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From:"STEWART,Kevin(HAMPSHIREHOSPITALSNHSFOUNDATIONTRUST)"<*******************>Subject:Re:Telephonemeeting24March2017onHSIB&whistleblowing,andmattersarisingDate:7April2017at15:36:37BSTTo:MinhAlexander<***********************>Minh,Ididn'tkeepcontemporaneousnotesrecordingourphoneconversation,butyournotesseemareasonablereflectionofit.BW.KevinSentfrommyiPhoneOn7Apr2017,at11:58,MinhAlexander<************************>wrote:
HiKevin,Ihavenotheardfromyouinregardstomyemailsof31Marchand3April.ThisisnowanotetosaythatIwillbepublishingmyrecordsofourtelephonemeetingof24thMarchthisweekend.Obviouslyifyougettimetodropmelinetosaywhetheryouagreewiththemeetingrecords-ornot-beforethen,thatwouldbehelpful.Ifnot,IwillpublishthemwiththeriderthatHSIBhasnotcommentedonmymeetingrecords.Notwithstanding,itwouldbeusefultoabidebythebestpracticeconventionthatmeetingsinvolvingpublicbodiesareproperlydocumented,andforrecordstobeagreed.Agreeingarecordisanimportantpartofaccountability.Bestwishes,MinhFrom:MinhAlexander<**********************>Subject:Telephonemeeting24March2017onHSIB&whistleblowing,andmattersarisingDate:3April2017at15:33:17BSTTo:KevinStewart<*************************>
Cc:BrianJarman<***********************>,CharlesVincent<**********************>,KeithConradi<************************>,CarlMacrae************************Thanks********.ItisindeedpunitiveandunfairthatdoctorsareobligedbytheGMCtoraiseandescalateconcerns,butfaceagoodchanceofvictimisationandlackofprotectionwhentheydoso.Kevin-1)I’vetakenalookatHSIB’spublisheddocumentsnowthatHSIBisoperational.Icouldfindnospecificreferencetowhistleblowingoranyexternalwhistleblowingpolicy.AquestionthatIraisedafewemailsbackhasnotyetbeenclearlyanswered-thatis,doesHSIBacceptthatithasprescribedpersonfunctionsunderthePublicInterestDisclosureAct,onaccountofbeingconstitutedaspartofNHSImprovement,whichisaprescribedpersonunderPIDA.Couldsomeonehelpwiththis,andalsoobviously,correctmeifIhavemissedanyrelevantdocuments.IfhoweveritiscorrectthatHSIBhasnoexternalwhistleblowingpolicyofitsown,coulditbeclarifiedwhetherHSIBintendstoproduceone,ortojustuseNHSI’sexternalwhistleblowingpolicy?2)I’vebeenaskedtowriteanarticleaboutNHSwhistleblowinggovernanceandIwillfocusonthelackofinvestigationandpoorinvestigationofNHSwhistleblowers’concerns.IfHSIBcanrespondtothesubstantiveissuesthatIraisedinmyemailbelowof31March19.13inthenextfewdays,evenifonlypartially,thatwouldbeveryhelpful.Iamsubmittingthecopyon6AprilandanindicationfromHSIBbythatdateaboutwhetheritagreestoholdanopenconsultationwithwhistleblowersaboutNHSfailurestoinvestigatetheirconcernsproperlyoratall,wouldbehelpful.Thanksandbestwishes,MinhFrom:*********************************>Subject:Re:Telephonemeeting24March2017onHSIB&whistleblowing,andmattersarisingDate:1April2017at09:25:40BSTTo:MinhAlexander<****************************>
Cc:KevinStewart<*************************>,KeithConradi<***********************>,CharlesVincent<************************>,CarlMacrae
[THIRDPARTYCORRESPONDENCE,REDACTED]
On31Mar2017,at19:13,MinhAlexander<***************************>wrote:
DearKevin,
Telephonemeeting24March2017onHSIB&whistleblowing,andmattersarising
ThankyouformeetingwithmebytelephoneonFriday24March.
Aspromised,Iwritetoprovide:
1)summarynotesofourmeetingforyouragreement–seeappendixbelow
2)AconcisesummaryofhowthesystemisdesignedNOTtoinvestigatewhistleblower’spatientsafetyconcerns
IbelievethatwhistleblowingshouldbecentraltoHSIB’scorebusinessbecause:
• WhistleblowingcasesoftenfeatureverypoorsafetyinvestigationpracticebytheNHS
Many,ifnotthemajority,ofNHSwhistleblowingdisclosuresarepoorlytoverypoorlyinvestigatedbytheNHS.Quiteoften,whistleblowers’disclosuresarenoteveninvestigatedatall,forobviousreasons.HSIBneedstogetagraspoftheextentoffailureinthisareaifitistofullydischargeitsremitforleadingimprovementonNHSsafetyinvestigationpractice.Someresearchand
measurementwouldbenecessarytoestablishabaselineoncurrentstandardsofpractice,asfarasIamaware,thatremainsagapintheevidence.
• WhistleblowingisanimportantsourceofintelligencethatcanhelpguideefficientprioritisationofHSIBinvestigatoryactivity
• Whistleblowers’disclosuresmaysometimesbetheonlysourceofevidencethatcanshowacoveruphastakenplace.
Forexample,whistleblowersmaybetheonlypeoplewhoknowandcanrevealthatimportantevidencehasbeendestroyedbyorganisations.Asyouacknowledgedinourmeeting,insuchsituationsofdeliberateconcealment,itmaynotbepossibleforHSIBtodetectthattherehasbeenacoverup.Unlessofcourse,whistleblowersarewillingtoentrustyouwithrelevantevidence.
Thecurrentregulatoryandlegislativelandscapepresentsobstaclestoinvestigationofwhistleblowers’concerns.
• Currentwhistleblowinglawmisdirectsfocusawayfromwhistleblowers’concerns,andtowardsensuingemploymentdisputes.
• Thereareoceansofineffectivegoodpracticeguidancewhichsaysthatwhistleblowers’concernsshouldbeinvestigated,butnoactuallegalcompulsiononemployerstoinvestigatewhistleblowers’concerns.
• NHSregulatorscurrentlylargelyrefusetoinvestigateindividualwhistleblowers’concerns,andtheyclaimthattheyhavenoremittodoso.Thisisarguabledependinghowtheirremitisinterpreted.Regulatorscouldcertainlyconductmorethematicreviews,whicharedefinitelywithintheirgift,wherethereareclustersofwhistleblowers.However,therehasbeenalackofpoliticalwilltodoso.TheevidenceisthattheCareQualityCommissioninfactfailstoactoneventhemostserious,multiplewhistleblowerdisclosures.1
• LocaltrustSpeakUpGuardiansandtheNationalGuardian’sofficehavecontroversiallybeendesignedNOTtoinvestigatewhistleblowers’concerns.23
IfyouneedmetoexpandontheevidenceforeachoftheabovepointsregardingNHSwhistleblowinginvestigatoryfailure,pleaseletmeknow.
Inshort,thereisSTILLnosafeplaceforNHSwhistleblowerstogo,despitetheDHpropaganda.
Despitegovernmentclaims,currentUKwhistleblowinglawalsoconfersnoprotection.Itonlygiveswhistleblowerstherighttosueforcompensationaftertheyhavebeenharmed.
IfHSIBistofullydischargeitsremittoidentifyserioussystemicrisksandimproveNHSsafetyinvestigationpractice,IthinkitmustaddresstheabovesystemicfailuresthatcollectivelymitigateagainsttheproperinvestigationofNHSwhistleblowers’concerns.
