1
00:00:05,800 --> 00:00:09,160
Tonight on Panorama,
we unearth the hidden secrets

2
00:00:09,160 --> 00:00:13,120
that some NHS hospitals
are keeping from us.

3
00:00:13,120 --> 00:00:17,200
Nothing that has happened
in this entire case has been open.

4
00:00:17,200 --> 00:00:20,840
This has been a cover-up
from start to finish.

5
00:00:20,840 --> 00:00:25,040
Transparency is key to
keeping patients safe.

6
00:00:25,040 --> 00:00:28,640
All we've wanted from day one
is some honesty, some transparency

7
00:00:28,640 --> 00:00:30,360
and just the truth to come out.

8
00:00:30,360 --> 00:00:34,960
But warnings about patient safety
are being kept from the public.

9
00:00:34,960 --> 00:00:37,000
They're trying to
keep something hidden.

10
00:00:37,000 --> 00:00:41,320
They know the service is failing and
they're trying to hide something.

11
00:00:41,320 --> 00:00:45,000
Not only did the trust know
about all the problems existed,

12
00:00:45,000 --> 00:00:48,480
they hadn't dealt with them
in any way, shape or form.

13
00:00:48,480 --> 00:00:52,360
Panorama has uncovered dozens
of expert reports highlighting

14
00:00:52,360 --> 00:00:56,200
serious concerns about patient care.

15
00:00:56,200 --> 00:00:59,240
You know, it means there
are possibly risks out there

16
00:00:59,240 --> 00:01:01,280
that the regulator is unaware of.

17
00:01:01,280 --> 00:01:04,520
And ultimately, those risks
can have tragic consequences.

18
00:01:04,520 --> 00:01:07,760
And we ask, are hospitals
putting their reputations

19
00:01:07,760 --> 00:01:10,440
before patient safety?

20
00:01:10,440 --> 00:01:12,840
We never felt as though
it was transparent.

21
00:01:12,840 --> 00:01:14,840
We felt like we were on the outside.

22
00:01:14,840 --> 00:01:17,200
We felt as though
we've had to continue fighting.

23
00:01:30,600 --> 00:01:32,960
I didn't have any
issues in my pregnancy.

24
00:01:32,960 --> 00:01:34,760
I had a very textbook pregnancy.

25
00:01:37,840 --> 00:01:40,000
We were obviously excited.

26
00:01:40,000 --> 00:01:42,680
We were going to be bringing
our baby home. We didn't know

27
00:01:42,680 --> 00:01:45,840
if we were going to have a boy
or a girl, so we were just excited

28
00:01:45,840 --> 00:01:48,560
about what was to come.

29
00:01:48,560 --> 00:01:52,160
In November 2017,
Sarah and Tom Richford

30
00:01:52,160 --> 00:01:56,120
were at the Queen Elizabeth, the
Queen Mother Hospital in Margate.

31
00:01:56,120 --> 00:01:58,560
It was the early stages
of Sarah's labour.

32
00:02:00,800 --> 00:02:04,240
I was there for quite a long time
and my labour wasn't progressing,

33
00:02:04,240 --> 00:02:08,720
so they said that I would be moved
to the high-risk labour ward.

34
00:02:10,360 --> 00:02:14,200
As Sarah's labour went into the
second night, two junior doctors

35
00:02:14,200 --> 00:02:15,920
were left in charge.

36
00:02:15,920 --> 00:02:18,840
One, a locum, had only
been there three days.

37
00:02:18,840 --> 00:02:21,120
The other was a trainee GP.

38
00:02:23,120 --> 00:02:26,600
At three in the morning, the
duty consultant, who was at home,

39
00:02:26,600 --> 00:02:30,240
agreed the inexperienced doctors
should carry out an emergency

40
00:02:30,240 --> 00:02:33,680
caesarean section without her.

41
00:02:33,680 --> 00:02:36,880
You could feel the change and
everybody did just start to panic.

42
00:02:36,880 --> 00:02:39,200
And there was a lot
of people shouting.

43
00:02:39,200 --> 00:02:41,680
There was people...

44
00:02:41,680 --> 00:02:44,840
..all of a sudden,
it just was very stressful,

45
00:02:44,840 --> 00:02:47,600
erm, and not a nice
environment to be in.

46
00:02:47,600 --> 00:02:51,160
We could hear the surgeons shouting
things like, "Cut her here,

47
00:02:51,160 --> 00:02:53,840
"cut her there". And there
was clearly quite an animated

48
00:02:53,840 --> 00:02:56,600
and heated discussion
about what was going on.

49
00:02:56,600 --> 00:02:59,640
And we now know, looking back
on it, that he was informing

50
00:02:59,640 --> 00:03:03,320
a very junior doctor to cut Sarah,
which she wasn't qualified to do,

51
00:03:03,320 --> 00:03:05,120
as she felt uncomfortable to do it.

52
00:03:06,920 --> 00:03:11,280
When the consultant did
eventually arrive, she was too late.

53
00:03:11,280 --> 00:03:13,640
Sarah's baby, Harry,
wasn't breathing

54
00:03:13,640 --> 00:03:16,640
and needed urgent resuscitation.

55
00:03:16,640 --> 00:03:19,000
To escape the
pandemonium around her,

56
00:03:19,000 --> 00:03:22,200
Sarah was offered
a general anaesthetic.

57
00:03:23,240 --> 00:03:27,120
And I said, yes, and I still
to this day feel guilty

58
00:03:27,120 --> 00:03:29,960
because I'd left Tom in that room.

