two of these electronic gadgets on the ward. One had disappeared and the other had stopped working. Disgracefully, the ward was unable to record any temps until replacements were supplied 4 or 5 days later! That didn’t stop B, because if you’re not in the habit of looking for a thermometer and never do take the trouble to use one, you can remain unaware that there isn’t one available. But you can still make some quick entries on the charts. Get it? 🤔 😜 If we were to afford B benefit of any doubt, we might allow that she’d taken possession of the missing thermometer for her own exclusive use and kept it in her pocket alongside her scissors. It is possible. It wouldn’t be unlike her.
While B would refer to her patients as “Bed 6” or “Bed 19”, I was accustomed to talking to “people” as I carried out duties around them. I found that we could get to know each other and build a relationship of trust, (that’s real trust, with a small t), without the amiable exchanges impeding my work in the slightest. By this means, I’d often pick up details that could be useful in their care, the patients’ preferences, difficulties & anxieties, as well as interesting feedback about other staff. In any case, such little chats were valuable in themselves. I’ve looked after some quite remarkable folk with fascinating stories to share; what a privilege & education it was to listen to many of them. But that’s all for another book. There were others too, of course. One patient, who really did like to chat, rang the ward one night after he’d been discharged, hoping to obtain some advice and discuss his difficulties, (at length), with me. Unfortunately for him, the phone was answered by “B”! When I turned up next morning, “B” angrily challenged me, “WHY DO YOU BOTHER talking to patients, Russell? WHY?” I was so taken aback, I couldn’t, there & then, think of a reason to give her. It seemed it was all my fault that the chap was so talkative. But that question, …from a “Nurse”?
I hope you’re getting the idea now. I didn’t report everything I saw. A lad can get a bad reputation doing that, …or a Reprimand! I am conscious of the importance of drawing a clear line between Personal & Professional differences. I was never going to like the woman, but I confined my objections to genuinely significant professional issues, those with some clear evidence to back them up. As she demonstrated later, Bentley doesn’t appear to be in the custom of making that distinction herself. I find her conviction that my disclosures arose from “personal differences” intriguing. I think she knows a great deal about personal differences. We’ll see if you agree shortly, when a vengeful matron, reflecting of course the highest values of her Trust, sets aside professional considerations to embark on a personal vendetta against me, for rocking her little boat.
These are VERY SERIOUS allegations, Russell! Let’s put them all behind us.
Matron’s recommendation was that, “The most important thing, Russell, is to put all this behind us and get back to work.” In time, I came to recognise this utterance as a sort of Morecambe Bay Mantra, an incantation to be replayed monotonously, over & over, until the “whistleblowing snitch” might be lulled into silent & submissive somnambulism.
🎵“Let’s put all this behind us now, put it all behind … 🎶 Let’s just not trouble to look into it at all, Stare deep into my eyes, you’re feeling sleepy. You must see now that your only remaining chance is to put all this behind you.”🎵
I learned at this meeting that Sr. Humphrey had left her post on Ward 23. As she would tell the Independent Grievance Investigator in March 2008, “I resigned my ward manager post because of this. I don’t know why Russell did not tell me about his suspicions”. A thoughtful reader of this history may be able to solve her puzzle for her. The evasive Humphrey continues to work for the Trust as a Clinical Lead Sister, on another ward.
🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🛌 🚶♂️
Back to work… on matron’s Brave New Ward.
I returned to work on Ward 23, during June / July 2007, on “phased return” building up weekly hours to full-time on day duty. I hadn’t worked day shifts for 16 years, so the routines could hardly be pretended to be familiar to me. Only a most inadvertent matron could have thought this a suitable re-introduction, to “support” me to “get back to work.” Quickly finding myself in charge of the care of 12 patients, I found the ward badly under-staffed and unbearably busy. I couldn’t cope with hopelessly inadequate handover reports, endless interruptions, ordered meals & medications not turning up, working with bank and relief staff not familiar with the ward, the telephone ringing all day long, etc. etc. Staff were getting all the telephone calls answered most efficiently, but not getting through all the nursing care! Please don’t ring a busy ward to inquire whether your relative received her “Get Well” card. Being a meticulous & conscientious worker, I’m never content to have just “done my best”, only to end in failure; I don’t so readily put failure behind me. I like to begin a task & see it through to satisfactory completion. Silly me. Having constantly to apologise for having only one pair of hands robs me of all satisfaction. I found it difficult to trust the other staff too; all new faces, I couldn’t share my troubles with them. I was still nervously awaiting the results of Matron’s Investigations as well, but she’d inadvertently forgotten to tell me she’d already “put all that behind us”.
Being targeted, in darker times
…& dodgy company.
“The most important thing, Russell, is to put all this behind us and…”
Despite encouraging & welcoming my return, Bentley, with ill-concealed satisfaction, promptly presented me with harassment, in the shape of a competency hurdle. Just what exactly are we putting behind us? This bureaucratic encumbrance was imposed ostensibly to demonstrate to her that I was fit to carry out my duties. My GP had already submitted confirmation that there was nothing about my condition that might impair my practice. She’d promised I could “just get back to work.” I can’t recall the title of the humiliating wretched paperwork that she wanted to be completed but, in any case, it wasn’t at all helpful on top of everything else. In my view, her objective was to be just as unhelpful as possible, as she was still resentful that I had exposed her
incompetence inadvertence regarding whistleblower confidentiality. Moreover, my unwelcome disclosures had brought about an almost complete decapitation of her precious ward. Disappointingly, considerations of “The Ward”, “The Hospital”, “The Trust” everywhere gain disturbing precedence over that of “The Patient”.
Reprisal – A Matron’s Childish Crime
In any case, bringing my competence into question contrasted sharply with the Trust’s treatment of both the accused nurses. Neither were ever confronted with the allegations, both having been allowed to leave service without seeing or hearing any of them. The Grievance Investigator later noted that it was illogical to insist that Nurse B could not be interviewed while she was off sick with sciatica, while I was being cross-examined & threatened while suffering certified Stress Anxiety! That Independent Consultant confirmed that, if my capacity to practice had been damaged to any extent, it had been as the direct result of matron’s “inadvertence“. There was no sign of her “putting all this behind us.” Instead, she did her damnedest to “get her own back” and screwed up my attempt to “just get back to work.” She it was, after all, that told me that was “The most important thing.”
