Tonight on Panorama, we unearth the hidden secrets
that some NHS hospitals are keeping from us.
Nothing that has happened in this entire case has been open.
This has been a cover-up from start to finish.
Transparency is key to keeping patients safe.
All we've wanted from day one is some honesty, some transparency
and just the truth to come out.
But warnings about patient safety are being kept from the public.
They're trying to keep something hidden.
They know the service is failing and they're trying to hide something.
Not only did the trust know about all the problems existed,
they hadn't dealt with them in any way, shape or form.
Panorama has uncovered dozens of expert reports highlighting
serious concerns about patient care.
You know, it means there are possibly risks out there
that the regulator is unaware of.
And ultimately, those risks can have tragic consequences.
And we ask, are hospitals putting their reputations
before patient safety?
We never felt as though it was transparent.
We felt like we were on the outside.
We felt as though we've had to continue fighting.
I didn't have any issues in my pregnancy.
I had a very textbook pregnancy.
We were obviously excited.
We were going to be bringing our baby home. We didn't know
if we were going to have a boy or a girl, so we were just excited
about what was to come.
In November 2017, Sarah and Tom Richford
were at the Queen Elizabeth, the Queen Mother Hospital in Margate.
It was the early stages of Sarah's labour.
I was there for quite a long time and my labour wasn't progressing,
so they said that I would be moved to the high-risk labour ward.
As Sarah's labour went into the second night, two junior doctors
were left in charge.
One, a locum, had only been there three days.
The other was a trainee GP.
At three in the morning, the duty consultant, who was at home,
agreed the inexperienced doctors should carry out an emergency
caesarean section without her.
You could feel the change and everybody did just start to panic.
And there was a lot of people shouting.
There was people...
..all of a sudden, it just was very stressful,
erm, and not a nice environment to be in.
We could hear the surgeons shouting things like, "Cut her here,
"cut her there". And there was clearly quite an animated
and heated discussion about what was going on.
And we now know, looking back on it, that he was informing
a very junior doctor to cut Sarah, which she wasn't qualified to do,
as she felt uncomfortable to do it.
When the consultant did eventually arrive, she was too late.
Sarah's baby, Harry, wasn't breathing
and needed urgent resuscitation.
To escape the pandemonium around her,
Sarah was offered a general anaesthetic.
And I said, yes, and I still to this day feel guilty
because I'd left Tom in that room.
Having to see the doctors working on Harry,
but also, obviously, me not wanting to be in that room,
it meant that he - because I'd been put under general anaesthetic,
he had to leave.
What was going through your mind at that point?
It... I didn't know if I'd ever see either of them again.
Really, and it's tough, because...
..you go in with all those hopes and expectations that you're going
to walk away as a family, and you're going to walk with Sarah
and Harry out to your car and everything,
and, eh...
Yeah, you just think that actually
you might be walking out on your own.
Harry's traumatic delivery, and a delayed resuscitation,
meant he'd suffered brain damage from a lack of oxygen.
He was transferred to intensive care.
And it was just a really difficult week, seeing him in his incubator
and how sick he really was, and then going back to my room
and then feeling guilty for not being with him.
And then, you know, it was just, it was...
..one of the hardest weeks of our lives. Yeah.
But we did get to spend time with him,
erm, which was good.
Tom and Sarah were told that Harry would have a very limited quality
of life. He would never be able to learn or feed himself.
After a lot of soul searching and advice, it was decided
to turn off his life support machine.
Nobody ever wants to have to make that decision.
It's the worst possible decision that you could ever have to make.
However, at the end of the day...
..it's a choice between...
..erm, your baby living and having no quality of life,
or not, and so we did, obviously, choose to make a decision
and for a long time, I felt really bad about that decision.
But I think...
..I don't regret it because, you know,
I wouldn't have wanted that for our baby. I know.
At first, the hospital wouldn't report Harry's death to the coroner.
The family feared a cover-up and set about doing their own research
into why he died.
Harry's grandfather, Derek, spent months online
going through the hospital's public records.
When things go wrong in hospitals, trust can commission reviews
from one of the medical royal colleges,
who set standards for care and practice.
Derek found a reference to a Royal College report
on the hospital's maternity unit
written two years before Harry's death.
I searched for this report on Google, everywhere,
and I was getting pretty good at it by this time.
Nothing, but nothing - couldn't find a thing.
Derek discovered he could compel the hospital to release the report
by sending a formal Freedom of Information request.
When you opened that email, I mean, what did you see?
I was absolutely stunned because even the introduction,
it goes into only about ten lines
that could have written Harry's demise.
It tells you about consultants not turning up overnight.
It tells you about a lack of escalation.
