Monsters in Iwerne

No, I couldn't say nothing, could I?

When I was a boy, my parents would drive us several times a year in our ancient black Austin A6 to visit my grandparents who lived on the south coast.

Those days of course were before motorways and in-car entertainment. So my father would help the journey pass with the pub sign game, in which you take turns to spot the number of legs on the pub sign - thus the Red Lion in Sturminster Marshall would give you four, while the George at Norton St Philip with St George on his horse would give you six. However trumping them all was the Thousand Millipedes, which Dad assured us was down a side-road in Iwerne Minster. 

Iwerne Minster has hit the headlines recently as it was one of the locations where the serial child abuser John Smyth, QC and Church of England lay reader, used to operate in the 1970s and 80s - decades after our car journeys. Summer camps for public school boys were held in a prep school there. His other locations were near Winchester (where he established links with the famous public school), Zimbabwe and probably South Africa - until his death in 2018. His sadistic and perverted actions were first publically hinted at in an article in The Sunday Mail in 2012. But they were already known about to a limited number of Anglican churchmen as long ago as 1982. In 2017 the story broke on the Channel 4 News when Smyth himself was challenged by Kathy Newman about his activities. In 2021 Andrew Graystone published an account in his journalistic book, Bleeding for Jesus. 

In 2019 the Church of England's Archbishops' Council commissioned an independent review of the abuse and the involvement of what are termed "church officers". Five years later Keith Makin and Sarah Lawrence have produced their report. It is 263 pages long. It is exhaustive and not an easy read in either its content or its style. (It could have done with a bit more proof-reading.) Much to the media's glee, Archbishop Justin Welby, after a campaign of pressure, announced that he had tendered his resignation to the King. The hanging offence seems to have been that he had been "insufficiently curious" when "informed" of Mr Smyth's grotesquely sadistic activity in the late 70s and early 80s. As Andrew Brown the Guardian writer has shown - see my next post - this is not borne out by the facts.

Holman Hunt, The Scapegoat (Liverpool Art Gallery)

I tend to agree with the author of the Sunday Mail article, Anne Adkins, on Newsnight, that the Archbishop is being treated as a scapegoat, since  we always want someone to blame, but the abuser himself is now dead and beyond the reach of human justice.

In my next post I shall explain more of my reasons. However for now I shall quote the comments of the Rev Dr Sam Wells, vicar of St Martin-in-the-Fields, in a letter to his church. They seem to me both judicious and helpful: 

"To be subject to profound and repeated physical abuse at a vulnerable age is among the worst things to befall anyone. Those who have had the courage to come forward and detail their experiences at the hands of a distorted individual over a period of decades must be at the very centre of the church’s care and concern.

"While the individual responsible was not an employee of the Church of England, and the channels through which he worked were not under the authority of the Church of England, it was nonetheless right that the Archbishop of Canterbury commissioned Keith Makin to investigate whether there was anything the church could have done to have prevented these terrible crimes and what lessons could be learned. After five years, the Makin Review has concluded that the church could have done much better, and has pointed the finger at certain individuals in particular. The central issue is that the information came to light in 2013, but between then and his death at his own hand in 2018, the perpetrator abused several dozen more people – and it’s not clear how this was permitted to happen.

"Over recent decades the church, along with many organisations, has undergone a radical reappraisal of its procedures around safeguarding children and adults at risk of harm. This has been a huge institutional culture change. The simple principles of vigilance, reporting and safeguarding being everyone’s responsibility have made the church a much safer place. One result of that is that failures stand out painfully; and failure in relation to a case as grievous as this is something neither church nor society is able to countenance. The church has failed many individuals whose lives have been impacted beyond description. It puts in question the significant progress that has been made. And it undermines the church’s credibility all over again.

"It is this that has led to the news today of the resignation of the Archbishop of Canterbury, as a result of the words in the Makin Report that suggest that he, along with others, could have acted differently – and that if they had, many could have been saved from an unspeakable experience of harm. Leadership can be lonely; in today’s culture, when there is a very great wrong, there is a corresponding tide of demand that a leader visibly pay the price for an institution’s failings. It is tragic that a primacy bringing such profound good in so many areas, conducted by a person of singular faith, courage, humility and integrity, should end like this. But it seems the Archbishop has concluded that the unheard pleas of survivors, the degree of institutional failure, and the fact that his own role in the case was not impeccable, have together made it impossible for him to continue. His dignity and selflessness are an example to all of us."