“The most important thing, Russell, is to… just get back to work.“
Bentley also found cause to reproach me vindictively for having “encouraged” a patient’s mother to write a formal complaint regarding her son’s care. I was asked by the worried mother if there might be any way in which a promised treatment could be expedited & carried out for her son. Agreeing with her that the procedure was now well overdue, when she asked, “Should I write a letter?”, I told her, “I think so. It can’t do any harm.” It did though! A frosty matron angrily made it clear, through clenched teeth, that she considered my support for the mother to be an act of deliberate treachery! She distributes her uncharitable “support” evenhandedly across patients, relatives & staff alike. This from a woman of undisguised personal ambition, who pleaded that she had inadvertently breached confidentiality, but only because she herself had not had adequate “support” from senior management. Poor thing. Although she herself needs support from above, she finds it difficult to offer any to others and simply cannot manage to “put it all behind” her.
Unwittingly, or perhaps inadvertently again, she had herself now fully completed the task of decapitating the ward. I was, by this time, the sole remaining experienced Staff Nurse on 23, …and I’d had enough. (The patient’s frustrated mother was not available to comment.)
Throughout all this time, Bentley, the trusty bloodhound appointed to investigate my raised concerns, knew that she had no intention of so doing, that she had not even begun to look into it at all. She knew all along that her communications with me bore an insincere title: “Re Ongoing Investigation”. She knew as well that the patient concerned had subsequently died and, most significantly, from the very same condition I’d been concerned about. She knew too that I was suffering prolonged stress & anxiety as a result of her inadvertence & delay. While she gloated over my predicament, ever careful to publicly wear that concerned & compassionate mask she keeps in an office drawer, she advised me to put it all behind me, …when she’d already done exactly that. The bright future belonged to her now. No dead patients nor dirty lowdown whistleblowers were going to get in her way, up to the top of the Trust tree.
“What shall it profit to gain all the wards?”
She’s already demonstrated issues around discerning “personal” from “professional”, so I’ve no doubt she’ll view these paragraphs as “personal” disparagement. That isn’t it though. It’s a denouncement of all those “healthcare professionals” who join, not to contribute, but to climb. When I’m old & ill one day soon, I may be sent many kinds of nurses, good, bad, indifferent, but, pray God, please don’t send the ambitious ones. I’ve found those to be nurses who don’t like to nurse. Actual humble nursing being for lesser mortals to carry out, they seek only recognition & reward from their superiors. Clambering uncaring over their patients, they are en route ASAP to higher things, (Sister, Matron, Chief Nurse and then, who knows, perhaps even Chief Exec, still claiming to have been a nurse once?) …putting all the bums behind them. I myself stand in little danger of being accused of pursuing appreciation from bosses. I wouldn’t find much value in that at all. I don’t seek their approval, their status, salaries or illustrious company. I’m a nurse. I like to keep my hands clean.
While we make great progress towards degrading nurses into mere unthinking process workers, moves are currently being made to have the title “Nurse” protected in law. This will serve to prevent anyone else from attempting to show they can make a better job of it. One will only be permitted to call oneself “Nurse” if matron acquiesces to it. The term “whistleblower” is not protected in any effective way. No appreciable advance has yet come to notice with regard to establishing a more precise & specific definition of the term “Caring”.
“You need more transparency. Part of what I have said is about being more welcoming to families and their involvement in what is going on , and the more people you have, (the force of numbers), occasionally overcomes the vindictive nurse, one would hope. In so far as they exist, (and we know they do exist; they did at Stafford), it is, I’m afraid, the duty of those around them to root that out. I cannot see any other answer to that.” – Sir Robert Francis QC, Mid-Staffs Public Inquiry. He neglected to offer counsel on “vindictive matrons”.
It was all too much. I no longer wished to work under the regime of such a mean matron. I could see no way to preserve personal principles under the “anything goes, just get through the work quickly, put it all behind you” culture that I could see dominating this very modern matron’s Brave New Ward. I felt I could not associate myself further with such hypocrisy that, ever smiling and appearing prepared to listen & help, can express vengeful resentment at relatives’ concerns and feel vehement impulse to suppress them. I won’t treat people like that.
“The world is put back by the death of everyone who has to sacrifice the development of his or her peculiar gifts to conventionality.” Florence Nightingale
It dismays me to learn that Matron Bentley has weathered her inadvertence, and all Morecambe Bay’s storms, to become Matron of “Acute & 24/7 Care” at Royal Lancaster Infirmary. A triumph of pure ambition over poor attitude. What a comfort it must be for her patients to learn that wicked & reckless nurses will receive support on her wards, that dead patients will just be put behind. The things we put behind us may one day return to bite us on the backside.
My sleep problems returned and I found I could not continue.
______________________________________🚶♂️ 🛏️ ______________________________________
Treating the Symptoms, …but NOT the Cause!
I saw the Occupational Heath Doctor who diagnosed Stress / Depression. Again I protested, “I’m not depressed. I’m just fed up!” In his considered opinion, “The most important thing, Russell, is to get you back to work and put all this behind us.” Aah, the monotonous strains of that 🎵 Bay Anthem 🎶 again.
He recommended that I try anti-depressants, “We have lots of staff on them!” I declined his offer.
I was eventually persuaded by my GP to try a course of anti-depressant medication which brought me to feel unconcerned certainly, but *detached, aimless, forgetful & drowsy, without improving my ability to sleep. My GP discontinued the treatment and told me that he believed my condition to be “Reactive Depression”, caused by external factors beyond my control. I was in no mood to disagree.
*Do not drive or operate machinery if affected. Consult your pharmacist. Alternative medicines are available.
Thinking that they’ve “got it in the bag”…
Morecambe Bay Trust boasts that it is a “Great Place”,
but admits that “lots of staff” use medication to carry on working.
