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20 Dec 2000 : Column 120WH

Birmingham Specialist Community Health NHS Trust

12.59 pm

Dr. Lynne Jones (Birmingham, Selly Oak): I would have preferred not to have to secure this debate. The serious matters to which I will refer are complex and cover a lengthy time scale. I must apologise for the tortuous events that I shall describe, but I must put them on record because there are serious failings in the system of investigating complaints about clinicians and managers in the NHS.

My involvement began at the end of October 1998, when my hon. Friend the Member for Cannock Chase (Dr. Wright) passed on some correspondence he had received from Dr. Imad Soryal, who is a consultant in rehabilitation medicine, about clinical practice at Hillcrest ward 3 unit at Moseley Hall hospital in my constituency. The documents included eight-month-old correspondence from the then clinical director of the unit, Dr. Steve Sturman, which was addressed to the unit's clinical manager. There was also an account of an incident on 2 October in which a patient, Peter Collins, was subject to degrading and inhumane treatment, including being denied bowel care for six and a half hours. I undertook to pursue the serious issues raised in those documents.

Although I was familiar with Moseley Hall hospital, I did not have any specific knowledge about the service provision at Hillcrest ward 3. My initial response to the correspondence was to make an unannounced visit on 9 November 1998. I found nothing untoward during the short time that I was there, although I noted that there were a number of empty beds. I subsequently received a letter from the general manager, John Wells, inviting me to meet him and Dr. Jim Unsworth, who had taken over as clinical director.

While the meeting was being arranged, I phoned Dr. Soryal to inform him that his correspondence had been passed to me and to question him about its contents. I particularly wanted to clarify the relationship between Dr. Sturman and Dr. Unsworth, and I was told that Dr. Sturman had given up his role as clinical director because there had been insufficient progress in taking up his suggestions to improve matters that he had raised with management. Dr. Soryal also explained what happened when he became involved as on-call consultant in the case of Peter Collins, a patient who had had a large brain tumour removed.

I wrote to Dr. Sturman to inform him that I had seen a copy of his letter. I asked him what response he had received to it, and whether he was satisfied that his concerns had been appropriately and adequately addressed. I also contacted South Birmingham community health council to ask what it knew about the unit. I was sent a note prepared by its then chair, which seemed to support the concerns expressed by Dr. Soryal and Dr. Sturman. The note stated:

The community health council had raised its concerns at a meeting with Birmingham health authority on 21 September 1998, when it was promised that it would be sent a copy of the service specification. In fact, that document was never sent. I finally got hold of a copy in

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April 1999, and passed it on to the community health council. Subsequent events demonstrated that the service specification was not being met.

I took up the invitation to meet Dr. Unsworth and John Wells, the general manager, and Dr. Unsworth explained the work of the unit, which provided care for adults under 65 who suffered from degenerative conditions such as multiple sclerosis, acquired impairment and traumatic and non-traumatic brain injury. They both denied that bed occupancy was low and Dr. Unsworth dismissed clinical psychology and other issues that Dr. Sturman had identified as important. I was informed that in relation to the incident involving Mr. Collins, there had been an internal inquiry and that the main issue had been the professional conduct of one member of staff, who turned out to be Dr. Soryal, although he was not mentioned by name. Dr. Unsworth informed me that he knew where I had obtained my information and that he also knew that staff who had left the unit bore grudges. Dr. Unsworth and Mr. Wells suggested that I contact the clinical manager, who later turned out not to be clinically qualified, with various other queries, so I immediately wrote to her requesting information in advance of our planned meeting, which I had arranged but later cancelled after no information was forthcoming.

After it became known that I had visited Hillcrest ward 3, a member of staff on the wards, who was anxious that her identity should not be revealed, contacted me. She gave me a copy of an anonymous letter that had been sent to the former chief executive of the Southern Birmingham Community Health NHS trust in 1995. The main grievance was the imposition of 24-hour contracts that would make it difficult for nurses to plan family life. It was also stated that in the staff's view the way in which the changes had been implemented would make it difficult for them to voice their grievances or identify a member of the management structure to whom they could express their concerns.

