1

Report by Associate Professor Stephen Bolsin

in the matter of concerns raised by
Dr Rita Pal in the North Staffordshire NHS Trust
Background
Inthepreparationof thisReport I havereviewedthefollowingdocuments.
1. Letter fromDr Pal toMr StevenHardy at theGMC dated4
th
November 2004.
2. Document headed Dr RitaPals statement annotated paragraphs 1to 3.5; 2
pages; unsigned.
3. Document headedEvent of theNeedlestick Injury
4. Facsimile copies of document headed North Staffordshire Trust; Medical
DivisionMemorandum; annotatedAppendix 1, fromMrs T FenechtoSister P
Wright.
5. Facsimile copies of document headed North Staffordshire Trust; Medical
DivisionMemorandum; Visit toWard87on25
th
May 1999.
6. Document headed Summary of Discussion Held at Meeting with Dr M
Spiteri,
7. Document headed Review of Standards of Care on Ward 87 following
allegations madebyRitaPal 30.11.98.
8. Commission for Health Improvement Clinical governance Report for North
Staffordshire Hospital NHS Trust dated March 2002. (Available at
http://www.healthcarecommission.org.uk/YourLocalHealthServices/NHSAZ/TrustDeta
il/fs/en?CONTENT_ID=4005433&chk=IMFs2b)
9. Letter fromDr C Campbell toDr J Greendated2
nd
December 1998.
10. Document headed Review of Standards of Care on Ward 87 following
Allegations byDr RitaPal 30.11.98.
Executive Summary
1. Dr Pal hadpreviously hadgoodworkingrelationships withsenior staff, junior
staff, nursing staff, patients and relatives before shestarted working in Ward
87in1998.
2. Dr Pal had previously shown high standards of patient careand commitment
prior toNovember 1998.
3. Dr Pal identified serious shortcomings in the nursing and medical care of
patientsonWard87.
4. Dr Pal verbalised and wrote these complaints to senior nursing and medical
staff.
5. The documents reviewed indicate the deficiencies Dr Pal identified were
confirmed in subsequent documents fromsenior consultants, senior nursing
staff, areviewof ward87andaCHI review.
6. The reactions of the nursing staff to a junior doctor were likely to be hostile
and might include reprisals (Firth-Cozens 2002; Firth-Cozens, Firth et al.
2004; Kingston, Evanset al. 2004).
7. The response of the employer to support the other staff against the whistle
blower is acommonandfearedresponseamongst healthcareworkers (Firth-
Cozens2002; Firth-Cozens, Firthet al. 2004; Kingston, Evanset al. 2004).
8. The predictable response appears to have occurred despite considerable
evidence available to the employer and the regulatory body that Dr Pals
complaintshadabasisinfact.
2
9. The opportunity exists for both the regulatory body and the employer to
indicate a changed response to a health care employer reporting episodes of
poor care in the NHS. Given the publicity that could surround such a
changed response aclear positivemessagewould be sent to NHS health care
professionalswishingtoreport poor careinthefuture.
10. At present this caseand others that havepreceded it stand as insurmountable
barriers to current health care professionals who wish to report poor care.
These monuments the victimisation of those who have criticised poor care
must be removed before incident reporting will be embraced in the NHS
(White2004).
Review of the Documents
1. Theinitial complaintsof Dr Pal concernthefollowing
a. Lack of staff onward87.
b. Lack of equipment onward87.
c. Lack of basic nursingobservationsonward87.
d. Lack of support for junior medical staff in this particular junior staff
rotationat thehospital.
2. These factors all contributed to a standard of care for at least one patient on
thewardbelowthat whichtheyhadaright toexpect.
3. Subsequent documentationindicatedthat at least 8patientsreceivedastandard
of carebelowthat whichtheyhadaright toexpect.
4. Dr Pal raisedtheseissueswithMrsBoonon4
th
November 1998.
5. MrsBoonnotedDr Palscomments.
6. Thefollowing week theNHS Trust arrangedfor asenior doctor tocover some
of theduties of thejunior houseofficer. This appears tohavehelpedinasmall
way.
7. On 12
th
November 1998 Dr Pal appears to have been accused of being
responsiblefor aneedlestick injury toawardcleaner by thenursingstaff on
Ward87.
8. A hospital inquiry found no supporting evidence for the accusations that Dr
Pal had caused the needle stick injury through the careless disposal of
needles. Therewas no apology for thewrongful or unsubstantiatedallegations
madeby thenursingstaff.
9. Dr Pal was thenaccusedof inserting thewrongdateonpatient records related
to drugadministration. It is not clear who madetheseallegations but they do
not appear tohavebeeninvestigatedor foundtobetrue.
10. Dr Pal thenfoundout that acolleaguehadcontactedher previous consultant to
ask if Dr Pal was capableof doingthejob. Dr Pal rightly foundthis extremely
upsettinganddemoralising.
