A Long History of Whistleblower Abuse.
Even before 347BC, Plato is said to have observed that “No-one is more hated than he who speaks the truth.”
Vilification of the whistleblower clearly began a very long time ago. Centuries later, it had become a well-established way of dealing with bad news.
In 69 BC, a large Roman Army led by the Consul Lucullus, was seen to be approaching Tigranocerta, the Royal City of the Armenian Empire. King Tigranes was less than happy to hear this.
“The first messenger to give notice of Lucullus’ coming was so far from pleasing King Tigranes that he had his head cut off for his pains, and no man dared bring further information. Without any intelligence at all, Tigranes sat, while war was already blazing around him, giving ear only to those who flattered him.”
The Romans destroyed his city and plundered the King’s Treasury. Though a great many agencies & reviews, since those times, have claimed to have put an end to such injustice, they have all failed to provide adequate protection for the Whistleblower.
Breaking News: June 6th 1944… Allied forces launch an invasion of “Fortress Europe” on five beaches in Normandy, France. As 156,000 Allied troops land by sea & air, the Nazi Fuhrer, Adolf Hitler is asleep. No-one dares to wake him with bad news. Crucial hours will be lost before command decisions can be transmitted to defenders. Stay tuned for updates as they come in…this one could go either way!
Morecambe Bay Trust’s Policy on Whistleblowing has been “reviewed” twice since I reported the malpractice(s) I witnessed in 2005 & 2007. Despite this, there is no appreciable difference between the three documents. Whenever difficulties or failures are exposed, the Trust issues apologies and platitudes, expecting the public to be satisfied that, “We are reviewing our policies.”
In fact there was very little wrong with the existing Policy had anyone involved troubled themselves to adhere to it. As a result, I am strongly of the opinion that such policies are written solely to fulfil external directives, then quickly consigned to a drawer, to be dusted off and proudly displayed whenever Inspectors require to see them. I quote from the Policy as it was in 2008.
“If you raise a genuine concern about this policy, you will not be at risk of losing your job or suffering any form of retribution as a result.”
I was eventually obliged to resign my post on principle that on both occasions my concerns had not been investigated at all. I expect that the Trust would here maintain that I was NOT at risk of dismissal had I chosen to return to work and remain silent about management failures to prioritise patient safety. During my ordeal, I was subjected to several detriments and retributions.
• My immediate Manager ignored and refused to speak to me.
• I was presented with competency hurdles as if there was doubt concerning my abilities.
• Several trivial, wholly irrelevant and unsubstantiated allegations about my own conduct were made in statements by other staff members (who were in any case indirectly implicated in my original concerns).
• I was threatened with dismissal if I did not return to work on the same ward that had already twice caused me to be ill.
• Insinuations were made concerning my mental health, even after the Trust had formally acknowledged that they had caused me to suffer a stress/anxiety injury.
• I was ‘persuaded’ to undergo a course of Cognitive Behaviour Therapy with a Trust Counsellor, (this despite the Trust Occupational Health Physician’s assertion that, in his opinion, my condition was “in status quo” pending resolution of my original concerns). The full transcript of these “Confidential” sessions was subsequently presented to Employment Tribunal as “evidence” (of what was never made clear).
“We will not tolerate the harassment or victimisation of anyone raising a genuine concern. However, we recognise that you may, nonetheless, want to raise a concern in confidence under this policy. If you ask us to protect your identity by keeping your confidence, we will not disclose it without your consent.”
• Within days of raising my second major concern, my confidentiality had been breached by Matron. This breach brought about my illness and was later formally acknowledged by a Trust Grievance Hearing.
“We will not tolerate harassment or victimisation and will take action to protect you when you raise a concern in good faith.”
• The Trust has recently admitted that much more ought to have been done to support me.
“Once you have told us of your concern, we will look into it to assess what action should be taken.”
• Grievance Hearings admitted that no investigations into either of my original concerns were ever begun, despite several letters written to me titled “Re: Ongoing Investigation”.
Indeed the only investigations made were into me, my mental health, my sickness record, my character, my conduct.
