Serious Case Reviews – published at last

Michael Gove is to be commended for publishing the two Serious Case Reviews (SCR) on the tragic events leading up to the death of Peter Connelly (Baby P). Labour always refused to do so – but if that somewhat overused phrase ‘lessons must be learned’ is to mean anything – then publishing SCRs is a real step in the right direction.

Finally, we can actually see what was in the first SCR – and then see what was in the second SCR commissioned by Ed Balls because he believed the first one was ‘inadequate’.

Having read both – twice – I think on closer inspection they raise more questions than they answer.

At the end of the trial of Baby Peter’s mother, boyfriend and lodger, together with about four others, I was allowed to read the first SCR under lock and key and with the proviso that I never revealed what was in it. So all I ever said about it was that people would be shocked to find such a litany of casualness by every individual and every agency involved in child protection.

And indeed, that was the verdict yesterday by the media and commentators. The extraordinary thing is that when there is a child protection plan in place as there was with Baby Peter – given that child has been assessed as ‘at risk’ we (the people) would expect those charged with the child’s safety to be rigorous in their attention to detail. Instead we find a litany of missed appointments, no follow-ups, files lost, handovers not done, meetings not attended. It is genuinely an appalling litany of casualness.

But all of this was quite clear in the first SCR. It wasn’t well written or well-analysed – but seemingly the information was there even if in a somewhat rambling form. So – why did Ed Balls commission a second SCR?

Looking at the second SCR – it doesn’t really answer that question. Yes – it is better written, better ordered and the analysis is sharper – but it doesn’t seem to add anything new. In fact – it addresses far less – and astonishingly seems to airbrush out the child health protection agencies. There doesn’t seem to be a mention in the body of the text (except introductory) of Haringey PCT, St Ann’s or Great Ormond Street Hospital (GOSH). Yes – there is a chronology of events – that describes going to doctors, visits to hospitals – individual’s failings on health – but nothing about the management of those services at all.

Given that I have been banging on about the child health protection part in all of this on the floor of the Chamber myself, on this blog, in articles and I even got Norman Lamb (at that point LibDem Shadow Health Secretary) to raise it – I find the omission extremely surprising.

I first raised the alarm on the health issue because I couldn’t understand why there was a locum in the first place – the locum who turned out to be the doctor who didn’t recognise the injuries of Baby Peter – just before he died. It turned out that there was a locum because the department was understaffed drastically because two senior paediatricians had resigned; one was on sick leave and one on special leave.

It also turned out that four senior paediatric consultants had written to the management of GOSH to raise the alarm on unsafe procedures and clinicians’ concerns not being listened to.

There’s more – but the essential issue – is why are all the issues around management failure in the child health protection team not included in the second SCR? They are in the first one. There are lots of recommendations in the first SCR for GOSH and Haringey PCT. Why are there none in the second? It’s as if GOSH and Haringey PCT have been spirited away.

Also, most strangely, the second SCR focuses almost entirely on Haringey Children’s Services – and whilst yes – they were undoubtedly the lead agency and deserved the priority scrutiny – the child protection health arrangements were a whisker behind. Was the second SCR directed by someone to focus attention more on one agency than another involved in the case? If so – why?

I will be interested to see what experts, professionals and commentators think after they have had time to read the reports fully. The day of publication was more to do with the shock of seeing the litany of failure that led to Peter Connelly’s death. In the cold light of day – with more time to read both SCRs together – more in depth analysis will be helpful.

0 thoughts on “Serious Case Reviews – published at last

  1. I believe this is the result of lack of support to NHS whistleblowers and the Labour’s quango recruitment. NHS staff must to encouraged to speak up without fear and reprisals but unfortunately there is still a culture of silence and anyone who raises concerns is victimized and at times criminal charges are pressed which either lead to no conviction/caution or dropped but the Chief Constable has the discretion to disclose it under ‘OTHER RELEANT INFORMATION’ section. Lynne, please look into it and make appropriate changes in the legislation as with appropriate support to NHS staff, unncessary litigation can be avoided.

    Mr Andrew Lansley, Health Secretary said on 9 Jun 10 , RIBUST NEW SAFEGUARDS FOR NHS WHISTLEBLOWERS’

    AND has come up with ‘The NHS Constitution and Whistleblowing – A paper for consultation’ , which is closing on l 12 Jan 2011. Hope things will change towards patients’ care.

  2. There is one area where there is full concentration on completely investigating why things go wrong: aircraft accident investigations. All too often the finding is that there was no single reason for the accident, but numerous errors, omissions and unexpected physical and human factor engineering failures contributed – and if just one of the factors had not been present, the catastrophic outcome would not have resulted. The same stringency is now being increasingly seen in motor vehicle accident investigations, and is (after tragedies such as the Ladbroke Grove accident) being applied to studying railway accidents and then making changes to operational procedures and engineering. We have to spread the same discipline into other areas, but already it is very clear that, as a country, we have a duty to bring about dramatic improvements in managerial standards in people-centric services, supremely so in areas such as that which is the subject of this thread. But we must also not forget that, from time to time, hopefully with increasing rarity, a coincidence of factors, each of which appears to be not critically important, will result in a tragedy. RIP Baby Peter.

  3. Of course the Doctor who tried to blow the whistle is still suspended as far as I’m aware.
    The other agency that doesn’t get much of a mention is, of course, the police.

  4. Whistleblowing Obstacles
    Submitted by Anonymous on 25 Sep 2010 @ 2:42pm.
    These days, new reports have emerged whereby Managers fabricate malicious vexatious, frivolous, if not minor allegations of sexual assault against whistleblowers and report them to police. The only thing required is a police report and the whistleblower is in the dock and the word of one person becomes a wider investigation with millions spent in court to bring the issue to trial. The spectre of “investigation” begins where attention from the real issues [ eg poor care] is diverted by persecuting and discrediting the whistleblower. The question we ask is this, does the Crown Prosecution Service have any concept of organisational reprisals as applied to whistleblower? It is interesting that a vexatious frivolous allegation will be energetically taken up by the police and the CPS thereby wasting millions of tax payers funds, yet the case of Dr Jane Barton who ended the lives of many was dropped at the first stage.

    Simultaneously, the Managers may refer him/her to GMC/other regulatory bodies and the poor person appears before the Interim Order Panel (IOP).If s/he is vigilant and has all the records of complaints, there is 50/50 chance that he may face sanctions until the issue is resolved by police which takes almost a year before the case reaches trial. During that period, the health professional has to disclose this GMC investigation in all his or her job application forms.

    Meanwhile, s/he/ may well be suspended by the Trust, has lost his/her good name and if a locum, s/he is unable to work with other agencies as the Enhanced CRB disclosure will contain these charges and even the existing agency may not offer him/her a job. So virtually s/he is jobless with huge gap in his/her C.V, which has to be disclosed . He/She will have no other option except to find job secretly and hide him/herself from Managers who are ‘haunting’ and all out to spread more rumors to colleagues and prospective employers.