🤖 🤖 🤖 🤖 🤖 🤖 🚪🚶♀️🚶♀️🚶♀️🚶♀️🚶♀️🚶♀️
In January 2008, at a “Sickness Absence Review Meeting” with “HR Business Partner” Barstow and Matron Bentley, I was threatened with dismissal, unless I returned to work on Ward 23. This insensitive threat was made to me while I was on certified sickness leave suffering Stress Anxiety. It was particularly hurtful because it was very plain to me that my illness would not, could not, improve until the Trust completed its investigations, those endless investigations that it later emerged matron had never begun. Their bullying brought me to submit a Formal Grievance regarding the extraordinary length of time the Trust was spending “investigating” my concerns & the careless manner in which my disclosures had been handled. No doubt Barstow will put his inappropriate ultimatum down to “an oversight” – inadvertence again.
“Put it all behind us and get back to work…”
When I expressed a wish to return to work, “just get back to work…” I was interested to consider alternative employment in a less stressful area, which had been the intention of the meeting as was proposed by the Occupational Health Doctor. Poor communication between departments led to some confusion because, while Occupational Health found that I was keenly appreciative of their warm cuddly offers of alternative employment, no such thing was actually being made available by HR. Again I was told that no alternative had been found and that I would have to work in the same ward that had already twice caused me to be ill in the past. How could that possibly help to “put all this behind me”? Matron admitted that the ward remained understaffed and that some newly-appointed staff were “not yet up to full competency“. I expressed my anxiety, but “must get back to work.” I felt compelled, against every instinct & principle I possessed, to agree to return to work on 14th January 2008. “just get back… must get back…”
Sadly, I found myself unable to comply with the terms of the planned return to work, due to sleep problems.
The night has fallen, an’ I’m lyin’ awake. I can feel myself fading away…
I was bruised and battered.
I couldn’t tell what I felt,
I was unrecognizable to myself.
Saw my reflection in a window
and didn’t know my own face.
Oh brother, are you gonna leave me wastin’ away,
on the streets of Philadelphia?
“I think one’s feelings waste themselves in words; they ought all to be distilled into actions which bring results.” – Florence Nightingale.
On January 31st 2008, I submitted my first Grievance complaining that the Trust had abused my rights under their “Whistleblowing Policy”. An Independent Consultant was appointed to investigate. He met with me on neutral ground, in my local pub, and took notes of my account of what had happened, but mostly what had not! He then set to his inquiries, interviewing all the participants that were still available and trawling through documentation. The defensive responses to his questions made very interesting reading indeed.
The Investigation Report, running to some 120 pages, was eventually published in April 2008 and was discussed at a Formal Grievance Hearing on 13th May 2008. The report comprehensively criticised the Trust’s handling of the issues and laid clear blame for my illness entirely on this, stating that I was suffering from “work-related stress injury”. Revealing that the Trust had breached every clause of its own policies and had yet, after over 12 months, to even begin investigating my allegations, it confirmed that confidentiality had been breached and no feedback provided. It recommended that arrangements be made for me to end my employment with *DIGNITY, if I so desired. Chairing the Hearing, Business Partner Barstow, scarcely able to conceal his impatience with the result, was nevertheless obliged to uphold my Grievance on behalf of the Trust. He offered an apology for any distress caused by the Trust’s failures. This was ironic as so much of that failure & distress had been caused by his own incompetence. No mention was made of the injured patient, the fact that he had avoidably died over 12 months before as a direct result, nor of any apology extended to his relatives! I’m certain that they will not have been informed of any particle of the circumstances surrounding his death. 🤫
Trust, noun: A firm belief in the reliability, truth, or ability of someone or something.
… then craftily Wash Your Hands & call it all “Historic”.
*DIGNITY? – Over ensuing years, the Trust has consistently repeated to Care Quality Commission, the Press and Police, that my “historic” concerns were investigated at the time. In PR statements, proving that no-one ever paid slightest attention to the Grievance Reports, they claimed, “Unfortunately, the lack of detailed evidence available to us… means we are unable, so many years later, to substantiate the issues he raised. The Trust did carry out investigations into many of these concerns, in 2008 and again in 2009 …”. That sounds so much tidier than the truth, doesn’t it? The only investigations made were into my “Grievances” of 2008 & 9, both arising as they did from failures to investigate and both confirming that no investigation of the original patient safety concerns was ever begun! Four years had gone by without looking into my concerns about patient hydration. Seven years had passed before the Trust could be brought to “review” the “Never Event” death of patient Mr. Beta. By then, they were unable to substantiate because they had shredded the evidence.
Truth no longer matters to this Trust, only what the public, who pay for & suffer it, can be led to believe. “Maintaining Public Confidence” would seem to be the only activity to remain fully under the control of bosses. Everything else must manage as best it can. If they can appear to be running an excellent hospital, without actually troubling to do so, they can enjoy a quiet life up there, with plenty of cake & biscuits.
___ _________________________🚶♂️___…leaving with what?_________________________
Upon reading the whole of the attached evidence and testimonies, I realised that I had very grave differences with some of the statements made to the investigation. I hoped to discuss these anomalies when I met the Divisional Senior Nurse Mark Hulme in June 2008. I was disappointed to hear him admit that he had read only the first four pages of the report, i.e. the Summary, Findings, Conclusions and Recommendations, but not all the attached appendices. He therefore had no knowledge of the issues I wished to raise and saw the meeting purely as a Return to Work interview, despite what he ought to have read in the Recommendations section. He would later conspire with the HR Business Partner Barstow, in evidence submitted to Tribunal, in denying telling me that he had read only 4 pages of the 120 page report. (This denial was of great interest to my Barrister who noted that he had declared earlier, in writing, that he had indeed only read the Summary. She looked forward to questioning Hulme & Barstow about their conspiracy in the Tribunal courtroom. I still have both his letter and his Tribunal Evidential Submission.) He spoke about possibilities of finding placement for me in another area, but admitted that all wards were stressful. He seemed puzzled when I expressed doubts about ever working in a nursing team again. I expressed my lack of faith in the management of these “teams”.
I found myself cast back again into a depression that, after all the ground gained in the Grievance process, I could yet locate no-one in the Trust with the time/inclination to acquaint themselves thoroughly with my position and the continuing patient safety risks issuing from their habitually defensive response to bad news & criticism. The Trust had effectively carried out a lengthy investigation it was not even prepared to read, let alone obtain any learning. Yet it still intended to firmly insist that it had.
