NHS failings over Baby P: Ignore the press release, read the report

The report into the NHS’s failures over Baby P is out today – and some, though not all, journalists appear to be committing the classic error of copying out the press release rather than reading the document itself.

The report deals with the fact that all four consultants at the clinic which sent Baby Peter home to die raised strong concerns, in writing, more than a year before he came to the clinic that overstaffing, poor record-keeping and the like were causing a “very high risk” to patient safety.

The NHS, which commissioned the report, has naturally been at pains to minimise its managers’ own failings, seizing on a finding that the concerns of doctors at the clinic which failed Baby Peter were “taken seriously.” If they were taken so seriously, one rather wonders why Baby Peter died at all.

The fact is (as you will find if you read the report carefully enough) that, far from taking their concerns about staffing seriously, the number of consultant posts at the Haringey clinic was cut after the letter was written – from four to three.

One of the four, Dr Kim Holt, told me that she was removed from her job on “totally spurious grounds” after the complaint and offered money to “buy my silence.” By the time Baby P came to the clinic she – and two of the others – were gone. He was seen by a temporary locum who allegedly missed the fact that he had a broken back.

Tucked away in paragraph 10.11 of the report is an admission that even by May 2008 – more than two years after the doctors first complained – child protection at the clinic was still a matter for “grave concern.”

Does that sound like the management “taking it seriously” to you?

The report itself is like so many of these things – a rather weedy front end masking some quite serious criticisms towards the back. Here’s my summary of those, with paragraph numbers:

5.3  “We would not agree” that the problems at the clinic did not affect patient safety.

5.5  The problems with individual consultant workload at the clinic in 2006/7 were “significant.”

5.7  Kim Holt was “a good doctor as to whose competence and clinical abilities no concerns have ever been raised.”

5.12  “We consider [Dr Holt] is entitled to feel aggrieved when having raised concerns… she is told she cannot return to her job.”

10.11 Another report finds that even by May 2008 arrangements for child protection cases are still a cause for “grave concern.”

10.15.1  “The workload of the consultant team was excessive between 2006 and May 2008.”

10.15.2  “There is no evidence that this was adequately addressed” before Dr Holt became unwell.

11.6 Four members of clinical staff in addition to Dr Holt reported aggression from management.

11.15 Junior doctors were assigned tasks which they believed were outside their level of expertise.

12.2 “The extent to which the matters complained of in the consultants’ letter were dealt with is variable.”

12.4 “It is accepted that some of the issues still exist” in 2009.

12.6 David Elliman, the manager responsible for the clinic, claimed to the enquiry that there were no child safety implications: “We are unclear as to how he reaches this view. The lack of notes and delays in seeing children must as a matter of common sense in our view have the potential to affect patient safety.”

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