59
00:03:31,560 --> 00:03:33,680
Having to see the
doctors working on Harry,

60
00:03:33,680 --> 00:03:36,440
but also, obviously, me not
wanting to be in that room,

61
00:03:36,440 --> 00:03:39,280
it meant that he - because I'd
been put under general anaesthetic,

62
00:03:39,280 --> 00:03:40,920
he had to leave.

63
00:03:40,920 --> 00:03:43,200
What was going through
your mind at that point?

64
00:03:43,200 --> 00:03:45,800
It... I didn't know if I'd
ever see either of them again.

65
00:03:47,600 --> 00:03:50,080
Really, and it's tough, because...

66
00:03:50,080 --> 00:03:52,880
..you go in with all those hopes
and expectations that you're going

67
00:03:52,880 --> 00:03:56,600
to walk away as a family,
and you're going to walk with Sarah

68
00:03:56,600 --> 00:03:59,320
and Harry out to your
car and everything,

69
00:03:59,320 --> 00:04:01,200
and, eh...

70
00:04:03,120 --> 00:04:04,920
Yeah, you just think that actually

71
00:04:04,920 --> 00:04:06,680
you might be walking
out on your own.

72
00:04:09,520 --> 00:04:13,440
Harry's traumatic delivery,
and a delayed resuscitation,

73
00:04:13,440 --> 00:04:16,640
meant he'd suffered brain damage
from a lack of oxygen.

74
00:04:16,640 --> 00:04:19,520
He was transferred
to intensive care.

75
00:04:21,240 --> 00:04:24,600
And it was just a really difficult
week, seeing him in his incubator

76
00:04:24,600 --> 00:04:28,680
and how sick he really was,
and then going back to my room

77
00:04:28,680 --> 00:04:31,080
and then feeling guilty
for not being with him.

78
00:04:31,080 --> 00:04:34,520
And then, you know,
it was just, it was...

79
00:04:34,520 --> 00:04:37,000
..one of the hardest
weeks of our lives. Yeah.

80
00:04:37,000 --> 00:04:39,400
But we did get
to spend time with him,

81
00:04:39,400 --> 00:04:41,360
erm, which was good.

82
00:04:43,080 --> 00:04:46,960
Tom and Sarah were told that Harry
would have a very limited quality

83
00:04:46,960 --> 00:04:50,680
of life. He would never be able
to learn or feed himself.

84
00:04:52,880 --> 00:04:56,160
After a lot of soul searching
and advice, it was decided

85
00:04:56,160 --> 00:04:58,800
to turn off
his life support machine.

86
00:04:59,880 --> 00:05:03,000
Nobody ever wants to have
to make that decision.

87
00:05:03,000 --> 00:05:05,800
It's the worst possible decision
that you could ever have to make.

88
00:05:05,800 --> 00:05:09,640
However, at the end of the day...

89
00:05:09,640 --> 00:05:11,920
..it's a choice between...

90
00:05:11,920 --> 00:05:15,600
..erm, your baby living and
having no quality of life,

91
00:05:15,600 --> 00:05:19,680
or not, and so we did, obviously,
choose to make a decision

92
00:05:19,680 --> 00:05:23,440
and for a long time, I felt
really bad about that decision.

93
00:05:23,440 --> 00:05:24,960
But I think...

94
00:05:24,960 --> 00:05:28,200
..I don't regret it
because, you know,

95
00:05:28,200 --> 00:05:31,400
I wouldn't have wanted
that for our baby. I know.

96
00:05:34,280 --> 00:05:38,960
At first, the hospital wouldn't
report Harry's death to the coroner.

97
00:05:38,960 --> 00:05:41,960
The family feared a cover-up and
set about doing their own research

98
00:05:41,960 --> 00:05:43,240
into why he died.

99
00:05:47,000 --> 00:05:50,120
Harry's grandfather, Derek,
spent months online

100
00:05:50,120 --> 00:05:53,240
going through the hospital's
public records.

101
00:05:54,320 --> 00:05:58,240
When things go wrong in hospitals,
trust can commission reviews

102
00:05:58,240 --> 00:06:00,480
from one of the medical
royal colleges,

103
00:06:00,480 --> 00:06:03,320
who set standards for care
and practice.

104
00:06:03,320 --> 00:06:06,160
Derek found a reference
to a Royal College report

105
00:06:06,160 --> 00:06:08,400
on the hospital's maternity unit

106
00:06:08,400 --> 00:06:10,880
written two years
before Harry's death.

107
00:06:12,040 --> 00:06:14,720
I searched for this report
on Google, everywhere,

108
00:06:14,720 --> 00:06:17,560
and I was getting pretty
good at it by this time.

109
00:06:17,560 --> 00:06:20,760
Nothing, but nothing -
couldn't find a thing.

110
00:06:20,760 --> 00:06:24,600
Derek discovered he could compel
the hospital to release the report

111
00:06:24,600 --> 00:06:29,080
by sending a formal
Freedom of Information request.

112
00:06:29,080 --> 00:06:32,440
When you opened that email,
I mean, what did you see?

113
00:06:32,440 --> 00:06:36,160
I was absolutely stunned
because even the introduction,

114
00:06:36,160 --> 00:06:38,680
it goes into only about ten lines

115
00:06:38,680 --> 00:06:41,520
that could have written
Harry's demise.

116
00:06:41,520 --> 00:06:44,360
It tells you about consultants
not turning up overnight.

117
00:06:44,360 --> 00:06:48,200
It tells you about
a lack of escalation.

118
00:06:48,200 --> 00:06:51,440
And it just says if you continue
to operate and practice the way

119
00:06:51,440 --> 00:06:54,480
you are currently doing things,
there's a high probability

120
00:06:54,480 --> 00:06:56,960
that there's going to be
an unassessed locum doctor

121
00:06:56,960 --> 00:06:58,880
working overnight.

