Download pdf - STEWART, Kevin (HAMPSHIRE HOSPITALS NHS FOUNDATION … · From: "STEWART, Kevin (HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST)" Subject: Re: Telephone meeting 24 March 2017 on HSIB &

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


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


To:MinhAlexander*******************

DrAlexander,

Sorryforthedelayingettingbacktoyou.I'msureweshouldmeetfacetofaceifpossible;I'dliketoheardirectlyaboutyourconcernsandfearsaboutHSIB,howwemightwork,yourthoughtsonhowwemightavoidsomeofthishappeningetc.HopefullyIcanreassureyouonsomeofthis.

I'minLondonalotoverthenextcoupleofweekssomaybewecanmeetthereifthatwouldworkforyou?IcanprobablyfindusspacetomeetatRCP.

CouldyouperhapsletmeknowanytimesanddatesthatmightworkforyouoverthenextcoupleofweeksinLondon?

Regards,

KevinStewart

SentfrommyiPhone

From:MinhAlexander<**********************>

Subject:Meeting


To:KevinStewart<************************>

Cc:KeithConradi<***********************>

PSIshouldsaythatI’mavailableanytimetodayandThursdayafter11am.

TomorrowandFridayI’motherwiseengaged.

SoifyouagreetoatelephonemeetingbuttodayandThursdayarenotconvenient,itwillhavetonextweek,whichisnotverygoodbecausetherewillbelittlechanceofmeaningfullyfeedingintoyourprocessbeforeHSIBgoeslive.

Minh

From:MinhAlexander<********************>

Subject:Meeting


To:KevinStewart<**********************>

Cc:KeithConradi<*********************>

HiKevin,

Canyouconfirmifatelephonemeetingwillbepossibleassuggested?

Thanks

Minh


Subject:Meeting


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


To:MinhAlexander

DrAlexander,

Sorryforthedelayingettingbacktoyou.I'msureweshouldmeetfacetofaceifpossible;I'dliketoheardirectlyaboutyourconcernsandfearsaboutHSIB,howwemightwork,yourthoughtsonhowwemightavoidsomeofthishappeningetc.HopefullyIcanreassureyouonsomeofthis.

I'minLondonalotoverthenextcoupleofweekssomaybewecanmeetthereifthatwouldworkforyou?IcanprobablyfindusspacetomeetatRCP.

CouldyouperhapsletmeknowanytimesanddatesthatmightworkforyouoverthenextcoupleofweeksinLondon?

Regards,

KevinStewart

SentfrommyiPhone

********************************************************************************************************************


Subject:HSIBandstakeholderinvolvement


To:JaneRintoul<*********************>,KevinStewart<**********************>,***************************************************************************************************************************************************************************************************************************************************************************************************************************************************,KeithConradi<**********************>

ThanksforyouremailJane.

Kevin-ashalfofMarchhasalreadypassed,Ithinkitwouldbebestifwecouldmeetbytelephoneforspeed.IwouldbasicallylikeanopportunitytohelpshapeHSIBpolicybeforeitispublishedwhenyougoliveon1stApril.

Couldyoupossiblyletmeknowifatelephonemeetingispossible,andifso,sometimesthatareconvenientforyou.

Couldyoualsoletmehave,asrequested,acopyofanydraftorinterimHSIBprotocolssofar,nomatterhowrough?AmeetingwouldbemoremeaningfulifIhaveinformationaboutHSIB’scurrentthinking.

Thanks,

Minh

From:MinhAlexander<**************************>



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


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<********************************************************************************************************************************************************************************************************************************


Hi,

ThanksforyouremailJaneandfortheindicationthatyouhaveconsultedwithmorethanonewhistleblower.

YouranswerstillleavesmeinafogaboutwhatspecificallyHSIBhaslearntfromthiscontactandhowitwillshapeHSIB’sprotocols.

ThestaffsurveypublishedyesterdayshowsafairlyconstantpictureofNHSstaffreluctancetoraiseconcerns:30%ofoveramillionNHSstaffdonotfeelsecuretoraiseconcerns.

Couldyoupleaseallowme,andthemajorityofwhistleblowerswhohavesonotbeenallowedaccesstoyourconsultation,theopportunitytocommentontherelevantdraftHSIBprotocolsbeforetheyarefinalised?

IwouldverymuchappreciateitifyoucouldsendmeacopyofanyrelevantdraftorinterimHSIBprotocolsthatyouhavesofar,nomatterhowrough?

Thedangersofthegovernment-IseethiscurrentcorrespondenceasmoreofconversationwiththeDHthanwithHSIB-onlyconsultingthosewithwhomitfeelscomfortableisthatitwillnotbesubjecttohealthyandeffectivechallenge.

Bestwishes,

MinhAlexander

From:JaneRintoul<*************************>



To:MinhAlexander<****************************>

Cc:***************************************************************************************************************************************************"KeithConradi"<************************>,KevinStewart<*****************************************************************************************************************************************************

DearDrAlexander,


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

******************************************************************************************************************************************************


HiJane,

InowunderstandthatyouhaveindicatedthatHSIBhasconsultedasingle,unnamedwhistleblower.

Ifso,isitpossibletoshare

a)whatlearningHSIBderivedfromthis

b)howitwillshapeHSIB’sapproachtowhistleblowingandthedraftingofHSIBprotocols?

Manythanks,

Minh

From:MinhAlexander<*************************>


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<************************>



To:MinhAlexander<***********************>

Cc:********************************************************************************************"KeithConradi"<**********************>,KevinStewart<**********************>,******************************************************************************************************************************************************

DearDrAlexander,


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<*******************>;******************************************************************************************************************************************************


HiJane,

Justcheckingifyoureceivedmyemailbelowof6February?

IgatherthatameetingwithstakeholdersistakingplaceonMonday.

Iwouldverygratefulforclarification,asrequested,ofwhetherandhowHSIBwillbeensuringthatitsframeworksandprotocolsaredesignedwithwhistleblowerinput.

Withbestwishes,

Minh

MinhAlexander

From:MinhAlexander<***********************>



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<************************>


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


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


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




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


To:MinhAlexander<**************************>

DrAlexander,

Thankyouforyouremail.InoteyourconcernsregardingtheCQC;howeverpleaseunderstandthatmycurrentpriorityistoestablishaninvestigationcapabilitythatwillbecomeoperationalon1April17.Wearecurrentlyworkingoncriteriatoselectour30investigationsayearandalsoourprotocolsondealingwithwhistleblowers.Thecriteriawillbepublishedonourwebsitewhenitbecomesfullyfunctional.

Regards,

Keith

KeithConradi|ChiefInvestigator

HSIB–HealthcareSafetyInvestigationBranch

From:MinhAlexander[***********************]

Sent:03January201716:41

To:KeithConradi<**************************>


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



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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