11. At the end of this week Dr Pal requested some leave, as she was unable to
continuetoadequately carefor patientsinthis environment. This wasamature
andresponsibleapproachtothesituationinwhichshefoundherself.
12. On 2
nd
December 1998 Dr C Campbell (Deputy Clinical Tutor) wrote to Dr
Green (Clinical Director Gastroenterology Department) to informhimof the
statement of Dr Pal and the allegations raised. Dr Campbell is disappointed
that he was not informed until over 2 weeks after the initial complaint. This
indicatesalack of effectivecommunicationaroundthejunior medical staff.
3
13. Dr Campbell alsoconfirms that theallegationsareof averyserious natureand
confirms that aninvestigationintotheallegationsisrequired.
14. Dr Campbell outlines his misgivings about the junior medical staff training
andattachments. Theseseemreasonableandjustifiableconcerns.
15. Dr Campbell confirms that several of the junior doctors were working in an
unsupervisedfashionandthat this contravenedtheGMC regulations. This had
beenoneof Dr Pals primary concerns at is confirmed as truenot only in her
casebut for other staff as well. This is confirmationof theunacceptablelevels
of supervisioninthepost that Dr Pal hadidentified.
16. Dr Pal has never beenapplaudedfor her attempt to improvethequality of the
junior medical officer trainingintheNHSTrust.
17. On13
th
May MrsT Fenech(DirectorateManager for InfectiousDiseases Unit)
heldameetingwithSister P Wright discussingsomeof theproblems inWard
87. The documentation of the meeting confirms that all of the complaints
madeby Dr Pal about Ward876months earlier hadconsiderablebasis infact.
These include lax attitudes to essential equipment, poor staffing numbers in
the ward and a serious lack of base line and routine observations and blood
testingonpatientsinWard87.
18. Thesebreaches wereso serious as to bedescribed by Mrs Fenech, as clearly
abreach of policy and the level of caredemonstrated for somepatients on
thewardat thetimeof my audit wasnothingshortof negligent.
19. This observation supports completely the allegations made by Dr Pal in
November 1998 and indicatea lack of action by the hospital in dealing with
Dr Palsperceptiveandinsightful observations.
20. Dr Pal has never been applauded for her observations and actions directed
primarily at improvingthestandardof patient careonWard87.
21. At ameetingwithDr Spiteri on21
st
May 1999Mrs Fenechraisedtheissueof
the medical staff identifying any shortfalls in patient observations that they
may observe. Dr Spiteri was concerned that this action would increase the
potential for frictiontooccur betweenthenursingandmedical staff.
22. Dr Spiteri is describingexactly what didhappen6months previously whenDr
Pal raisedconcernsabout thestandardsof nursingcareonWard87.
23. Theevidenceis that inMay 199therehadbeenlittlechangeinattitudes since
November 1998.
24. The Review of Standards of Care appears to have taken place over a
protractedperiodandby several members of thenursing staff. Theaccount of
theneedlestick injury appearstobeprejudicial tothereputationof Dr Pal. The
descriptionindicatesthat therewasnever enoughevidencetoconcludethat Dr
Pal wasresponsible. Thisisnot madeclear inthisreview.
25. Thefirst inquiry initiatedby MRS Boonwas not writtenupalthoughanaudit
carriedout by Sister BrittainwasconcludedbeforeSister Brittainleft theTrust
inMarch1999.
26. Theverbal report appears to havebeenfalsely reassuring giventhestatements
of MrsFenechinMay1999.
27. Mrs Boonreviewed thecasenotes of thepatients that Dr Pal hadcomplained
had received poor care. Mrs Boon claimed that the standards of nursing care
wereadequate.
28. I would need to examine the casenotes of these patients to comment on this
finding but it is at odds with the descriptions of Dr Pal that have been
demonstratedtobetruebyaninquiry6monthslater.
4
29. Mrs Fenech, as a new Directorate Manager, appears to have independently
initiated an inquiry into the nursing practices in ward 87. This led to the
shockingconclusionsin17& 18above.
30. The Review of the ward did identify serious failings in the nursing practices
onward87andreport that thereisstill roomfor further improvement.
31. InMarch 2002theCommission for Health Improvement published aClinical
Governance Review of the North Staffordshire NHS Trust. This review
identified several deficiencies in the operation of the Trust, which coincide
withtheproblemsidentifiedonWard87byDr Pal 3yearsearlier.
32. Page vii notes that the CHI was concerned with the level of supervision,
workloadandwork patterns of junior doctors workingwithin medicine. CHI
was so concerned that they suggestedthis posed apotential risk to patients
and requested urgent action. Dr Pal had raised these concerns in almost
exactlythesamewayinthesameareainNovember 1998.
33. Page viii notes that the Trust had recently recruited 140 nurses from the
Philippines boosting the numbers of nurses on the wards. This supports the
observation of Dr Pal in November 1998 that the wards were under staffed
withnurses.