122
00:06:58,880 --> 00:07:03,040
Sort of, maybe 20 months later,
that's exactly what happened to us.

123
00:07:03,040 --> 00:07:05,680
So they knew all of that
was going on at that time.

124
00:07:05,680 --> 00:07:08,280
And it was two years prior to Harry.

125
00:07:08,280 --> 00:07:10,000
Honestly, we were stunned.

126
00:07:12,800 --> 00:07:15,120
You feel incredibly angry
and upset and emotional

127
00:07:15,120 --> 00:07:17,880
because it was so avoidable.

128
00:07:17,880 --> 00:07:21,120
It is the most easily
avoidable mistake going.

129
00:07:21,120 --> 00:07:23,960
You just see, this is the mistake.
OK, let's avoid that

130
00:07:23,960 --> 00:07:26,000
and change our practice,
and then it won't happen.

131
00:07:26,000 --> 00:07:27,840
But it didn't happen for us.

132
00:07:29,080 --> 00:07:33,080
Since 2015, trusts are supposed
to share Royal College reports

133
00:07:33,080 --> 00:07:36,520
with the regulator - in England,
the Care Quality Commission,

134
00:07:36,520 --> 00:07:40,240
or CQC. The trusts should then
inform the public,

135
00:07:40,240 --> 00:07:43,520
but there is no law
to enforce this.

136
00:07:43,520 --> 00:07:47,080
The Margate hospital told the CQC
about the review,

137
00:07:47,080 --> 00:07:49,640
but didn't give them the report.

138
00:07:49,640 --> 00:07:51,960
So we went up to London
and had a meeting with them

139
00:07:51,960 --> 00:07:54,080
and showed them the documentation
which we had.

140
00:07:54,080 --> 00:07:57,080
They said they'd never seen it. It
was the first time they'd seen it.

141
00:07:57,080 --> 00:07:59,520
And they were obviously
quite worried by the fact

142
00:07:59,520 --> 00:08:02,520
that they hadn't seen something
like that important before.

143
00:08:02,520 --> 00:08:05,680
Hospitals need to own their mistakes
and their weaknesses.

144
00:08:05,680 --> 00:08:08,680
Whereas if you try to hide them,
more patients

145
00:08:08,680 --> 00:08:10,480
are going to be harmed.

146
00:08:10,480 --> 00:08:12,720
And you took the report
to the regulator, the CQC,

147
00:08:12,720 --> 00:08:14,400
had a meeting with them.

148
00:08:14,400 --> 00:08:16,560
Can you just describe
that meeting for me?

149
00:08:16,560 --> 00:08:19,320
They were shocked,
genuinely shocked.

150
00:08:19,320 --> 00:08:21,640
And we actually left
our copy with them

151
00:08:21,640 --> 00:08:24,360
so that they could have this
to prove that there had been

152
00:08:24,360 --> 00:08:26,320
all of this going on in the past.

153
00:08:26,320 --> 00:08:28,960
How can you regulate...

154
00:08:28,960 --> 00:08:31,480
..something as important
as a hospital

155
00:08:31,480 --> 00:08:35,040
without knowing at least
what the extreme risks are?

156
00:08:35,040 --> 00:08:38,720
"East Kent Hospitals Trust
says it is deeply sorry

157
00:08:38,720 --> 00:08:41,760
"it failed Harry, Sarah
and the Richford family,

158
00:08:41,760 --> 00:08:44,400
"and apologises unreservedly to them

159
00:08:44,400 --> 00:08:46,840
"and to other families
for the things

160
00:08:46,840 --> 00:08:49,280
"that could have
been done differently."

161
00:08:49,280 --> 00:08:52,880
It says it used the Royal College's
findings "to inform changes,

162
00:08:52,880 --> 00:08:55,120
"including increased
staffing, training

163
00:08:55,120 --> 00:08:57,840
"and improved clinical oversight."

164
00:08:57,840 --> 00:09:01,440
It says it reports its
progress to the regulators

165
00:09:01,440 --> 00:09:04,760
and "continues to make improvements"
to its maternity service.

166
00:09:12,240 --> 00:09:15,920
I've been working as a GP
for over a decade, but I knew

167
00:09:15,920 --> 00:09:19,560
very little about these
independent expert reviews.

168
00:09:19,560 --> 00:09:24,040
Harry's story really hit home for
me about how important they are

169
00:09:24,040 --> 00:09:27,360
for patient safety, but only
when they're acted upon.

170
00:09:28,800 --> 00:09:32,520
Asking for a Royal College
review can be a good sign.

171
00:09:32,520 --> 00:09:36,200
It shows the hospital wants to
find out if things have gone wrong,

172
00:09:36,200 --> 00:09:39,480
so lessons are learned
and care improved.

173
00:09:39,480 --> 00:09:42,080
Guidelines for these reviews are set

174
00:09:42,080 --> 00:09:45,080
by the Academy of
Medical Royal Colleges.

175
00:09:45,080 --> 00:09:48,200
They are done in a spirit
of openness within the department.

176
00:09:48,200 --> 00:09:51,640
They encourage honest discussion
and honest sharing in that spirit

177
00:09:51,640 --> 00:09:53,400
of quality improvement.

178
00:09:53,400 --> 00:09:56,480
The fact a review is done
should never be secret, and indeed

179
00:09:56,480 --> 00:10:00,840
the summary of the findings
should always be published.

180
00:10:00,840 --> 00:10:03,920
But neither the public nor
the regulator knew the extent

181
00:10:03,920 --> 00:10:07,320
of the risks in Margate's
problem maternity ward.

182
00:10:07,320 --> 00:10:10,000
I wanted to find out
how many other hospitals

183
00:10:10,000 --> 00:10:12,560
had been hiding safety problems.

