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Gosport Independent Panel Report

The word-search terms equipment maintenance, calibration, faulty, broken and Medical Device Agency, were applied to the whole report, and returned zero counts.
The term Hazard Notice returned one mention. Of interest is the Panel's response to the consideration of Hazard Notices in their analysis. Paragraph 3.9

I'm sure they would have been happy to blame it on the MS-16A if only they could.

Oh ... hang on a minute.

But surely the Real Story is why did it take so long for this abysmal trail of events to come to light? Apparently, the doctor concerned left the hospital eighteen years ago!

Never mind, no doubt "lessons shall be learned" (again); meanwhile, the GMC et al will carry on "doing its utmost to protect patients".

Just as long as you're not a "troublesome" patient, of course.

Perhaps Edith Egger could contribute, notes taken from her book, The Choice:

Pg 174 At Auschwitz, at Mauthausen, on the death march, Edith survived by drawing on her inner world. She found hope and faith in life within her, even when she was surrounded by starvation and torture and death. After her first flashback, she began to believe that her inner world was where the demons existed. That there was a blight deep inside her. Her inner world was no longer sustaining, it became the source of her pain: unstoppable memories, loss, fear. She could be standing in a queue at the fish counter and when the clerk called her name she would see Mengles face transposed over his. Walking into the factory some mornings she would see her mother beside her as plain as day, she would see her turn her back and walk away . She tried to banish her memories of the past. She thought it was a matter of survival . Only after many years did she come to understand that running away does not heal pain. She made a cell of her dread and sealed the lock with silence.

In some way I am reminded of organisational change where an advocate of change would weigh up the positions of other stakeholders and when the time comes unlock the system, promote the change and once accepted, close the system back down with the change accepted as part of the normal business processes. But in the situation Edith describes, she had already accepted the new way of doing things, the economic environment and social conditions are the accepted norm. The old ways are not talked about or considered. Redundancies, bad debt, change of management team are all possible reasons why there has been a change from a bad situation. If the past cannot be discussed, there is a chance of repeating the mistakes again.

Risk management should have recorded the event for consequences and causes investigated, root cause analysis should have been applied. Yet these are rational tools for rational situations. What happens in the context of survival, if the events have been too horrific, embarrassing, or litigation costs too great, to document or disclose to other staff? For example the cases of Harold Shipman, The Stafford hospital, the Ian Paterson scandals, the Gosports? Didn’t these situation lead to secrecy, to a culture of guarded behavior, to shift the blame to others or fail to acknowledge what was going on? These events happened during relative prosperity within the system, imagine how much worse things could get when the economic hardship really tightens its grip.

What structures are most prone to guardedness, blame, secrecy and denial? A coercive hierarchical structure or one which is transparent, self organising, confederal? Where is it most likely that someone will thump the desk and say I am not supporting this form of abuse?

As the NHS has become the de facto New Religion in this country, we are not allowed the criticise it. That would be heresy.

But should anyone dare to put their head above the parapet, they can expect to become ostracised, shouted down, hounded out - or worse.

There have always been "cover ups"; and we can expect them to continue - if only to perpetuate the myth that "our NHS" is the "envy of the world!"

Meanwhile, I know ... let's bung yet more money at it - no doubt that'll do the trick!

I note the Mail reports 'faulty syringe drivers' the ms26 and 16 were basic devices, user confusion over which device was which does not constitute a faulty device. I remember the very early devices only had small 1 hour and 24 hour notices on the front panels possibly leading to confusion but the later ones as picture by the Mail should be clear?

Yes; and yet a hospital "consultant ... told the police that the two drivers were 'totally confusing' and he could not remember which was which".

But don't worry, as the doctor at the centre of the fiasco "is believed to have left the country"!

The Mail piece also mentions that the Graseby syringe drivers at Gosport were withdrawn in 2000.

As is common in the MSM these days, evocative language is used:-

"Faulty syringe pumps ... are to blame for deaths across the UK" becomes "may have been" later down the page, for example.

But check out the comments section ... as usual, it provides the real insight into what has been going on. In fact, it is the only part worth reading!

Here's another one for you to check out, Sean:- How Good is the NHS? (the NHS at 70).

Bottom line? When compared with similar countries, the NHS comes out as "middling" (average, let's say) by most measures.