Professor Steve Bolsin conducted a review of all the evidence.  His review is listed here.

 

 

 

Medical Division Memorandum 

Ward 87

From Ms Teresa Fenech 

Directorate Manager for Infectious Diseases City General Hospital Stoke on Trent. 

Reference TF/CLS/005 

18th May 1999

 

Point 3

 

"  I informed you that I had undertaken an audit of every single patient on the ward the previous week. I identified a serious lack of baseline and routine observations. In the case of some patients there was also clearly a breach of policy and there was an apparent lack of misunderstanding from the staff of the importance of such issues. I informed you that in my opinion the level of care demonstrated for some patients on the ward at the time of my audit was nothing short of negligent"

 

In  May 1999, the Medical Division received an Adverse Incident Form from Ward 87 which identified a malfunction of a defibrillator used during resuscitation. A two stage investigation was began. 

 

 

A letter from Dr Colin Campbell to Dr John Green, Clinical Director at City General Hospital Stoke on Trent, read as follows: (CAC/ AR/LET 2nd December 1998) Point 2 (first page) . 

 

"To summarise other discussions that we have had on the medical PRHOs, I think that the following should be addressed within the directorate as a matter of urgency - (2) They should have proper clinical supervision at all times and help from a more experienced colleague... should always be available (The New Doctor GMC), On discussion with several of them they are still working without immediate supervision for significant periods.”

 

 

2.    A March 2002 report by the Commission of Health Improvement of a Clinical Governance Review at North Staffordshire NHS Trust found serious shortcomings in the supervision of junior doctors, 

 

"CHI was informed that junior doctors working in medicine were often inadequately supervised and often left alone on wards, particularly on the medical assessment unit (MAU). During an evening visit we found only two junior doctors covering MAU, which was full to capacity, with a further junior doctor covering MAU and emergency admissions; one junior doctor covered the medical wards and one covered medical outliers but these patients could be on wards on either site. CHI felt this situation posed a potential clinical risk to patients.”
 

 

3.       The 2002 report went on to say, in Paragraph 5.78:

 

"There were a number of concerns raised regarding support and supervision for junior doctors working in medicine. We were told of a number of occasions when it was felt there was a lack of support both during the day and when problems arise whilst oncall. The Trust has acknowledged that medical staffing at all levels is under resourced in medicine".

4. The Creamer Report 
 

The summary of the 2001 Creamer Report concealed by the GMC stated as follows 

 

(a) “Patient care was clearly affected by the failures identified”;
(b) “The Directorate failed to take appropriate action when the allegations were made in a statement by Dr Pal”;
(c) “Although medical and nursing staff were concerned about the range of issues...no one voiced their concerns except Dr Pal which either demonstrated a general acceptance of the issues or staff felt unable to raise concerns”.

5. Email dated 10th June 2010. From the Care Quality Commission.

* With regard to North Staffordshire NHS Trust - The data that Chris Sherlaw-Johnson referred to in an email to Sarah Seaholme as follows: "Earlier data from Dr Foster does suggest that they did have more concerning mortality in years before 2003/2004."

The Information Governance Team has now processed your request and I can now advise you of the following.

Mr Sherlaw-Johnson was using the HSMR's (Hospital Standardised Mortality Rates) published by Dr Foster.

Year HSMR 2000/01 115.9 2001/02 113.5 2002/03 113.1 Dr Foster classified each of these as 'significantly high'.