184
00:10:14,360 --> 00:10:17,640
We submitted hundreds of our own
Freedom of Information requests,

185
00:10:17,640 --> 00:10:22,520
asking every NHS Trust in the UK
to release all Royal College reports

186
00:10:22,520 --> 00:10:24,760
from the previous five years.

187
00:10:26,800 --> 00:10:32,080
In response, we were told about
111 reports across 69 trusts.

188
00:10:32,080 --> 00:10:35,280
Some hospitals had had
multiple reports.

189
00:10:37,880 --> 00:10:41,000
Only 80 were released to us.

190
00:10:41,000 --> 00:10:44,640
Around two thirds highlighted
potential or actual

191
00:10:44,640 --> 00:10:46,680
patient safety concerns.

192
00:10:46,680 --> 00:10:49,520
Here's one
from a chemotherapy department.

193
00:10:49,520 --> 00:10:52,200
16 patients were thought
to have been given an overdose,

194
00:10:52,200 --> 00:10:54,600
potentially killing one of them.

195
00:10:54,600 --> 00:10:58,480
It says this was a potentially
very serious event.

196
00:10:58,480 --> 00:11:01,360
The trust's internal investigation
appears inadequate

197
00:11:01,360 --> 00:11:04,840
and heavily influenced
by one clinician.

198
00:11:04,840 --> 00:11:08,520
Another review into breast
surgery found private patients

199
00:11:08,520 --> 00:11:12,240
were prioritised
over those on the NHS.

200
00:11:12,240 --> 00:11:15,000
It says that private
patients had compromised

201
00:11:15,000 --> 00:11:18,400
NHS cancer patient lists
and it was a serious matter

202
00:11:18,400 --> 00:11:21,440
that had disadvantaged NHS patients.

203
00:11:21,440 --> 00:11:25,080
And another showed concerns about
people dying on the waiting list

204
00:11:25,080 --> 00:11:27,120
for heart surgery.

205
00:11:27,120 --> 00:11:31,600
"Wait times are of significant
concern bordering on unacceptable.

206
00:11:31,600 --> 00:11:36,040
"The true scope of the problem
had yet to be recognised."

207
00:11:36,040 --> 00:11:40,200
Of the 80, just 26 were shared
in full with the regulator

208
00:11:40,200 --> 00:11:43,680
and just 16 were made public.

209
00:11:43,680 --> 00:11:48,000
We know about 111 reports.
But the Royal Colleges have told us

210
00:11:48,000 --> 00:11:51,800
they did more than 260
in the same period.

211
00:11:51,800 --> 00:11:54,680
So it looks like even more
may have been hidden.

212
00:12:00,240 --> 00:12:04,000
The recommendations that hospitals
should share Royal College reports

213
00:12:04,000 --> 00:12:06,720
with the regulator,
and publish a summary,

214
00:12:06,720 --> 00:12:10,920
were proposed by NHS
investigator Dr Bill Kirkup.

215
00:12:10,920 --> 00:12:13,680
I think it's a great
disappointment to me.

216
00:12:13,680 --> 00:12:19,920
I think that it is a shame that
the two relevant recommendations

217
00:12:19,920 --> 00:12:22,800
weren't taken more seriously.

218
00:12:22,800 --> 00:12:26,320
And people should know that there is
something that is important enough

219
00:12:26,320 --> 00:12:29,040
to be looked at and they
should know what the results

220
00:12:29,040 --> 00:12:31,040
of that scrutiny are.

221
00:12:31,040 --> 00:12:33,920
I'm dismayed to hear that
summaries aren't being published

222
00:12:33,920 --> 00:12:35,960
and aren't routinely
in the public domain.

223
00:12:35,960 --> 00:12:39,320
That is not what our guidance says,
because if things are not

224
00:12:39,320 --> 00:12:42,040
being shared, and if that
has implications for patient safety,

225
00:12:42,040 --> 00:12:43,880
that must be put right.

226
00:12:45,720 --> 00:12:49,960
This review from 2015 was about
the Royal Liverpool Hospital

227
00:12:49,960 --> 00:12:52,200
and its treatment of vasculitis,

228
00:12:52,200 --> 00:12:56,200
a disease that affects
blood vessels.

229
00:12:56,200 --> 00:12:59,280
It says some doctors
stopped referring patients

230
00:12:59,280 --> 00:13:03,120
to the vasculitis departments,
which they felt was over diagnosing

231
00:13:03,120 --> 00:13:05,960
the condition, and they
were worried that patients

232
00:13:05,960 --> 00:13:07,480
were being over-treated

233
00:13:07,480 --> 00:13:11,320
with strong drugs, with the
risk of serious side effects.

234
00:13:11,320 --> 00:13:14,560
We tracked down one
of the department's patients

235
00:13:14,560 --> 00:13:18,360
who'd heard about the review,
but had never seen the report.

236
00:13:18,360 --> 00:13:21,280
He wants to remain anonymous,
as he fears speaking out

237
00:13:21,280 --> 00:13:23,920
might affect his treatment.

238
00:13:23,920 --> 00:13:26,200
Initially, it felt like
I'd finally found somewhere

239
00:13:26,200 --> 00:13:29,160
where I could be looked after,
but then things haven't really

240
00:13:29,160 --> 00:13:30,800
worked out that way.

241
00:13:30,800 --> 00:13:33,600
I still don't think
I'm on the optimal treatment.

242
00:13:33,600 --> 00:13:38,320
With his agreement, I showed him
the report for the first time.

243
00:13:44,840 --> 00:13:46,680
What are your initial thoughts?

244
00:13:46,680 --> 00:13:48,880
I'm really upset by it.