Nursing a Grievance
I submitted a further Grievance dated 30.11.2008, which complained that there had been an earlier instance of the Trust not dealing properly with serious reports. This second Grievance specifically referred to the June 2005 report I had made concerning the withholding of fluid infusions. Informed by learning gained from the earlier Grievance process, I was now aware that proper acknowledgement & feedback ought to have been provided regarding any resulting investigation.
The second Grievance Investigation and Report was completed on 9th January 2009. During the painfully long period of fifteen weeks between its completion and its Hearing, the Trust Occupational Health Physician received a referral for me from Senior Nurse Hulme, who had expressed concerns about my mental health. I have some about his. This resulted in my attending sessions of treatment with a Cognitive Behaviour Therapist. Upon review by Occupational Health Dept., the Doctor replied to the Senior Nurse stating that my mental condition was in “status quo“, (ie. without prospect of improvement), while delay in dealing with the underlying issues continued. There was no apparent resulting contact or discernible hastening of the process. The Trust’s concern for my mental health did not, it seems, stretch as far as an obligation to comply with its own stated timescales. The Trust’s Grievance Procedure calls for timely response: “…expeditiously address disputes raised by staff”,“…managers should ensure that grievances are answered and resolved as speedily as possible”, “…timescales given should be seen as a maximum.” Despite repeated appeals from myself, for adherence to the Procedure’s principles, I was to be allowed to go on suffering until such time as the glacial Trust might “in due course” reach a determination.
The Grievance Hearing of April 28th 2009, held after unexplained & inexcusable delay by the Trust of over 15 weeks after completion of investigation, upheld my complaint; the report in question having been found in the Matron’s archive files, unactioned and unacknowledged for almost 4 years. My report had made reference to an intent to hasten the death of selective patients and can hardly be imagined to be more serious. It had been simply date-stamped & filed away without comment or acknowledgement. It would have been most helpful to me to have been given the opportunity to discuss the content at the time. I had, after all, effectively, although avoiding the use of such strong terms, accused a colleague of multiple deliberate & pre-meditated attempted murders and was suffering an understandable level of anxiety as a result. It’s not a thing I have to do most days. In addition, and surely no less, I knew that there was certainly at least one other nurse who shared the view that some patients ought to have their deaths hastened improperly. That nurse thought so little of her patients’ prospects that she would go on later to use one as a “Guinea Pig” to showcase her abilities, resulting in his avoidable death. In refusing to acknowledge or discuss my disclosure, bosses had thrown away their opportunity to explore that issue with her before she took it so far. The Trust apologised to me for any distress caused in a formal written acknowledgement of Grievance Findings. I have no doubt that they did not think to extend that apology to the patients’ relatives. 🤫 “Shush. Don’t tell the relatives.”
During the Hearing, I found that I had to explain my motives to the Chairman, Mr Phil Downey, who asked me impatiently, “Where is all this leading?” I might have hoped that attempting to shed light, into the darker areas of Trust failure, would be appreciated for its own sake. We ought never to ask where events may lead, when we decide to do the right thing. They will lead to somewhere better. I told him that I thought that I had reluctantly almost taken the decision not to continue nursing, no easy move to make concerning my only means of support. He wrote later insisting that I had simply declared that I did not intend to continue nursing! Even his note-taking is not the best. I think he’d inadvertently heard what he wanted to hear. These people are very good at that.
Downey had already inadvertently let slip how little he understood this subject when, muttering “Mitigation. There must be some mitigation…” to himself as he brushed aside wiser counsel, he forcefully, and very foolishly, suggested that S/N A’s victims may nevertheless have been patients who were on the “LCP” (Liverpool Care Pathway). This is a detestable backdoor-euthanasia practice by which patients deemed “terminal” are deliberately, but “legitimately”, dehydrated to death. Had he much experience of such matters, he would have seen that his desperate get-out proposition could not offer the Trust much hope. Doctors do not prescribe fluids for “LCP” patients, so nurses cannot decide at will to arbitrarily withhold them later. (The patients who had suffered deliberate dehydration were not available for comment.)
Corporate Inadvertence. Everyone’s going down with that dastardly “Bay Plague“.
I see that Downey’s sketchy clinical knowledge has been no great impediment to him. Today he is Divisional Chief Operating Officer @ Aintree University Hospital NHS Foundation Trust.
I did find it less than surprising to learn from the Grievance Investigator that, when questioned about the report of June 2005, the unforthcoming Sr. Humphrey told him that she had “no recollection” of it. That was, we may hope, the most gravely serious report a Ward Manager might ever see in her entire career, but amnesia gets the better of her yet. I cannot now hang on to hope that the Trust will show any interest in exploring further Humphrey’s remarkably unreliable powers of recall. It must remain my expectation that future unseemly events on her ward are likely to be “forgotten”, in the interests of keeping up appearances. 🤫
“For Amusement Only”
So now that’s two upheld Grievances,…for what they’re worth.
—————-bogus trifling worthless void null void worthless trifling bogus—————-
“There is no part of my life, upon which I can look back without pain” – Florence Nightingale.
In summary, I believe that I have been ignored and abandoned by the Trust, threatened & punished by some of its members, defamed by my Manager and estranged from my colleagues because I dared to bear the full responsibilities of my position. I felt it my duty to draw attention to the evidence that one colleague was acting malevolently to patients and yet another was dishonest and slovenly. It was my clear duty to inform management and, naively, I relied on their support. I did not expect any recognition for this. I wished only for the malpractice to be rectified and to be allowed to continue my work. I could not have fully appreciated then what incompetence, inadvertence, complacency and self-interest would make of my efforts to maintain standards. As a result, one nurse was allowed to retire without being questioned about very serious neglect of duty, possibly even attempted murder, and a second allowed to avoid facing charges of Gross Misconduct, by resigning to find NHS employment elsewhere. In admitting and apologising for failures, the Trust has shown only an eagerness to put it all behind us. This was done without showing me any reason to desire trusting what might remain of my career to one of their badly-managed and ill-disciplined “nursing teams”. I’m confident that the secretive Sister Humphrey will be able to “forget” all that her memory lapses caused. It’s unlikely that I will find that so easy.