Thisisparticularlyaswhistleblowers’concernsoftenrelatetothemostseriouspatientsafetyrisks.
Entwinedwiththisinvestigatoryfailureisthelackofprotectionforwhistleblowers.InthesamewaythattherearecallstocriminaliseobstructionofHSIBinvestigations,
“Critically,itshouldbeanoffencetohideortamperwithevidenceorotherwiseinterferewithanHealthcareSafetyInvestigationBranchinvestigation”Macrae&Vincent,10March20174
IthinkHSIBmustalsorecognisethatasimilarimperativeappliestothecriminalisationofwhistleblowersuppressionandreprisal,asoriginallyenvisagedbyRobertFrancis5,andasrecommendedbyexperts6andbycampaigners.Therealsoneedstobealegaldutyofpre-detrimentprotectionuponemployers.IfHSIBdoesnothelptoensurethemostrobustprotectionforwhistleblowers,itcannotexpectfulldisclosurebyNHSstaff.
InfactanycriminalisationofconcealmentassuggestedbyMacrae&Vincent,whilstwelcome,couldbepotentiallybecounterproductiveandunfairtoNHSstaffifthereisnotcommensurateprotectionfordisclosure.Itwouldbeunjustifstaffwhohavebeenterrifiedintosilenceruntheriskofacriminalconviction,yethavelittlehopeofprotectioniftheyspeakup.
IhavenothadaccesstoHSIB’sdraftprotocolsasrequested.Butforvariousreasons,IdonotthinkHSIBhasgoodgraspyetofwhistleblowingrealitiesandthecomplexitiesthatstaffmustnavigatewhentheyspeakup.Inparticular,IdonotthinkHSIBhasagraspyetofthedepthofNHScorruptionandthenegligenceandcollusionofNHSbodiesthataremeanttoenforcetransparency.
AsIhavementionedbefore,whistleblowingisaspecialistareabutisbyitsnatureunder-documented.Alittlebitofknowledgecandoharmtobothstaffandpatients.
IwouldsuggestthatHSIBdevelopsindepthexpertise,especiallyofqualitativeandexperientialaspects,andthatasastarttothisjourneythereshouldbeaproper,openconsultationwithNHSwhistleblowers.
Whistleblowersholdmuchoftherealorganisationalmemoryonwhatgoeswrong,andthemeansbywhichNHScoverupsareachieved.
Duringourmeeting,Isuggestedanopenlyadvertisedeventwithwhistleblowerstostarttheprocess.Iparticularlyadvisethatyoudonotrelyonjustthe‘usualsuspect’organisationsforwhistleblowingadvice,asoftenhappenswhenNHSbodiesconsult.Thisisbecause
whistleblowingorganisations,forcommonsreasonsofcaptureandconflictsofinterest,usuallydonotrepresentthemostchallengingvoicesandarenotrepresentativeofallwhistleblowers.Inaddition,someofthewhistleblowingorganisationsarealsonotHealth/NHSspecialists.
Youkindlyagreedtoconsidersuchaconsultationandtoholdanevent.PleaseletmeknowifHSIBwillimplementthis.Iamhappytohelpifneeded.YoumayalsofinditusefultoconsultthewhistleblowingresearchteamheadedbyProfessorDavidLewis,MiddlesexUniversity,whichprovidedacademicsupporttotheFreedomToSpeakUpReview.
Pleasealsoletmeknowifyouagreewithmynotesofourtelephonemeeting,below,orotherwise.
Lastlyaspromised,hereisthelinktotheinteresting-nottosaydiverting–presentationbyPeterWilmshurstwhichrevealedthedegreeofGMCcomplicitywithsomeNHScoverups:
https://www.youtube.com/watch?v=Xze-yPubFIY&feature=youtu.be&a
HereistheHansardrecordofadebateledbyRosieCooperMPabouttheLiverpoolCommunityHealthscandal,whichdescribescollusionbyNHSregulatorstoprotectabusers:
https://hansard.parliament.uk/Commons/2016-07-13/debates/1DEAEDE8-BA1C-4BF7-A16A-7CFB9831CFB2/CapsticksReportAndNHSWhistleblowing
Withbestwishes,
MinhAlexander
ccKeithConradi
ProfCharlesVincent
ProfBrianJarman
CarlMacrae
APPENDIX
NotesfromtelephonemeetingbetweenMinhAlexanderandKevinStewart24March2017,4pm–5.15pm
Thesenotesaretakenfromcontemporaneousrecordsofthediscussion.Theyrepresentabroadsummary.Somebutnotallpassagesareverbatim.
KSBusy.Alottodo.[HSIB]willmoldintowhatwecomeacross,won’tgetitrightfirsttime.Getgoodbitsfromotherindustries.Goodpeople,rightmotives.
KSindicatedthatinadditiontoheadingtheHSIBintelligenceunit,hewillspendadayaweekonclinicalwork.[It’s]oneofthestipulations.
MAHowwillintelligenceunitwork?
KSAsopenaviewaspossibletogetreferrals…accessibletoasmanypeopleaspossible.
25investigationsayear.[Sourcesofreferral]Families,staff,patients,providers,regulators.Ourbag:learningacrosshealthcare.[Choose]areasofgreatestimpactforimprovement,improvementforthelargestnumberofpatients.[Shouldbe]representativeofthesystem.
Asiftingandpreliminaryinvestigationapproach.Qualitativeaswellasquantativeforthefullpicture.[Lookat]thingsthatdon’tnormallygetmeasured.Investigatingpoorinvestigations.Norecognitionofhumanfactors.Developmethodologyandgettruststomodelit.Keentogetindependence.[Staffwhohavedisclosed]haditusedagainstthembyGMCandDH.
MAWhat’syourviewondeliberatecoverups,howwillyoufindit?
KSNotright.Issuesofpervertingcourseofinvestigation,notproducingevidenceorinterferingwithevidence.Thinkwewillpressurisethesystemalot.Don’tblamepeoplefornottrustingthesystem.Somuchtodo.Somanyunknowns.Somanythingstotripitup,likepoliticalinterference.
MAHowwouldyoufindoutthingslikeshreddednotes?
KSWemightnotfindit.Butperhapsifstaffreportsdon’tcorrespond.That’swhereweshouldbefocussingregulatoryandlegalstuff.Wewillpublishitifwefindit.Wewillringpolice.Learnedhelplessness–[peoplemaysay:]‘you’renevergoingtogettothebottomofit.Buttoxicculture[maybeevident]ifstaffwon’ttalkortalkincarparksetc…andnotonpremises.
KSWorkwhereprovidersagreeable
MAWillprovidershaveachoice?
KSWeprobablyhavepowertoactunderdirection.eg[wherethereare]shedloadsofdeathsandtrustsays‘no’.Willithappenlikethat?Idon’tknow.Don’tknowwhatwillhappenon1April.Ithinkweneedtokeepanopenmind.
MASolefocusonhumanfactorswon’tdoit.Ifstaffstillseecoverups,theywillunderstandthatthereisstillnosafeculture.Willdeterreporting.HSIBneedsto1)develop
understandingofNHSwhistleblowing-staffexperiencesandpatterns2)receiveinformationfromstaffinasafeway.