245
00:13:48,880 --> 00:13:53,160
I just feel...I'm really
devastated, really.

246
00:13:53,160 --> 00:13:56,000
It's upsetting, but it's
a positive thing to discover.

247
00:13:56,000 --> 00:13:59,040
I'm not surprised
this hasn't been shared.

248
00:13:59,040 --> 00:14:01,680
The hospital told the
regulator about the review,

249
00:14:01,680 --> 00:14:04,320
but didn't give them
the full report.

250
00:14:05,560 --> 00:14:08,720
That just sounds like they're
trying to keep something hidden.

251
00:14:11,440 --> 00:14:15,520
The report said independent checks
needed to be done without delay

252
00:14:15,520 --> 00:14:18,600
on patients
covering the last two years.

253
00:14:20,640 --> 00:14:22,840
But was this audit completed?

254
00:14:25,680 --> 00:14:28,560
We put in further
Freedom of Information requests,

255
00:14:28,560 --> 00:14:33,440
which revealed there were 400
patients at the time of the review.

256
00:14:33,440 --> 00:14:36,080
But more than 18 months later,

257
00:14:36,080 --> 00:14:38,840
less than a quarter
had been checked.

258
00:14:40,160 --> 00:14:43,960
In one set of 26 patients
on potent drugs,

259
00:14:43,960 --> 00:14:47,280
they found two were given
them inappropriately.

260
00:14:48,600 --> 00:14:52,680
Another four were given
possibly excessive doses,

261
00:14:52,680 --> 00:14:57,600
and three died while suffering
from the side effects of the drugs.

262
00:14:57,600 --> 00:15:00,520
Because they never
completed the full audit,

263
00:15:00,520 --> 00:15:03,360
we don't know the true
extent of the problem.

264
00:15:03,360 --> 00:15:06,080
the regulator has
confirmed to Panorama

265
00:15:06,080 --> 00:15:08,720
that it didn't know an
audit had been recommended.

266
00:15:08,720 --> 00:15:11,720
If it had, it would have
monitored the findings.

267
00:15:11,720 --> 00:15:14,360
It really makes me afraid of it.

268
00:15:14,360 --> 00:15:15,760
It...

269
00:15:15,760 --> 00:15:17,400
..makes me afraid of the service.

270
00:15:17,400 --> 00:15:19,480
Is it safe?

271
00:15:19,480 --> 00:15:22,120
It's just shocking, really,
that, you know...

272
00:15:22,120 --> 00:15:25,480
..what about the patients that have
not had their diagnosis reviewed?

273
00:15:25,480 --> 00:15:28,640
Do we know that the
diagnosis is correct?

274
00:15:28,640 --> 00:15:31,440
So I think
that's absolutely outrageous.

275
00:15:31,440 --> 00:15:34,760
And imagine how it would
feel to be, erm, a patient

276
00:15:34,760 --> 00:15:36,320
who's used that service?

277
00:15:36,320 --> 00:15:40,560
You know, it's really a betrayal
of the trust of patients.

278
00:15:41,840 --> 00:15:45,000
What it's really telling me
is that, not only is the service

279
00:15:45,000 --> 00:15:47,720
not safe, but the hospital
management dealing with it

280
00:15:47,720 --> 00:15:48,920
is not safe.

281
00:15:52,400 --> 00:15:55,480
We've also discovered
the Royal College of Physicians,

282
00:15:55,480 --> 00:15:59,280
who recommended the audit, were
worried about its slow progress,

283
00:15:59,280 --> 00:16:02,400
but they didn't tell the regulator.

284
00:16:02,400 --> 00:16:05,280
We have found examples
where the Royal College

285
00:16:05,280 --> 00:16:07,320
has not been happy,

286
00:16:07,320 --> 00:16:10,400
but they haven't passed
this on to the regulator.

287
00:16:10,400 --> 00:16:12,480
What do you think about that?

288
00:16:12,480 --> 00:16:14,240
I would want to know more about it.

289
00:16:14,240 --> 00:16:17,160
But if there are concerns
that are so serious

290
00:16:17,160 --> 00:16:20,040
and there is any anxiety
that they may not be followed up on,

291
00:16:20,040 --> 00:16:23,640
then we would expect the experts
to be reporting them

292
00:16:23,640 --> 00:16:25,480
directly to regulators.

293
00:16:25,480 --> 00:16:27,720
I'm disappointed and
dismayed to hear it.

294
00:16:32,080 --> 00:16:35,640
The Royal College of Physicians
says it satisfied the trusts

295
00:16:35,640 --> 00:16:38,320
"made reasonable attempts
to complete the audits",

296
00:16:38,320 --> 00:16:42,560
but it was "very disappointed with
the speed of response and progress."

297
00:16:44,400 --> 00:16:47,040
It says "the trust had
a clear obligation

298
00:16:47,040 --> 00:16:50,280
"to share serious ongoing
concerns with patients

299
00:16:50,280 --> 00:16:52,520
"and the relevant regulator."

300
00:16:54,440 --> 00:16:56,600
The Royal Liverpool Hospitals Trust

301
00:16:56,600 --> 00:17:00,120
says it's "committed to providing
safe and excellent care",

302
00:17:00,120 --> 00:17:02,680
and says the
recommendations identified

303
00:17:02,680 --> 00:17:05,040
in the Royal College
of Physicians report

304
00:17:05,040 --> 00:17:07,640
"have since been
successfully implemented

305
00:17:07,640 --> 00:17:11,600
"or are part of longer-term actions
currently in progress."

