A Whistleblower’s Woes.
A summary written for my Solicitor on the day I resigned in July 2009.
(with some later updates)
“Tell-tale tit, your tongue shall be slit”
…..from a nursery rhyme.
March 1980: I joined 307 Field Ambulance RAMC, Territorial Army, subsequently training to Combat Medical Technician Class 1 and gaining the rank of Corporal.
April 1987: I began Nurse Training to RGN.
August 1990: I was registered 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).
I have worked continuously as Full-Time Staff Nurse for the Trust, since 1990, with the exception of a six month period in 1996, during which I was called up, by the Territorial Army Medical Services, for service as a Medic in the Civil War in The Former Yugoslavia. I was attached to the Parachute Regiment as Med. Corporal in charge of a British Army Base Medical Centre in the world’s most heavily-mined town.
1997: I moved to Ward 23 at Royal Lancaster Infirmary, a 24-bed both genders ward: the Acute Stroke Unit. We also see 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.
It was never my ambition to become a “Whistleblower”. I wouldn’t have known what it meant. Rather, that role grew around me as my experience of caring increased my awareness. Starting on little whistles led on inexorably to bigger whistles, as a growing determination to have things done well led me into conflict with some other staff. In fact it was bosses that first termed me “whistleblower” when they sent me a copy of their Whistleblowing Policy. I’d never heard of it before &, as it turned out, neither had they!
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 intended to steal stronger “Kapake”, a Prescription-Only medicine, from the ward drugs cupboard. When I next worked with this nurse, 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. It was over 12 months before the Trust finally dismissed the woman. Before this conclusion, it became obvious that, somewhere along the course of management’s procedures, confidentiality had been breached. My informant colleague was shunned and “sent to Coventry” by other staff, at work and elsewhere, receiving anonymous threats of violence & death by telephone. A Police call-recording tracing device was put on her phone-line. Objects were thrown into her garden at night. She was forced to take time-off sick. She still today feels disadvantaged at work, because of the part she played. I would later receive an “Admonishment” from the Nursing Director for not sharing my suspicions before the theft!
During this lengthy nightmare, 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 running, without the 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 had just seen, behaving suspiciously. I had stopped at a junction, when a car, coming away from the farm at speed, braked violently as it passed me, mounting the kerb and skidding to a halt on the grass verge, some 50 yards beyond the junction. As I drove on away from the junction, I watched in the mirror as the car made a violent U-turn in the road, accelerating to follow me aggressively, very close, for about 400 yards, before falling behind. 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. But the woman has two sons, as well as a husband! I felt exposed, frightened and resentful, but knew nothing of Whistleblowing provisions at that time. Neither did management, it seems!
And this is the life of a nurse?! Some ignorant people think it “Cissy” to be a nurse. Which kind of nurse would you be?
or a Whistleblower?
Hospitals are only an intermediate stage of civilization.” Florence Nightingale.
In May 2005, 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, i.e. not being administered because the giving-set clamp was switched 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.
Realising that something was amiss, I set about finding the cause. I realised that these incidents were affecting only those patients cared for by Staff Nurse A and were apparent only on those occasions when my shift followed those on which she had been in charge of twelve of the ward’s patients.
On one night, S/N A was giving me details of a particular patient, during “handover” as I took over the ward. I became suspicious when she told me, in a manner more detailed 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.” I went straightaway to that patient and found that his infusion had been switched off at the roller lock at the very moment that the bag had emptied and before the giving-set chamber had run down. This implied that a member of staff had been aware that a fresh unit was required. I took the view that S/N A had turned off the infusion and had not attempted to continue it, concealing her omission by that incoherent report.
In early June 2005, I found an opportunity to talk to S/N A about these incidents. Believing we were not overheard, I 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 excuses. However, I was shocked to hear her say, “Well, he is terminally ill. What are you doing when you give these patients fluids? You are just killing them slowly, aren’t you?”
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?”
So there are two of them then!
It matters not that S/N A should protest her own opinion of this man’s “terminal” state. The fact remains that a Doctor had taken the decision to prescribe fluids and her clear duty was to carry out those instructions.
On 4th June 2005, I told a Junior Sister, Sr. C, about my discovery. She told me “Russell, I can’t do anything about that unless you put it in writing!” I felt obliged to make a hand-written report during the following night and handed it to Sr. C next morning, 5th June 2005.
I did not see Sr. C again for several months, because she took promotion to another area, but I do know that she passed on my report to the Ward Manager, Sr. D. When I started work one night, Sr. D 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. Nevertheless, I expected that Management, or even the Police, would want to, at least, 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.
