Mid Staffordshire lawyers say they withheld report from coroner to protect trustBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6486 (Published 10 October 2011) Cite this as: BMJ 2011;343:d6486
Two former senior members of the legal team at Mid Staffordshire NHS Foundation Trust have defended their failure to disclose to the local coroner a damning consultant’s report on the death of a patient who, it later emerged, had died from an undiagnosed ruptured spleen.
The accident and emergency consultant Ivan Phair concluded in his report that 20 year old John Moore-Robinson’s death might have been avoided and could have been caused by a junior doctor’s negligence in failing to carry out a proper examination. Mr Moore-Robinson, who had been injured in a mountain bike accident, was seen at Stafford Hospital in April 2006 but was sent home and died a day later in another hospital.
After joining the trust in May 2006 the head of legal services, Kate Levy, received the report, which had been ordered by her predecessor. She asked Mr Phair to change his conclusions, which he did after initially objecting, but Ms Levy failed to send either the amended report or the old report to the coroner. Instead she put the new report into a file.
When Stuart Knowles was appointed trust solicitor in August 2006, Ms Levy handed the file over to him. Neither the original report nor the amended version was ever given to the coroner.
Both solicitors told the public inquiry into the trust’s failings, chaired by Robert Francis QC, that they were acting in the best interests of their client (the trust) in not disclosing the consultant’s report. As solicitors, they said, their over-riding duty was to act in their client’s best interests. They argued that they were not under any duty to disclose the report to the coroner. Ms Levy said that the coroner was concerned with the facts and establishing the cause of the patient’s death, not with negligence or blame.
Mr Phair had not been involved in the patient’s care, and his report, which was produced from the medical notes without the benefit of any postmortem report, was asked for at a time when the trust was not sure that it could locate the junior doctor involved, she added. But the junior doctor had been found and his factual account had been provided to the coroner.
Ms Levy was criticised in the report of the first inquiry into the failings at Mid Staffordshire, also chaired by Mr Francis, and was suspended from her job in January 2010. Her claim for unfair dismissal is due to go to an employment tribunal next February.
Mr Moore-Robinson’s family filed complaints against the two solicitors with the Solicitors Regulation Authority, which initially decided to refer their conduct to the Solicitors Disciplinary Tribunal. But after the lawyers issued judicial review proceedings, the authority reconsidered its decision and the allegations were dismissed.
The public inquiry also heard that evidence given to it in May by board members from the Care Quality Commission concerning the CQC’s processes was “aspirational” rather than reflecting what was actually happening on the ground. The inquiry had received a leaked CQC internal review setting out 24 points where the information given in evidence was said to differ from actual practice at the health and social care regulator (BMJ 2011;343:d6154, 26 Sep, doi:10.1136/bmj.d6154).
Rona Bryce, the senior operations analyst who carried out the review, told the inquiry that she had been threatened with suspension after the document was leaked. She said it was a genuine attempt to pull together concerns about potential weaknesses in the existing systems.
Cite this as: BMJ 2011;343:d6486