When my NMC Nurse Registration came up for renewal, I had to submit my application forms to the Trust for their approval and endorsement. The Trust inadvertently “LOST” my renewal forms, TWICE! I finally got the message & surrendered my Nurse Registration. Stuff it!
Convenient Inadvertence : Against all the odds, these apparently “random” errors & omissions do all seem to lean in the same direction, don’t they? Always to the Trust’s advantage. #NHSdirtytricks
“Take this damn badge off o’ me. I can’t use it anymore.
It’s gettin’ dark, too dark to see. Feel I’m knockin’ on heaven’s door.
The Careless Profession
Management, always too busy to concern themselves with what is actually happening in the hospital, have distanced themselves from the vexing daily dilemmas to be found at ward level, where they are rarely, if ever, seen . Seeking only confirmation of their superiority, they hear only what they want to hear. A widely-held, & well-founded, belief that complaint will not be listened to or handled professionally has silenced many staff. The Trust never, in 20 years, sought my opinion on any meaningful practical subject. Staff surveys are biased and limited in scope, designed to elicit the responses desired by the Trust. All staff suggestions are dismissed in one of two ways: either they are too trivial however inexpensive, or they are too expensive. Disinterested and disconnected, Trust management continue to trumpet their achievements in PR announcements, press and TV, as well as in applications to Government. Theirs is a “virtual” hospital hovering high above the “real” one with very little contact. The pursuit of *“Foundation Trust” status only made this situation worse. Nothing that may conceivably detract from the achievement of Flagship recognition can be allowed any attention.
*Note: The term “Foundation” is not to be confused with the phrase, “Down to Earth”.
“No man, not even a doctor, ever gives any other definition of what a nurse should be than this — ‘devoted and obedient’. This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman.” (…nor a whistleblower!) – Florence Nightingale
Such management diversions allow staff to work independently and unsupervised, adopting whatever disagreeable practice or expedience, confident that detection is unlikely and can be relied upon not to result in any form of accountability. Those staff who dare report incidents will be summarily “dealt with”, …but only those. These measures select for the qualities of scared & silent subordination and ditch the conscientious & caring, undermining the whole profession. The portrayal of a hospital ruled by fear & reprisal, defended by tight lips & unfair dismissals, is not an appealing one. Such a depiction clashes with its polished PR image of mythical benevolent “Angels” guided by wise & vigilant professionals, steered by experienced & engaged administrators.
“Clinical Governance” here is no more than ethereal euphemism with no tangible existence. The term conceals an indolent, ill-disciplined, laissez-faire rat’s-nest of convenient inadvertence, incompetence, complacent self-interest & vengeful retribution, carefully crafted to deliver up a palatable delusion to regulators & privileged bosses. I can still hear their sycophantic bullies whispering to each other,“Everything’s under control. Anyone who says different must be a mistaken, disloyal troublemaker.” Just how exactly, in the name of any type of transparency, could my “openness & candour” so swiftly sweep me from “Hard-working, valued team-member” right down to “discarded dissident”?
Did I really undergo 3 years training only to stride, “devoted & obedient”, in synchronised lockstep left, right, left, with a scared & silent *Sonderkommando? Smiling sympathetically, meek & medicated, they do just as they’re told and keep their secrets close, or else! They don’t care for the patients; they care only what the miserable matron might say. I can just hear them now, softly chanting their chilling refrain, “🎵 putting it all behind us, putting it all behind us, la-la-la-laa-la, it’s all behind us now…🎶 “. Their little wings flutter gently as, detached & forgetful, they get back to work, …burning the evidence. 🤐 No thanks, I’ll march along with Florence for now.
Medicated staff sleep-walk to work on Matron’s Model Ward.
* The Nazi death-camp Sonderkommando were prisoner inmates, ruled by fear of cruel punishment, deprived of all rights to complain or refuse, whose primary duty was to dispose of corpses. As they had detailed knowledge of the Nazis’ practice of mass murder, the Sonderkommando were considered Geheimnisträger – “bearers of secrets“, held in isolation away from others and prevented from speaking out. Periodically, they would be “disposed of” themselves and replaced with new arrivals to ensure secrecy. One such unfortunate, Zalman Gradowski, buried his note-book, before he was murdered in 1944: “Dear finder of these notes, I have one request of you, which is, in fact, the practical objective for my writing … that my days of Hell, that my hopeless tomorrow will find a purpose in the future. I am transmitting only a part of what happened in the Birkenau-Auschwitz Hell. You will realize what reality looked like …from all this you will have a picture of how our people perished.”
I suppose this miserable narrative of my NHS career will have to suffice as my paltry equivalent of that poor man’s hidden notes. “…that my hopeless tomorrow will find a purpose in the future.”
🔥 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🔥 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🛏️ 🔥
What’s the matter? Do you feel I’m being too hard on the poor things? Our precious NHS surely deserves more reverence & respect than this, does it? Ought we not to be more tolerant of a hospital run with the cheery nonchalance of Monty Python’s “Always look on the bright side of life” …& death? 🤡 Should we not put all that inadvertence behind us and just be thankful for healthcare delivered with the happy-go-lucky aptitude of Peppa Pig? Can we not simply learn to live & let die with the rough & tumble ethics of the school playground?
Oh, don’t worry. I’ll let you get back to your angelic daydreams in a moment or two. I’m not, after all, quite so disparaging of the “real” hospital. The “Caring” in this Trust gains consistently “Good” scores at CQC Inspections. Most staff do maintain decent standards under trying conditions. It’s the Management functions that never fail to get low ratings. We’re all grown-up enough to know that there are bound to be an odd one or two bad apples. My agonies at their hands convinced me that there are bigger problems up yonder, in that hovering “virtual” bosses’ hospital above us, where the very existence of bad apples is strongly repudiated and underhanded tricks are played to prevent their removal from the barrel.