(Post amended for accuracy 25th November 2024)

Scape-goating Dr Hadiza Bawa-Garba

I referred to the NHS Newsday post on the left in a comment on my post of Carillion. It should give us all pause for thought and check any enthusiasm for contracting out even minor services. Here it is.

It’s not often I find myself agreeing with Jeremy Hunt, whom I suspect of being the smiling face of NHS privatisation – and it appears I’m not alone (Stephen Hawking and others accuse Jeremy Hunt of backdoor NHS privatisation) -, but I agreed with him when he tweeted that he was “concerned” about the implications of the case of Dr Hadiza Bawa-Garba. The General Medical Council may have been technically correct in upholding the rulings of the court, but if the original court did not hear all the evidence surrounding the tragic death of Jack Adcock, particularly about the systemic failures in the Royal Leicester Infirmary and the health trust then the question is whether justice was done in the first place.

I understand the boy’s mother wanting someone to be held responsible, but it seems unlikely that the right person was found guilty. The fact that Dr Bawa-Garba’s fellow doctors have crowd-funded over £200,000 to remedy what they fear is a miscarriage of justice which could affect them all is telling. An orthopaedic registrar explained their feelings on their Facebook page.

“The Orthopaedic Registrar

26 January at 22:17 ·

“So yesterday, a highly regarded junior doctor was struck off the GMC register after the GMC successfully appealed against the judgement of the Medical Practitioners' Tribunal Service.

“She was struck off because a child died. And that is a terrible thing. But as a tribe, we junior doctors are horrified. Why? Because this junior registrar, just back at work after more than a year off for maternity leave, has been scapegoated for system failings.

She was doing the job of two registrars, and the consultant who was supposed to be supervising her was in another city. So she was covering six wards and dealing with medical issues on the surgical wards, plus taking referrals and calls, with one FY1 (foundation year 1 doctor) and one SHO (senior house officer), both of whom were new to paediatrics. She was moving as quickly as she could, and working as hard as she could. She was no doubt anxious to make a good impression in her new post. She had had no trust induction. The blood reporting system was broken. She had missed handover because of a cardiac arrest. She mixed up two children and confused one DNAR (do not attempt resuscitation) child with another who was not - note the nurses had swapped the two patients beds around, and not told her. Concerns about the child deteriorating were also not raised to her by the nursing team. The child was given a medication for blood pressure, the last thing you would want for an unwell, dehydrated child, which she had quite rightly not prescribed, and then they arrested. How is this manslaughter? How she was then treated by her senior colleague and by the police when they arrested her 18 months later (it's not polite or reasonable to keep a breastfeeding mother away from her two-week old baby for seven hours while questioning her and any statement she signed at that time must be considered under duress) is another, horrifying issue.

“So why are we horrified? We have all been here. We have all been that doctor who is doing the job of more than one person, where our boss is not helping, and we are hours behind in what we need to do, everyone is annoyed with us, and we are annoyed with ourselves because we know our patients are not getting the care they should have. We have all been desperate to eat, and go to the toilet, and just sit down and do nothing for five minutes. We have all mixed patients up. So all of us look at this and think: 'This could me'.”

There’s an impressive professional assessment of the affair by a number of paediatric consultants: Account of GMC action against Dr Bawa-Garba.

As a mere layman, it seems that the hospital administration which permitted such pressure to be placed on a comparatively junior doctor’s shoulders have some answering to do. It appears to me that the sad sad death of a precious boy with Down’s Syndrome was caused by something more than one doctor’s human error. It involves poor management within the hospital, the irresponsible stretching of resources and, ultimately, the restricting of those resources by central government for its own socio-political purposes. That the individual doctor at the fulcrum of the system which caused her to make a mistake which proved fatal should bear the whole blame is a reprehensible example of scape-goating – a habit which it seems is becoming increasingly popular. There was once a time when the man at the top would accept responsibility for things which went wrong on his watch.

In the words of a searing article from the right-wing Bow Group,

“The outcome is to inflict a penalty on a single individual; to destroy an otherwise flawless career on this chain of events should chill every professional and indeed any member of the public. We all have a right to know our accuser and in this case it was clearly not the GMC as a whole. It has put back accountability of healthcare at least a decade by returning to the culture of shame the system by blaming the doctor. It was this refusal to see systemic failures that led to so many deaths in Mid Staffs and Morecambe Bay among others and has led in a much less publicised manner to a cruel and needless assault on the mental health and financial viability of many doctors, for some of whom it was too much to survive.” 

Finally I recommend an excellent post by Dr Rachel Clarke, a palliative care doctor who knows the pressures of being a junior hospital doctor in the NHS. She expresses the dangers of the case far more clearly than me. The Hadija Bawa-Garba case is a watershed for patient safety.

