Catalogue of failures by the NHS

THE NHS may never be the same again.

After highlighting how health service staff failed - time and again - to act on complaints about consultants William Kerr and Michael Haslam, the official report into the scandal urges the Government to make revolutionary changes.

Changes to the way the service deals with complaints, changes to the guidelines issued to mental health staff and changes to the way references are checked when staff are being appointed.

As a matter of urgency, the Government is also being urged to clarify precisely when staff are obliged to report suspicions of patients abuse by colleagues.

The inquiry, set up in 2001 to investigate the way the NHS handled complaints against Kerr, of Easingwold, and Haslam, of Crayke, near Easingwold, was published yesterday. Running to more than 950 pages, it is a damning document, revealing how the service failed dozens of women patients.

It tells how complaints about the two psychiatrists repeatedly fell on deaf ears, with many doctors, nurses, psychologists and others ignoring warning bells, or dismissing rumours, and choosing to remain silent when they should have been raising their voices.

"It is also a story of management's failure, failed communication, poor record keeping and a culture where the consultants were all-powerful," said the report.

Only one person is highlighted as a persistent whistle-blower: Deputy Sister Linda Bigwood, who was not prepared to "turn a blind eye" but pursued her concerns about Kerr's alleged misconduct over five years.

The report says, however, that no investigation was made into Kerr's practice and he retired in 1988 with a letter of thanks for his "valuable contribution" to the health service in the Yorkshire region. Linda herself suffered "professional detriment".

The present system, according to the report, is much improved, and opportunities for the abuse of patients much reduced.

"Nevertheless, we conclude that substantial risks remain that patients and staff who raised concerns or complaints will not be heard, and we are not persuaded that their concerns will even now, in 2005, be speedily and appropriately addressed".

However, it says that North Yorkshire, which has had "more than its fair share of medical care-based scandals", has clearly learned some "very painful lessons" and there are indications that attitudes had changed - at least in this county.

The report reveals that the number of allegations against Kerr has grown since he had been found to have indecently assaulted a former patient in 2000.

It says the total number of former patients now making allegations of "sexualised behaviour" by Kerr comes to at least 67, with 38 former patients claiming they had made disclosures to NHS staff before he retired.

At least ten former patients, according to the report, had now made allegations against Haslam, who was convicted of indecently assaulting three former patients in 2003 and recently released from a three-year jail sentence.

The exception involved a complaint in 1979 by a patient to her GP about alleged advances by Kerr, which were accepted by the doctor as being true. "It is one of the great ironies in this account that the consultant to whom the doctor chose to speak about his concerns regarding William Kerr was Michael Haslam. Perhaps unsurprisingly, given his attitude to sexual contact between patients and doctors, Michael Haslam did not take the matter any further".

The report also reveals that Kerr was taken on in York in 1965 even though an allegation of inappropriate sexual conduct had been made the previous year in Northern Ireland. But no references from there were ever provided or checked, and it appeared the interview panel had no knowledge of the circumstances in which he left Northern Ireland.

:: The patients' reactions

FORMER patients of Kerr and Haslam have welcomed the report - and called on the Government to act on all its recommendations.

Kathy Haq, spokeswoman for a group of ex-patients, said the document marked the end of eight years of determined efforts to expose the "disgraceful" truth of what went on within North Yorkshire psychiatric services for almost 25 years.

She said one of the biggest shocks during the inquiry had been to discover that Kerr had come to work in York after leaving Northern Ireland following a complaint by a young woman patient. At the same time, Haslam had left York "under a cloud" only to work at a private clinic in Harrogate and then a senior NHS post in County Durham.

Kathy, a former patient of Kerr, said the doctors had been able to abuse their power because complaints were ignored by senior managers and other professionals.

"We had to listen to their excuses and denials as to why nothing was done to deal with these two disgraceful men, thereby allowing them to continue unheeded," she said.

"We hope these people are holding their heads in shame today because in our eyes, their lack of action to protect patients makes them even more accountable."

Lila Taylor, of York, who was indecently assaulted by Haslam, said she felt "very pleased" after her initial reading of the report. She believed it was very thorough, and said it was essential the recommendations were implemented by the Government to ensure other patients were protected in future.

Another former Kerr patient, Ruth Payne, of Ripon, said: "During this inquiry, we have been shocked and very angry at the number of health authority staff - mostly those at the top - who knew what was Kerr and Haslam were doing to patients and failed to stop them. I hope they have learned a very hard lesson from it."

She insisted that former patients had never been involved in a "witch-hunt" against the doctors, as one of their solicitors had suggested. "All we were ever interested in was the truth - and to be believed."

:: The official reaction

HEALTH bosses have offered sincere and unequivocal apologises to Kerr and Haslam's victims - and pledged to do everything possible to ensure such a scandal never happens again.

David Johnson, chief executive of North and East Yorkshire & Northern Lincolnshire Strategic Health Authority, said the NHS in North Yorkshire would study the report closely.

"It follows events which happened more than 20 years ago, when mental health services everywhere were very different from the way they are today," he said.

"However, it is important we look in some detail at the content of this report and in particular focus on the recommendations.

"Our feelings are very much with the women affected by these events. We hope they will gain some comfort from this report and from the fact that modern mental health services offer patients more protection and easier ways of reporting concerns, than in previous years."

Meanwhile, Phil Willis, the Liberal Democrat MP for Harrogate and Knaresborough, said the report's recommendations had the potential to transform the way patients with mental health problems were treated within the NHS.

"At last, dozens of vulnerable women who complained about their treatment without being believed know that their suffering should not and must not ever occur in the future," he said. "Indeed it is their courage that has made the planned changes come about."

He said the report demonstrated "catastrophic failures" within the NHS to protect one of the most vulnerable groups of patients - women with mental health conditions.

"Fortunately many of the flaws in the system, that allowed two consultants to go unchallenged, have been rectified but much needs to be done if we are to have confidence in one the most crucial services in the NHS.

"It is equally staggering to note the professional wall of silence that protected both Kerr and Haslam, despite very real concerns being raised by GP's and others."

An organisation called POPAN - the Prevention of Professional Abuse Network - called on the Government to fully implement the recommendations.

Chief executive Jonathan Coe said: "The offences committed by these doctors, who were in positions of trust and power, were truly horrendous and the scars inflicted by them last to this day. We hope the health authorities will learn lessons and ensure that nothing ever happens again."

:: The report makes more than 70 recommendations, to be acted on in 12 months, to prevent the abuse of vulnerable patients. These include:

Properly checked references should be needed from three most recent employers before making NHS appointments

No new unorthodox treatments should be given without approval of healthcare team

New guidance is needed for NHS managers in handling sex complaints

All trusts to develop new guidance to reduce likelihood of "sexualised behaviour" by staff

NHS to produce standardised complaints system for all trusts/organisations

NHS to convene expert group to set boundaries between mental health workers and patients

NHS to urgently clarify when staff have obligation to inform management of suspicions of abuse of patients

Updated: 09:48 Tuesday, July 19, 2005