Management abused their authority by unilaterally imposing on the organisation a major change that caused some members of staff to fear victimisation if they expressed their opinions. Loss of staff morale was mentioned, as was their ability to care effectively for patients. Concern was also expressed about inadequate cover by trained staff on duty between 9.15 pm and 7.45 am. I was given the names of former staff who might discuss with me their experiences on the unit that indicated intimidation of staff and patients. I should make it clear that it was not the person who gave me the anonymous note who provided those names.

Copies of complaints from former patients were also given to me, including one that referred to poor treatment, racism and an attempt by Dr. Unsworth to undermine Dr. Sturman. Those events occurred long before Dr. Soryal appeared on the scene. I also received two replies from Dr. Sturman which made it clear that he never received a written response to the detailed concerns expressed in the letter that was included in the bundle given to me by my hon. Friend the Member for Cannock Chase. Dr. Sturman said that he had been disappointed to be told--presumably by the clinical

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manager--that an early meeting to discuss his letter would not be possible, although he added that he was able to conduct a few training sessions for nursing and therapy staff. Dr. Sturman said that he was saddened not to have been able to make more progress during his time as clinical director.

I obtained a copy of the investigation of the incident of 2 October involving Mr. Collins to which Dr. Unsworth had referred. The investigation was conducted by Dr. Alistair Main, clinical director of services for the elderly, and a senior personnel officer. The acting chief executive wrote to tell me that he had discussed the report with the director of personnel, and with Dr. Unsworth in his capacity as medical director of the trust--a post that he held in addition to those of clinical director of Hillcrest and medical director of the regional rehabilitation unit. After seeking legal advice, the approval of the chairman of the trust was obtained to institute intermediate procedures for the discipline of consultant medical staff and the consultant in question was to be Dr. Soryal. Dr. Main concluded that the way in which the matter was handled by the nurse manager, whose conduct Dr. Soryal had complained about, could not be criticised, but Dr. Soryal was criticised for poor professional judgment.

Dr. Main's report proved to be extremely one-sided. He did not interview Mr. Collins or his wife. By that time, Dr. Unsworth had moved Mr. Collins, without notice, to a local nursing home. He subsequently received proper treatment at Rivermead rehabilitation unit in Oxford. Dr. Unsworth's judgment of Mrs. Collins suggested that she refused to believe that her husband was cognitively impaired, or that he had shouted and used abusive language. Her supposed lack of acceptance of his cognitive and frontal lobe defects was the crucial factor in events leading to the breakdown in confidence between the nursing staff, Dr. Unsworth and Mr. and Mrs. Collins. It was those events that led Mr. and Mrs. Collins to make complaints. It was also suggested that Mr. Collins bore responsibility for not accepting bowel care early in the morning.

I have not discussed the details of Mr. and Mrs. Collins' complaint because it is subject to a separate and on-going complaints procedure. I have read Mrs. Collins' formal complaint, and Dr. Main's interpretation is a travesty of the views expressed in it. Mrs. Collins, who is a graduate psychologist, in fact demonstrates rather greater insight into her husband's condition than the professionals who were supposed to be caring for him. She offered to assist ward staff, as she was trained in lifting and handling, but her offer was rebuffed.

It subsequently became clear that the evidence given by the nurses and the registrar was heavily influenced by behind-the-scenes intimidatory pressure. Nevertheless, despite its inadequacy, Dr. Main's report offered some interesting insights into the running of Hillcrest ward 3. The nurse manager, who was on G grade, was able to select which patients were accepted on to Hillcrest on the basis not of clinical need, but of her perception of their suitability for the unit. She was able to transfer a patient from one ward to another without consulting his consultant or family and was able to control the information that was given to certain consultants. She had advised Dr. Sturman not to talk to the family. The

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clinical manager, who had a background in occupational therapy, was able to influence the psychology services that people needed, which seemed to be none at all, despite the views of the former director, Dr. Sturman, to the contrary. Those views were ignored.