On 23rd September 2006, I was on night duty on Ward 23 RLI. As I began work on the ward, a patient, Mr DS, 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 I 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. I was unable to afford him the time it might have taken to explore his feelings.
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 threw himself at me, head-butting me in the face and bringing his knee upwards into my groin with great force. It is difficult to account for the next minute or two, but after a considerable effort, I pushed him to the floor in a store room, sitting 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 testicles, as well as general aches and pains from the volley of blows that I had received. DS was uninjured.
At 06.30hrs on the following morning, 24th September 2006, Mr DS 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 arrived. During this attack, 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 DS had been told that he had his own tobacco, locked in the CD cupboard for safekeeping. No-one had thought to inform me of this arrangement and DS was unable to explain to me.
I suffered a considerable amount of stress following the assaults, the episode being the more regrettable, because it could have been so easily avoided. It is 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. I had some difficulty reconciling my mixed feelings. I concluded that circumstances had forced me to behave in a wholly uncharacteristic manner.
The way in which these incidents were handled by management would come in for comprehensive criticism later, from the Independent Investigator of my first Grievance of 31.01.2008.
I believe these events were continuing to have effect upon my motivation, when I met with my Ward Manager Sr. D 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 kindly observations would not prevent her from attempting to discredit me later, during the investigation of the first Grievance.
But still 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 could instantly see 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 S/N 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 S/N B, but she agreed. At 02.00hrs, Night Sister came to the ward and told S/N B that she was free to leave. S/N 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 have 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 D.
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 history of S/N B’s past misconduct. The incidents I had mentioned had all been reported and “dealt with” earlier. The Fraud Investigator took the impression that I was making a first report of those events, a number of which had occurred some 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. 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, which had been copied to my Ward Manager Sister D, breaching confidentiality!
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 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 found this attitude to misappropriation of over £35 discreditable. Sr. D 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, Sr D 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.
Laboratory Guinea Pigs
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, “GW”, she proudly told me that she had recently qualified to pass naso-gastric feeding tubes on patients with swallowing difficulties (common in Stroke patients) and had been hoping to find a patient who required one. She glowed with pride as she told me to “let Sister D know” that she had successfully demonstrated her new skill on GW. She admitted “I shouldn’t have, he’s already had four inserted and pulled them all out”. The clinical protocol, as it was understood on Ward 23, required 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. At this point, I made no comment, but lowered my spectacles to stare over them in a mixture of disbelief and disapproval. Revealing that she was aware of my 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”. When I reached GW, I immediately recognised that he was slumped down in the bed, very flushed, and hyperventilating. As we lifted him up the bed, he vomited and I had the feed pump switched off. His temperature was in excess of 39 degrees. I immediately administered oxygen at a high rate and called the doctor, who diagnosed Aspiration Pneumonia, prescribing high doses of two intravenous antibiotics. I observed that the Dietician had emphasized that the feed should have been given during the “Daytime Only” by marking the chart accordingly. It ought not to have been started as it was, during the late evening, set to run for fifteen hours, during which period the patient would not be as aware as he might. I reported this to Sister D, when she came on duty in the morning. She looked shocked and concerned, commenting “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 re B. 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.
Despite my recounting the events and producing documentary evidence to Modern Matron 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 the clinical protocol a patient’s life was put at risk.” The Trust did not reveal to me that patient GW had died some ten days later. I only discovered that fact when the HR Director assured Police, in 2015, that there was “nothing to suggest that his death was in any way affected by the alleged procedure carried out by (Nurse B)“. His Death Certificate lists 1. “CVA” (Stroke) & 2. “Aspiration Pneumonia” as causes. A review of the death, carried out (without informing relatives) by the Trust a full 7 years Post Mortem, revealed that, original notes having been destroyed, the microfilmed page of notes referring to the NG Incident had somehow become illegible on microfilming. The Trust Chief Nurse carried out this review & suggested, optimistically, that the patient “may” have had Aspiration Pneumonia on admission. If that were the case, it went undiagnosed throughout!
Previous incidents concerning B’s clinical practice had been made known to Sr. D in the past. On one occasion, while helping an elderly lady to bed, a pair of scissors had protruded through a hole in S/N B’s uniform pocket and stabbed the patient in the leg. The leg became very badly infected and swollen requiring treatment with IV antibiotics; the patient being very ill, 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. Yet Sr. D does not know of “any specific incidents that led (her) to be concerned about B’s competence”. I regarded this “accident” as criminally careless, especially when, some weeks afterwards, I saw B with unprotected scissors still poking menacingly from the hole in her pocket.
“Let’s play Doctors & Nurses.”