    So after discovering, the NHS staff is subjected to allegations of sexual assault , the employer will try subtly ask him/her to leave or will not extend his/her locum and will be rigorously watched as a ‘suspect’. So he/she has lost his/her friends, confidence, trust and avoids attending conferences fearing he/she may have to face members who had subjected him/her to subtle surveillance and organized mobbing.

    Now the case reaches court. The prosecution may deny that it has anything to do with whistleblowing and wants reasons for malicious allegations. The NHS staff defends themselves by saying it’s part of organized mobbing and it takes a huge amount of courage and risk to whistleblow and the allegations are premeditated just to discredit complaints.

    Though the defendant says, the complainant might have motive to make allegation and the complaints might have gone to Care Quality Commission (CQC) who could have downgraded star rating leading to job losses affecting the complainant herself, the problem is how to convince the Jury which comprise only 12 ordinary individuals on electoral register who might have relavant prejudices/ bias . Also the defendant might not be articulate and impressive and lose the case altogether. So the consequences are that an innocent has a criminal record and ends up on sex offenders register, has ruined his/her career with no livelihood, out of medical profession and virtually unable to find a job overseas as he/she would be erased from the GMC/Other regulatory bodies’ register.

    Another scenario!!! the Jury may not reach a verdict and it could be a hung jury. The CPS may ask for re-trial. Are the consequences easily understandable to the public?. How can s/he prove her/his innocence if he/she is not in the UK and how can he defend without earning. How can s/he seek the services of a solicitor to challenge Enhanced CRB disclosure even if the charges are dropped but appear under ‘other relevant information section’ of the Enhances CRB Disclosure. The scenario is such that even if the charges against a whistleblower are dropped, the very fact there was an “investigation” is held against his or her name. The prejudice and stigma will be a lifelong sentence.

    These are a few of endless problems such as Appraisal/Revalidation/CPD being faced by whistleblowers. If they raise concern, they are prosecuted, if not still persecuted.

    Is there anyone in the town who dare to speak and help NHS Whistleblowers????????????????????/????????

    Persecution of NHS Whistleblowers
    Thursday, September 2, 2010

  5. Organized Mobbing and Organizational Reprisals:

    Mobbing was first described by Heinz Leyman in Sweden in the early 1980’s. Kenneth Westues reported in At the Mercy of Mob as, “an impassioned, collective campaign by co-workers to exclude, punish, and humiliate a targeted worker”. The behaviour generally include social conflicts such as defaming a person, isolating them, spreading rumors leading to major conflicts, such as preventing employment, lack of promotion and even threats of physical violence. It may be deliberately coordinated, or may develop through the influence of a copycat atmosphere in the workplace. Ramage explains that its often insidious and hard to detect (1).

    There are various forms of bullying. One of them is organized mobbing whereby members of an organization team up against an individual who dare to challenge wrongdoing. Sometimes sham peer review is used to destroy the medical career with improper motive.(2) Whistleblowers are most often subjected to organizational reprisals and various research has replicated these finding that its still hazardous to speak up.(3). A number of NHS staff have faced dire consequences because of whistleblowing which is , in fact, their professional obligations. Sadly they are perceived as troublemakers rather than a solution. Sometimes they are accused of inappropriate behaviour, misconduct and even mental illness (4,5). Martin & Rifkin clearly highlighted their concerns about managers saying ‘managers often appear to be deeply threatened by whistleblowers, who are subject to severe reprisals, including ostracism, petty harassment, threats, punitive transfers, referral to psychiatrists, formal reprimands, demotion, and dismissal. Management’s response, when perceived as excessive, can generate sympathy for the whistleblower. Many observers see an injustice when a lone individual reports a problem that needs fixing or investigation and management responds with a massive attack on the credibility, working conditions, and livelihood of the individual’ (6).

    Normally management justifies such official actions by claiming that the employee is a “difficult personality,” incompetent, inadequately trained, or has made some serious error. It is not unusual for an outspoken employee’s file to be scrutinized and old complaints or allegations pulled out – sometimes from many years earlier – and used to justify actions’.(6). Coull (2004) believes ‘many whistleblowers find that their career, physical health, and mental health all suffer’ and sometimes ‘false allegations of sexual impropriety, financial irregularities, drug abuse, or other criminal activity can be made against the whistleblower’.(7). Sadly, at times, whistleblowers are reported to police and subsequently the CPS press criminal charges despite having no clear charging criteria for whistleblowers. This is contrary to the Government pledge to provide ‘ROBUST NEW SAFEGUARDS FOR NHS WHISTLEBLOWERS’ as can be seen in the following links,

    1.Price.M: Campaign on bullying needed with rise of mobbing. Hospital Dr. 29
    0ct 2009.
    2. Huntoon. L.R. The psychology of sham peer review. Journal of American and Surgeons. Vol 12, number 1, 2007
    3.BMJ: Changing the face of whistleblowing. 2009; 338:b2090 doi: 10.1136/bmj.b2090 (Published 27 May 2009)
    4.Campell.B:The persecution of NHS Whistleblowers., Friday 11 December 2009 10.00 GMT
    5.Lakhani.N: NHS is paying millions to gag whistleblowers. The Independent Sunday 1 Nov 2009
    6.Martin.b & Rifkin.W: The dynamics of employee dissent: whistleblowers and organizational jiu-jitsu.
    7.Coull.R:studentBMJ 2004;12:45-88 February ISSN 0966-6494

  6. In the US, whistleblowers are rewarded for speaking up as can be seen in the following link,,,5917709,00.html

    but unfortunately in the UK, they are persecuted/prosecuted. A cultural shift and change of attitude is vital to avoid unncecessary litigation.

  7. Mike, similar article but read this- bit- If this is true- that is disgusting- The newspaper source-

    “To her amazement, Dr Pal found a series of internal memos openly questioning her sanity.

    They had been exchanged between GMC officials, including Peter Lynn, deputy to GMC chief executive, and Dr Sheila Mann, who ‘screens’ investigations into doctors before they go ahead.

    One memo from Mr Lynn, dated November 30, 2000, read: “She may be suffering from mental illness. There must be some concern about this doctor having direct access to patients.”

  8. This is real example of organized mobbing which so many pressure groups are campaigning and trying to make the regulatory bodies understand that their primary duties as written in their manifesto is to protect patients. Unfortunately anyone who speaks for patients and in fact follows GMC/NMC guidelines, is subjected to reprisals and his/her reputations is tattered making his/her unable to work again in the NHS. Managers refer these whistleblowers to GMC/NMC and the investigation takes ages and the regulatory bodies intentionally delay and takes dictations from the NHS Managers as they all work for them. They frame these hard working staff and disclose these pending investigation to employers saying ‘its in public interest’ forgetting that its more in public interest to highlight malpractice and those who are real culprits are protected as the regulatory bodies don’t disclose why these allegations are made against them.

