'Extremely ill-judged': scathing report into hospital's whistleblower handling

West Suffolk Hospital A&E.

West Suffolk Hospital A&E. - Credit: Archant

A damning report into the whistleblower handling by bosses at the West Suffolk Hospital trust has found it was “controversial and fundamentally flawed".

The independent review by Christine Outram MBE said clinicians at the Bury St Edmunds hospital had been subject to an “intimidating” process of seeking fingerprints and handwriting samples to identify the author of an anonymous letter by a whistleblower. 

This letter had been sent to widower Jon Warby and raised concerns over the care his wife Susan received at the hospital in 2018. 

Jon Warby received the anonymous letter

Jon Warby received the anonymous letter highlighting errors in a medical procedure carried out on his wife Susan at the West Suffolk Hospital in Bury St Edmunds - Credit: PA

The scathing 226-page report, which was published yesterday, was commissioned by NHS Improvement in February 2020, at the request of the Department for Health and Social Care. 

It said: "The decision to use fingerprinting and handwriting analysis in an NHS hospital, in the context of an anonymous letter and where no crime has been committed, was highly unusual and without doubt extremely ill-judged." 

It added: "Wrong as it was to send an anonymous letter to a deceased patient’s family, that does not mean that it was appropriate to seek to identify the author.  

“Identifying the author of an anonymous letter would in any circumstances be very difficult, but for an NHS Trust to choose to divert its resources and the time of executive members of the Board in an attempt to do so (in what was likely to, and did, prove a futile attempt) was disproportionate and inappropriate.” 

The “seminal” event that triggered a chain of events and ultimately the review, was when a consultant anaesthetist self-administered medication for back pain on November 5, 2017, while responsible for an anaesthetised patient.

Referred to as Dr A, he had been in theatre with Mrs Warby on July, 27, 2018, when the wrong arterial line had been put up, although, as was later confirmed at the coroner’s inquest in September 2020, he was not personally responsible for that error. 

West Suffolk NHS Foundation Trust has apologised to staff and families affected

West Suffolk NHS Foundation Trust has apologised to staff and families affected - Credit: PA

Senior clinical colleagues had raised the alarm about the self-medicating incident, but the report said the concerns raised were “effectively ignored”. 

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Dr A was allowed to continue to undertake unrestricted clinical duties. 

The report said the trust “reasonably deduced” that the anonymous letter referred to the 2017 self-medicating incident and attempted “to unmask the culprit”. 

Part of the anonymous letter, as included in the report

Part of the anonymous letter, as included in the report - Credit: Screenshot

Four of the seven individuals singled out for further investigation were those who had raised concerns relating to Dr A.  

“The investigation adopted an intimidating process that distressed and damaged individual staff members,” the report added.  

"The requests for fingerprints were incendiary. No evidence was produced to me that fingerprinting had previously been used in the NHS in a potential disciplinary investigation such as this where the police had already confirmed that there was no evidence that a criminal act had been committed.” 

An anaesthetist, referred to in the report as Dr C, was among those to raise concerns about the “red flag” self-medicating event.

In one attempt, the report said Dr C emailed Trust Chair [Sheila Childerhouse] in confidence setting out her concerns and requesting a meeting, but this was forwarded to the chief executive Dr Stephen Dunn.

An incident where an anaesthetist self-medicated is described as the "red flag" event that triggered other events

An incident where an anaesthetist self-medicated is described as the "red flag" event that triggered other events - Credit: West Suffolk NHS Foundation Trust

The report said: "The CEO [then chief executive Stephen Dunn] and DWC [then director of workforce and communications Jan Bloomfield] quite wrongly mingled Dr C’s attempt to Speak Up with an attempt to address their perceptions about conduct."

The report later said: "It was unreasonable and unfair to use anonymised concerns about the anaesthetic department as part justification for a disciplinary investigation into a single individual. 

"There was no evidence to implicate Dr C in writing the Anonymous Letter, and it should have been irrelevant in the decision to pursue a formal MHPS [Maintaining High Professional Standards] process." 

Jan Bloomfield is stepping down from her role as executive director of workforce and communications

Jan Bloomfield, former executive director of workforce and communications at West Suffolk NHS Foundation Trust - Credit: Archant

Once rated 'outstanding' by the Care Quality Commission, the hospital - the main one in former health secretary Matt Hancock's constituency - fell to the second-lowest rating of  'requires improvement' in January 2020

Inspectors who visited in September and October 2019 found the leadership "did not demonstrate an open and empowering culture" and said staff felt a "lack of freedom to speak up". 

Ahead of the results of the independent review, it was announced the trust's medical director Nick Jenkins and chief operating officer Helen Beck would be leaving their senior roles.  Dr Dunn also stepped down this year as chief executive.

The review said it was “extremely important" to note that this report describes a series of events that took place two or more years ago. 

“During the time that has elapsed since the Review was first announced in early 2020, the Trust has undertaken considerable work to improve the confidence of its staff in its Speak Up culture. I commend them for these efforts and wish them well for the future.” 

West Suffolk Hospital CEO Steve Dunn with Trust Chair Shelia Childerhouse. Picture: GREGG BROWN

Former West Suffolk Hospital CEO Steve Dunn with Trust Chair Sheila Childerhouse - Credit: Archant

Craig Black, interim chief executive for West Suffolk NHS Foundation Trust, said the trust board would be considering the findings in full over the coming days and weeks. 

“We take full responsibility for failings and short comings around the handling of events leading up to and surrounding the whistleblowing, and are truly sorry to the staff and families affected,” he said. 

He said they would use this report to make further changes “to continue our work to create an open, fair and inclusive organisation that puts our staff and patient safety front and centre”. 

Paul Pearson, UNISON Suffolk Area Health branch secretary, said it was now important to work with the new management to make sure “nothing like this can ever happen again”. 

He said: “It is a credit to the staff that they’ve continued to deliver excellent services throughout and a vindication for those who stood up for what they thought was right in the face of huge pressure. 

“UNISON has supported all staff who’ve suffered, and continue to do so, because of the botched handling of the situation by the trust.” 

Minister of State for Health Edward Argar said in a written statement in the Commons: "The Trust and other relevant organisations including NHS England and NHS Improvement, the GMC [General Medical Council] and CQC will need to take stock of the findings of this important report. Indeed, this is a lesson for all NHS organisations to actively work to promote an open culture." 

For the full report see here.