306
00:17:28,600 --> 00:17:32,120
Hospitals have a duty
to be open and transparent

307
00:17:32,120 --> 00:17:34,840
with their regulator.
Over the last year,

308
00:17:34,840 --> 00:17:38,840
Panorama has seen evidence
that England's regulator, the CQC,

309
00:17:38,840 --> 00:17:42,080
was misled by England's
most famous hospital,

310
00:17:42,080 --> 00:17:45,520
misled about the number
of children, potentially hundreds,

311
00:17:45,520 --> 00:17:48,280
who might have been harmed
by their treatment.

312
00:17:55,080 --> 00:17:57,840
I'm 16, I'm in sixth form.

313
00:17:57,840 --> 00:18:00,360
I live in London.

314
00:18:00,360 --> 00:18:04,000
Sammy Bentwood used to be
a child actor, appearing in adverts

315
00:18:04,000 --> 00:18:08,760
with his twin brother and starring
in Billy Elliot in the West End.

316
00:18:08,760 --> 00:18:13,560
I was, like, very into acting
and as good as that was,

317
00:18:13,560 --> 00:18:17,240
I'd like, miss maybe like,
three or four shows a week

318
00:18:17,240 --> 00:18:19,840
because of pain.

319
00:18:19,840 --> 00:18:23,520
Sammy suffered severe stomach pain,
and in 2008,

320
00:18:23,520 --> 00:18:27,080
age four, he was diagnosed
at Great Ormond Street Hospital

321
00:18:27,080 --> 00:18:29,000
with a rare gut illness,

322
00:18:29,000 --> 00:18:33,440
eosinophilic gastrointestinal
disease known as Egid.

323
00:18:33,440 --> 00:18:36,120
He underwent intensive treatment.

324
00:18:36,120 --> 00:18:39,160
He was fed through a tube
in his stomach and didn't eat

325
00:18:39,160 --> 00:18:41,320
for six years.

326
00:18:41,320 --> 00:18:43,280
You miss out on a lot of stuff.

327
00:18:43,280 --> 00:18:44,640
A lot like...

328
00:18:44,640 --> 00:18:46,600
..everything revolves around food.

329
00:18:46,600 --> 00:18:49,920
If you go to a party,
where you see with friends, like,

330
00:18:49,920 --> 00:18:52,560
you go get food and...
And so you were taking,

331
00:18:52,560 --> 00:18:55,200
if I understand, a lot a lot
of pills, is that right?

332
00:18:55,200 --> 00:18:58,640
Quite a few medications?
30 a day. 30 a day? Yeah.

333
00:19:00,280 --> 00:19:04,320
Sammy's consultant prescribed
powerful drugs, which suppressed

334
00:19:04,320 --> 00:19:08,560
his immune system, including
some used to treat cancer.

335
00:19:10,440 --> 00:19:13,720
Steroids were always part of it,
and he kept on being

336
00:19:13,720 --> 00:19:16,800
more and more aggressive
with the treatment plans,

337
00:19:16,800 --> 00:19:20,000
adding and more and more,
erm, medicines.

338
00:19:20,000 --> 00:19:22,200
What sort of medicines
are we talking about?

339
00:19:22,200 --> 00:19:24,680
How strong are they? We're
talking chemotherapy medicines.

340
00:19:24,680 --> 00:19:28,120
I mean, it's like using
a sledgehammer to crack a walnut.

341
00:19:28,120 --> 00:19:29,920
But let's be very clear.

342
00:19:29,920 --> 00:19:33,480
We did this because they made it
very clear that he needed

343
00:19:33,480 --> 00:19:36,240
to have these medicines
to stay alive.

344
00:19:37,640 --> 00:19:41,320
What Sammy and his family didn't
know was that Great Ormond Street

345
00:19:41,320 --> 00:19:44,320
had commissioned a Royal College
review of the department

346
00:19:44,320 --> 00:19:46,600
that was still treating him.

347
00:19:46,600 --> 00:19:50,640
In 2015, the reviewers heard
a range of serious allegations

348
00:19:50,640 --> 00:19:53,920
that the service may be
causing avoidable harm

349
00:19:53,920 --> 00:19:56,560
to around 400 children.

350
00:19:59,200 --> 00:20:02,240
The college wrote this letter
to the trust ahead of its report.

351
00:20:02,240 --> 00:20:05,080
It said they'd heard concerns
about treatments which could

352
00:20:05,080 --> 00:20:07,720
unnecessarily compromise
their physical

353
00:20:07,720 --> 00:20:10,560
or psychological wellbeing.

354
00:20:10,560 --> 00:20:13,720
Sammy's doctor was restricted
from seeing patients

355
00:20:13,720 --> 00:20:16,040
as part of the review process.

356
00:20:16,040 --> 00:20:19,520
But the Bentwoods weren't told why.

357
00:20:19,520 --> 00:20:21,960
There were forms with people
discussing what's going on,

358
00:20:21,960 --> 00:20:24,800
but Great Ormond Street
never said anything to us.

359
00:20:24,800 --> 00:20:27,320
Worried, they sought
a second opinion

360
00:20:27,320 --> 00:20:29,640
from the Royal London Hospital.

361
00:20:29,640 --> 00:20:33,040
There, they received
life-changing news.

362
00:20:34,120 --> 00:20:36,760
I remember sitting with
my wife and he said,

363
00:20:36,760 --> 00:20:40,160
"You don't need to
be on any medicines.

364
00:20:40,160 --> 00:20:43,040
"Sammy can eat food
as much as he wants."

365
00:20:44,240 --> 00:20:46,920
And I remember, I stood up
and I hugged the guy.

366
00:20:50,200 --> 00:20:53,200
And what were you thinking
at that stage when they told you

367
00:20:53,200 --> 00:20:55,400
that had been your life,
your experience,

368
00:20:55,400 --> 00:20:58,120
every day for so many years?
I'm excited.

