In commenting on his Panel’s report on deaths at Gosport War Memorial Hospital, The Right Reverend James Jones KBE likened it to the title of his Report on Hillsborough, which concerned the death of 96 Liverpool football fans at the 1989 FA Cup Semifinal:
“THE PATRONISING DISPOSITION OF UNACCOUNTABLE POWER”
His Panel concluded that the lives of over 450 people at Gosport War Memorial Hospital were shortened owing to an, “Institutionalised regime” of prescribing and administering opioids without medical justification.
Gosport War Memorial Hospital in now managed – you guessed it – by Southern Health, which issued a public statement containing the usual duck-billed platitudes¹. Read its statement here→ and the Panel’s Report here→
So we have:
- Bristol Royal Infirmary Public Inquiry [Sir Ian Kennedy QC, July 2001]
- The Mid Staffs Public Inquiry [Sir Robert Francis QC, February 2013]
- Liverpool Care Pathway Review [Baroness Julia Neuberger DBE, July 2013]
- University Hospitals of Morecambe Bay Report [Dr Bill Kirkup CBE, March 2015]
- Southern Health Independent Review [Mazars LLP, December 2015]
- Gosport War Memorial Hospital Report [Rt Rev James Jones KBE, June 2018]
So, from babies undergoing heart surgery (Bristol) to adults with physical ill-health (Mid Staffs and Gosport) to dying patients (Liverpool and elsewhere) to maternity and neonatal services (Morecombe Bay) to those with mental health issues and learning disabilities (Southern Health), it appears that all are at risk of similar patterns of behaviour by NHS clinicians and executives, as described in these Inquiries.
In his report on the high mortality rate of babies undergoing heart surgery at Bristol Royal Infirmary, Sir Ian Kennedy QC referred to:
“‘An old boy’s culture’ among doctors, a lax approach to safety, secrecy about doctors’ performance and a lack of monitoring by management [and] an arrogance born of indifference [our emphasis].”
And in the Liverpool Care Pathway review, Baroness Neuberger (and others) wrote:
“It is clear to us [from verbal and written evidence] that there have been repeated instances of patients dying on the LCP being treated with less than the respect that they deserve. It seems likely that similar poor practice may have taken place in the case of patients with no close relatives, carers or advocates to complain, or where families have not felt able or qualified to question what has taken place. This leads us to suspect this is a familiar pattern, particularly, but not exclusively, in acute hospitals.
“Reports of poor treatment in acute hospitals at night and weekends – uncaring, rushed, and ignorant – abound [our emphasis].”
Patronising, unaccountable power, institutional regime, ‘old boy’s culture’, lax safety, secrecy, lack of monitoring, arrogance, indifference, disrespect, poor practice, uncaring, rushed and ignorant? Surely not!
And when ‘found out’, NHS executives run around like headless chickens to cover their backs rather than adopt recognised Crisis Management techniques and learn.
And, as soon as the crisis appears to have been resolved, let’s return to square one.
¹ More on duck billed platitudes here→