NHS scandals

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United Kingdom specific

  • The United Kingdom NHS as a concept originated in the 1944 White Paper "A National Health Service". It is a political animal so has scandals with certain common themes:
  • NHS inquiries range from small internal inquiries to statutory ones set up by parliament. The later are now regulated by a 2005 Act and are not cheap. In 2013 the second Francis enquiry had consumed over £13M by the time of the report[1].
  • Lessons are not always learnt[2] (thus it always has been with history !)
  • Failures are organisational and cultural, and so changes do not happen just because of report recommendations, usually the politicians have to be motivated to act for others to effectively prevent the lessons being forgotten. Classically terms of reference are used to limit the potential fall out but if this might fail the government is well advised to have reorganised the NHS in advance of a public enquiries findings.
  • Sometimes individuals are to blame, with even acts of commission such as murder being hard to detect, and culture still tries to scapegoat those involved in acts of ommission

The time line below has a politically reflective colour coding: Green: National/coalition government, Yellow: Liberal, Red: Labour, Blue, Conservative. It is biased towards more recent events that had political overtones. It uses as dates the official reaction to the scandal, rather than either date of exposure or date of the events. Accordingly scandals should only be added to this timeline once an official enquiry is convened, and updated as to time when report published.

  • 1952 Smallpox outbreak at Birmingham due to breakdown of laboratory isolation
  • 1967 Ely Hospital scandal. Nursing cruelty to patients, threatening behaviour, theft of patients' food and clothing, indifference to complaints and a lack of care by the physician superintendent and another member of the medical staff. The first modern enquiry that made the political career of Geoffrey Howe. It established for the NHS the usual approach of vindicating the objective concerns of the whistleblower and criticising the whistleblower's subjective characteristics/personality/responses.
  • 1968 Findings and Recommendations Following Enquiries into Allegations Concerning the Care of Elderly Patients in Certain Hospitals (Banstead Hospital, Cowley Road Hospital, Friern Hospital, St. James's Hospital, Storthes Hall Hospital, St. Lawrence's Hospital, Springfield Hospital)
  • 1970 Hospital Advisory Service established, mainly as reaction to scandals in psychiatric and geriatric hospitals. Over the years it has morphed directly into the HASCAS (Health and Social Care Advisory Service), Scottish HAS etc and according to the political manipulations of the day into the Commission for Health Improvement, then the Commission for Healthcare Audit and Inspection(2002), then Healthcare Commission (2004) and as of 2010 the Care Quality Commission(2009)
  • 1974 Health Ombudsman established, mainly as reaction to perceptions of closed shop handling of complaints
  • 1975 Report of the Committee on mentally abnormal offenders - Butler Report
  • 1977 State Hospital Carstairs: Report of public local inquiry into circumstances surrounding the escape of two patients on Nov 30, 1976 - Carstairs Report
  • 1978 Normansfield Hospital for learning disabilities in Middlesex - interesting as strike action involved[2]
  • 1980 Inequalities in health: report of a research working group - Black report. Main scandal was attempt to suppress the implications of the report as politically uncomfortable
  • 1986 Deaths from food poisoning of 19 elderly patients at Stanley Royd Hospital, Wakefield leads to removal of Crown immunity from the NHS in respect of food and health and safety legislation
  • 1992 Deaths and injuries to children at Grantham and Kesteven Hospital caused by nurse Beverley Allitt - Clothier Report
  • 1994 Independent Inquiry relating to deaths and injuries on the children's ward at Grantham and Kesteven General Hospital - Allitt Inquiry, Confidential inquiry into homicides and suicides by mentally ill people - Boyd Report
  • 1997 Review of cervical cancer screening services at Kent and Canterbury Hospitals Trust - Wells Report
  • 1999 Report of the Committee of Inquiry into the Personality Disorder Unit, Ashworth Special Hospital - Blom Cooper Report results in hospital closure due to breaches of security and illegal activities[3]. Hunter review into care of children with Down's syndrome at Royal Brompton and Harefield hospitals confirms health staff discrimination.
  • 2000 Review of the Cardiac Unit at the Royal Liverpool Children's Hospital NHS Trust Alder Hey - Ashton Report, Report of the inquiry into quality and practice within the National Health Service arising from the actions of Rodney Ledward - Ritchie Report
  • 2001 Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary, 1984-1995. - Kennedy Report reveals about 30 excess deaths. The same year the Evans report found no serious concerns at Royal Brompton and Harefield hospital
  • 2004 The inquiry into hyponatraemia-related deaths is commissioned in Northern Ireland to explore some paediatric deaths in hospital. The inquiry did not report until 2018.
  • 2005 6th and final report of Harold Shipman enquiry[4] by Dame Janet Smith, a doctor serial killer of about 250 patients
  • 2006 Healthcare Commission reports into Clostridium difficile deaths at Stoke Mandeville
  • 2007 Healthcare Commission reports into Clostridium difficile deaths at Maidstone and Tunbridge Wells.
  • 2009 Investigation into Mid Staffordshire NHS Foundation Trust reveals at least 400 excess deaths due to management prioritisation[5] The public were allowed another bite at mid Staffordshire as the public enquiry that looked at each individual case, first Francis report, released at the same time as the Care Quality Commission report, was to give the chair further employment when the terms of reference were conceded to be too narrow
  • 2009 Lack of joined up working leading to the death of a baby results in reform in child abuse detection systems[6].
  • 2013 The second Francis report that was politically allowed in 2010 due to change of government and their plan to reorganise English NHS finds that the then commissioning, supervisory and regulatory bodies in the monitoring of Mid Staffordshire Foundation NHS Trust had 290 deficiencies.[7] The response includes the appointment of a Chief Inspector of Hospitals. These reports are supplemented by the Berwick report.
  • 2013 Baker report[8] indicates the general nature of the problems implicate in the Gosport War Memorial Hospital scandal of the 1990s.
  • 2013 Neuberger report on Liverpool care pathway confirms the risks of incentives for complex interventions when used beyond their evidence base[9]
  • 2013 Poor commissioning of the NHS 111 service first announced in July 2010 and that was supposed to be implemented in England in March 2013 will cost several tens of millions of pounds to put right.
  • 2015 Morecambe Bay Investigation: Report published on care provided by the maternity and neonatal services of the University Hospitals of Morecambe Bay NHS Foundation Trust between January 2004 and June 2013. The findings slate local and the supervisory organisations governance with themes on conflicts of interest, process being impaired by politics and failure of openness[10].
  • 2015 NHS Protect on 27 March, recovers the most ever to date, £2,161,758.45 from a convicted fraudster who was a head of financial accounting for two East Sussex primary care trusts. Detection of the fraud happened due to NHS reorganisation[11].
  • 2016 NHS Protect reports that an NHS manager and accomplices were found guilty of a £3.5m NHS fraud involving training programs[12].
  • 2016 Excess of neonatal deaths at Countess of Chester Hospital noted, blamed on some of usual reasons and then in 2018 an individual nurse is arrested.
  • 2018 The inquiry into hyponatraemia-related deaths in Northern Ireland finally reports on 5 deaths after 14 years.
  • 2018 The Independent Enquiry[13] into the Gosport War Memorial Hospital scandal finally reports into events that might have been nipped in the bud as early as 1991 if the nature of the problem was understood. However systems to do so did not start to exist until about 1998 in the NHS when the scandal first broke.