    You can see interesting information in the following link. I am not sure if GMC/NMC etc. will gain insight and think rationally. Their reputations is increasingly damaged and here in the UK and worldwide and many doctors are opting for Australia and the US as they don’t trust them.

  9. What Dr Pal is 100% correct that two different set of criteria are used to investigate complaints and harsh action is taken against doctors from ethnic minorities. Liam Donaladson, the former CMO said that ethnic minority doctors face systemic prejudice, racism and harassment (Donaldson.L; Chief medical officer calls for action against racism in NHS, BMJ, 19 July 2008). These doctors are 12 times more likely to face allegations of indecent behaviour and subjected to GMC Fitness to Practise Hearing. GMC has assassinated livelihood of a number of bright doctors and its so sad that there is no accountability for them (Esmail.A. Asian doctors in the NHS: service and betrayal, British Journal of General Practise, October 2007). In a latest article published in the BMJ,it has emerged that black and ethnic minority are more likely to face Stream I (more serious) investigation (Sandhu B: Alarm over ethnic profile of disciplinary statistics. BMJ 24 May 2011). Unless regulatory bodies change their attitudes and be fair in their proceedings, patients’ care will never improve.

  10. GMC guidelines are clear on raising concerns but doctors are sceptical as time and again they face retributal and are left all alone at the mercy of the NHS Managers who then refer them to police, GMC and subjected them to ostracism, horrifying investigating process, dismissal etc. I suggest the GMC guidelines lack clarity on real support after raising concerns as the PIDA don’t support adequatley because of a number of loop holes and health professionals can’t affort hefty legal costs as the Trade Unions hardly support a PIDA claim. Doctors opt to silence fearing further reprisals by the NHS Managers.

    GMC screening process should be robust and if a whistleblower provides evidence of raising concerns prior to complaints, he/she should not be referred to the FTP as it will send a wrong message to other doctors and will discourage them to speak up for their patients.

    The GMC Annex F

    Responding to incidents and complaints

    44. Concerns about patient safety or the conduct, health or performance of staff can come from a number of sources, such as patients’ complaints, colleagues’ concerns, critical incident reports and clinical audit. If you receive such information you have a duty to act on it promptly and professionally. You can do this by investigating and resolving concerns locally or by referring serious or repeated incidents or complaints to senior management or regulatory authorities.
    45. If you are responsible for investigating incidents or complaints you should make sure that:
    appropriate adverse event and critical incident reports are made within the organization and to other bodies, such as the National Patient Safety Agency
    you have a working knowledge of the relevant law and procedures under which investigations and related proceedings are conducted
    patients who make a complaint receive a prompt, open, constructive and honest response
    clinical staff understand their duty to be open and honest about such events with both patients and managers
    all other staff are encouraged to raise genuine concerns they have about the safety of patients, including any risks that may be posed by colleagues
    staff members who raise concerns are protected from unwarranted criticism or actions
    systems are in place to ensure that incidents, concerns and complaints are investigated promptly and fully
    the person or people being investigated are treated fairly
    patients who suffer harm receive an explanation and, where appropriate, an apology18
    recommendations that arise from investigations are implemented or referred to senior management.

  11. Because of a culture of fear and retribution in the NHS,many doctors don’t speak up. However a minority do raise concerns trusting the system and stop when they face reality and see the double standard. The GMC guidelines are clear encouraging doctors to speak up but when they do speak up, NHS Managers persecute them and refer them to GMC. There is no support for doctors when they are suspended as the GMC does not involve in employment issues, knowing the cause of suspension is because of following the GMC guidelines. The NHS Managers fabricate spurious complaints and the GMC take it as Stream 1 (more serious) especially if a doctor is from ethnic minority.

    I suggest, GMC should be proportionate in its response and if a whistleblower produces evidence of raising concerns before being subjected to spurious complaints,GMC should close the matter at the initial stage as referral to FTP panel will discourage other doctors from speaking up and GMC wants doctors to highlight malpractice or wrongdoing.

    Only with proportionate response by the GMC, doctors will have confidence to speak up without fear of reprisals.

  12. The following case illustrates how the Caucasian doctors are treated more favourably by the GMC.. Dr.Thomas, a Gynaecologist who was alleged to have given his patient, Ms Giles ‘leg bucking orgasm’ and received lewd messages on his phone was taken lightly after his patient made a complaint against him and the GMC did not take any action despite its own guidelines, that the presumption for sex assault allegation is to refer to the Fitness to Practise (FTP) Panel hearing and substantial disputes should not be resolved by the case examiners.(The Telegraph By Nick Britten and Matthew Moore 6:16PM GMT 18 Dec 2009)

    If it were a black or an ethnic minority doctor, he could have been immediately suspended and dragged all the way to the FTP Panel hearing and most likely erased.

  13. 1.Ian Kennedy, the last Chairman of Healthcare Commisson has acknowledged the
    widespread problem of deterrance in raising concerns saying “My experience of the
    Department of Health is they have a tendency to shoot the messenger rather than
    embrace changes that need to be made. Their first priority is to ‘handle’ the situation
    rather than consider and implement change. Those were the realities we had to work
    with,” (BMJ 2011; 342:d2900 doi: 10.1136/bmj.d2900 (Published 6 May 2011)

  14. Some Pressure groups are campaigning to abolish biased GMC and I am not sure if the DH/NHS who use regulatory bodies to silence and persecute genuine doctors will ever let it happen. GMC shows bias on almost every stage starting from investigation leading up to FtP decisions. For Caucasians in particular White British doctors, preferential treatment is given and if there is no strong written evidence, complaint will be perceived as vexatious especially if it is from a patient or member of the public. However NHS Medical Managers’ concerns are taken as stream 1 (more serious) if the doctor is from ethnic minority and GMC take long time to conclude and for White British doctors, the case is either closed swiftly or brought to FtP panel in a few months with favourable outcome. A number of reports have shown that NHS Managers make false allegations and complaints against White British doctors come to light only if the case of of Shipman or Kerr/Haslam level

    as the NHS management support them. By contrast, even a minor concern abut ethnic minority doctors is taken seriously and reported to GMC and the NHS management use other staff as witnesses and the ethnic minority doctors face prosecution by the GMC which is part of the mob culture. In nutshell, many experts in whistleblowing say, its wise to keep quiet and keep your head down.

  15. GMC guidelines on rasing concerns are sketchy as they don’t provide any platform of support when a whistleblower is subjected to complaint and reprisal as the NHS Managers and Trusts will never admit that its retribution or anything to do with whistleblowing. Even the CPS has no charging criteria when the Trusts press criminal charges. So who dares to speak up and ends up losing his good name, livelihood and almost impossible to work again in the NHS. Even regulatory bodies take drastic action when referred by the NHS Managers and whistlbleblowing issue is not taken seriously. How to prove that its part of mobbing and whistleblowing if the evidence is in the form of written complaints and the NHS Managers use malicious allegations through other staff or known patients. If the whistleblower is from ethnic minority, he/she is unable to produce any witness as NHS Managers threaten any potential witness of dire consequences of supporting a whistlebower.