KSReferredtocoverupsas‘nowandagain’
MAIt’smorethannowandagain.Endemic.ReferredtoexampleofPeterWilmshurstattendingaGMChearingtofindthattheseniorGMCofficialhadtorecusehimself,asifhehadgonetotheOldBaileyandtheLordChiefJusticehadtorecusehimselfbecausehehelpedtoburythebody.BriefreferencetoanNHStrusttryingtoevadeevenamandatoryinvestigationofamentalhealthhomicideforalmosttwoyears.NeedtounderstandwhatliesbeneathsuperficialNHSrespectability.
KSDobodieslikeGMC,BMA&RCNhelpwhistleblowers?
MAThey’repartoftheproblem.Unionsoftendumpwhistleblowersaslikeanyotherinsurers,don’tliketopayupforcostlylegalservices.Alsoconflictsofinterests–seniormemberswhoaretheabusers.HSIBneedstounderstandthemechanicsofNHScoverup.Abusersprotected.NHSregulatorsevenlietoMPswhentheyprotectandrecyclepoormanagers–exampleofRosieCooperMPandNHSregulatorsprotectingLiverpoolCommunityHealthNHSTrustmanagers.
KSWecan’tdo20yearsofwhistleblowercases.
MAYoudon’thaveto,butcanatleastgatherintelligencefromandconsultwhistleblowersabouttheirexperiences.Tryanopenlyadvertisedevent.
KS[Agreedtoconsider].
MAWillwrite.
REFERENCES
1WhistleblowersunheardbyCQC.Alexander,Linton,Sardariandfourthauthor,2December2016.Seepages17-18ofthereportfordetailsofCQC’sinactioninresponsetoeventhemostseriousdisclosuresaboutNorthCumbria.
https://minhalexander.com/2016/12/05/whistleblowers-unheard-by-cqc/
2ReportbyRobertFrancisoftheFreedomtoSpeakUpReview,11February2015
Page19:
“78TheINO[NationalGuardian]willhavediscretiontoconsiderhowanexistingcaseisbeingorhasbeenhandled,andtoadviseanorganisationonanyactionstheyshouldtaketodealwiththeissuesraised.Theofficerwouldneedtooperateinatimely,non-bureaucraticway.He/shewouldnottakeontheinvestigationofcasesthemselves,butwouldchallengeorinviteotherstolookagainatcasesandwouldneedsufficientauthoritytoensurethatanyrecommendationsmadeweretakenseriouslyandactedupon.”
Page169:
“7.6.17TheINO[NationalGuardian]wouldinessencefulfilaroleatanationallevelsimilartotheroleplayedbyeffectiveFreedomtoSpeakUpGuardianslocally.Theywouldnottakeoncasesthemselves,butcouldchallengeorinviteotherstolookintocaseswhichdidnotappeartohavebeenhandledinlinewithgoodpracticeorwhereitappearedthatapersonraisingaconcernhadexperienceddetrimentasaresultofraisingtheconcern.”
http://webarchive.nationalarchives.gov.uk/20150218150343/https://freedomtospeakup.org.uk/wp-content/uploads/2014/07/F2SU_web.pdf
3NationalGuardian:LetterfromWonderland.MinhAlexander,20February2017https://minhalexander.com/2017/02/20/national-guardian-letter-from-wonderland/
4Anewnationalsafetyinvestigatorforhealthcare:theroadahead.Macrae&Vincent.10March2017,JournaloftheRoyalSocietyofMedicine;2017,Vol.110(3)90–92DOI:10.1177/0141076817694577
http://journals.sagepub.com/doi/pdf/10.1177/0141076817694577
5SirRobert’sFlipFlops,MinhAlexander,26September2016
https://minhalexander.com/2016/09/26/sir-roberts-flip-flops/
6LetterbyProfDavidLewis,15February2015
https://www.theguardian.com/society/2015/feb/15/whistleblowers-should-law-punish-hospital-bosses
Article:http://www.sundayguardianlive.com/world/6512-whistle-blowers-should-be-encouraged-protected-law
From:MinhAlexander<***********************>Subject:IssuesaboutconsultationbyHSIB&accesstoHSIBdocumentsDate:23March2017at08:35:13GMTTo:KevinStewart<*******************>Cc:KeithConradi<**************************************************************************
******************************************************************************************************************************************************
DearKevin,
Thankyouforyourfurtheremailandthesuggestedtimetospeak.
Meeting
Ican’tdefinitelyconfirmatelephonemeetingat4pmtomorrow.IwillletyouknowassoonasIcantoday.4.30pmmaybebetter.
Aspermypreviousemail,Iamavailablealldaytoday,ifyoufindthereistimetocall.
HSIBexpertise,ingroupbiasanddiversity
IremainconcernedaboutthefactthatHSIBhasnotconsultedopenly,andwillnotallowwhistleblowersameaningfulopportunitytocommentonitsprotocolsbeforeitgoesliveinonlyoneweek’stime.
Theapproachsofar,basedonyourandKeith’scomments,suggesttomethatHSIBlacksexpertiseinthisimportantarea.HSIBisstilltreatingwhistleblowingasperipheralissue.
YousayyouhopethatCarlMacraewillhelpHSIBdevelopaprocessfor"capturinginformationfromwhistleblowers”andthatyoubelieveheisawareoftheacademicliteratureonwhistleblowers.
IhopethatHSIB’sapproachwillencompassmorethanjustcapturinginformation.
IdonotknowexactlywhatexpertiseCarlMacraehasonwhistleblowingbutuponreadinghisownaccountofhisskillssetandexperience*,Ithinkitisveryunlikelythathehasanyspecialistexperienceofwhistleblowing.
Uponabriefsearch,IcanfindnopublishedmaterialbyCarlonwhistleblowing,otherthaninasinglesentencereferencetotheMidStaffsdisaster.**
Ishouldpointoutthatafamiliaritywiththeacademicliteratureonwhistleblowingdoesnotconstituteexpertise.
Whistleblowingisahighlycomplexminefieldwithmanyaspectstouchingonmanyfieldsofgovernance,lawandpolicy.Bythenatureofsuppressionandofpower,thefullhistoryofwhistleblowingisnotreflectedinacademicjournals.
Powerfulexperientialaspectsofwhistleblowingcannotbefullyappreciatedfromtheacademicliteraturealone.
Therearealsosectorspecificissues.Knowledgeofwhistleblowingissuesinaviation,whichIthinkisthemodelthatHSIBmaylargelyrelyingon,cannotbesimplisticallytransferredtoHealth.
AsStevenShorrockrecentlycommentedtome:
“Butmyviewisthathealthcareismanytimesmorecomplex&messythanaviation.Soexperience,e.g.whistleblowingdiffers.”
IamconcernedthatHSIBcontinuestorelyonasmallclubtodefinepolicy,andthatHSIBisremotefromthebloodinessandhumanrealitiesofNHSsuppressionofthefrontline.
YoucannothopetobegintograpplewithsafetycultureifyoudonothaveproperhandleonNHScoverup,anintricatelycraftededifice.
HSIBwillnotwinasmuchNHSworkforceconfidenceasitcould,orasmuchstaffdisclosureasitcould,ifitdoesnotdemonstrateahighlevelofcompetenceandinsightintothehandlingofconcernsandtheprotectionofstafffromreprisal.
YousurmisecorrectlythatI“knowabout”theacademicliteratureonwhistleblowing.Icampaigninthisareaandnetworkwithacademics,andIamamemberofaninternationalwhistleblowingresearchnetwork.Addedtothisismylivedexperience,andongoingcontactwithcurrentwhistleblowersandtheintelligencethattheysupply.