369
00:20:58,120 --> 00:21:01,520
I'm very, very excited to be able
to reintroduce food and come off

370
00:21:01,520 --> 00:21:04,200
all this. But it's also like...

371
00:21:05,200 --> 00:21:08,640
Like, are you sure? Like...

372
00:21:09,880 --> 00:21:13,080
I spoke to Sammy's current doctor,
who doubts he had the disease

373
00:21:13,080 --> 00:21:15,160
in the first place.

374
00:21:15,160 --> 00:21:19,360
So when we reviewed, erm,
a lot of the investigations,

375
00:21:19,360 --> 00:21:23,920
I personally found very little
evidence that he had this condition.

376
00:21:23,920 --> 00:21:28,680
We were able to reduce
all his medications.

377
00:21:28,680 --> 00:21:33,920
And in fact, he went from being
dependent on tube feeding,

378
00:21:33,920 --> 00:21:35,880
directly into his stomach,

379
00:21:35,880 --> 00:21:37,480
to eating normal foods.

380
00:21:41,160 --> 00:21:45,440
Sammy was weaned off his treatment
and began to lead a normal life.

381
00:21:45,440 --> 00:21:49,280
Great Ormond Street shared the Royal
College report with the regulator

382
00:21:49,280 --> 00:21:53,960
and told them they would check the
treatment of more than 300 children

383
00:21:53,960 --> 00:21:58,560
who'd received potent drugs without
a clear medical justification.

384
00:21:58,560 --> 00:22:01,960
But they reviewed just 42.

385
00:22:01,960 --> 00:22:04,840
They told the regulator
they had discounted the rest

386
00:22:04,840 --> 00:22:07,880
because they had separate
medical conditions.

387
00:22:07,880 --> 00:22:10,800
But Panorama has seen
internal emails

388
00:22:10,800 --> 00:22:14,160
that suggests that wasn't the case.

389
00:22:14,160 --> 00:22:19,080
Sammy was one of the hundreds
whose treatment wasn't reviewed.

390
00:22:19,080 --> 00:22:23,400
All trusts under a legal
obligation to be open and candid

391
00:22:23,400 --> 00:22:25,960
with the regulator.

392
00:22:25,960 --> 00:22:29,280
I showed our evidence to
a barrister who specialises

393
00:22:29,280 --> 00:22:32,320
in medical negligence.

394
00:22:32,320 --> 00:22:35,480
Do you think that Great
Ormond Street were open

395
00:22:35,480 --> 00:22:39,360
and transparent about why
they ended up reviewing 42 patients,

396
00:22:39,360 --> 00:22:43,280
and not the 300 that they
initially were planning to do?

397
00:22:43,280 --> 00:22:46,760
On the information
I've seen, no, I don't.

398
00:22:46,760 --> 00:22:50,720
There, in my view, is a mismatch
between the explanation

399
00:22:50,720 --> 00:22:54,880
that was given to the
CQC for that cohort

400
00:22:54,880 --> 00:22:57,720
being numbered at 42,

401
00:22:57,720 --> 00:23:01,240
and the explanation
that we see in the email

402
00:23:01,240 --> 00:23:04,240
that has been disclosed
by the hospital.

403
00:23:04,240 --> 00:23:08,120
So do you think then the hospital
was honest, open and transparent

404
00:23:08,120 --> 00:23:10,520
with the regulator?
Not sufficiently, no.

405
00:23:12,840 --> 00:23:17,440
So what of the hundreds of children
like Sammy, who were not reviewed,

406
00:23:17,440 --> 00:23:20,920
many of whom might have
no idea that their treatment

407
00:23:20,920 --> 00:23:23,320
may have been unnecessary?

408
00:23:25,160 --> 00:23:29,360
My concern would be if there
were many other children like Sammy,

409
00:23:29,360 --> 00:23:34,480
who, eh, medication continued
without any strong evidence.

410
00:23:34,480 --> 00:23:37,600
No medications
are without side effects,

411
00:23:37,600 --> 00:23:40,880
and there is therefore always
the potential of harm.

412
00:23:40,880 --> 00:23:45,480
Great Ormond Street Hospital has
never publicly accepted any children

413
00:23:45,480 --> 00:23:48,600
were needlessly given
potent drugs, or harmed

414
00:23:48,600 --> 00:23:50,960
by any unnecessary treatments.

415
00:23:50,960 --> 00:23:54,440
The internal documents
that I've seen indicate the hospital

416
00:23:54,440 --> 00:23:58,080
accepted that some children
had indeed suffered

417
00:23:58,080 --> 00:23:59,720
at least moderate harm.

418
00:24:02,360 --> 00:24:05,160
Do you think then that Sammy
has been harmed as a result

419
00:24:05,160 --> 00:24:08,200
of this treatment? Yes, I do.

420
00:24:09,240 --> 00:24:11,880
I still can't believe
what we've been through.

421
00:24:11,880 --> 00:24:13,920
And...

422
00:24:13,920 --> 00:24:16,160
I don't know, where do we start?

423
00:24:16,160 --> 00:24:20,400
How about, he was on steroids
for so long that it's given him

424
00:24:20,400 --> 00:24:23,040
long term problems with his bones?

425
00:24:23,040 --> 00:24:26,480
I've had proper, like,
stunted growth,

426
00:24:26,480 --> 00:24:28,960
so I'm like, five, three.

427
00:24:28,960 --> 00:24:32,400
And my twin brother
is five, eight five, nine.

428
00:24:32,400 --> 00:24:36,000
How about the fact
that he's missed so much school

429
00:24:36,000 --> 00:24:39,520
that impacted his childhood
and his learning,

430
00:24:39,520 --> 00:24:41,680
and impacted his GCSEs?

