Imagine this edited version of the BBC’s summary of Lady Justice Thirlwall’s report findings were written about vulnerable adult patients like you and me. My conclusion is: Many of us with life-changing health conditions, disabilities and other vulnerabilities aren’t against “assisted dying” in principle but cannot contemplate such a dysfunctional organisation as the NHS (from front-line staff through management and regulatory bodies), having that power of life-or-death over us. The system needs to be proved as capable before more legislation is proposed.
Try this version of the report:
Hospital ‘missed opportunities’ to prevent murders. The first three deaths weren’t viewed as a cluster (even though this was the annual number of deaths, concentrated into two weeks). Review of the fourth unexpected death, by a serious incident panel was treated as a formality. “What is surprising is that no connection was made by any of the people involved to the earlier deaths,”
The report also found:
- safeguarding action would have prevented multiple attacks on patients and the deaths of several.
- One doctor failed to report, others failed to raise safeguarding responsibilities at an executive meeting: it was a system of “dysfunctional management and governance”.
Executives tried to ‘control the narrative’: hospital bosses repeatedly failed in their duty of candour with families, investigators and regulators and their behaviour was “high-handed, against all safeguarding principles, and foolhardy”.
The Medical director “sought to control the narrative”, and presented the case as he saw it, making sure that only documents that supported his case were seen, if necessary writing them himself.
- The Director of nursing (head of safeguarding) knew she had to act when there was a suspicion that a patient had been harmed, and others might be at risk – but did not
- The Chief executive was dictatorial in his approach to consultants, and executive presentations to the hospital’s board were an “exercise in spin”. He added to the unnecessary delay in contacting police and his intention was to stall or obstruct their investigation.
- Various internal and external reviews were criticised and wider NHS failings played their part, with a tendency across the health service for management to become pre-occupied with avoiding blame and focusing on reputation management: “toxic negativity” that discouraged people within the NHS from speaking out, even though efforts had been made over the last decade to strengthen protections for whistleblowers.
Regulation was also found to be lacking. The Care Quality Commission inspected the hospital but failed to stop attacks on patients. Key information was withheld from inspectors, but the regulator was criticised for not showing enough curiosity to look beyond what it was being told, even though the CQC had been warned by other patient deaths that it needed to take a tougher approach.