Ifitishelpfulinadvanceofourmeeting,someofmyanalysisofNHSwhistleblowinggovernanceandsomeofthedatathatIhavebeenassemblingiscollatedhereinacollectionofreportsandcommentaryonmanyaspectsofNHSwhistleblowing:
MinhAlexander.com
Ishouldpointthatissuesofdiversityareimportanttojustcultureandgoodgovernance,andthatthereisempiricalevidencethatNHSBMEworkersaremorelikelytobeignoredorvictimisedwhentheyraiseconcerns.
TheNHSHumanFactors/HSIBprojecthassofarlookedverymaleandwhitetome,withquestionsaboutingroupbias.
ThiswillmakeitmoredifficultforHSIBtounderstandtheexperiencesandanticipatetheneedsofothers.
ItispartlybecauseofthisthatIurgeHSIBtocollaboratemoreopenlyandwidelywithallrelevantparties.
AccesstoHSIBdocuments
Ireallywouldprefertohaveacopyofyourprotocolsatthisstageandbeforeourmeeting,nomatterhowrough,althoughIfindithardtoimaginethattheyarethatroughgiventhatHSIBgoesoperationalinjustaweek’stime.
ItisimpossibletomakeinformedcommentswithoutseeingwhatHSIBhasinmind,andtheprinciplestandsthatHSIBshouldbemakingalleffortstoensurethatithasthebestworkingprotocolspossiblebeforeitgoeslive.
ThepurposeofthephonecallistodiscussHSIB’sapproachandatpresentIhavenospecificproposalsfromHSIBtocommenton.
Iwouldbegratefulifyouwouldsendmewhateveryouhave.
Withbestwishes,
MinhAlexander
*AutobiographicaldetailsonCarlMacrae’swebsite:
"CarlMacraeisasocialpsychologistspecialisinginhoworganisationsachievehighlevelsofsafety,reliabilityandresilience.Hisworkfocusesonaviationandhealthcareandisparticularlyconcernedwithhowsafetyimprovementsareinitiated,interpretedandorganised;howorganisationsrespondtodisruptions,manageriskandlearnfromerror;andhoworganisationalandregulatorysystemscanbedesignedtosupportlocalinnovationandimprovement.
CarlisaSeniorResearchFellowintheDepartmentofExperimentalPsychologyattheUniversityofOxford,aResearchAssociateattheLondonSchoolofEconomicsCentreforAnalysisofRiskandRegulationandaCharteredPsychologist.Hisworkspansresearch,policy,regulationandpracticeinarangeofsafety-criticalindustriesandheholdsaPhDinriskandsafetymanagement.
PreviouslyhehasheldpostsincludingHealthFoundationImprovementScienceFellowandSeniorResearchFellowatImperialCollegeLondon,SpecialAdvisorandBusinessArchitectattheNHSNationalPatientSafetyAgency,SeniorResearchFellowatUniversityofLeicestermedicalschool,twoESRCresearchfellowshipsattheLondonSchoolofEconomics,andvisitingpositionsatStanfordUniversity,UniversityofCaliforniaSanFrancisco,CranfieldUniversitySafetyandAccidentInvestigationCentreandtheAustralianNationalUniversity,Canberra.Hehasalsoworkedasaregulatoryandprudentialaffairsassociateintheriskmanagementgroupofaninvestmentbank.”
http://www.cjm.ac/styled-3/index.html
**EarlyWarnings,weaksignalsandlearningfromhealthcaredisasters,MacraeC.BMJQualSaf2014;0:1–6.doi:10.1136/bmjqs-2013-002685
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.901.4712&rep=rep1&type=pdf
From:"STEWART,Kevin(HAMPSHIREHOSPITALSNHSFOUNDATIONTRUST)"<***************>
Subject:Re:Meeting
Date:21March2017at18:21:22GMT
To:MinhAlexander<********************>
Minh,
Sorryforthedelay;I'vebeenflatout.IsFridayafternoonthisweekanygoodtoyou?IhaveaclinicwhichrunsonuntilmidafternoonbutIcanusuallyfreeupsometimearound3.30or4pm.I'dreallyliketogetanunderstandingofwhatyourconcernsareaboutHSIB;formypartI'mcomingatitwithaveryopenmindandafocusondoingthingsdifferently.Iknowthatfolkswho'vehadverypoorexperiencesofNHSprocessesinthepastwillbenaturallysuspiciousofthis,butIsuspecttheonlywaythatwewillreallybeabletocounterthisisbydemonstratingitbyourapproachtoinvestigationwhenwestartdoingthem.
Iamconsciousthatmostwhistleblowershavehadverynegativeexperiencesandthatmanyotherclinicianswillhavebeenreluctanttospeakupforthisreason(Idon'tknowifyou'veseenourRCPreportonthispublishedlastweek?).Isuspectthatyoualsoknowabouttheacademicliteratureontreatmentofwhistleblowersinhealthcareandotherindustries,whichIdon'tknowwell,butCarlMacraedoes.IamhopingthatCarlwillhelpususethistodevelopourapproachtocapturinginformationfromwhistleblowers.Idon'tknowifanyotherhealthcaresystemdoesthiswell,butwewilllookatotherindustriesaswell.Carlseemstothinktheyhavegoodprocessesinbanking.
Repoliciesandprocedures,wehaveveryroughdraftsattheminutebutwillpublishpreliminarydocumentsonourwebsiteinthefirstfewdaysofApril.Likemuchelsethesewillnotbesetinstoneandwillbesubjecttochangedependingonutility,feedbacketc.Weareveryconsciousthatweareundertakinganewventurethathasn'tbeendonebeforesoexpectthatwewon'tgeteverythingrightstraightawayandthatourmethodsandapproachwillhavetogrowanddevelopwithus.IappreciateyourinterestinourworkbutIdon'tthinkthatIcansharedraftsornoteswithyouattheminutewithoutsharingthenwithlotsofotherindividualsaswellandwereallydon'thaveanythingthatisreadyforthat.
Anyway,letmeknowifyoucandoacallFridayafternoon.
Regards,Kevin
SentfrommyiPhone
On21Mar2017,at06:53,MinhAlexander<*********************>wrote:
HiKevin,
Canyouconfirmifatelephonemeetingwillbepossibleassuggested?
Thanks
Minh
From:MinhAlexander<*********************>
Subject:Meeting
Date:17March2017at12:24:21GMT
To:KevinStewart<**********************>
HiKevin,
Thanksfortheinvitationtomeetfacetoface.
ThereareanumberofreasonswhyIwouldpreferatelephonemeetingatthisstage.
IamconcernedaboutspeedandwouldliketoensurethatthereissomesemblanceofmeaningfulexchangeaboutwhistleblowingmattersbeforeHSIBgoeslivein2weekstime.
IamalsoacarerandtravellingtoLondonrequiresalotofarrangements.Unusually,IaminLondonforacoupleofmattersinthenexttwoweeksbuttherewillnotbetimeoneitherofthosedaystoaccommodateanadditionalmeeting.
So,pleasecanwemeetbytelephoneinthefirstinstance.
Icanspeakanytimetodayafter1pm,andanytimeafter11amonSundayandMonday.Pleaseletmeknowatimethatsuitsyou.
Beforewespeakcanyoupleasesendmeanyprotocolsrelevanttowhistleblowingandsafespaceforstaff,whatevertheirroughness.
Idon’tthinkitwouldbemeaningfultomeetwithoutthisinformation.