• The Trust would later insist to local & national press that the investigations of my Formal Grievances were investigations into those concerns. This is NOT the case. Both Grievance Investigations were confined to the breaches, including breaches of the Whistleblowing Policy, committed by the Trust itself. The original concerns were not looked into, not even after the Trust had been obliged to formally admit that it had failed to investigate.
“Within 21 days of you having raised a concern, we will write to you summarising your concern and setting out how we propose to handle it or if not, why not.”
• In both of my Formal Grievance Hearings, the Trust was forced to admit that no written acknowledgement had been provided.
“…we will give you as much feedback as we possibly can…”
• In both of my Formal Grievance Hearings, the Trust was forced to admit that no written feedback had been provided.
“OUR ASSURANCES TO YOU”
• In view of the breach of each and every one of those assurances, on two separate occasions, there can be little choice but to conclude that the Policy is, in practice certainly, insincere. It is interesting to note that the two subsequent policy reviews, (both carried out by a manager who was put in overall charge of my case, who personally threatened me with dismissal and chaired my first Grievance Hearing) have not materially improved the Policy or indeed altered it very much at all, save to change a few of the words used. No emphasis has been placed upon requirement of strict observance of the Policy itself. None of the versions contain mention of disciplinary action to be taken against those who might harass or victimise the whistleblower.
In the absence of the goodwill required from management to actually apply the Policy’s intentions, I believe that future whistleblowers will continue to find themselves standing alone against a powerful authority which has shown itself to be quite unable to countenance criticism.
20th June 2015
“The term ‘never event’ was first introduced in 2001 in reference to particularly shocking medical errors that should never occur.” … Care Quality Commission
In 2007, I made a report to Morecambe Bay Trust management that a patient had been injured by inappropriate insertion of a naso-gastric feeding tube which had resulted in ‘Aspiration Pneumonia’ or feed being pumped into the lung(s). Misplaced naso-gastric tubes are listed as ‘never events’ because they ought never to happen. The patient died 10 days later. The Death Certificate did not blame the never-event; as though it had never happened. When the Trust failed to initiate any investigation of the incident, I resigned my post as Staff Nurse citing Trust failure to prioritise patient safety.
Four years later, I read, the Trust was responsible for the death of another patient by the same means:
NORTH-WEST EVENING MAIL Thursday, 20 February 2014
Hospital patient had feeding tube in lung A HOSPITAL patient died days after a wrongly placed feeding tube was found in their lung. The catastrophic error was one of nine “never events” – mistakes so bad they should never have taken place – recorded at the University Hospitals of Morecambe Bay NHS Foundation Trust during the three-year period spanning 2011, 2012 and 2013. UHMBT faced a clinical negligence claim for one of the events, the misplacement of a naso-gastric feeding tube at its Royal Lancaster Infirmary site in 2011. Confirming details of the incident the Trust said: “The patient had an NG tube in situ and had been fed through this tube and feeds had been running for four hours in total. The patient experienced right-sided chest pain and an urgent chest x-ray showed the NG tube in the right lung. The patient died two days later.”
“We take these events extremely seriously, investigate them thoroughly and ensure that we share learning from each to minimise any re-occurrence of a similar event.“
“The safety of our patients is our priority and we actively encourage members of staff to report any events which take place where they have concerns that patient care may have been compromised.”
Plus ca change, plus c’est la meme chose…
Now please recall that, in 2007, the Trust had failed to investigate an identical event. When I took out a Formal Grievance in 2008, on that very subject, the Trust admitted the failure, but again failed to initiate any investigation. Imagine then my surprise, to read that the Trust Press Responses to inquiries from both a national and a local newspaper assured readers that “The Trust did carry out investigations into many of these concerns, in 2008…”
I first heard this song in 1970, but had never fully appreciated the significance of the lyrics until Morecambe Bay NHS Trust attempted to conceal what I had reported to them. Every effort was made to stop anyone from hearing what I had witnessed. When they had cheated and lied their way to overcoming my efforts to expose their failures to prioritise patient safety, they forced me, under financial duress, to sign a Compromise Agreement, complete with Confidentiality “Gagging” Clause. At that time, the Trust’s much-trumpeted reputation could not be challenged. Silence thus preserved, they went on to record the highest Hospital Mortality Rate in the country. Board “resignations”, Coroners’ verdicts, Police investigations, Media revelations, NHS Watchdog inspection failures, Special Measures, DoH Inquiry and utter disgrace followed in rapid succession.