    Its not easy to raise concerns. A robust screening process is vital and if a whistleblower provides written evidence of raising concerns before reprisal and subjected to referral to regulatory bodies, he/she should not be investigated and the matter must be closed as soon as possible. It will encourage other NHS staff to speak up and will minimise culture of silence and fear as many NHS staff feel, regulator bodies are part of mob culture.

  16. GMC has two different set of criteria to investigate concerns and some people are justified to say that its not less than a double standard. The following article written by a British Cardiologist Dr.Peter Wilmshurst provides evidence of racial bias despite GMC’s claim that its not due to ethnicity but the place of work which brings more International Medical Graduates to Fitness to Practise (FtP). A British Professor who claimed false qualification was given only PRIVATE WARNING . Seven Black and Ethinic minority doctors claiming false qualifications and/or making false job applications were treated harshly; three were erased, one suspended and another reprimanded. Is it fairness in this most civilized nation.

    You can find full article in the following link


    A Personal View. Dr Peter Wilmshurst

    ‘….Some may ask why the Professional Conduct Committee publicly suspended or erased from the Medical
    Register a number of doctors, all of whom had African or Asian names, for claiming qualifications that they had not been awarded, but the GMC decided that in the case of a white British professor at a major academic institution only a private warning not to do it again was required…..’

    Not to mention that Dr Pal, an ethnic minority doctor who raised concerns on patients’ safety was labelled as mentally ill and the judge branded GMC as a ‘STALANISTIC REGIME’. Its unfortunate that the GMC has assassinated the career of a brilliant doctor and the NHS has lost an eminent professional merely because of racial bias. GMC has been and will be used to silence and prosecute whistleblowers and drastic action will be taken against ethnic minority doctors. There is still hope if the GMC and other regulatory bodies change their attitudes and stop taking dictations from NHS Managers and stick to their primary duty of patients’ care and not to punish genuine whistleblower.

  17. GMC needs to change its mind set that the NHS Medical Managers’ concerns are always credible. The reality is that most of them are really corrupt and biased against ethnic minority doctors particularly locum doctors. If anyone raises concern, they report him to GMC with spurious complaints and sometimes play dirty and the concerns remain under the carpet. They don’t investigate fearing reality as it will imply they are poor managers and historic arms of the GMC are used to silence and punish whistleblowers. GMC now says its role is not to punish doctors but to protect patients and public but the evidence shows completely different.

    Its just a lollypop that PIDA protects whistleblowers as Trade unions will almost never support PIDA claim and a whistleblower can’t afford hefty fee and even if he wins, he will not get back his legal cost and will be subjected to further reprisal. GMC encourages to speak up but many whistleblowers say its professional suicide. In other words, GMC ask doctors to commit suicide after raising concerns. GMC just want to satisfy public that they are protecting patients but when a whistleblower faces reality, financial, emotional hardship and almost unlikely to work again in the NHS, he will advise others to keep your head down and never whistleblow. GMC destroys career by investigating a whistleblower and bringing him before a Fitness to Panel (FtP) hearing and seek dictations from DH/NHS Managers to prosecute whistleblowers with harsh punishment for ethnic minority doctors. Even if the allegations are unfounded, the doctor will have a life long sentence as he will have to disclose it in all future job applications and the employers will be reluctant to offer him a job. This is direct contrast to GMC as well as DH pledge to support whistleblowing. In other words, GMC as well as the NHS/DH send a clear message to other staff to keep their mouth shut and in theory encouraging them to raise concerns on patients’ safety. I believe, its all hypocrisy and nothing is going to change.

  18. The best way for the GMC to build up its rapidly damaging reputation is to start being honest and fair by investigating NHS Medical Managers under Stream 1 (more serious) allegations and bring them before the Fitness to Panel (FtP) hearing when they refer genuine whistleblowers to GMC with spurious complaints. If the whistleblower provides evidence of raising concerns before being referred to GMC, the case must be closed at the investigation stage (Registrar stage). This will send a clear message to all doctors to raise concerns and discourage NHS Managers’ gang culture.

    ENOUGH IS ENOUGH!!!GMC must NOW stop taking anymore dictations from the NHS/Department of Health although we still believe its an uphill task for the GMC.


    Rt Hon Andrew Mitchell MP gets Parliamentary Health Select Committee inquiry on whistleblowers
    0 Comments – 05 Jul 2011

    We are very pleased that hard working Rt Hon Andrew Mitchell MP has been successful in obtaining agreement from Rt Hon Stephen Dorrell for an inquiry into NHS whistleblowers. Dr Rita Pal, veteran whistleblower (ward 87, North Staffordshire) alerted Rt Hon Andrew Mitchell of problems associated with doing the right thing for the patients in a dysfu…

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    Mr Nunn Orthopaedic Surgeon and David Cameron PM do their best by Dr Helen Bright
    0 Comments – 24 Jun 2011Click on the photograph to watch the videoMr Nunn, Orthopaedic Surgeon who would know only to well what happens when infection spreads through the bones and kills objected to filming crew not complying with hospital hygiene rules. It certainly is best to be safe. David Cameron, PM did the best he could in the situation and asked filming crew to c…

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    Tuesday, 5 July 2011
    Rt Hon Andrew Mitchell MP gets Parliamentary Health Select Committee inquiry on whistleblowers

    Posted by Doctors4Justice at 11:35
    We are very pleased that hard working Rt Hon Andrew Mitchell MP has been successful in obtaining agreement from Rt Hon Stephen Dorrell for an inquiry into NHS whistleblowers. Dr Rita Pal, veteran whistleblower (ward 87, North Staffordshire) alerted Rt Hon Andrew Mitchell of problems associated with doing the right thing for the patients in a dysfunctional system of medical regulation.

    Dr Rita Pal, North Staffordshire whistleblower (care of the elderly in Ward 87) with help of Rt Hon Andre Mitchell MP managed to get a committeemen from Rt Hon Stephen Dorrell:

    “The committee will look into whistleblowers. It is every professional’s business to ensure that clinical care where they work is of a certain standard. Like Sir Ian Kennedy said after the Bristol babies inquiry: ‘It wasn’t that nobody knew, it was that everybody knew.’ Every doctor and nurse has an obligation to act if they know there is a problem and those who do nothing should be questioned by their regulator; it would soon stop this kind of thing.”

    We agree.

    However, we do know that when we inform medical regulator, regulator can turn nasty towards whistleblower too, so some measures would have to be introduced to deal with regulators’ wrongdoing. The first such measure would be for regulators to agree to consent order for whistleblower’s rehabilitation where regulator wrongly persecuted whistleblower and introduced sanctions against their professional practice. This would allow High Court to quash GMC findings, for example.