British Blame Culture

A lot of awful things have been in the news since I last blogged, so much so that I have, unusually, resorted to turning off the news from time to time. There's been Gaza, Iraq, Libya, Ukraine, and close to home Rotherham. In different ways they are all horrific.

What has struck me in much of the news coverage and comment is how prevalent is the culture of seeking to attach blame. This morning yet again John Humphrys of the Today Programme was belabouring his interviewee (a representative of local authorities) about the sexual abuse of under-age girls in Rotherham. "There must be someone to blame" was his repeated point. He wanted his interviewee to agree that local council officers (like police officers and like Shaun Wright, the councillor responsible for children's services) should be "punished". Humphrys seemed to want a few scapegoats, a few heads to roll. However as history tells us, scapegoats may make people feel better, but they don't ever solve the problem.

He clearly had failed to hear Kier Starmer, the former Director of Public Prosecutions, yesterday, who pointed out that what was wrong in Rotherham, and no doubt, in many other communities across the UK was a matter of culture, but in this case a culture of disbelief of certain sorts of youngsters, and of young people in general. A culture is a shared responsibility, a communal one. An exceptional individual may stand against the prevailing tide, but unless the community, across the generations, in all sectors, stands with them the tide will not change. In the meantime we simply avoid the issue and evade our own complicity by blaming a few (or many) individuals. The fault also lies in ourselves. 

I confess I'm not immune from the blame-game myself. On an entirely trivial level I found myself fulminating against the "unfairness" of the eviction of Iain Watters from the Great British Bake Off, after his gloriously original baked alaska had been removed from the freezer by another of the bakers and thus ruined. He binned it! Actually one learns now that there was a certain amount of manipulation in the editing to elicit just such a response. It makes, of course, for "better" TV and higher viewer ratings.

With the unethical exclusive stake-out by the BBC when South Yorkshire Police raided Cliff Richard's Berkshire apartment, and the publishing of his name before charge, one wonders whether the BBC has lost sight of its ideals in the pursuit of populist appeal. Has it become the British Blame Corporation? 

Might it not be a good idea to stop the blame game? Let's stop saying Gaza was Israel's fault, Ukraine was Putin's fault, Iraq is ISIS's fault, that the state of education was Michael Gove's (or teachers') fault and the NHS Michael Lansley's (or nurses') fault. As Lewis Hamilton has wisely written on his Facebook page, following the incident when Nico Rosberg took him out at the Belgian Grand Prix: "Nico and I accept that we have both made mistakes and I feel it would be wrong to point fingers and say which one is worse than the other...."

The report with no names

It is 4000 pages long, Robert Francis QC's final report of his inquiry into the shortcomings of the Mid Staffordshire NHS Foundation Trust. Its findings, I gather, make more than disturbing reading. The one positive reaction I had from hearing and reading news reports was to be glad that Mr Francis had not entered the populist "name and shame" game. Instead he had looked at the endemic institutional reasons that such widespread deficient care had been able to take place.

In his accompanying letter to the Secretary of State, he outlined some.
The report has identified numerous warning signs which cumulatively, or in some cases singly, could and should have alerted the system to the problems developing at the Trust. That they did not has a number of causes, among them:
•A culture focused on doing the system’s business – not that of the patients;
•An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern;
•Standards and methods of measuring compliance which did not focus on the effect of service on patients;
•Too great a degree of tolerance of poor standards and of risk to patients;
•A failure of communication between the many agencies to share their knowledge of concerns;
•Assumptions that monitoring, performance management or intervention was the responsibility of someone else;
•A failure to tackle challenges to the building up of a positive culture, in nursing in particular but also within the medical profession;
•A failure to appreciate until recently the risk of disruptive loss of corporate memory and focus resulting from repeated, multi-level reorganisation.

Scapegoating is such an easy game to play. One can understand why aggrieved parties should want a scalp. But it is a deeply primitive and unattractive instinct. One only has to remember the hue and cry which led to Ed Balls shamefully ensuring the unfair dismissal of Sharon Shoesmith, Haringey's head of children's services, after the Baby P affair to see an egregious example of the sort of thing. By and large those who go into the caring professions do so for the right reasons. When they fail, there are almost certainly reasons beyond themselves to blame, such as time restraints, staff shortages and multi-agency involvement.

Robert Francis is to be congratulated in not falling into the trap of blaming individuals or denigrating professionals. It's to be hoped that his report sets a trend - and that the media and lawyers do not pursue a witch-hunt.