Thankandbestwishes,
Minh
From:"STEWART,Kevin(HAMPSHIREHOSPITALSNHSFOUNDATIONTRUST)"<****************>
Subject:Meeting
Date:17March2017at07:26:01GMT
To:MinhAlexander*******************
DrAlexander,
Sorryforthedelayingettingbacktoyou.I'msureweshouldmeetfacetofaceifpossible;I'dliketoheardirectlyaboutyourconcernsandfearsaboutHSIB,howwemightwork,yourthoughtsonhowwemightavoidsomeofthishappeningetc.HopefullyIcanreassureyouonsomeofthis.
I'minLondonalotoverthenextcoupleofweekssomaybewecanmeetthereifthatwouldworkforyou?IcanprobablyfindusspacetomeetatRCP.
CouldyouperhapsletmeknowanytimesanddatesthatmightworkforyouoverthenextcoupleofweeksinLondon?
Regards,
KevinStewart
SentfrommyiPhone
From:MinhAlexander<**********************>
Subject:Meeting
Date:21March2017at06:57:42GMT
To:KevinStewart<************************>
Cc:KeithConradi<***********************>
PSIshouldsaythatI’mavailableanytimetodayandThursdayafter11am.
TomorrowandFridayI’motherwiseengaged.
SoifyouagreetoatelephonemeetingbuttodayandThursdayarenotconvenient,itwillhavetonextweek,whichisnotverygoodbecausetherewillbelittlechanceofmeaningfullyfeedingintoyourprocessbeforeHSIBgoeslive.
Minh
From:MinhAlexander<********************>
Subject:Meeting
Date:21March2017at06:53:42GMT
To:KevinStewart<**********************>
Cc:KeithConradi<*********************>
HiKevin,
Canyouconfirmifatelephonemeetingwillbepossibleassuggested?
Thanks
Minh
From:MinhAlexander<**********************>
Subject:Meeting
Date:17March2017at12:24:21GMT
To:KevinStewart<**********************>
HiKevin,
Thanksfortheinvitationtomeetfacetoface.
ThereareanumberofreasonswhyIwouldpreferatelephonemeetingatthisstage.
IamconcernedaboutspeedandwouldliketoensurethatthereissomesemblanceofmeaningfulexchangeaboutwhistleblowingmattersbeforeHSIBgoeslivein2weekstime.
IamalsoacarerandtravellingtoLondonrequiresalotofarrangements.Unusually,IaminLondonforacoupleofmattersinthenexttwoweeksbuttherewillnotbetimeoneitherofthosedaystoaccommodateanadditionalmeeting.
So,pleasecanwemeetbytelephoneinthefirstinstance.
Icanspeakanytimetodayafter1pm,andanytimeafter11amonSundayandMonday.Pleaseletmeknowatimethatsuitsyou.
Beforewespeakcanyoupleasesendmeanyprotocolsrelevanttowhistleblowingandsafespaceforstaff,whatevertheirroughness.
Idon’tthinkitwouldbemeaningfultomeetwithoutthisinformation.
Thankandbestwishes,
Minh
From:"STEWART,Kevin(HAMPSHIREHOSPITALSNHSFOUNDATIONTRUST)"<********************>
Subject:Meeting
Date:17March2017at07:26:01GMT
To:MinhAlexander
DrAlexander,
Sorryforthedelayingettingbacktoyou.I'msureweshouldmeetfacetofaceifpossible;I'dliketoheardirectlyaboutyourconcernsandfearsaboutHSIB,howwemightwork,yourthoughtsonhowwemightavoidsomeofthishappeningetc.HopefullyIcanreassureyouonsomeofthis.
I'minLondonalotoverthenextcoupleofweekssomaybewecanmeetthereifthatwouldworkforyou?IcanprobablyfindusspacetomeetatRCP.
CouldyouperhapsletmeknowanytimesanddatesthatmightworkforyouoverthenextcoupleofweeksinLondon?
Regards,
KevinStewart
SentfrommyiPhone
********************************************************************************************************************
From:MinhAlexander<**********************>
Subject:HSIBandstakeholderinvolvement
Date:13March2017at15:13:31GMT
To:JaneRintoul<*********************>,KevinStewart<**********************>,***************************************************************************************************************************************************************************************************************************************************************************************************************************************************,KeithConradi<**********************>
ThanksforyouremailJane.
Kevin-ashalfofMarchhasalreadypassed,Ithinkitwouldbebestifwecouldmeetbytelephoneforspeed.IwouldbasicallylikeanopportunitytohelpshapeHSIBpolicybeforeitispublishedwhenyougoliveon1stApril.
Couldyoupossiblyletmeknowifatelephonemeetingispossible,andifso,sometimesthatareconvenientforyou.
Couldyoualsoletmehave,asrequested,acopyofanydraftorinterimHSIBprotocolssofar,nomatterhowrough?AmeetingwouldbemoremeaningfulifIhaveinformationaboutHSIB’scurrentthinking.
Thanks,
Minh
From:MinhAlexander<**************************>
Subject:HSIBandstakeholderinvolvement
Date:13March2017at15:13:31GMT
To:JaneRintoul<*************************>,KevinStewart,******************************************************************************************************************************************************
******************************************************************************************************************KeithConradi<**********************>
ThanksforyouremailJane.
Kevin-ashalfofMarchhasalreadypassed,Ithinkitwouldbebestifwecouldmeetbytelephoneforspeed.IwouldbasicallylikeanopportunitytohelpshapeHSIBpolicybeforeitispublishedwhenyougoliveon1stApril.
Couldyoupossiblyletmeknowifatelephonemeetingispossible,andifso,sometimesthatareconvenientforyou.
Couldyoualsoletmehave,asrequested,acopyofanydraftorinterimHSIBprotocolssofar,nomatterhowrough?AmeetingwouldbemoremeaningfulifIhaveinformationaboutHSIB’scurrentthinking.
Thanks,
Minh
From:JaneRintoul<**************************>
Subject:RE:HSIBandstakeholderinvolvement
Date:13March2017at12:47:24GMT
To:MinhAlexander<***************************>
Cc:"KeithConradi"<*****************************************************************************************************************************************************KevinStewart<*****************************************************************************************************************************************************>
DrAlexander
Thankyouforyouremail.
CanIsuggestthatDrKevinStewartandyourselfarrangetomeet,atyourconvenience?
Ithinkhecanthenexplainwherewearewithdevelopingprotocols,andgetyourviewsandthoughts.
IwillaskKevintogetintouch.Heiscurrentlymovingbetweenroles,soapologiesifthereisashortdelayinhearingfromhim.
BestWishes
Jane
From:MinhAlexander[************************]
Sent:08March201708:40
To:JaneRintoul<*************************>
Cc:KeithConradi*********************KevinStewart<********************************************************************************************************************************************************************************************************************************
Subject:HSIBandstakeholderinvolvement
Hi,
ThanksforyouremailJaneandfortheindicationthatyouhaveconsultedwithmorethanonewhistleblower.
YouranswerstillleavesmeinafogaboutwhatspecificallyHSIBhaslearntfromthiscontactandhowitwillshapeHSIB’sprotocols.
ThestaffsurveypublishedyesterdayshowsafairlyconstantpictureofNHSstaffreluctancetoraiseconcerns:30%ofoveramillionNHSstaffdonotfeelsecuretoraiseconcerns.
Couldyoupleaseallowme,andthemajorityofwhistleblowerswhohavesonotbeenallowedaccesstoyourconsultation,theopportunitytocommentontherelevantdraftHSIBprotocolsbeforetheyarefinalised?
IwouldverymuchappreciateitifyoucouldsendmeacopyofanyrelevantdraftorinterimHSIBprotocolsthatyouhavesofar,nomatterhowrough?