    Another measure would be financial fines for regulator who treats whistleblowers badly. I learned, for example, from training unwilling men to do housework that it was easier to achieve my goal by asking them to contribute towards cleaners’ salary that to give them lectures on feminism or to manipulate them by cooking nice meals for them (I am a good cook).

    Doctors4Justice has campaigned for a couple of years now for improvements in regulation of medical profession. We have produced several papers on whistleblowing. Here is one:

    Read Sir Ian Kennedy’s Witness Statement to Staffordshire Public Inquiry HERE.


    Hung out to dry: scandal of the abandoned
    NHS whistleblowers
    By Nina Lakhani
    Monday, 4 July 2011
    Sharmila Chowdhury faces losing her home
    A parliamentary inquiry is to be held into the treatment of NHS whistleblowers amid growing
    evidence of cover-ups which can destroy careers, waste millions of taxpayer pounds and endanger
    patients by creating a culture of fear among health workers.
    The Coalition Government faces a swell of anger among health professionals who are demanding
    better protection for staff who speak out about substandard patient care and malpractice. Some
    health services are being cut and tens of thousands of jobs lost as the NHS faces unprecedented
    financial pressure over the next four years.
    Stephen Dorrell, who was Health Secretary under John Major and is now the chairman of the
    Commons Health Select Committee, last night promised to hold an inquiry into the treatment of
    NHS whistleblowers after outrage over the latest case to emerge.
    Sharmila Chowdhury, 52, a radiology manager at a London district general hospital, is likely to lose
    her home after an inquiry found she was unfairly sacked after alleging that doctor colleagues were
    wrongly claiming thousands of pounds of public money every month, which the doctors and trust
    Ms Chowdhury, a radiographer with an unblemished 27-year NHS career, was marched off the
    premises following an unfounded counter-allegation of fraud made against her by a junior whom
    she had reported for breaching patient-safety procedures.
    Ms Chowdhury’s employer, Ealing Hospital NHS Trust, has spent hundreds of thousands of pounds
    getting rid of her, leaving her depressed, unemployed and broke. After an employment tribunal
    judge found in her favour, the trust has decided to make her redundant. Her “special severance”
    must be approved by the Health and Treasury departments at a time when the NHS is cutting
    thousands of jobs and slashing services in order to save £20bn. She is expected to lose her home
    because of her inability to meet mortgage payments.
    During the inquiry, MPs can expect to hear from an abundance of NHS whistleblowers – doctors,
    nurses and even chief executives – who have been punished over the past decade while trying to
    expose colleagues’ wrongdoing or incompetence.
    Mr Dorrell is likely to demand that professional regulators, such as the General Medical Council
    (GMC) and the Nursing and Midwifery Council, come down harder on clinicians and managers
    who are found to be complicit in wrongdoing through their silence.
    Mr Dorrell told The Independent: “The committee will look into whistleblowers. It is every
    professional’s business to ensure that clinical care where they work is of a certain standard. Like Sir
    Ian Kennedy said after the Bristol babies inquiry: ‘It wasn’t that nobody knew, it was that everybody
    knew.’ Every doctor and nurse has an obligation to act if they know there is a problem and those
    who do nothing should be questioned by their regulator; it would soon stop this kind of thing.”
    On the subject of fraud, he added: “If doctors are dishonestly claiming public money then they, and
    their medical managers, should be in front of the GMC.”
    Labour introduced the Public Interest Disclosure Act in 1998 following a series of industrial
    accidents and health and financial scandals, introducing legal rights for employees who expose
    corruption, safety breaches and fraud.
    When in opposition, Andrew Lansley, now the Health Secretary, promised to beef up protection for
    NHS whistleblowers amid growing evidence that the Act was failing to protect employees. The
    Coalition agreement said: “We will introduce new protections for whistleblowers in the public
    The Department of Health insists that it has “acted swiftly to deliver on this commitment” by
    consulting on changes to the NHS constitution and by introducing a new contractual right for NHS
    employees to raise public-interest concerns. However, patients and staff are unconvinced. Examples
    continue to emerge from hospitals and care homes for vulnerable patients where whistleblowers
    have been ignored.
    Peter Walsh, the chief executive of patient-safety charity Action against Medical Accidents , said:
    “The Government’s approach to whistleblowers is totally inadequate. We have fine words and
    guidance in abundance but NHS organisations have shown a consistent ability to work outside the
    spirit of these well-intended measures, and regulators seem to stand by when organisations blatantly
    flout them.”
    Case study: Legal bills – and no hope of employment
    The radiology manager at Ealing Hospital NHS Trust reported in 2007 that two radiology
    consultants appeared to be taking turns to work at a nearby private hospital every Monday while
    they were being paid to see NHS patients. The NHS trust says it has found no wrongdoing.
    She reported others for making duplicate claims and for claiming hours they hadn’t worked. She
    also reported her discovery of discs containing reports and scans from about 100 patients with
    conditions including kidney cancer which a junior radiographer had failed to upload on to the
    imaging system for six months.
    In 2009 Ms Chowdhury was interviewed by the internal fraud officer; days later she was suspended
    and marched off the premises. She was sacked, but pending a full hearing an employment tribunal
    ordered the trust to reinstate her full pay after concluding that “she would probably win”.
    Following this, and an independent investigation which found no evidence to support her dismissal,
    the trust wants to make her redundant. She will be left with less than a year’s salary after paying her
    £100,000 legal bill. Like many whistleblowers, she cannot get another job.
    Medics who dared to speak out
    * Dr Steve Boslin, the anaesthetist who finally exposed paediatric heart surgeons in the Bristol
    babies scandal in 1995, moved to Australia after being ostracised by the NHS.
    * Margaret Haywood was struck off the nursing register after she went undercover for a BBC
    documentary, exposing poor standards of care for elderly patients at a Sussex hospital. Five years
    later she was reinstated by the Court of Appeal.
    * Dr Kim Holt repeatedly warned Great Ormond Street Hospital that its Haringey clinic was unsafe
    because of staff shortages and inadequate training. Baby Peter Connelly’s life-threatening injuries
    were missed at the same clinic, two days before he died. Dr Holt remains on “special leave”.
    * John Watkinson was sacked as chief executive of the Royal Cornwall Hospital NHS Trust in 2007
    after he refused to remove cancer services without first consulting local people. An employment
    tribunal awarded him nearly £900,000 in compensation; he has been unable to find another job.
    * Dr Ramon Niekrash, a urological surgeon, was suspended after he refused to stop highlighting
    patient-safety problems caused by cost-cutting measures at Queen Elizabeth Hospital in south-east
    London. He was awarded £17,000 by an employment tribunal, but was left with a £180,000 legal