And it just says if you continue to operate and practice the way
you are currently doing things, there's a high probability
that there's going to be an unassessed locum doctor
working overnight.
Sort of, maybe 20 months later, that's exactly what happened to us.
So they knew all of that was going on at that time.
And it was two years prior to Harry.
Honestly, we were stunned.
You feel incredibly angry and upset and emotional
because it was so avoidable.
It is the most easily avoidable mistake going.
You just see, this is the mistake. OK, let's avoid that
and change our practice, and then it won't happen.
But it didn't happen for us.
Since 2015, trusts are supposed to share Royal College reports
with the regulator - in England, the Care Quality Commission,
or CQC. The trusts should then inform the public,
but there is no law to enforce this.
The Margate hospital told the CQC about the review,
but didn't give them the report.
So we went up to London and had a meeting with them
and showed them the documentation which we had.
They said they'd never seen it. It was the first time they'd seen it.
And they were obviously quite worried by the fact
that they hadn't seen something like that important before.
Hospitals need to own their mistakes and their weaknesses.
Whereas if you try to hide them, more patients
are going to be harmed.
And you took the report to the regulator, the CQC,
had a meeting with them.
Can you just describe that meeting for me?
They were shocked, genuinely shocked.
And we actually left our copy with them
so that they could have this to prove that there had been
all of this going on in the past.
How can you regulate...
..something as important as a hospital
without knowing at least what the extreme risks are?
"East Kent Hospitals Trust says it is deeply sorry
"it failed Harry, Sarah and the Richford family,
"and apologises unreservedly to them
"and to other families for the things
"that could have been done differently."
It says it used the Royal College's findings "to inform changes,
"including increased staffing, training
"and improved clinical oversight."
It says it reports its progress to the regulators
and "continues to make improvements" to its maternity service.
I've been working as a GP for over a decade, but I knew
very little about these independent expert reviews.
Harry's story really hit home for me about how important they are
for patient safety, but only when they're acted upon.
Asking for a Royal College review can be a good sign.
It shows the hospital wants to find out if things have gone wrong,
so lessons are learned and care improved.
Guidelines for these reviews are set
by the Academy of Medical Royal Colleges.
They are done in a spirit of openness within the department.
They encourage honest discussion and honest sharing in that spirit
of quality improvement.
The fact a review is done should never be secret, and indeed
the summary of the findings should always be published.
But neither the public nor the regulator knew the extent
of the risks in Margate's problem maternity ward.
I wanted to find out how many other hospitals
had been hiding safety problems.
We submitted hundreds of our own Freedom of Information requests,
asking every NHS Trust in the UK to release all Royal College reports
from the previous five years.
In response, we were told about 111 reports across 69 trusts.
Some hospitals had had multiple reports.
Only 80 were released to us.
Around two thirds highlighted potential or actual
patient safety concerns.
Here's one from a chemotherapy department.
16 patients were thought to have been given an overdose,
potentially killing one of them.
It says this was a potentially very serious event.
The trust's internal investigation appears inadequate
and heavily influenced by one clinician.
Another review into breast surgery found private patients
were prioritised over those on the NHS.
It says that private patients had compromised
NHS cancer patient lists and it was a serious matter
that had disadvantaged NHS patients.
And another showed concerns about people dying on the waiting list
for heart surgery.
"Wait times are of significant concern bordering on unacceptable.
"The true scope of the problem had yet to be recognised."
Of the 80, just 26 were shared in full with the regulator
and just 16 were made public.
We know about 111 reports. But the Royal Colleges have told us
they did more than 260 in the same period.
So it looks like even more may have been hidden.
The recommendations that hospitals should share Royal College reports
with the regulator, and publish a summary,
were proposed by NHS investigator Dr Bill Kirkup.
I think it's a great disappointment to me.
I think that it is a shame that the two relevant recommendations
weren't taken more seriously.
And people should know that there is something that is important enough
to be looked at and they should know what the results
of that scrutiny are.
I'm dismayed to hear that summaries aren't being published
and aren't routinely in the public domain.
That is not what our guidance says, because if things are not
being shared, and if that has implications for patient safety,
that must be put right.
This review from 2015 was about the Royal Liverpool Hospital
and its treatment of vasculitis,
a disease that affects blood vessels.
It says some doctors stopped referring patients
to the vasculitis departments, which they felt was over diagnosing
the condition, and they were worried that patients
were being over-treated
with strong drugs, with the risk of serious side effects.
We tracked down one of the department's patients
who'd heard about the review, but had never seen the report.
He wants to remain anonymous, as he fears speaking out
might affect his treatment.
Initially, it felt like I'd finally found somewhere
where I could be looked after, but then things haven't really
worked out that way.
I still don't think I'm on the optimal treatment.
With his agreement, I showed him the report for the first time.