34. Page ix notes that supervision of staff is poor in medicine. This led CHI to
express major concerns about the supervision of junior doctors working in
medicine.
35. Thisconfirms theobservationsof Dr Pal madeinNovember 1998.
Summary & Opinion
1. Thereis littledoubt that thefailings injunior medical staff supervisionidentified
by CHI in the Clinical Governance Review in 2002 are the same failings
identifiedbyDr Pal inNovember 1998.
2. Thereis littledoubt that the failings identified by the Ward Reviewof ward 87
undertakeninMay 1999arethesamefailings identified by Dr Pal inNovember
1998.
3. There is little doubt that the problems identified by Dr Campbell in December
1998arethesameproblemsdetailedbyDr Pal inNovember 1998.
4. I amfirmly of theopinionthat Dr Pal identified standards of nursing carebelow
that which patients in an NHS Trust have a right to expect and took action to
correct thoseverylowstandards.
5. I amalso firmly of theopinionthat Dr Pal identifiedstandards of junior medical
cover belowthat which apatient and ajunior doctor hadaright to expect in an
NHSTrust andtookactiontocorrect thosestandards.
6. I amalso firmly of the opinion that Dr Pal identified standards of equipment
provision belowthat which apatient in an NHS Trust had aright to expect and
tookactiontoimprovethosestandards.
7. Dr Pal is to be applauded for her courageous stand against poor standards in
healthcare. Themotivationfor thosewishing to denouncesuch actions must be
examinedinorder toidentify thejustificationfor suchcriticism.
8. Withrespect totheissues of possibleretaliation by thenursingstaff toDr Pals
complaints about the standards of equipment and care on Ward 87 these are
unfortunately normal responses inUK andAustralian healthcareprofessionals
(Firth-Cozens2002; Firth-Cozens, Firthet al. 2004; Kingston, Evanset al. 2004).
It is thefear of suchreprisals fromnot only colleagues but employers andother
5
regulatory bodies that restricts themajority of UK junior doctors fromreporting
poor carewhenit isencountered(White2004).
9. I amfirmly of theopinion that the employer andthe regulatory body must now
ceasetheattemptsat reprisals against Dr Pal.
10. Thesebodies shouldhelptoput inplaceanenvironment inwhichreportingpoor
care or errors is seen as a helpful quality improvement exercise that will
contributetothefuturesafetyandquality of all NHShealthcareorganisations.
11. Although this may seemto be an impossible task for individual employers or
organisations a start made at this time in this case will signal an intention to
change that will initiate a process that could lead to the creation of supportive
environments for any professional wishing to report an episode of poor care
anywherein theNHS (Bolsin 2000; Bolsin andColson 2000; Bent, Creati et al.
2002; Bolsin and Colson 2003; Bolsin 2003; Bolsin and Colson 2003; Bolsin,
Solly et al. 2003; Morton2003; Bolsin, Colsonet al. 2004).
Associate Professor Stephen Bolsin
BScMBBSFRCA FANZCA MHSM DLit (Hon)
6
References
Bent, P., B. Creati, et al. (2002). Professional monitoring and critical incident
reportingusingpersonal digital assistants. MJA 177: 496-499.
Bolsin, S. (2000). Routes to Quality Assurance: Risk adjustedoutcomes & personal
professional monitoring. International Journal for Quality in Health Care 12: 367-
369.
Bolsin, S. and M. Colson (2003). The use of statistical process control methods in
monitoringclinical performance. Int J Qual HealthCare15(5): 445.
Bolsin, S., M. Colson, et al. (2004). Theuseof statistical process control methods to
monitor and improve clinical performance. Qual Safe Health Care: Submitted for
publication.
Bolsin, S. N. (2003). Whistleblowing. Medical Education37: 294-296.
Bolsin, S. N. and M. Colson (2000). Methodology Matters; CUSUM. International
Journal for QualityinHealthCare12: 433-438.
Bolsin, S. N. and M. Colson (2003). Making the case for personal professional
monitoringinhealthcare. International Journal for QualityinHealthCare15: 1-2.
Bolsin, S. N., R. Solly, et al. (2003). Thevalueof personal professional monitoring
performancedataandopen disclosurepolicies in anaesthetic practice: acasereport.
International Journal for QualityinHealthCare12: 295-297.
Firth-Cozens, J. (2002). Barriers to incident reporting. International Journal for
QualityinHealthCare11(1): 7.
Firth-Cozens, J., R. A. Firth, et al. (2004). Attitudes to andexperiences of reporting
poor care. Clinical Governance8(4): 331-336.
Kingston, M. J., S. M. Evans, et al. (2004). Attitudes of doctors and nurses towards
incident reporting: aqualitativeanalysis. MJA 181(1): 36-39.
Morton, A. (2003). The use of statistical process control methods in monitoring
clinical performance. International Journal for Quality inHealthCare15: 361-362.
White, C. (2004). Doctors mistrust systems for reporting medical mistakes. BMJ
329(7456): 12.