431
00:24:41,680 --> 00:24:46,000
So, at my worst, it was around -
my attendance was like, 40%.

432
00:24:47,640 --> 00:24:50,080
Great Ormond Street needs
to be honest and say,

433
00:24:50,080 --> 00:24:51,960
we've made a mistake.

434
00:24:51,960 --> 00:24:55,680
They need to own up to it
and contact all the patients

435
00:24:55,680 --> 00:25:00,440
and go through what has happened,
why it's happened, and how they can

436
00:25:00,440 --> 00:25:04,280
support the families moving forward
with any long term implications,

437
00:25:04,280 --> 00:25:07,320
not pretend nothing happened.

438
00:25:10,560 --> 00:25:12,880
Do you think the trust
put its own reputation

439
00:25:12,880 --> 00:25:16,040
above being open and transparent
with the patients

440
00:25:16,040 --> 00:25:18,520
that use the service?

441
00:25:18,520 --> 00:25:21,840
In certain respects, I think
I'm afraid I think it did, yes.

442
00:25:24,200 --> 00:25:28,280
The Care Quality Commission says
that while it did identify concerns

443
00:25:28,280 --> 00:25:32,720
during an inspection in 2018, about
how the trust shared information,

444
00:25:32,720 --> 00:25:35,960
it doesn't have evidence
"either then or now,

445
00:25:35,960 --> 00:25:39,640
"to indicate the trust
deliberately misled the CQC."

446
00:25:46,320 --> 00:25:49,520
Great Ormond Street Hospital
says it has acknowledged publicly

447
00:25:49,520 --> 00:25:51,840
it has "not always
got the care right",

448
00:25:51,840 --> 00:25:53,880
and has apologised and says

449
00:25:53,880 --> 00:25:56,400
it's "now confident
there have been vast improvements

450
00:25:56,400 --> 00:25:58,320
"across the service."

451
00:26:00,960 --> 00:26:06,120
It says by 2019, it had "reviewed
all its gastroenterology patients"

452
00:26:06,120 --> 00:26:10,120
and was "assured they were
receiving appropriate treatment."

453
00:26:10,120 --> 00:26:14,160
It says it has worked really closely
with the regulators throughout.

454
00:26:16,000 --> 00:26:20,760
Our investigation has shown some
NHS hospitals still have a problem

455
00:26:20,760 --> 00:26:22,880
with transparency and learning.

456
00:26:22,880 --> 00:26:27,240
So it's actually pretty devastating
that we're still finding

457
00:26:27,240 --> 00:26:31,720
serious issues affecting patient
safety that are not being openly

458
00:26:31,720 --> 00:26:33,480
and transparently reported.

459
00:26:33,480 --> 00:26:35,760
They're not being shared
with the regulator.

460
00:26:35,760 --> 00:26:39,520
NHS England says there are "robust
and transparent systems

461
00:26:39,520 --> 00:26:42,960
"to ensure hospitals learn
and improve services."

462
00:26:42,960 --> 00:26:46,880
It says "all independent reviews
should be made available"

463
00:26:46,880 --> 00:26:49,600
to health commissioners
and regulators,

464
00:26:49,600 --> 00:26:52,200
and it "expects trusts
to take prompt action"

465
00:26:52,200 --> 00:26:54,400
to address recommendations made.

466
00:26:56,040 --> 00:27:00,080
The Care Quality Commission says
hospitals and Royal Colleges have

467
00:27:00,080 --> 00:27:04,120
"a responsibility to ensure that
any serious patient safety issues"

468
00:27:04,120 --> 00:27:06,280
are shared with the CQC.

469
00:27:06,280 --> 00:27:10,280
But it says it "continues to see
examples of a lack of transparency",

470
00:27:10,280 --> 00:27:13,880
a measure of the "culture change
that is still needed to

471
00:27:13,880 --> 00:27:17,120
"to make health services
as safe as they can be."

472
00:27:22,000 --> 00:27:26,080
Can hospitals be trusted
to be open and transparent?

473
00:27:26,080 --> 00:27:30,720
Or does the law need to be changed
to ensure they are held to account?

474
00:27:32,200 --> 00:27:34,200
I think we may need

475
00:27:34,200 --> 00:27:38,040
to consider making this
a legal duty of trusts

476
00:27:38,040 --> 00:27:40,680
that they have to, erm, disclose

477
00:27:40,680 --> 00:27:42,800
when these investigations
are being done.

478
00:27:45,000 --> 00:27:48,200
In Margate, Harry Richford's
family are determined

479
00:27:48,200 --> 00:27:51,640
their baby's short life will
bring about permanent change.

480
00:27:54,320 --> 00:27:56,960
There should be a
Harry's Law that says

481
00:27:56,960 --> 00:27:59,920
all invited reviews

482
00:27:59,920 --> 00:28:03,840
must be published to the
regulator, number one.

483
00:28:03,840 --> 00:28:06,640
And once the regulator
has had them for three months,

484
00:28:06,640 --> 00:28:08,880
they must then be made public.

485
00:28:08,880 --> 00:28:12,080
In court, East Kent
Hospitals Trust pleaded guilty

486
00:28:12,080 --> 00:28:17,680
to a failure to provide safe care
and treatment for Harry and Sarah.

487
00:28:17,680 --> 00:28:20,240
It will be fined next month.

488
00:28:20,240 --> 00:28:24,520
I hope that this change
happens in Harry's name.

489
00:28:24,520 --> 00:28:26,800
We've been through...

490
00:28:28,160 --> 00:28:33,240
..we've been through so much and
we have to get change, because...

491
00:28:33,240 --> 00:28:35,000
..this can't happen again.