What are your initial thoughts?
I'm really upset by it.
I just feel...I'm really devastated, really.
It's upsetting, but it's a positive thing to discover.
I'm not surprised this hasn't been shared.
The hospital told the regulator about the review,
but didn't give them the full report.
That just sounds like they're trying to keep something hidden.
The report said independent checks needed to be done without delay
on patients covering the last two years.
But was this audit completed?
We put in further Freedom of Information requests,
which revealed there were 400 patients at the time of the review.
But more than 18 months later,
less than a quarter had been checked.
In one set of 26 patients on potent drugs,
they found two were given them inappropriately.
Another four were given possibly excessive doses,
and three died while suffering from the side effects of the drugs.
Because they never completed the full audit,
we don't know the true extent of the problem.
the regulator has confirmed to Panorama
that it didn't know an audit had been recommended.
If it had, it would have monitored the findings.
It really makes me afraid of it.
It...
..makes me afraid of the service.
Is it safe?
It's just shocking, really, that, you know...
..what about the patients that have not had their diagnosis reviewed?
Do we know that the diagnosis is correct?
So I think that's absolutely outrageous.
And imagine how it would feel to be, erm, a patient
who's used that service?
You know, it's really a betrayal of the trust of patients.
What it's really telling me is that, not only is the service
not safe, but the hospital management dealing with it
is not safe.
We've also discovered the Royal College of Physicians,
who recommended the audit, were worried about its slow progress,
but they didn't tell the regulator.
We have found examples where the Royal College
has not been happy,
but they haven't passed this on to the regulator.
What do you think about that?
I would want to know more about it.
But if there are concerns that are so serious
and there is any anxiety that they may not be followed up on,
then we would expect the experts to be reporting them
directly to regulators.
I'm disappointed and dismayed to hear it.
The Royal College of Physicians says it satisfied the trusts
"made reasonable attempts to complete the audits",
but it was "very disappointed with the speed of response and progress."
It says "the trust had a clear obligation
"to share serious ongoing concerns with patients
"and the relevant regulator."
The Royal Liverpool Hospitals Trust
says it's "committed to providing safe and excellent care",
and says the recommendations identified
in the Royal College of Physicians report
"have since been successfully implemented
"or are part of longer-term actions currently in progress."
Hospitals have a duty to be open and transparent
with their regulator. Over the last year,
Panorama has seen evidence that England's regulator, the CQC,
was misled by England's most famous hospital,
misled about the number of children, potentially hundreds,
who might have been harmed by their treatment.
I'm 16, I'm in sixth form.
I live in London.
Sammy Bentwood used to be a child actor, appearing in adverts
with his twin brother and starring in Billy Elliot in the West End.
I was, like, very into acting and as good as that was,
I'd like, miss maybe like, three or four shows a week
because of pain.
Sammy suffered severe stomach pain, and in 2008,
age four, he was diagnosed at Great Ormond Street Hospital
with a rare gut illness,
eosinophilic gastrointestinal disease known as Egid.
He underwent intensive treatment.
He was fed through a tube in his stomach and didn't eat
for six years.
You miss out on a lot of stuff.
A lot like...
..everything revolves around food.
If you go to a party, where you see with friends, like,
you go get food and... And so you were taking,
if I understand, a lot a lot of pills, is that right?
Quite a few medications? 30 a day. 30 a day? Yeah.
Sammy's consultant prescribed powerful drugs, which suppressed
his immune system, including some used to treat cancer.
Steroids were always part of it, and he kept on being
more and more aggressive with the treatment plans,
adding and more and more, erm, medicines.
What sort of medicines are we talking about?
How strong are they? We're talking chemotherapy medicines.
I mean, it's like using a sledgehammer to crack a walnut.
But let's be very clear.
We did this because they made it very clear that he needed
to have these medicines to stay alive.
What Sammy and his family didn't know was that Great Ormond Street
had commissioned a Royal College review of the department
that was still treating him.
In 2015, the reviewers heard a range of serious allegations
that the service may be causing avoidable harm
to around 400 children.
The college wrote this letter to the trust ahead of its report.
It said they'd heard concerns about treatments which could
unnecessarily compromise their physical
or psychological wellbeing.
Sammy's doctor was restricted from seeing patients
as part of the review process.
But the Bentwoods weren't told why.
There were forms with people discussing what's going on,
but Great Ormond Street never said anything to us.
Worried, they sought a second opinion
from the Royal London Hospital.
There, they received life-changing news.
I remember sitting with my wife and he said,
"You don't need to be on any medicines.
"Sammy can eat food as much as he wants."
And I remember, I stood up and I hugged the guy.
And what were you thinking at that stage when they told you
that had been your life, your experience,
every day for so many years? I'm excited.