    Tuesday, 5 July 2011
    Pressure is mounting on Government ministers to introduce tougher laws to protect whistleblowers
    as health professionals and MPs speak out against a “code of silence” in the NHS.
    A group of leading doctors are urging the government in this month’s Journal of the Royal Society
    of Medicine (JRSM) to consider US-style protection systems which have improved the plight of
    whistleblowers since the Enron financial scandal.
    American whistleblowers are entitled to a proportion of fines imposed on employers who punish or
    silence employees. In contrast, UK managers and bosses appear to operate with immunity while
    whistleblowers often face unemployment and financial hardship even when vindicated in court.
    Dr Peter Wilmshurst, co-author of the JRSM paper, says the huge financial cost of fighting an unfair
    dismissal in the UK acts as a powerful deterrent for colleagues left behind.
    “People know that whistleblowers do not do well in the NHS. This is a political problem that no
    minister is prepared to deal with but it is also a cultural problem within the profession. There is a
    code of silence and so those who do talk about problems are considered aberrant. There is no doubt
    there is a knock-on effect for all those left behind who get too frightened to stand up and speak out.”
    Last year, Ramon Niekrash, a surgeon from South London Healthcare NHS trust who was
    suspended after reporting patient safety breaches at Queen Elizabeth Hospital, before it merged to
    form a new supertrust, was left with a £180,000 legal bill despite winning his employment tribunal.
    A senior surgeon from the trust told The Independent that “things are out of control here, someone
    needs to do something”. Another surgeon said: “After Ramon, there has been a general feeling of
    fear and most people will not complain or take a stand… the doctors are totally de-motivated.”
    The trust said there was “no question” of any staff member facing any consequence as a result of
    raising concerns.
    Dr Stephen Bolsin, co-author of the JRSM paper, who exposed high death rates among babies with
    cardiac problems at Bristol Royal Infirmary in 1995, was forced to move to Australia after being
    ostracised by the NHS. His case triggered the 1998 Public Interest Disclosure Act, but doctors say it
    has “not been as effective as anticipated”.
    John Pugh, chair of the Lib Dem health policy group, welcomed the Health Select Committee
    inquiry, revealed in The Independent yesterday, and said he would ask the Health Secretary to
    consider the US model for protecting whistleblowers. “It’s time to blow the whistle on
    whistleblowers and provide them with protection that works,” he said.
    A Department of Health spokesperson said recent changes made to the NHS contract would help
    but “there is already strong legal protection for whistleblowers and it is clear that people who have
    been subject to detriment are able to seek redress”.


    “The GMC to encourage whistleblowing” – anyone believe it?
    Mon, 2011-08-22 14:47
    The House of Commons Health Select Committee believes that the GMC
    should send a clear signal to doctors that they must report concerns about
    a fellow doctor.[1] My experiences suggest that the GMC itself has been
    involved in concealing misconduct.
    As chair of the medical committee of a government recognised national
    organisation, I reported a group of doctors, because the committee had
    concerns about their research.[2] It involved injecting a radioactive
    isotope into patients suffering from a neurological illness. Before
    investigating the allegations, the GMC investigated me for the counter-
    charge of disparaging the doctors. The GMC investigated the allegations
    against the doctors only after clearing me, but allowed the two most
    senior doctors to voluntarily remove their names from the Medical
    Register, which meant that the charges that they had covered up misconduct
    could not be investigated. The GMC then confirmed that ethics committee
    and ARSAC approvals had not been obtained. No consent forms were
    available. It was stated that patients were only asked to give verbal
    consent. The GMC decided that it was unable to adjudicate on allegations
    of data fabrication because the authors failed to produce the data. Many
    might consider failure to produce data at the request of the GMC prima
    facia evidence of falsification. The GMC held no public hearing and issued
    no public statement. The senior doctors involved, including a medical
    professor and a consultant in nuclear medicine, who told the GMC that they
    did not understand the requirements for ethics approval and for
    administration of radioactive isotopes, were given private warnings and
    In 2002, Dr Clive Handler was suspended from the Medical Register
    after I reported him to the GMC for financial misconduct.[2,3] Dr Handler
    had left Northwick Park Hospital in 1998 after an inquiry there revealed
    the misconduct. The GMC was informed that a severance agreement between
    the hospital and Dr Handler included an agreement not to inform the police
    or the GMC. The hospital trust board, including the Medical Director,
    Professor Peter Richards approved the agreement. At the time Professor
    Richards was a GMC member. When Dr Handler appeared before the
    Professional Conduct Committee, Professor Richards was the Committee’s
    chairman and I was amazed to witnessed the bizarre conduct of a
    dysfunctional organisation. Professor Richards had to stand-down from
    hearing the case because of his involvement in the cover-up. Despite that,
    Professor Richards returned to chairing subsequent PCC hearings.
    The messages from these cases are clear. Ordinary doctors who report
    misconduct may be victimised by the GMC and the GMC tolerates its own
    members concealing crime.
    The Health Select Committee should be asking “quis custodiet ipsos
    1. Jacques H. Doctors should be held to account for behaviour of
    colleagues, say MPs. BMJ 2011;343:d4794.
    2. Wilmshurst P. Dishonesty in medical research. Medico-Legal Journal
    3. Dyer C. GMC hearing reveals how doctor won deal to have earlier inquiry
    documents destroyed. BMJ 325 : 1189 doi: 10.1136/bmj.325.7374.1189/a
    Competing interests: I have reported concerns about conduct of other doctors.
    Peter T Wilmshurst, Consultant Cardiologist
    Royal Shrewsbury Hospital

  23. I think the Commons HSC should be vigilant when investigating GMC as it may be misleading like the CQC as can be seen in the following news clip,
    Whistle-blowers are the unsung heroes of the NHS
    Everyone working in the NHS should be free to criticise bad working practices without fearing for their livelihoods.