Thedangersofthegovernment-IseethiscurrentcorrespondenceasmoreofconversationwiththeDHthanwithHSIB-onlyconsultingthosewithwhomitfeelscomfortableisthatitwillnotbesubjecttohealthyandeffectivechallenge.
Bestwishes,
MinhAlexander
From:JaneRintoul<*************************>
Subject:RE:HSIBandstakeholderinvolvement
Date:6March2017at13:24:11GMT
To:MinhAlexander<****************************>
Cc:***************************************************************************************************************************************************"KeithConradi"<************************>,KevinStewart<*****************************************************************************************************************************************************
DearDrAlexander,
Thankyouforyouremail.
HSIBis,andwillcontinuetoconsultwithmorethanonewhistleblower.
Weknowthatweneedtomeetwithmoreorganisationsandindividualsrepresentativeofbothpatient/familiesandwhistleblowers.
Ourmeetingshavebeenverymuchaboutlisteningtoissuesandexperiences.
Theseandfuturemeetingsarehelpingustoshapeourapproach,bothinrelationtosafespace,andindraftingprotocolsthatreflecthowweworkwithindividualsduringinvestigations.Indeed,listeningtopeople’sexperiencesconfirmedourdecisiontohaveanopenreferralprocessintoHSIB.
Wearecurrentlyplanningfurtherinputintoourprotocolwriting.
Kindregards
JaneRintoul
From:MinhAlexander**********************
Sent:04March201707:52
To:JaneRintoul<********************>
Cc:KeithConradi<********************>;KevinStewart<***********************>;HenriettaHughes
******************************************************************************************************************************************************
Subject:HSIBandstakeholderinvolvement
HiJane,
InowunderstandthatyouhaveindicatedthatHSIBhasconsultedasingle,unnamedwhistleblower.
Ifso,isitpossibletoshare
a)whatlearningHSIBderivedfromthis
b)howitwillshapeHSIB’sapproachtowhistleblowingandthedraftingofHSIBprotocols?
Manythanks,
Minh
From:MinhAlexander<*************************>
Subject:HSIBandstakeholderinvolvement
Date:28February2017at09:19:01GMT
To:JaneRintoul
Cc:***************************************************************************************************************************************************KeithConradi<*********************>,KevinStewart<**************************>,HenriettaHughes******************************************************************************************************************************************************
HiJane,
ThanksforgettingbacktomeandclarifyingthatyouandHSIBseeinputfromawiderangeofstakeholders,includingwhistleblowers,askey.
Iremainunclearwhoexactlyisbeingconsultedatthisstage-Iamawareonlyofsomeoftheparties-andIdonotunderstandwhythereisnotanopenprocess.Issuesofequityariseasthoseinvolvedatanearlierstagehaveagreatervoice.
MyspecificquestionaboutwhetherwhistleblowerswillbeinvitedtocontributetothedraftingofHSIB’sprotocolswheretheyimpactonwhistleblowers(asopposedtoHSIBproducingafinalisedprotocolasafaitaccompli-whichappearedtobewhatKeithwasproposinginhisemailbelowof6thJanuary11.16)remainsunanswered,Ithink.
Withbestwishes,
Minh
MinhAlexander
From:JaneRintoul<************************>
Subject:RE:HSIBandstakeholderinvolvement
Date:28February2017at09:10:37GMT
To:MinhAlexander<***********************>
Cc:********************************************************************************************"KeithConradi"<**********************>,KevinStewart<**********************>,******************************************************************************************************************************************************
DearDrAlexander,
Thankyouforyouremail.
AsIsaidinmypreviousemail,weareworkingandwillcontinuetoworkwithawiderangeofstakeholders.Wearestillverymuchinthedesignphaseandwillcontinuetorefineourprotocolsaftergoinglive.Weseetheinputofabroadrangeofstakeholders,includingwhistleblowers,askey.
ReferralstoHSIBwillbeopentoall.WearecurrentlyworkingonhowthissystemwillworkanddecidingonhowourAdvisoryBoardfunctionwillwork.
Moreinformationwillbeavailableonourwebsite,whenitgoesliveattheendofMarch.
ThankyouforyourinterestinHSIB.
Kindregards
Jane
JaneRintoulCBE|DirectorofCorporateAffairs
HSIB–HealthcareSafetyInvestigationBranch
From:MinhAlexander[**********************]
Sent:16February201718:19
To:JaneRintoul<***********************>
Cc*************************************************************************************************KeithConradi<************************>;KevinStewart<*******************>;******************************************************************************************************************************************************
Subject:HSIBandstakeholderinvolvement
HiJane,
Justcheckingifyoureceivedmyemailbelowof6February?
IgatherthatameetingwithstakeholdersistakingplaceonMonday.
Iwouldverygratefulforclarification,asrequested,ofwhetherandhowHSIBwillbeensuringthatitsframeworksandprotocolsaredesignedwithwhistleblowerinput.
Withbestwishes,
Minh
MinhAlexander
From:MinhAlexander<***********************>
Subject:HSIBandstakeholderinvolvement
Date:6February2017at11:49:59GMT
To:JaneRintoul<***********************>
Cc:*************************************************************************************************KeithConradi<**********************>,KevinStewart
<********************************************************************************************************************************************************************************************************************************
HiJane,
Thanksverymuchforyouremail.
Torecap,
IfirstwrotetoKeithlastsummeraboutregulatoryfailuresthatallowedpoorNHSincidenthandling,andIsoughtaresponseattheNewYear.
IalsoaskedHSIBamonthagoifitwouldinvolvewhistleblowers,patientsandfamiliesindraftingitsprotocols.
TheanswersthatIreceivedfromKeithandKevinimpliedthattheanswermightbe'no',soIthereforeaskedforclarification.
IthenlearntthatHSIBsubsequentlyapproachedafewindividualsandorganisationstoofferaccesstoitsprocess(withapatientandfamilyfocus).
YounowadvisethatHSIBisconsultinginformallyandusingexistingstakeholdergroups.Butthisdoesnotfullyanswermyquestion.
Idonotknowhowequitableorrepresentativeyourapproachis.Ithinkthereisariskthatitisnot,andthatitlacksthetransparencyneededfortheculturechangethatHSIBistaskedwithdriving.
However,tomyknowledge,whistleblowerswerenotrepresentedintheestablishmentofHSIBtodate.Therefore,ifHSIBreliesontheexistingclubwhichhelpedtoestablishit,itwillexcludeamajorsliceofintelligenceandinsightintohowseriousanddeliberateNHSinvestigativefailurehappens.
IwouldhavethoughtthatthissomethingwhichHSIBwouldseektounderstand.
On6JanuaryKeithreferredbelowtoHSIBprotocolsfor"dealingwithwhistleblowers".
ThissuggeststhatthereisworktobedoneonhowHSIBconceptualisesandunderstandstheissuesaroundwhistleblowing.Theoperationofsocalled'safespace'islikelytobemechanisticandflawedwithoutfundamentalunderstandingofhowtheNHSsilencesstaff.Thechangerequiredisinfinitelymorecomplexthansimplydesignatingaspace'safe'.
TherearesomanywaysinwhichtheNHScanintimidatestafffromtellingthewholetruth.IamshortlyspeakingtoyetanotherstaffvictimofcurrentNHSsuppression.AndIhavejustheardliterallymomentsagofromsomeonewhohasdecidedthattheyhavenochoicebuttosubmittoarestrictivecompromiseagreement.Iamalsotodayhelpinganotherex
memberofNHSstafftosearchforpersonaldataaboutlikelyblacklistingforspeakingup.Thesearetypicalscenariosandtheycontinueallthetime.