Alistair Main took no steps to help staff who felt intimidated to come forward and give evidence confidentially, although he was aware of the anonymous letter, which he dismissed. He said that he had no time for staff who made such accusations but who wished to remain anonymous for fear of losing their jobs. No attempt was made to investigate the grievances that were raised, yet that could have been done had there been the will to do so. On the positive side, Dr. Main did at least request a non-punitive and constructive inquiry into the unit by an individual or team from a similar specialist rehabilitation unit and a list of sensible issues to be reviewed. To cut a long story short, I pressed for such an inquiry, which was eventually agreed to.

I must add that at no point was I acting on behalf of Dr. Soryal, who was being advised by his BMA representative. My concerns were solely about the services offered to patients. I have kept the documents that were sent to me and were confidential in relation to other people who contacted me.

The independent inquiry was a model of good practice. All senior and middle grades of staff on the unit were interviewed, as well as 50 per cent. of the junior staff--who were randomly chosen--and interviews took place away from the unit. I began to receive feedback that staff were pleased at the way in which the inquiry was being conducted and felt confident enough to express themselves.

During the inquiry, which was chaired by Professor McLellan of Southampton general hospital, members of the panel were so worried about the possible maltreatment of staff and patients that they felt obliged to tell the chief executive of their most acute concerns. As a result of that information, the G grade nurse manager was suspended. In its full report, the inquiry team recommended that the nurse manager's suspension should be confirmed and that she should be formally investigated for oppressive and unprofessional practices. The team also recommended that the post of clinical manager should be discontinued and that Dr. Jim Unsworth should be replaced as clinical director of the unit, while continuing in his role as director of the West Midlands Centre for Rehabilitation, of which the unit is a key component. As a result, two female staff were suspended from work and Dr. Unsworth was suspended from his role as clinical director. Formal disciplinary inquiries were then instituted using internal trust procedures.

Contrary to the view that my hon. Friend the Minister expressed in a letter to me--I am not sure where she obtained the information--I had no criticisms of the independent inquiry or its conclusions. The McLellan report exposed the inadequacy and bias of the earlier Main report. That is an important point, to which I shall return.

I was approached with further allegations about inappropriate behaviour on the part of Dr. Unsworth, but this time the complaint was unrelated to Hillcrest ward 3. The complainant was an orthotist, Alan Drew. He had already submitted a formal complaint about

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Dr. Unsworth to the General Medical Council, but it was unsuccessful because the allegations did not impinge on Dr. Unsworth's competence to practise as a doctor. I add that that has never been in question. I advised Mr. Drew to put his concerns in writing and contact his Member of Parliament to request that they be investigated. Mr. Drew did so and sent me a copy of his correspondence.

On 21 February, I wrote to the outgoing chair of the former trust, to inform her that I had received feedback to suggest that some more senior staff--whose evidence would be crucial in the disciplinary process that would follow the inquiry--might feel that silence would be the best policy if their career progression was not to be damaged. I also sent a copy of a letter dictated by Dr. Sturman in February to Dr. Unsworth, which enclosed a copy of his letter to the clinical manager, to which I referred earlier. Dr. Sturman stated that, because of his overcommitment, he felt unable to provide a safe or adequate service to his patients, adding that he was prepared to carry on with the clinical director's brief for a little longer.

Dr. Sturman stated, however, that if there was little positive response to the letter to the clinical manager, he would have to conclude that she and her colleagues did not want to work with the clinical director structure, and that there was little point in carrying on. He was looking for evidence of change within two weeks, and would then stop using the service because, he said, it was clearly morally wrong to use it when there were such grave concerns about its efficacy and organisation. That judgment was vindicated by the McLellan report. Dr. Sturman also told Dr. Unsworth that any complaint or legal action would be indefensible, yet no action was taken in relation to Dr. Sturman's concerns.