If all this seems a bit strong, then do bear in mind that mine is a cold sober, after-dust-settled evaluation of just two or three shameful episodes, in a long well-documented chain of poor performance that continues to this day. It’s my open & transparent account of events that I personally witnessed & experienced, all candidly unvarnished. That’s the least any proud whistleblower ought to offer you. Oh, the named antagonists will have their own stories, I’m sure, but might I suggest that, if they can’t stand the heat of accountability, then they could do us all a favour. There’s no barbed wire around that particular devil’s kitchen yet. They must learn that cock-ups, however suspiciously inadvertent or not, do carry consequences. Perhaps now I can show them that their childish Reprisal crimes do sometimes, eventually, return with repercussions. In fact they keep returning, don’t they? It’s difficult to “put them all behind.” Well, they did get 12 years of anonymity. That’s enough now.
I may sound a little bitter perhaps. Aye, I’ll give you that; but I challenge you to say it’s without good cause. When you’ve been kicked while you’re down, it can take a lot of forgiving. I speak out boldly now from experience of a long & painful ordeal. I lost a lot of friends, money, confidence, peace of mind, all joie de vivre, raison d’etre, all my hope in fact. All the little projects I was working on went to rack & ruin, all gone. I was left for years among the worthless wreckage of my life, struggling to pay the rent and staring empty-eyed, at some undefined point 10 feet beyond a blank wall. But then of course, let’s not forget that at least one patient did actually lose his life! I’m not prepared to euphemise all that. Others can be relied upon to slap on their coats of whitewash.
Some may decide my treatment was all just damned bad luck, old boy. The result of unhappy inadvertence perhaps, but I detected far too much self-interested intent, deception & backroom tinkering to accept it was all meted out by fickle fortune. No, that wasn’t luck. It was a rare example of efficient & co-ordinated managerial-team engineering. Each time opportunity arose to learn and set things on the right course, each faint-hearted flunky in turn scurried down the path of least resistance, toward their shared-cultural default position of “Must Defend Trust Reputation, Down with the Troublemaker”, “What will my boss think if I don’t stop him now?” No-one is ever quite sure what might please a Chief Executive up there in his comfortable eagle’s nest. Perhaps he’s not sure himself. Given that all the information he can ever receive will have been through all the filters & “purification” processes I encountered, I would little wonder. There are never any flies in his soup, everything’s just fine.
But anyway, I can’t be all that much mistaken. Both Grievance Reports were accepted in full by the Trust, with apologies. Assuming they were ever read at all, I hoped that I might have taught some valuable lessons. The Human Resource Director assured me that my case “would not be handled in that way today”. But they’re still at it! I’m not alone.
“Inadequate / Requires Improvement”
This Trust does invite, deserve and receive strong condemnation from a large number of sources, not least: https://www.cqc.org.uk/provider/RTX
… as well as: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf
And don’t just take my word for it…
Ask Sue Allison, a Radiographer whistleblower, ostracised, harassed, subjected to extensive bullying & unlawfully gagged.
Ask Peter Duffy, Consultant Urology Surgeon whistleblower, unfairly dismissed for raising concerns but still being roasted alive in Trust furnaces, as I write.
Available from Amazon (other suppliers may not be available)
We may never know how many others there are out there, broken-hearted in the cold & silent wilderness.
Morecambe Bay have an unsavoury history, for instance, of banishing their critics & whistleblowers to the outer fringes of their Empire. As just one of the available penalties, anyone raising concerns can be exiled, to commute daily to work at the Trust Penitentiary Gulag in Barrow-in-Furness, 50 miles away!
Not at all in the spirit of “putting all behind us”, I myself was treated to a pathetic regurgitation of every shortcoming & infringement the Trust could dig up from my “historic” record. They must have been disappointed to find they didn’t have much against me; the most substantial being that ridiculous “Reprimand” handed me for not sharing tittle-tattle. Trust misdemeanours are consigned to a “historic” scrapyard, but staff transgressions, be they ever so trivial, are preserved & stored away in archives to be recycled later. It didn’t take them 21 weeks this time to unearth mine, Sister Humphrey can remember some things. Much was made of my not turning up for a shift once, years before, after multiple swaps, crossed-out, ‘Tippexed’-over amendments & re-alterations to the “Off-Duty Roster” had left it looking like the results of a noughts & crosses game in a Children’s Nursery. I will always suspect that “flexible approach” to Nurse B’s working hours that Humphrey mentioned. If “B” doesn’t want to work Wednesday night, she can just
Tippex it out & pencil Russell in for it. When I’d left the ward on Monday morning, I wasn’t down to work that Wednesday night… but, apparently, it was all my fault. 🙄 It was nice to be missed though. Nurses only become important when they’re not there. Luckily, they hadn’t the slightest suspicion of me parking my bike in an unauthorised place. Phew! Got away with that one. If I’d started to list the Trust’s failings in reply, we’d have been there all week and more.
“How does the witness plead? Guilty? or Not Guilty?”
But seriously, must one be TRULY PERFECT to be heard in their 🦘 courts? I was a WITNESS, not the accused. Do Criminal Courts try witnesses first before they see the defendant?
The over-riding top priority in Morecambe Bay is not Patient Safety, (that’s too embarrassing for them, shhh… don’t even mention it 🤫), but Reputation. Frequent PR press releases crow about how well they are doing in trivial & insignificant areas, …but never a mention of that uncomfortable subject, “Patient Safety“. 😳
🗣️📢 💨 “This is Superficial Appearance Control speaking. Are you believing me? Over…?”
These days, all their talk is about moving forward, moving on. They like to describe their own past failings as “historic”, “we put it all behind us”, as though they might have occurred long, long ago in some far-off medieval monastery, but oppressive practices continue; methods much polished & perfumed over years of experience, refined so as to soothe the anxious observer & avoid offending those of a delicate disposition. It’s all done subtly, out of sight, quietly & politely, these days.
They just don’t mention this sort of thing in those TV hospital dramas, do they? I never watch them anyway.
“Ain’t no angel gonna greet me, it’s just you and I my friend…”
🧚 🧚 🧚 🧚 🧚 🧚 🧚 🧚 🧚 🧚 🧚 🧚
If about now you’ve begun to suspect that I may be opposed to the very notion of a publicly-owned, democratically-accountable, free-at-point-of-use NHS healthcare system, then I apologise. I must have failed to put across my objectives clearly. I was born in this hospital and it looks likely I might die in there too. They have tried to bury me in it already. My aim is to reboot the bosses to an extraordinarily novel programme. Brace yourselves, I know this is going to come as a shock. They are NOT expected to run a “Business”, along the lines of what they learned in Business School. This industry ought not to be at all like some braggart’s Second-Hand Car Showroom. They should aim to run a “Service” that puts patients before all else.
