A long overdue public inquiry into the appalling standards of care at Mid Staffordshire NHS Trust is complete. The findings are not unexpected.
It is, however, a matter of grave concern that such efforts should be necessary before the plight of patients on sub-standard wards is noticed. Indeed, in many cases, complaints of poor treatment are more likely to be concealed than made the focus of any meaningful investigation.
In 1998, I raised concerns about poor care witnessed on Ward 87 at University Hospital of North Staffordshire NHS Trust and elsewhere. Having made no progress with the Trust, I finally saw no further option other than to take the matter public in early 2000 [Evening Mail and Sunday Times ]. Concerns were raised with the Department of Health and 10 Downing Street.
I was unaware that the publicity had forced the Trust to undertake a detailed internal investigation into my concerns, which found them to be largely upheld . Indeed, the Trust went to great lengths to keep knowledge of those findings - and their very existence - from me. Furthermore, the Trust released a statement to Stoke Radio on the 3rd April 2000 stating (amongst other things)
"Where allegations were made about the treatment of specific patients, case-notes were reviewed and her claims could not be substantiated."
I raised my concerns with the GMC, which then began to investigate me, instead of the doctors responsible for the poor standards of care that I had witnessed. As the Guardian describes here, by 2003, I had little choice other than to litigate against the GMC. I won the first hearing -subsequently the GMC settled.
Through the litigation, I learned that they had commissioned the then Regional Director of Public Health, Professor Rod Griffiths, to investigate my concerns - largely because it was, in their own words, a "high profile" issue - and that, astonishingly, he had eventually reported back to the GMC that all was, more or less, well.
In making a complaint to the GMC about Professor Griffiths' conduct in this matter, I learned of the Trust's report into my initial concerns, and tried to obtain a copy. The Trust refused, even though it was needed for a complaint before the GMC. Eventually, I was able to force the GMC to (reluctantly) obtain a copy, which they then refused to disclose to me, (allegedly) returning their only copy to the Trust when I threatened to litigate - again! - to obtain it. [ Report Extraction ]
In 2005, after Ward 87 was closed down, a heavily redacted report sent to me. The redacted copy is available here. Worryingly the Department of Health, GMC, Care Quality Commission (CQC), Health Ombudsman, NMC, the coroner and others have refused to inform the relatives of those who died, of the report's findings [ Private Eye ]
The damning report was based on minority data - my list of 29 patients over one week. No wider detailed investigation has ever been conducted. The problems existed long before that week, and continued to exist long after it with no method to calculate local ward mortality rate.
The Commission for Health Improvement (CHI), a forerunner of the CQC, reported problems at the Trust in 2002, many months after the Trust's internal report was completed, yet there has never been a wider investigation to determine exactly how many patients' care was impacted, or how many may have died needlessly.
Certainly, at around that time, North Staffordshire NHS Trust's litigation costs were far higher than those of Mid Staffordshire -
Mid Staffordshire General Hospitals NHS Trust £652,418
North Staffordshire Combined Healthcare NHS Trust £106,764
University Hospital of North Staffordshire NHS Trust £3,515,590
Source- Hansard [15 Mar 2006 : Column 2326W]
Even the CQC admits privately that death rates at the Trust were abnormally high. In an email dated 9th December 2009 at 13.15, Chris Sherlaw-Johnson, the Surveillance Manager at the CQC, wrote to his colleague, Sarah Seaholme,
"Earlier data from Dr Foster does suggest that they did have more concerning mortality in years before 2003/4".
Of course, by then, the CQC felt it was "too late" to investigate that concerning mortality.
Consequently, nobody has been held accountable for the circumstances I drew attention to. The consultant responsible for the ward was given a national award. Professor Griffiths, the then Regional Director of Public Health, NHS Executive West Midlands, retired after the GMC complaint. Professor John Temple, who was responsible for adequate junior supervision, continues to be revered in the National Health Service . David Fillingham, Chief Executive at the time, went from North Staffordshire to Royal Bolton NHS Trust where he presided over a spike in mortality rates.
Had appropriate action been taken in 1998, I believe that many lives could have been saved, but the responsibility for that failure does not end with University Hospital of North Staffordshire NHS Trust. By 2006, at the latest, both that Trust and Mid Staffordshire NHS Trust fell under the control of West Midlands Strategic Health Authority, as run by Cynthia Bower, who later ran the CQC.
The SHA, the CQC and their forerunners were all aware of my concerns. They could have compared the mortality rates at North Staffordshire with others in the region, including Mid Staffordshire. Had they done so, the Mid Staffordshire scandal may have come to light years earlier, saving countless lives. Instead, it was left to campaigners like Julie Bailey to expose problems via the media.
Ward 87 had no campaigners. No one knew of the serious medical shortfalls in care. Relying on whistleblowers and complainants to raise concerns is an unreliable way to detect early problems in patient safety. Dr Foster's statistics only detects mortality abnormalities, late in the day, when lives have been lost. Mid Staffordshire Inquiry has not developed a better solution to date nor has it ever acknowledged these serious obstacles placed in the way of junior whistleblowers.