“Today, the name of Morecambe Bay has been added to a roll of dishonoured NHS names…” … Dr Kirkup, Chair of Morecambe Bay Investigation, March 2015
I have taken the liberty of editing the lyrics, though the words pretty much stand up for themselves.
“Silence like a cancer grows”
Hello, darkness, my old friend
I’ve come to talk with you again
Because a vision softly creeping
Left its seeds while I was sleeping
And the vision that was planted in my brain
Within the sound of silence
In restless dreams I walked alone
Narrow streets of cobblestone
‘Neath the halo of a streetlamp
I turned my collar to the cold and damp
When my eyes were stabbed by the flash of a neon light
That split the night
And touched the sound of silence
And in the naked light I saw
Ten thousand people, maybe more
People talking without speaking
People hearing without listening
People writing songs that voices never shared
No one dared
Disturb the sound of silence
“Fools,” said I, “You do not know
Silence like a cancer grows
Hear my words that I might teach you
Take my arms that I might reach you”
But my words like silent raindrops fell
And echoed in the wells of silence
And the people bowed and prayed
To the neon
god Trust they made
And the sign flashed out its warning
In the words that it was forming
And the sign said, “The words of the
Are written on the
subway Facebook walls
tenement Twitter halls scrolls
And whispered in the sounds of silence”
“It’s getting dark, too dark to see,
Feel I’m Knocking on Heaven’s Door”
To Rt Hon Jeremy Hunt MP Secretary of State for Health House of Commons London SW1A 0AA
Dear Mr Hunt,
An apology and practical redress
Following the example of Mr Gary Walker, I write to ask you for “an apology and practical redress”.
I refer you to the Complaints and Raising Concerns Report – Fourth Report, by the Health Select Committee, Published 24 January 2015: Recommendation at paragraph 115 “We expect the NHS to respond in a timely, honest and open manner to patients, and we must expect the same for staff. We recommend that there should be a programme to identify whistleblowers who have suffered serious harm and whose actions are proven to have been vindicated, and provide them with an apology and practical redress.”
The above suggests that you will be looking for three requirements:
• A whistleblower
• Who has suffered serious harm
• That whistleblower is vindicated
I propose the following definitions:
• To be a “whistleblower” you need only raise concerns qualifying for protection under Section 43 of the Public Interest Disclosure Act 1998. There is no legal requirement for a finding in a tribunal merely the existence of the qualifying disclosure.
• To have suffered “serious harm” Resignation on declared principles with resultant loss of income, pension, career, status, and employment prospects should qualify.
• To be “vindicated” should require a finding either from a tribunal or court judgement or the finding of subsequent inquiries, CQC investigations, or police investigations.
• Did I disclose concerns qualifying for protection under Section 43 of the Public Interest Disclosure Act 1998?
Yes. I made 2 qualifying* disclosures, concerning serious risks to the lives of patients, which were both ignored and not investigated. These failures were admitted by the Trust in two separate Formal Grievance Hearings.
*Public Interest Disclosure Act 1998. Protected disclosures. Disclosures qualifying for protection:
(1)In this Part a “qualifying disclosure” means any disclosure of information which, in the reasonable belief of the worker making the disclosure, tends to show one or more of the following—
(a)that a criminal offence has been committed, is being committed or is likely to be committed,
(b)that a person has failed, is failing or is likely to fail to comply with any legal obligation to which he is subject,
(d)that the health or safety of any individual has been, is being or is likely to be endangered,
(f)that information tending to show any matter falling within any one of the preceding paragraphs has been, is being or is likely to be deliberately concealed.
• Did I suffer “serious harm” with resultant loss of income, pension, career, status, and employment prospects?
Yes. Morecambe Bay Trust failed to initiate investigations upon my first reporting of concerns and also after admitting those failures at Grievance Hearings. They admitted causing me a stress injury incurred as a result of these and other failures. They failed to demonstrate to me that my upheld Grievances had brought about investigation of my concerns or any improvement in the handling of staff concerns. I will not take any part in a conspiracy to convince patients that they are being cared for while management fail to prioritise safety.