I enclosed the correspondence from Alan Drew with my letter. On second thoughts, I felt that it needed further investigation and should be taken into account before any conclusions were drawn about the possibility of disciplinary investigation into Dr. Unsworth's conduct. I copied the correspondence to my noble Friend Lord Hunt of Kings Heath at the Department of Health, and to the chair of Birmingham health authority.

The chair advised me in response that Dr. Sturman had discussed his letter of 23 February during his interview with the team investigating what disciplinary action might be justified. The internal audit service was to investigate financial allegations made by Mr. Drew, and there would be an investigation into other allegations. I subsequently learned that the investigation was to be carried out by none other than Dr. Alistair Main. Despite misgivings, I accepted assurances that the outcome of the independent inquiry had resulted in Dr. Main reappraising his earlier efforts. I was reassured by the acting chief executive that the inquiry would be open and objective--but I should have known better.

When it was eventually announced that disciplinary action was felt appropriate against two members of staff, but not Dr. Unsworth, I was surprised. Sylvia Fry, who conducted the investigating interviews, told me that Dr. Sturman and Dr. Unsworth had said that the concerns in the 1998 correspondence had been tackled. I did not feel that to be credible, considering the contents

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of the McLellan report and the appalling treatment to which we know that Mr. Collins was subsequently subjected.

I had also had access to three of the statements collected by Sylvia Fry and had spoken to another individual who had not yet been interviewed. Also, of course, there was the Alan Drew complaint, which was completely separate. I was told that his allegations had been thoroughly investigated, but how could the investigation have been complete when he was not even interviewed? I have gained evidence that that inquiry, again conducted by Alistair Main, was far from thorough.

I think it important to read a copy of the letter that Alistair Main sent to one of the witnesses. It states:

Despite the leading nature of that letter, I know that the response that was received confirmed some of Drew's allegations and concluded that there might be some substance to the complaint, and that it might need to be investigated. Cynthia Bower, the new chief executive of the new Birminghamwide trust, which replaced the old community trust, tried to assure me that the investigation was thorough. To be as charitable as possible, I can conclude only that what she said must have been based on assurances that she did not bother to check.

I have been very concerned about the behaviour of Cynthia Bower since she took on the job of chief executive of the new Birminghamwide trust. Her behaviour seemed to lack insight into the situation that she had, unfortunately, inherited. For example, on her first visit to Hillcrest ward 3 on taking up her position as chief executive, she was accompanied by Dr. Unsworth, despite the continuing disciplinary inquiry. Dr. Unsworth was seen to be influencing the manner in which the trust implemented the McLellan recommendations on the future of the unit, even though McLellan had recommended that he should not have a role. Cynthia Bower's memorandum to staff included the information that she and Jim Unsworth would begin work to redefine the new director post, thus implying that he still had a hands-on role in relation to the future of rehabilitation services. Other consultants felt excluded from the process.

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Cynthia Bower seems also to have been unaware of the impact of Dr. Unsworth's announcement in March that he would be leaving the trust--an announcement that was mentioned in the trust board's April minutes and in her circulars to staff--while failing to submit his resignation. That did not come until September. He was not then required to work out his three months' notice and he received full pay. Dr. Unsworth is seen to be close to the chief executive, who is a close friend of his partner. In view of this, I believe that the chief executive should have taken greater care to dissociate Dr. Unsworth from any future developments at Hillcrest ward 3.

I wrote to Cynthia Bower informing her that I found it remarkable that the investigation should have found sufficient evidence for action to be taken against the nurse manager and the clinical manager but not enough to justify action against Dr. Unsworth. I told her that all the feedback that I had received would suggest that he was more than aware of the way in which those two individuals ran the ward. I had received accounts from independent sources of how they would collectively humiliate Dr. Sturman. We know that Dr. Unsworth was fully aware of the contents of Dr. Sturman's letter of 23 February 1998 and his grave concerns about practice on the unit. All the evidence suggests that no action was taken to deal with those concerns.