PleaseadvisemoreclearlyifHSIBwillinvolvewhistleblowersindraftinganyprotocolsthatrelatetowhistleblowingandtherelatedbutdifferentmatterof'freedomtospeakup'.
IalsocopythistotheNationalGuardian,SirRobertFranciswhowillbechairingtheAccountabilitycommitteefortheNationalGuardianofficeandtherelevantselectcommitteechairs.
Withbestwishes,
Minh
MinhAlexander
SentfrommyiPhone
From:JaneRintoul<************************>
Date:6February2017at08:43:07GMT
To:MinhAlexander<*************************>
Cc:KevinStewart<*********************>,"KeithConradi"<********************>,*********************************************************************************************************************************************************************************************************************************
Subject:Re:CQCchecksontheaccuracyandqualityofproviders’incidentinvestigations
DearDrAlexander,
IamreplyingforKevin,asheisonleavethisweek.
Wearekeentolearnfrompeople'sexperiencesandtogettheirviewsaswedevelopHSIB.
Inestablishment,wearegoingaboutthisinaninformalwayandareusingorganisationsandexistingstakeholdergroupswherepossible.
Longerterm,assetoutinthedirectionsforHSIBestablishment,wewillhavesomeformofadvisory"board".Wearecurrentlyworkingthroughoptionsforthis.
WearealwayshappytoreceiveyourviewsonHSIBandthankyouforyourinterest.
Kindregards
JaneRintoul
DirectorofCorporateAffairs
HSIB
SentfrommyiPad
On3Feb2017,at16:43,MinhAlexander<***********************>wrote:
HiKevin,
IamsorrytochaseasIrealiseyoumustallbebusytryingtogetHSIBoperationalbyApril.
However,asthereisverylittletimetogo,couldyouoranothercolleaguegetbacktomeregardingthequestionofwhetherHSIBwillinvolvewhistleblowers,patientsandfamiliesindraftingitsprotocols?
Iunderstandthatyoumaybestartingtoinviteindividualsbutitwouldbegoodtohearmoreabouthowyoumaybeapproachingtheseissues.
Manythanks,
Minh
MinhAlexander
From:MinhAlexander<**********************>
Subject:CQCchecksontheaccuracyandqualityofproviders’incidentinvestigations
Date:18January2017at17:05:22GMT
To:KevinStewart
Cc:KeithConradi<*********************>,JaneRintoul********************,******************************************************************************************************************************************************
HiKevin,
Thanksverymuchforyouremailthisafternoon,copiedbelow,whichIamguessingisaresponsetomyemailtoKeithConradiof6Januaryat11.45,alsocopiedbelow.
I’mgladthatHSIBviewsfavourablytheprincipleofusingintelligencefromstaffandfamilies.Imayhavetoquibblewithyoualittleaboutcharacterisingtheintelligenceas
“soft”,asitisoftenvery“hard”andwellevidenced.ItisjustthattheNHSmaybrazenlyignoresseriousconcernsandtriestodismissthemasmisconceived.
Inmyownexperience,theNHSwascapableofevenignoringafullyevidencedreportofamentalhealthhomicide(andeventhoughthehomicidewasacknowledged,investigatedbyalltheotheragenciesinvolvedandsubjecttoacriminalprosecution).
MyquestiontoKeithConradiof6thJanuarywaswhetherHSIBwillbeinvolvingwhistleblowers,patientsandfamilies:
“Willitbepossibleforwhistleblowers,patientsandfamiliestocontributetothedevelopmentofHSIB’sprotocolswherethesehaveanimpactonthesestakeholdergroups?”
MayIjustdoublecheckifHSIB’sintentionistoinvolveusinthedraftingofHSIB’sprotocols?
Fromtheperspectiveofwhistleblowers,itwouldbehelpfulifwecancontributetothedevelopmentofyourexternalwhistleblowingpolicyandstandardsforhowyouinteractwithwhistleblowersandactupontheirdisclosures.
IpresumeHSIBwillhavelegalPrescribedPersonfunctionsunderthePublicInterestDisclosureActasitispartofNHSImprovement.ItwouldalsobeusefultoknowwhatHSIB’sapproachtothiswillbeandalsotoknowifHSIBwillhaveorseekPrescribedPersonstatusifitgainsthestatutoryindependencethatitisreportedlyseekingatpresent.
Manythanksandbestwishes,
Minh
From:"STEWART,Kevin(HAMPSHIREHOSPITALSNHSFOUNDATIONTRUST)"<***********************>
Subject:ContactwithKeithConradi
Date:18January2017at15:27:56GMT
To:MinhAlexander*********************
Cc:KeithConradi*********************,JaneRintoul<**************************>
DearDrAlexander,
Helloagain;KeithConradihasaskedmetorespondtoyouonhisbehalf.AsIsaidinmylastemail,IamintheprocessoftransitioningbetweenmyRCPjobandHSIB,soIcan'treallygiveyoualotofspecificrepliesattheminute.Asageneralcommenthowever,HSIBwillbelookingtogatherinformationandintelligencefromallpossiblesourcesinorderto
informourfocus.
Tomethismeansbeingopentothepossibilitythathelpfulinformationmaycomefrom"softintelligence"gainedfromstaffmembersorfrompatients'familiesthatmightnotbedetectedbyformaldatareporting,inspections,reportsorothersystems.
Icertainlyappreciatethatinthepasttherehavebeentoomanyindividuals(staffmembers,patients,families)whohavetriedtoraiselegitimateconcernsbutfoundthatthesehavebeenignored,orworsethattheyhavebeentreatedinpunitivefashion(attheCollegewehearthesestoriesquitealotasyoumightimagine).BycontrastIhavebeenimpressedwiththeapproachthatKeithhasbroughtwithhimtoHSIBfromhisairaccidentinvestigationexperience,whichreallydoesfocusonthejust,respectfulculturethatwehavebeenlackinginhealthcare.
ThecaveatforHSIBIguessisthatweareasmallorganisationwithlimitedresourcesandsowillbefairlyrestrictedinwhatwecaninvestigateourselves,atleastinitially,butourprinciples,whichwehopetospreadthroughouttheNHS,willbetodealwithpatients,familiesandstaffinajust,openandrespectfulmanner.
IwillgetbackintouchwithyouwhenIperhapshaveabitmoredetailtoshare.
Bestwishes,
KevinStewart
From:MinhAlexander<***********************>
Subject:CQCchecksontheaccuracyandqualityofproviders’incidentinvestigations
Date:6January2017at11:45:47GMT
To:KeithConradi<*************************>
Cc:**************************************************************************************************************************************************
Hi,
Manythanksforgettingbacktome.
Iappreciatethismustbeabusytimeforyou.
1)Willitbepossibleforwhistleblowers,patientsandfamiliestocontributetothedevelopmentofHSIB’sprotocolswherethesehaveanimpactonthesestakeholdergroups?
Whistleblowingisanespeciallycomplex,specialistareaandIhopethattherecanbeinputbywhistleblowerstohelpensurethatHSIBgetsitright.
WhistleblowersarelargelycurrentlyexcludedfromtheNationalFreedomtoSpeakUpGuardian’sprocesses,despiteconcernsraisedaboutthis,andIverymuchdoubtthatyouwillgetacompleteinsightfromthecollaborationwiththeNationalGuardian’soffice.