“Take this damned badge off o’me,
I can’t use it anymore.”
Consequently, on that principle, I was obliged to resign my position as Staff Nurse with University Hospitals of Morecambe Bay NHS Trust in 2009, with the expressed intention of having Employment Tribunal examine the failings of management at Royal Lancaster Infirmary to protect the safety of patients. Under the duress of having been cut off financially, while remaining incapable of work due to the stress injury caused to me, I was coerced to give the Trust time to look for alternative employment for me, although they failed to offer anything acceptable. After spending £9000 on legal fees, I was advised that by conceding to that delay, I had been tricked into “continuing my employment”, in legal terms. I could not then complain to Tribunal about the admitted breaches, because I could be deemed to have accepted those breaches by ‘continuing my employment’ in that way. I was obliged to enter into a Compromise Agreement with a “Gagging Clause”. I was made the subject of further harassment when my applications for Renewal of Nurse Registration were twice “lost” and not submitted by Trust managers resulting in my NMC Nurse Registration being lapsed. Consequently, I have lost income, pension, career, status, and employment prospects.
• Was I vindicated by the findings of subsequent inquiries and/or police investigations?
Yes. The Trust admitted failing to investigate my concerns (among other failures) and causing injury to me in two upheld Formal Grievance Reports. The consequences for patient safety by my being silenced can only be guessed at, but neglect of safety at Trust hospitals has since become a matter of public disgrace.
By 2011 Morecambe Bay Trust had the highest mortality rate in the country.
The Morecambe Bay Investigation into the deaths of mothers and babies declared “Today, the name of Morecambe Bay has been added to a roll of dishonoured NHS names that stretches from Ely Hospital to Mid Staffordshire.”
The Trust, now in “Special Measures”, remains the subject of ongoing Police investigation.
You yourself found reason to tell The House, “The Royal Lancaster Infirmary is not the main focus of the Kirkup report, but of course as part of the same Trust it suffered from the same management failings. There are Members of this House who have had problems at the Royal Lancaster Infirmary and found that they were not listened to when they made complaints, because proper management was not in place.”
Sir Robert Francis, in his Freedom to Speak Up review published on 11 February 2015, recommended “principle 12″ in which he said: Action 12.1 NHS England, the NHS Trust Development Authority and Monitor should jointly devise and establish a support scheme for NHS workers and former NHS workers whose performance is sound and who can demonstrate that they are having difficulty finding employment in the NHS as result of having made protected disclosures. Action 12.2 All NHS organisations should actively support a scheme to help current and former NHS workers whose performance is sound to find alternative employment in the NHS.
Will you now provide an apology and practical redress to me? Will you now ensure that all whistleblowers will get an apology and practical redress? I await your response and would be delighted to meet with you to discuss this.
With thanks to Gary Walker ex-CEO United Lincolnshire NHS Trust.
07/11/2017 I have never received a reply or acknowledgement from Secretary of State Jeremy Hunt.
The Report of MY OWN
Morecambe Bay Investigation
“ICEBERG! DEAD AHEAD!”
University Hospitals of Morecambe Bay NHS Foundation Trust?
• I reported a nurse who admitted switching off prescribed fluid infusions, preventing administration to poorly dependent patients. • The report was unacknowledged, unactioned, date-stamped and filed.
• I reported wages fraud. • The Trust decided that “although it did appear to be fraudulent, the amount was not worth pursuing”.
• I reported an improper procedure carried out on a patient which caused injury and life was put at risk. • The report was unacknowledged and not investigated.
• I had two Formal Grievances upheld. • The Trust used trickery and lies to avoid Employment Tribunal penalties.
• I submitted applications for Renewal of my Nurse Registration. • The Trust “lost” my applications…TWICE…I lost my Registration.
• The Trust admitted causing me a work-related stress injury.
• The Trust cancelled my Temporary Injury Allowance without applying for Permanent Injury Benefit.
The Trust made insinuations about my mental health, despite having already admitted responsibility for my condition.