    All NHS employees should feel free to speak out against bad practice  Photo: ALAMY
    By Max Pemberton
    7:30AM GMT 30 Jan 2012
    It takes bravery and courage to stand up and speak out when the stakes are high. While many of us like to think we are possessed of that fortitude, in reality, few of us are. We therefore owe a considerable debt of gratitude to those NHS whistle-blowers who have publicly denounced malpractice, corruption or poor care, often risking their jobs in the process.
    They are the unsung heroes of the health service, who often receive appalling treatment at the hands of furious managers. Behind closed doors, there are attempts to strike deals with such staff, forcing them to keep quiet. Healthcare workers are frequently required to sign confidentiality agreements if they quit their job over a dispute with their NHS trust. For fear of ruining their careers entirely and receiving no severance package, many capitulate and sign on the dotted line.
    Last year, an investigation by the Bureau of Investigative Journalism and Channel 4 found that doctors routinely had to sign contracts forbidding them to talk publicly about the trust they worked for. Furthermore, three trusts were found to have made clinicians sign contracts specifically banning them from talking to the General Medical Council, the organisation responsible for regulating doctors.
    These gagging clauses have no place in a public institution such as the NHS, where being forced to keep silent puts patients’ welfare at risk. The public has a right to know if there are problems in the NHS, and managers have a duty to ensure that this information is freely available.
    For a while now, politicians have been saying that NHS whistle-blowers must be protected, but little has been done to ensure this. Although a helpline was launched at the end of last year for NHS employees who had concerns, there seemed no way of ensuring that those who spoke out would be protected. It appears, however, that at last the problems are being taken seriously, in some quarters at least. The GMC last week announced that it will be writing to every doctor, advising that they never sign a contract that contains a gagging clause to prevent them speaking out against bad practice.
    The GMC is rightly emphasising that such clauses interfere with a doctor’s duty of care towards a patient. But while this move must be applauded, it seems that this focus on openness and patient welfare hasn’t reached every corner of the NHS. It has emerged that the Care Quality Commission (CQC)– the health watchdog responsible for protecting whistle-blowers – has, itself, asked at least six former employers to sign confidentiality agreements. The CQC offered six individuals severance packages on condition that they signed a contract promising that they would not ”make or repeat any statement which disparages or is intended to disparage the goodwill or reputation of the CQC or any Specified Person’’.
    This is the same CQC that has been dogged by controversy and claims that it is failing patients in its role as regulator for NHS hospitals and care homes. A damning report by the Health Select Committee last September accused the CQC of not doing enough to protect patients and focusing on bureaucracy instead. It has also been found to have misled Parliament over the number of inspections it has undertaken, and, in 2009, a leaked letter revealed that employers had complained of a “bullying culture”.
    It is a disgrace that any public organisation can put restrictions on former employees speaking out about what they perceive to be wrong. It’s all very well, then, the GMC saying that doctors shouldn’t sign confidentiality contracts, but this should apply to all who work in the NHS. Most importantly, we should be targeting those who draw up these contracts. There is no place for gagging clauses in the NHS – they should be banned.
    The most galling present I’ve ever received
    A nurse in Carlisle has been found guilty of misconduct and received a caution from the Nursing and Midwifery Council after they heard that she had received cash and gifts from a patient during an 11-month affair. The Council quite rightly found that she had failed to maintain professional boundaries and had undermined the reputation of her profession. The patient paid for hotel rooms and bought her a television, clothes and even a car. I couldn’t help but think of the presents I’ve been given by patients over the years. Aside from boxes of chocolates, a patient once gave me two of the gallstones she had recently had removed, to thank me for referring her for the operation. I remember staring at them as they sat in the gift box, not quite sure what to say. She had thought that maybe I could have them made into cufflinks. It was one of those instances when I felt the response “really, you shouldn’t have” was very appropriate.
    Max Pemberton’s new book, ‘The Doctor Will See You Now’ is published by Hodder. To order a copy, call Telegraph Books on 0844 871 1515, or visit


    Why are we so soft on dodgy doctors? There are thousands of complaints about them in a single year – yet just ELEVEN are struck off
    By Jane Feinmann
    Last updated at 2:56 PM on 9th February 2012
    • Comments (92)
    Doreen Williams had a chest infection — it wasn’t serious but her GP thought it best to admit the 71-year-old to hospital so that she could have stronger, intravenous antibiotics.
    Seven days later, Mrs Williams was dead as a result of a pulmonary embolism — a blood clot on the lungs which had developed while she was in hospital.
    Her death was entirely needless, says her daughter Karen Rutland.

    Karen Rutland’s mother Doreen Williams was admitted to hospital for a chest infection. Neither the doctors nor nurses intervened to save her life
    ‘My mother was a busy retired teacher who had visited Wales and Cornwall in the two months before her death,’ she explains.
    ‘She had chronic obstructive pulmonary disease, a long-term lung condition, but it never seriously affected her daily life.
    ‘It just meant she had to be careful to get proper treatment for chest infections.’
    Mrs Rutland, 56, has no doubt what was to blame for her mother’s untimely death.
    ‘She was not given the intravenous antibiotics or standard blood tests until five days after she was admitted to hospital.
    ‘And although she was at high risk of a blood clot because of her age and her lung condition, she was never given the blood-thinning medication that would have prevented it.’
    The doctor in charge also issued a ‘do not resuscitate’ order — without discussing it with the family.
    So, as Mrs Williams lay dying, neither the doctors nor nurses intervened to save her life.
    Shocked and distressed by this betrayal of her mother, Mrs Rutland, a former management consultant from Cornwall, did what most people would do. She tried to complain. She got nowhere.
    The doctor denied any responsibility for her mother’s death. And Luton and Dunstable Hospital Trust, where Mrs Williams spent her last days, refused to accept any wrongdoing.

    There were 7,000 complaints to the General Medical Council (GMC) last year. Only 17 per cent of those by patients were investigated
    Perhaps most frustrating, however, was the response of the General Medical Council.
    This is the only medical regulatory body in the UK with the power to suspend or strike off doctors in the interests of patient safety.
    Initially, the GMC’s senior investigating team recommended the doctor in charge of Mrs Williams’s care should face a Fitness to Practise hearing.
    But the hearing was cancelled — twice — because the GMC’s medical advisors said there was ‘an insufficient case to answer’.
    However, the coroner who later examined the case said he found it ‘inconceivable that vital steps were not taken to follow up’ particular warning signs that something was seriously wrong.
    ‘There was every reason to believe that after a short stay in hospital, Mrs Williams should have been well enough to return home,’ he said.
    So why didn’t the GMC take action? It is a question being asked in an increasing number of cases of alleged medical negligence.
    The concern is that the GMC, which is funded by the doctors it regulates, is biased in their favour and shields those it is supposed to discipline.
    Furthermore, it is accused of treating whistleblowers who try to expose malpractice as pariahs.
    Five years ago Sir Liam Donaldson, who was then the government’s Chief Medical Officer, described the GMC as ‘secretive, tolerant of sub-standard practice and dominated by professional interest rather than that of the patient’.
    It’s a criticism that won’t go away.
    Last year, the Parliamentary Health Select Committee described the GMC in a highly critical report as ‘overly lenient’ to doctors — while just a few months ago, the chair of the Patients’ Association, Dr Mike Smith, accused the organisation of ‘clearly under-investigating complaints submitted by patients’.
    The statistics speak for themselves. There were 7,000 complaints to the GMC last year. Only 17 per cent of those by patients were investigated — with only 11 doctors struck off as a result of these patient complaints. It is worth noting that once the GMC makes a decision, there is no right of appeal from the complainant.
    Even when decisions do go against doctors, the criticism is that the disciplinary process takes far too long, allowing incompetent doctors to continue putting the public at risk.