2)Idon’tseetheissuesaboutCQCasseparatetotheestablishmentofyouroperationalframework.Rather,regulatoryfailuretoinspectthequalityofincidentinvestigations(andrelatedtothis,theDutyofCandour*)itisacoreissuethatisholdingbackimprovementandsafetyintheNHS.CQCisalsocontinuingtofailingwhistleblowers,asrecentlyhighlightedbyareportthatIco-authored,whichwasreportedbytheTimes:
https://minhalexander.com/2016/12/05/whistleblowers-unheard-by-cqc/
IwasverygladthereforetoseethatHSIBisseekingpowers,whichwillextendtoNHSregulators.
Woulditbepossibletodiscusssomeoftheseissues?
IcopythistoInquestasIpromisedtosharetheresponsefrommycorrespondencetoyouofJune2016,andIcopythistoAvMAasregardstheissuesofcandour.IalsocopythistofellowcampaignerswhoIamawarearealsointerestedinhowHSIBdevelops.
Bestwishes,
Minh
*RegulatingtheDutyofCandour.AvMAAugust2016
https://www.avma.org.uk/?download_protected_attachment=Regulating-the-duty-of-candour.pdf
From:"KeithConradi"<************************>
Subject:RE:CQCchecksontheaccuracyandqualityofproviders’incidentinvestigations
Date:6January2017at11:16:29GMT
To:MinhAlexander<**************************>
DrAlexander,
Thankyouforyouremail.InoteyourconcernsregardingtheCQC;howeverpleaseunderstandthatmycurrentpriorityistoestablishaninvestigationcapabilitythatwillbecomeoperationalon1April17.Wearecurrentlyworkingoncriteriatoselectour30investigationsayearandalsoourprotocolsondealingwithwhistleblowers.Thecriteriawillbepublishedonourwebsitewhenitbecomesfullyfunctional.
Regards,
Keith
KeithConradi|ChiefInvestigator
HSIB–HealthcareSafetyInvestigationBranch
From:MinhAlexander[***********************]
Sent:03January201716:41
To:KeithConradi<**************************>
Subject:CQCchecksontheaccuracyandqualityofproviders’incidentinvestigations
BYEMAIL
KeithConradi
ChiefInvestigatorHSIB
3January2017
DearMrConradi,
1)IwrotetoyouinJuneandwasinformedbytheIPSISsecretariatthatyouwouldreceivemycorrespondencenolaterthanSeptember2016,whenyoutookuppost.AsIhavenotheardfromyou,IwouldbegratefulforyourresponseontheconcernsraisedaboutCQC’sapproachandomissions.
Forcompleteness,IattachafurtheremailthatIsentyouon14July2016abouttheCQC,andIcopybelowalinktoapublishedsummaryofconcernsaboutCQC’srecentso-called“DeathsReview”:
https://minhalexander.com/2016/12/15/covering-up-the-cover-ups-cqcs-revisionism/
2)IalsonoticethatyouhavebeeninvitedtotheNationalFreedomToSpeakUpGuardian’sconsultationeventon20January,abouttheestablishmentofastakeholderadvisorygroupwhichtheNationalGuardianhastoldthepresswillselectcasesforreviewbyheroffice.
MayIaskifHSIBhasdevelopedanypolicyorprotocolyetonhowwhistleblowerswillfeatureinitsoperations,andhowHSIBmayrespondifcontactedbyNHSwhistleblowers?
Manythanks.
Yourssincerely,
DrMinhAlexander
From:MinhAlexander<***********************>
Subject:CQCchecksontheaccuracyandqualityofproviders’incidentinvestigations
Date:10June2016at10:02:41BST
To:[email protected],[email protected]
Cc:[email protected],KatherineMurphy<[email protected]>,[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],HealthCommittee<[email protected]>,[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],BernardJenkin<[email protected]>,[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],[email protected],"Docherty,Matthew"<[email protected]>
ToKeithConradi,ChiefInvestigator,HealthcareSafetyInvestigationBranch10May2016
DearMrConradi,
CQCchecksontheaccuracyandqualityofproviders’incidentinvestigations
Congratulationsonyourappointment.WithregardstoHSIB’sremitforleadingimprovementinNHSincidenthandling,IwritetosuggestthatHSIBseeksandreviewsquantitativeassurancedatafromCQConitspreviousclaimthatitcheckswhetherprovidersare“writingtruthful”incidentreports.(1)
Indeed,currentCQCinspectionframeworksincludeassessmentofinvestigationquality:
“Whenthingsgowrong,arethoroughandrobustreviewsorinvestigationscarriedout?Areallrelevantstaffandpeoplewhouseservicesinvolvedintherevieworinvestigation?”(2)
However,CQCinspectionreportsgivelittledataaboutsuchinspectionactivityandthecontinuingexperienceofmanypatientcomplainants,familiesandwhistleblowersisthatCQCinfactresistsexplorationoftheirreportsthatincidentinvestigationsareflawed,evenwherethereisconcernaboutfalsification.
ItwouldbeusefulifthereistransparencyaboutCQC’smethodology,andpublishedevidenceonwhetherCQCisconsistentlyreviewingmeaningfulsamplesofincidentreportsforreviewstobeeffective.
Asaveryseriousexample,CQC’sreportofitsinspectionofSouthernHealthin2014(3)didnotconveythefullscaleandgravityofthetrust’sgovernancefailingsaroundseriousincidentinvestigations.MyreadingofCQC’sreportisthatCQCcommentedonmattersofprocess,andnotedexternalstakeholder’sperceptionsofinvestigationquality,butgavenoassessmentofitsownonwhethertrustinvestigationreportswere‘truthful’,baracommentontheincorrectclassificationofasingleNeverEventandageneralobservationthattherewasalackofstaffunderstandingaboutincidentgradingandrelatedissues.ThisapparentlackofdirectassessmentofinvestigationqualitybyCQCwasdespitethefactthatCQC’sreportgaveseveralexamplesoforganisationalfailuretolearnfromrisksandincidentsthatlogically,oughttohavepromptedcloserscrutinyofinvestigationquality.NorcouldIfindclearcommentinCQC’sreportonthetrust’sfailuretoinvestigatedeathsthatshouldhavebeeninvestigated.Ifoundonereferencetoafailuretoarrangeanexternalreviewinasinglecase.CQCconcludedthatthetrustmerely‘RequiredImprovement’asopposedtobeing‘Inadequate’onthesafetydomain.
AquestionarisesaboutthedegreetowhichCQChasfailedtoadequatelyflagseriousgovernancefailureelsewhere.
Iwouldbegratefultohearfromyouregardingthis.
Yourssincerely,
DrMinhAlexander
1)CQCannualreport2014/2015
http://www.cqc.org.uk/content/annual-report-201415
2)CQCinspectionframeworksJanuary2016http://www.cqc.org.uk/content/inspection-frameworks-hospital-and-ambulance-core-services
3)CQCreportofaninspectionofSouthernHealthNHSFoundationTrust7-10October2014,published25February2015http://www.cqc.org.uk/sites/default/files/new_reports/AAAB9266.pdf
ccPublicAdministrationandConstitutionalAffairsCommittee
PublicAccountsCommittee
HealthCommittee
NormanLambMP
LucianaBergerMP
SuellaFernandesMP
AndrewSmithMP
AlistairBurtMinisterofStateforCommunityandSocialCare
SirRobertFrancisQC
KatherineMurphyCEOPatientsAssociation
PeterWymanCQCChair
ProfLouisApplebyCQCNED
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