To put it in terms with which they may be familiar:
- For “Stakeholders”, read “Staff”
- For “Shareholders”, read “Patients”
- For “Customers”, read “Patients”
- For “Profits”, read “Patients”
- For “Business Partners”, read “Relatives”
- For “Spreadsheet”, read “Hospital Mortality Rate”
- For “Who the hell are we trying to please?”, read “Patients!”
- Boasting is not quite the same as advertising. Quit boasting until everyone else is proud of you. No, just quit bragging. Just stop it!
- Reputation is for later. It will naturally follow along behind good service, just as it should.
- Public Confidence has to be earned, not cultivated, even less demanded.
As I’ve told here, no report potentially damaging to management reputation will be acknowledged, investigated or acted upon, even if it contains information relating to an intent to murder, or practice likely to endanger the lives of patients. Business interests, image and appearance have become everything.
Keeping Up Appearances
We need not care for patients, but we must appear to do so. If we avoid listening to patients & relatives, adorn the beds with paraphernalia not actually in use, meticulously chart & record the patients’ decline, smile sympathetically while making false promises, discourage complaint, silence & frustrate all dissent, hand out misleading briefings to Press & Police, burn the evidence and ignore every warning from history, then we may be able to pull it off. Then we can LOOK like a real hospital, without going to all the bother of being one. We can each carry out our own abhorrent criminal agendas, use real live patients to practice on, employ medical terminology & the sorcery of 🌀spin to bewilder inquiry, keep our superior noses in the air with minds seemingly fixed on “higher” things, shift blame onto the only staff doing any really productive work and keep putting it all behind us. If problems do come to external attention, then we can appoint yet another Director in a fanfare of publicity, always protesting that funding does not allow recruitment of more nurses. And throughout, Trust reputation will be maintained at some “acceptable” level, “no worse than the rest”, by the stubborn efforts of low-paid staff to continue protecting patients whatever happens.
This cannot be the way in which the public expects a hospital to be run. Indeed it owes more to the style of dishonest doorstep sales than the business of caring. What do they teach them in those Business Schools? Such a scandalous situation deserves my most strenuous attention.
On 20th July 2009, as yet unable to interest any management member in the whole truth, I was obliged to submit my resignation from the post of Staff Nurse.
No cakes & pop for Russell.🎉🎈🥂 No slap on the back, nor any handshakes.🥳 No ceremony at all.
Not that I like that sort of thing. I emptied my locker, leaving the key in its open door, and walked slowly away. Only my echoing footsteps on the stairs were there to applaud me as I left the NHS (with great dignity) & glass doors swished shut behind me.
Aged 15, I remember telling my school “Careers Master” that I knew what “career” meant. It meant “rolling downhill out of control”! All my grateful patients are probably now dead & gone, leaving only the HR Department to deal with my earthly remains. No doubt by now there is “nothing to suggest” that I ever did anything at all. The more experienced a nurse becomes, the more that bright young things brandishing *brand-new* qualifications and with eyes fixed on the sparkling future will treat the old drudge as anachronism. Embarking on their exciting journey, they gaze ever upward and over a sad, tired left-over from times long past. It doesn’t even feel fair to tell them what’s in store. New was always so much better than old, wasn’t it?
I was 58 years old now with no job, no usable qualifications, no transferable skills, £25000 in debt and suffering long-term depression, PTSD, anxiety & insomnia. NHS left me in worse shape than the Army.
I remained on certified sickness leave, with only half-pay after early September 2007, until my entitlement ended altogether in early March 2008 (while still awaiting results of my Grievance). Thereafter I existed without *income of any kind, until I began receiving “NHS Temporary Injury Allowance (TIA)” from the Trust, but only after they had conceded my Grievance, in May 2008. The Trust then discontinued paying TIA on my leaving, inadvertently forgetting to apply for NHS Permanent Injury Benefit on my behalf as they ought to have done. I was assured, in writing, that, I would be retired on “ill-health grounds”, as verified by the Grievance Reports, but this was “inadvertently” overlooked and “could not be amended” afterwards! After resigning, I was able to claim “Incapacity Benefit”, and later “Industrial Injury Disablement Benefit”, assessed by DWP to be “30% Psychologically Disabled”, as a result of Stress arising from mismanagement.
Professional Inadvertence, noun: an error, an omission, not as was intended? Have you noticed yet? Unlike what we know about falling buttered-toast, their “entirely inadvertent” dropped clangers consistently tumble in the Trust’s favour. It’s butter-side up for them, every time! Lucky-lucky! #NHSdirtytricks
* By April 2008, my application for Incapacity Benefit had been turned down and although the local Council had notified entitlement to a 0.64p a week interim payment of Housing Benefit, I hadn’t yet received even that! Other benefits were unavailable to me as I was still seen as “employed”, albeit now unpaid. Incapacity Benefit was eventually granted after undergoing an appeal process later. However, when I attended the April 2008 Grievance Hearing, I had “no visible means of support”, in more ways than one.
“A person who has no visible means of support and loiters in a public place might be arrested and prosecuted for vagrancy.” The Trust, having reduced me to this status, would later, with no hint of self-consciousness or shame, offer me their “gratitude and respect” for my 22 years hard & dedicated work! 🙄
By cleverly exploiting my financial dire straits, brought about by the illness incurred from whistleblowing, the Trust obliged me to agree to give them “time to look for alternative employment in a less-stressful area”. (Oh yes, I fell for that same old offer again!) After a very lengthy search, they admitted that there were no such opportunities available; nowhere I might be able to find my feet again, (…and perhaps even rebuild my faith), in all three hospitals of that “Great Place to Work” – “All the wards are busy & stressful.” The Trust then inadvertently took 21 weeks to report on my 2nd Grievance. By this time, any claim I might have made to Employment Tribunal re the findings of the 1st Grievance was “time-barred”. The Trust has clearly played this game before. I’d paid £9000 in legal fees from my pension lump-sum to discover this deception and felt compelled in 2010 to sign a non-disclosure agreement (NDA Gagging Clause) to recover that sum. This so-called “SuperGag” prohibited me, not only from ever mentioning the above events, but also from disclosing that I had signed an NDA agreement at all. I was to to keep quiet and not mention that I was keeping quiet! Patient Safety concerns had successfully been concealed.