    It took 12 years after the first complaints were made about Dr Jane Barton for the GMC to initiate the investigation
    In January 2010, Dr Jane Barton was found guilty of serious misconduct after a GMC investigation found she’d given painkillers at six times the recommended dose to 12 elderly patients, causing their death at two wards she ran at the Gosport War Memorial Hospital in Hampshire.
    Yet it took 12 years after the first complaints were made for the GMC to initiate the investigation.
    ‘If Dr Barton had been suspended by the GMC in 1998 when her actions were first questioned, then many of these patients would have been saved, including my mother,’ says Ann Reeves, 57, whose mother Elsie Devine died aged 88 of a ‘substantial overdose’ of opiates administered by Dr Barton in 1999.
    Incredibly, despite finally finding Dr Barton guilty of serious misconduct, a Fitness to Practise panel — who are appointed by the GMC — still allowed her to continue working as a GP (she has since retired).
    Indeed, in 2010, 39 other doctors were permitted by panels to remain on the medical register even though the GMC’s own investigators recommended they be struck off.
    One of these was general surgeon Gideon Lauffer, who was found guilty of serious misconduct after a series of botched operations that caused the death of two patients and injured 18 more.
    Yet a Fitness to Practise panel ignored the advice and imposed a six-month suspension allowing him to return to work ‘under supervision’. By November 2011, he was back at work.
    Karen Rutland had little idea of the failings of the GMC when she decided to complain to the organisation about her mother’s death in 2006. While Doreen Williams was in hospital, her husband Ralph had become increasingly worried.
    Mrs Rutland recalls: ‘He told me the consultant in charge of my mother, Dr Tariq Mirza Rehman, hadn’t started her on the intravenous antibiotics.’
    So, the next day, the concerned father and daughter spoke to Dr Rehman. ‘He told us in a reassuring voice how very seriously he was taking our mother’s care.’
    But after her mother’s death, Mrs Rutland learned that from the moment Mrs Williams was admitted, Dr Rehman was responsible for a series of glaring omissions in her care. The full extent of neglect was revealed at an inquest in January 2011 — five years after Mrs Williams’s death.
    The inquest heard that not only did Dr Rehman fail to prescribe Mrs Williams antibiotics, but he didn’t give her medication routinely prescribed to hospital patients of her age and health background to prevent the blood clot.
    There were other more serious failings too. The level of oxygen in Mrs Williams’s blood dropped — a warning sign of a pulmonary embolism — and fell further on the day of her death, which should have resulted in her emergency transfer to intensive care.
    At 3pm on Mrs Williams’s final day, Dr Rehman issued a ‘do not resuscitate’ order, a step that is supposed to be taken by doctors at the end of a terminally ill person’s life to stop resuscitation in the event of a cardiac arrest — thereby preventing unnecessary suffering.
    Such a step was ‘entirely inappropriate and unwarranted’, according to Dr Vincent Mak, a respiratory medicine and intensive care consultant at Central Middlesex Hospital, North West London, and an independent expert witness at the inquest.
    He noted Mrs Williams’s health prior to admission was ‘of reasonable quality’, adding that ‘she had recently had an echocardiogram that showed her heart was working well’.
    By issuing the ‘do not resuscitate’ order, Dr Rehman breached two sets of legally binding guidelines, including failing to record the reason for taking this drastic step — which is mandatory.
    Nor did he consult with Mrs Williams, later insisting that she did not have mental capacity — another claim denounced as untrue by the coroner.
    It is also mandatory for doctors to notify a coroner if a death is unexpected —Dr Rehman did not do this. Instead, he allowed Mrs Williams’s death certificate to carry the cause of death as septicaemia and pneumonia.
    Dr Mak said Dr Rehman presided over a regime of ‘suboptimal care that led to (Mrs Williams’s) death’.
    The coroner summed up his concerns as Dr Rehman stood in the witness box as: ‘You failed to pay attention and treat the patient in front of you’.
    Despite these findings, the hospital trust supported Dr Rehman and denied any wrongdoing.
    So Mrs Rutland turned to the GMC for help.
    ‘We saw it as our duty to ensure no other family would suffer as we have,’ she says.

    Dr Kim Holt was suspended by Great Ormond Street Hospital after blowing the whistle on staff shortages and a ‘chaotic’ appointment system at the clinic
    Yet in 2008, the Fitness to Practise panel, a group of medical and non-medical volunteers, appointed to investigate Dr Rehman’s behaviour, was cancelled — because an independent medical expert claimed ‘none of the points in respect of medical management reflect either incompetence or malpractice’.
    Astonishingly, the same thing happened a year later when a second hearing was set up following a complaint from the Rutlands.
    Despite the coroner’s unusually critical verdict last January, the GMC insists its own rules prevent it from ‘reviewing a decision to cancel a hearing’.
    Chief executive Niall Dickson recently defended the organisation’s record, claiming problems often lie with flawed perceptions of the GMC’s responsibilities.
    ‘Our job is not to punish doctors but to protect patients by taking action against a failing doctor,’ he said.
    ‘We look closely at every complaint to see if the doctor’s fitness to practise could be impaired but will only take a case forward if the complaint indicates serious concerns about the doctor. In the majority of cases where a doctor has made a single mistake, this is not indicative of a bad doctor, however catastrophic the consequences.’
    So what exactly does a doctor have to do in order to provoke ‘serious concerns’ by the GMC? The worrying answer may be to tell the truth — there is growing concern that doctors who try to blow the whistle on unsafe practice could can end up facing disciplinary action themselves.
    Two weeks ago, the GMC issued new guidance reminding doctors they have a duty to raise concerns about poor patient care.
    Yet it’s an empty warning for Dr Kim Holt, a consultant community paediatrician at Haringey Primary Care Trust.
    In 2006, Dr Holt was excluded by Great Ormond Street Hospital, the trust that then employed her, after blowing the whistle on staff shortages and a ‘chaotic’ appointment system at the clinic where, months later, Baby P (Peter Connelly) was treated days before his death.
    ‘It didn’t ever get to the stage of a complaint to the GMC. But there was an attempt to discredit me, to force me out of medicine as a damage limitation exercise,’ she recalls.
    ‘I was lucky in that I’ve now been reinstated in my job. But I’ve met several doctors who have been reported to the GMC by their trusts after they became whistleblowers, and a handful who have even been struck off the medical register.
    ‘Hospitals use threats of referral and actual referral to the GMC as a means of ensuring silence from medical staff.’
    Brian Jarman, professor of primary health care at Imperial College, London, agrees changes are needed.
    ‘There is precious little evidence the GMC supports doctors who speak out when they see failing practice. Why doesn’t the GMC have a confidential helpline for people who see problems at their hospitals? That would be a start.’
    Later this year, the GMC will supervise the launch of a revalidation scheme under which doctors’ performances will be evaluated every five years.
    Katherine Murphy, of The Patients’ Association, is not impressed.
    ‘Unfortunately the GMC’s record on managing complaints makes you wonder how revalidation will work — and whether it’s going to be friends revalidating friends,’ she says.
    ‘We have many experiences of good care and unsung heroes in the NHS,’ adds Mrs Rutland.
    ‘But there has to be a way of taking action against the bad ones — otherwise standards slipping and people dying unnecessarily becomes acceptable.’