Liverpool Care Pathway - A Real Eye-Opener

When the law is just the spin the politicians put on it, that is an eye-opener. When the law is what the lawyers make it, that's a blinder...

What are plainly crimes are committed, so how may they go unpunished?

Those who enact the law do not act; those who implement and apply the law misapply it; those who enforce the law are no longer a force but a service and do it disservice... 

The Sunday Mirror first revealed four years ago how John, 20, from Coalville, Leics, died after a fatal blunder at the hospital.

He arrived there in April 2006 after falling off his bike, suffering from a ruptured spleen.

A junior doctor failed to notice the injury and John, a telecommunications worker, died in agony at home.

In the days after John died, Stafford Coroner Andrew Haigh requested an expert report into his death.

That report - written by senior Stafford Hospital consultant Ivan Phair - concluded that the death was “avoidable” and there was a “high probability that the level of care delivered to Mr Moore-Robinson was negligent”.

However, Kate Levy - the hospital’s then head of legal services - told the consultant to delete the comments to avoid adverse publicity.

It meant his damning report was never sent to the coroner.

A separate report by independent investigator Michael Taylor also laid bare systemic failings at the very top of the hospital.

The 100-page dossier revealed that executives “failed spectacularly” and condemns them as “callous, unprofessional, discourteous and unworthy of a public body”.

Our revelations led to Ms Levy being sacked and to a police investigation as to whether there was a conspiracy to pervert the course of justice.

Ms Levy was later awarded £100,000 for unfair dismissal after she succesfully argued her actions were “consistent with her duties as a lawyer”.

John’s family want the reports by Dr Phair and Mr Taylor to be heard at a new inquest as they believe it will prove their son was killled due to neglect.

And, ultimately they want criminal charges, brought against those responsible.

- The Mirror

Private Eye  reports on another aspect of this -

THE success of lawyer, Robert Francis QC in stopping the NHS from covering up the harm it causes depends crucially on the behaviour of his own profession.

At the time of the Mid-Staffordshire scandal, there was unequivocal guidance for NHS trusts, Managers and clinical staff to be open and transparent when patients may have been harmed by their care. Lawyers, however, tend to focus on the law and who is paying their fees. Hence the solicitor’s code of conduct – to act in the best interests of their client – invariably trumps any wider ethical guidance to the NHS, particularly when it comes to admitting anything that might expose a hospital to bad press, litigation or financial loss. Francis’ solution – to make non-disclosure of harm a criminal offence – is as big a shift in the culture of medical law as it is to the NHS.

The Eye goes on to mention the use of public money by the NHS to pay lawyers to stop whistleblowing and, in the case of John Moore-Robinson, to discuss how a 'defensive – but entirely legal - culture' obstructed the course of justice and prevented John's parents from discovering the truth of his cruel and untimely death.

No-one was prosecuted over the attempted cover-up following his death.

Chief executive Martin Yeates actually told the parents of 20-year-old John that it was time to ‘move on’!

Mr Yeates was suspended on full pay – £15,000 a month, what a joke! – following the report from the Healthcare Commission that found that his NHS Trust board prioritised Government targets over basic patient care.

Gordon Brown coughed up an apology at the time, but when are the politicians and uncivil servants at the DoH going to be held to account? They all played their part in this terrible, terrible, disgraceful tragedy!

Private Eye elaborates and adds further damning, cogent facts -

The Trust received a request from the Coroner for information in relation to the death. The junior doctor had left the trust, so Mr. Ivan Phair, the senior A & E consultant, was asked by the trust’s legal team for a “report addressed to the coroner for use in the inquest”. Phair concluded that the junior doctor should have interpreted that Mr. Moore-Robinson could have been suffering from some form of bleeding. “I cannot find enough evidence which would lead me to conclude that a thorough abdominal examination was carried out. I would therefore raise the possibility that his unfortunate, untimely death may have been avoided, had he been more properly assessed on his initial attendance to the A & E department.

On 25 May 2006, Kate Levy, the trust’s in-house solicitor, wrote to Mr. Phair saying his report had not been forwarded to the coroner. “Whilst it would be entirely appropriate as a report in respect of a clinical negligence claim it goes beyond the issues which concern the coroner. The coroner is undertaking a fact finding exercise and does not concern himself with matters of blame or potential negligence. I would therefore like to suggest that the section of your report headed ‘Conclusion’ with the exception of the final para be removed.”

When Mr. Phair refused, she wrote, “As reports are generally read out in full at the Inquest and the press and family will be present, with a view to avoiding further distress to the family and adverse publicity I would wish to avoid stressing possible failures on the part of the Trust.” She suggested removing the two paragraphs of the conclusion. “I feel such a concluding statement may add to the family’s distress and is not one which I would wish to see quoted in the press.”

The report was amended but not to the solicitor’s satisfaction.

Levy decided not to disclose either version to the coroner or to John’s parents.

And neither did her fellow Mid-Staffs solicitor, Stuart Knowles, who also happened to be the deputy coroner.

When the Francis Inquiry discovered the failure to disclose Phair’s report, Levy was dismissed from the trust in 2010.

Levy fought a case for unfair dismissal and won damages of £100,000!

By any moral yard stick or metre rule, in excluding evidence from the coroner’s court, Levy was perverting the course of justice.

By the legal yard stick or metre rule, Levy acted

Entirely professionally in line with the employment contract and the solicitors’ code of conduct, and she had no case to answer.

The focus of both reports is that Mr. Ivan Phair was asked to doctor his original report to the coroner and that the report was ultimately not submitted to the coroner at all.

The real focus should be that - as the Eye article explains - when the Coroner asks the hospital for information, the medical records are not submitted; what is submitted is a 'report'. To crown folly with folly, the report is written by the doctor who last treated the person who has died.

And the jewel in the crown has to be that it is submitted to the hospital's legal censor before it is submitted to the Coroner's Court!

The guilty are permitted to write their own script to be submitted as evidence.

The other aspect already mentioned in both articles is that of the compensation and damages payments demanded of the NHS.

The hybridised NHS is still a National Health Service and this is paid out of public money. What punishment is there for the perpetrators? But then, it is all about 'learnings' isn't it and not about justice...?

Still, why should the public have to pay, at source as a taxpayer, at supply as a consumer, and as judicial victim?