They insisted that I attend Cognitive Behaviour Therapy, then presented the transcript of my confidential CBT sessions to Employment Tribunal as evidence.
• I requested ill-health retirement on resignation. • The Trust assured me that my pension was being set up on ill-health grounds but failed to do so.
• The Trust eventually (9 years late) agreed that they ought to investigate one concern…but were unable as one involved was seriously ill ‘on her death-bed’. • 9 months later, that same nurse was found to be living independently and able to answer questions.
• The Trust agreed to investigate another concern (7 years late). • The Trust fell silent on the subject for 9 months.
• I contacted CQC. • The Trust immediately claimed to have completed investigation 6 months earlier.
• I asked for a copy of results. • The Trust ignored the request.
• I gave evidence to Morecambe Bay Investigation. • Trust suddenly “anxious to meet to share findings of investigation”.
• My story was published in a national newspaper. • Trust respond claiming “the lack of detailed evidence available to us at this time means we are unable, so many years later, to substantiate the issues he raised.”…”our Trust, like many across the country, has worked hard to tighten its whistleblowing policies, and has seen a sea-change in the way it responds to and investigates staff concerns.”
Since telling the world that there can be no investigation findings, “unable, so many years later, to substantiate the issues he raised“, the Trust has made repeated invitations to meet me to “share” the non-existent findings.
So was there an investigation… with findings that could be shared …or not?
No “sea-change” there then? But perhaps we can hope that the tide is going out!
“The Invaders, alien beings from a dying planet, their purpose to make it THEIR ward.
Russell has seen them. For him, it began one lost night on a lonely NHS ward, looking for a management that he never found. It began with the landing of a craft from another philosophy. Now Russell knows that the Invaders are here, that they have taken Foundation Status. Somehow, he must convince a disbelieving world that the nightmare has already begun…”
The guest stars in tonight’s story: CQC, The Earl Howe, PHSO, Sir Robert Francis QC, Sir David Nicholson and supporting cast.
Public Concern at Work: “We strongly recommend that you follow internal procedures and give the Trust opportunity to address the issues. It may damage your case if you involve external bodies.”
My Formal Grievance was upheld and Trust admitted not investigating my concerns.
A second Formal Grievance was upheld admitting that concerns had not been investigated.
Robert Francis QC: “I was very sorry to read about your experiences as a whistleblower and the serious consequences this has had for you…”
Morecambe Bay Trust achieve Foundation Status
Morecambe Bay Trust achieve highest Hospital Mortality Rate.
David Morris MP (Morecambe & Lunesdale): “I was concerned to read of your experience both at the time, and of the longer term effects that you continue to endure.”
The Right Hon. The Earl Howe PC, Dept of Health: “I was very sorry to hear of Mr Dunkeld’s experiences and his concerns about how whistleblowers are treated… I hope this reply is helpful.”
Sir David Nicholson, Chief Executive of the NHS, told MPs on the Public Accounts Committee that whistleblowers who have been gagged will be written to and told they can finally speak out. “You may be aware that a new CEO, Jackie Daniel, started at the Trust last year. You may wish to contact her directly to inform her of your concerns…”
Now free to speak up…but no-one is listening!
Jackie Daniel CEO Morecambe Bay Trust: “You may wish to meet with David Wilkinson, Human Resources Director, in the first instance,…”
BBC: “The NHS story we were looking at has actually changed now to one about hospital hotels. Unfortunately the whistle-blowing one is not very prominent now on the website.”
Care Quality Commission: “CQC’s role is to check that health and social care services in England meet quality and safety standards; our role does not include investigating individual complaints and neither do we have the power to take up your individual complaints with the trust. You may be able to take this further with the Health Service Ombudsman.”
Health Service Ombudsman: “I understand the CQC have advised you to contact us but, from the information available on their website, they would be the appropriate organisation to consider your concerns.”
David Wilkinson, HR Director: “…we are unable, so many years later, to substantiate the issues he raised.”
Morecambe Bay Investigation: “Thank you for taking the time to bring your concerns about University Hospitals of Morecambe Bay NHS Foundation Trust to our attention.”
Eight bloody years! Are there serious failings occurring now? We won’t hear about them until 2023!