I quoted the McLellan report, which stated:

I mentioned that, according to the report,

The report also stated:

Mr. Deputy Speaker : Order. I hope that the hon. Lady realises that only seven minutes remain in which the Minister may contribute. This is supposed to be a debate.

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Dr. Lynne Jones : I am drawing to a close, but I must put this matter on record. The report that I quoted mentioned

I also reread Alistair Main's internal report, in which Dr. Unsworth takes complete responsibility for the staff under him, notably the clinical manager and the nurse manager. That report shows a discrepancy between the information given by Dr. Sturman to Dr. Main and that which he gave to Sylvia Fry, as reported to me. My main concern is about the impartiality of the internal inquiries in the Southern Birmingham Community Health NHS trust and subsequently the Birmingham Specialist Community Health NHS trust.

I sought a meeting with my hon. Friend the Minister to discuss my on-going concerns, as well as with the regional director of public health, who has still not replied, despite a letter dated 9 November apologising for not being able to get back to me until Monday 4 December. The Minister was reluctant to meet me. I had several telephone conversations with her office and I was asked to put my request for a meeting in writing. I subsequently received a copy of a letter from her colleague, my hon. Friend the Member for Birmingham, Edgbaston (Ms Stuart), to Dr. Unsworth, addressed to "Dear Jim", and ending:

I apologise for having gone on at length. There is more that I wanted to say and I am sorry that the Minister has so little time to respond.

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1.27 pm

The Minister for Public Health (Yvette Cooper ): I congratulate the hon. Member for Birmingham, Selly Oak (Dr. Jones) on securing the debate, although I have only three minutes to reply to it, which is wholly inappropriate when so many allegations have been made and anxieties raised. I shall try to respond as rapidly as I can, but it will be difficult in the circumstances.

Concerns first arose about the in-patient unit of the rehabilitation service of the Birmingham Specialist Community Health NHS trust in September 1998 when a patient's formal complaint about the standards of care was received. As a result of investigations into that complaint and other concerns raised by consultants at the rehabilitation service, an internal investigation was ordered by the acting chief executive. That led soon afterwards to arrangements being made early the following year to put together a multidisciplinary review panel under the chairmanship of Professor Lindsay McLellan, which examined, as part of an independent inquiry, all the issues involved.

On the basis of emerging evidence, the senior nurse manager at the in-patient unit was suspended in October. Later that year, when the McLellan panel reported to the trust, the board accepted the recommendations and proceeded with disciplinary investigations. At that point, the clinical manager, line manager to the senior nurse manager, and the director of the regional rehabilitation service were suspended.

The disciplinary action was carried out under the proper procedures and according to employment law. That disciplinary action has now concluded; the senior nurse manager has been dismissed and the line manager has been disciplined. No disciplinary action was taken against the director of the regional rehabilitation unit. He was not appointed as medical director of the new trust and I am advised that those disciplinary procedures followed all the proper procedures and that the trust acted correctly on the basis of the available evidence under employment law.

There remain two outstanding issues: the completion of an investigation into the patient's complaint that triggered the McLellan investigation, which was put on hold while disciplinary procedures were implemented, and the on-going investigation into grievances between senior clinicians and the previous trust management at the regional rehabilitation centre. That review has not yet been completed, and it is being conducted in accordance with annexe E of HSC (90) procedures. I do not think that there is evidence to justify a repeat inquiry when there has already been an independent inquiry and a disciplinary inquiry has been carried out according to proper procedures, and when a grievance inquiry and a complaints inquiry have not yet been resolved. In addition, substantial changes have taken place in the unit since the new trust was established, and I am informed that there have been considerable improvements.

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