🤫 Remarkably, absolutely no inadvertence was detectable in the cover-up effort.
Throughout my captivity, ensnared in a weird web of self-adoration Morecambe Bay had spun & woven for itself, the Trust cruised on sublimely to achieve Foundation Status. Few dared challenge their much-trumpeted success, though even fewer knew quite what that success might actually be. Flattered & fascinated then by their own reflection in the public eye, they gazed outward and dreamed of conquering new empires. They made promising bid to take control of all Cumbria’s Health Services and looked set to deliver their undisputed benevolent influence right across the North-West and next, …the world. Blissfully blind that their renown might rest only upon their own vain assertions, caked in cover-up cosmetics, propaganda perfumed, an unheeding Titanic Trust steamed on, arrogantly contemptuous of whistled warnings, certain & unsinkable …straight into the ice-field.
Maintaining Public Confidence
A long series of tragic incidents at Furness General Hospital’s Maternity Wing had brought forth pressure from a group of determined South Cumbria protestors who, after stubbornly negotiating heaped piles of Corporate *BS, engaged the interest of Police. As cops began to investigate multiple deaths and injuries of mothers & babies, executives explored different ways of spinning these adverse tidings. They were “confident that the Trust offered the highest standards of care”, “determined to put things right”, “reviewing their strict policies & robust procedures”. Above all, they were keen to “put it all behind them.” The most important thing now must be to “maintain public confidence”, they implored. But a flood tide had turned against them. Various Watchdogs & Regulators stirred from slumbers to hastily scribble down a few inspection reports, distancing themselves, before it was all too late. Vulture-like they circled, wearing condemnatory expressions, to observe the stricken ocean giant helplessly foundering in stormy seas.
* BS = Bovine Sanitation.
“Iceberg! Dead Ahead!”
A colossal iceberg then loomed out of the tempest. Statistics signalled that the “White-Wash Line” flagship had set a new record for itself, achieving the country’s highest Hospital Mortality Rate! Oh, how they did make such valiant efforts to dismiss the findings as “statistical error”. “The catchment area has a high proportion of elderly residents,” they pleaded. “Methods used in the calculations are questionable”, they hoped. But now the vessel was irreparably holed beneath the waterline and eminent Board Members were seen to make good their escape into lowered lifeboats. Some sailed off into ignominious obscurity, no doubt to protest in memoirs that they had tried their best, but failed only through the inadvertence of lesser midwives. But others did survive the sinking, to swim away, blaming each other & everyone else, still clutching whatever valuables they could quickly snatch up. They found refuge in lucrative positions elsewhere, deep inside the welcoming embrace of the labyrinthine NHS, and tried to “…put it all behind them.”
Exploring the Wreck
Next came launch of an Independent Investigation. The Chair, Dr Kirkup, would plumb the murky depths, taking evidence from many sources, grieving parents, injured patients and relatives… as well as staff witnesses. I duly took my place on the witness-stand. Promising to tell the Truth, the whole Truth and nothing but, I poured out my heart on the subject of “Trust Responses to Raised Concerns.” The Trust ultimately accepted the Report’s Findings and Recommendations in full and apologised most profoundly. Those words seemed strangely familiar. 🤔
So, thus vindicated, (& comforted), by the richly-deserved entry of “the name of Morecambe Bay” on Kirkup’s “Roll of NHS Dishonour”, reinforced by the mortality rate score, and further armed with a letter from Sir David Nicholson, NHS Chief Executive, who declared that gagging clauses with regard to Patient Safety issues were “utterly unacceptable”, I decided I should no longer accept my “Gag”. All of my disclosures were well qualified under the Public Interest Disclosure Act and had been side-stepped & suppressed only to preserve that once-precious, now-disgraced, “name of Morecambe Bay”.
Calling out the Trust’s bluff, now that they have no reputation worth saving, I have “blabbed” to Channel 4 Dispatches, Sunday Times, Lancaster Guardian, Radio 4, Bay Radio, Heart Radio, The Morecambe Bay Investigation, Lancashire Police Major Crimes Unit, Morecambe Bay CEOs Jackie Daniel & Aaron Cummins, NHS England, NHS Improvement, Jobcentre & Citizen’s Advice staff, several barmaids, half a dozen taxi drivers, that bloke on the train, Uncle Tom Cobley, Facebook, Twitter and, yes, there are more to come! That’s just what’s expected of a dirty lowdown whistleblower, isn’t it?
We thought him a promising man, but he was just a man of promises.
Thank you for your patience in reading as far as here. I’m grateful. You’ve done more than any Trust Manager ever wanted to do. Although I did my best to have all this understood by the 🙉 bosses, and although, (in a period when I felt like just curling up in a ball), I laboriously put it all down in writing to present to an Employment Tribunal, a proper hearing of the whole truth was denied me. Passage of time hasn’t diminished the urgency to have it heard. Indeed, recent revelations have strengthened the desire to have it all put right urgently. The Trust has NOT learned from the experiences of its last 15 years and continues on its ponderous robot-like destructive course, accepting & concealing a number of avoidable deaths, still ignoring, bullying & punishing whistleblowers, self-satisfied and arrogantly convinced that it has nothing much to learn really. “Putting it all behind them.” The Human Resource Director defended their appalling “historic” treatment of those who raise concerns by saying, “We’re no worse than the rest.“ That is a most extraordinary contentment, isn’t it? A body, that consistently finishes each race among the stragglers at the back, finds solace in being among a crowd of so many others, no better than the rest of the losers! If you’d prefer to believe them that all is well, or near enough, then you’ll be able to find plenty of people that will back that up and assure you they had no complaints when they were in hospital. You’re unlikely to hear from many who did get a rough ride.
Hush! 🤫 Can you hear any whistleblowers? No? Neither can I.
Russell Dunkeld ex-RGN 🤐