I'm very, very excited to be able to reintroduce food and come off
all this. But it's also like...
Like, are you sure? Like...
I spoke to Sammy's current doctor, who doubts he had the disease
in the first place.
So when we reviewed, erm, a lot of the investigations,
I personally found very little evidence that he had this condition.
We were able to reduce all his medications.
And in fact, he went from being dependent on tube feeding,
directly into his stomach,
to eating normal foods.
Sammy was weaned off his treatment and began to lead a normal life.
Great Ormond Street shared the Royal College report with the regulator
and told them they would check the treatment of more than 300 children
who'd received potent drugs without a clear medical justification.
But they reviewed just 42.
They told the regulator they had discounted the rest
because they had separate medical conditions.
But Panorama has seen internal emails
that suggests that wasn't the case.
Sammy was one of the hundreds whose treatment wasn't reviewed.
All trusts under a legal obligation to be open and candid
with the regulator.
I showed our evidence to a barrister who specialises
in medical negligence.
Do you think that Great Ormond Street were open
and transparent about why they ended up reviewing 42 patients,
and not the 300 that they initially were planning to do?
On the information I've seen, no, I don't.
There, in my view, is a mismatch between the explanation
that was given to the CQC for that cohort
being numbered at 42,
and the explanation that we see in the email
that has been disclosed by the hospital.
So do you think then the hospital was honest, open and transparent
with the regulator? Not sufficiently, no.
So what of the hundreds of children like Sammy, who were not reviewed,
many of whom might have no idea that their treatment
may have been unnecessary?
My concern would be if there were many other children like Sammy,
who, eh, medication continued without any strong evidence.
No medications are without side effects,
and there is therefore always the potential of harm.
Great Ormond Street Hospital has never publicly accepted any children
were needlessly given potent drugs, or harmed
by any unnecessary treatments.
The internal documents that I've seen indicate the hospital
accepted that some children had indeed suffered
at least moderate harm.
Do you think then that Sammy has been harmed as a result
of this treatment? Yes, I do.
I still can't believe what we've been through.
And...
I don't know, where do we start?
How about, he was on steroids for so long that it's given him
long term problems with his bones?
I've had proper, like, stunted growth,
so I'm like, five, three.
And my twin brother is five, eight five, nine.
How about the fact that he's missed so much school
that impacted his childhood and his learning,
and impacted his GCSEs?
So, at my worst, it was around - my attendance was like, 40%.
Great Ormond Street needs to be honest and say,
we've made a mistake.
They need to own up to it and contact all the patients
and go through what has happened, why it's happened, and how they can
support the families moving forward with any long term implications,
not pretend nothing happened.
Do you think the trust put its own reputation
above being open and transparent with the patients
that use the service?
In certain respects, I think I'm afraid I think it did, yes.
The Care Quality Commission says that while it did identify concerns
during an inspection in 2018, about how the trust shared information,
it doesn't have evidence "either then or now,
"to indicate the trust deliberately misled the CQC."
Great Ormond Street Hospital says it has acknowledged publicly
it has "not always got the care right",
and has apologised and says
it's "now confident there have been vast improvements
"across the service."
It says by 2019, it had "reviewed all its gastroenterology patients"
and was "assured they were receiving appropriate treatment."
It says it has worked really closely with the regulators throughout.
Our investigation has shown some NHS hospitals still have a problem
with transparency and learning.
So it's actually pretty devastating that we're still finding
serious issues affecting patient safety that are not being openly
and transparently reported.
They're not being shared with the regulator.
NHS England says there are "robust and transparent systems
"to ensure hospitals learn and improve services."
It says "all independent reviews should be made available"
to health commissioners and regulators,
and it "expects trusts to take prompt action"
to address recommendations made.
The Care Quality Commission says hospitals and Royal Colleges have
"a responsibility to ensure that any serious patient safety issues"
are shared with the CQC.
But it says it "continues to see examples of a lack of transparency",
a measure of the "culture change that is still needed to
"to make health services as safe as they can be."
Can hospitals be trusted to be open and transparent?
Or does the law need to be changed to ensure they are held to account?
I think we may need
to consider making this a legal duty of trusts
that they have to, erm, disclose
when these investigations are being done.
In Margate, Harry Richford's family are determined
their baby's short life will bring about permanent change.
There should be a Harry's Law that says
all invited reviews
must be published to the regulator, number one.
And once the regulator has had them for three months,
they must then be made public.
In court, East Kent Hospitals Trust pleaded guilty
to a failure to provide safe care and treatment for Harry and Sarah.
It will be fined next month.
I hope that this change happens in Harry's name.
We've been through...
..we've been through so much and we have to get change, because...
..this can't happen again.