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by Chris Marshall
19 September 2023
Whistling in the Wind: How the NHS failed and failed again to listen to whistleblowers

The Scottish Government has now agreed to hold a public inquiry into the actions of Sam Eljamel

Whistling in the Wind: How the NHS failed and failed again to listen to whistleblowers

It wasn’t until months after undergoing surgery to have a brain tumour removed that Jules Rose realised something was badly wrong. Having been assured by her surgeon, Professor Sam Eljamel, that the procedure had been a complete success, she was awaiting pathology reports and confirmation the tumour had been benign when she received the news that would dominate her life for the next decade.

In the months after the surgery at Dundee’s Ninewells Hospital in 2013, Rose eventually received word of the specimen Eljamel had removed – it was normal lacrimal gland tissue, a healthy tear duct. The tumour, the reason the operation had been undertaken in the first place, remained. The next time she met Eljamel his demeanour had changed: he was defensive and intimidating; he told Rose she would have to undergo surgery for a second time.

After the second operation, during which the benign tumour was successfully removed, Rose began corresponding with another of Eljamel’s former patients. Pat Kelly had been left in constant pain and facing the risk of paralysis after almost dying because of botched surgery on his spine in 2007. Eventually it became clear there were many more like them, dozens of patients left with life-changing injuries caused by a surgeon who should not have been operating. 

“I did a count last night – 160 patients have now contacted me,” says Rose who has become the focal point of a campaign to win justice for Eljamel’s victims. “The last decade has been sheer hell. It’s been psychological torture.”

She says Eljamel’s actions left her feeling as if she had been “raped”. “I was not able to give informed consent, an informed choice…I wasn’t given a voice. If I had known anything, do you think I would have gone in for the first surgery let alone the second?”

Eljamel, a former head of neurosurgery at NHS Tayside, was finally suspended in 2013 and later voluntarily removed himself from the General Medical Council’s register. He fled to Libya where he is understood to have continued working. Attempts are now being made to have him extradited to Scotland.

Earlier this month, just over a decade on from her original surgery, Rose joined other campaigners at the Scottish Parliament to call for a public inquiry into the actions of Eljamel and NHS Tayside. Protesters dressed in medical scrubs, carried placards, and posed for pictures as one of their number lay on the floor surrounded by pieces of tissue paper dyed red to look like cuts of meat from an overzealous butcher.

A day later, health secretary Michael Matheson acceded to their demand, telling the Scottish Parliament that he had been struck by the campaigners’ bravery and persistence amid what he called “significant distress and compounded trauma”. 

It was a major victory for the campaigners and a significant change in position from the Scottish Government, which had rejected calls for a public inquiry just weeks earlier after First Minister Humza Yousaf was heckled by another of Eljamel’s victims, Theresa Mallett, during a speech in Dundee. 

So what changed? Matheson was clear that for him it had been the publication of a so-called due diligence report by NHS Tayside, released in late August, which found that despite complaints about Eljamel dating back to at least 2011 and the triggering of a Significant Clinical Event Analysis (SCEA) in December 2012, the surgeon had been able to continue operating on patients right up until his suspension. It meant that even though he had been put under indirect supervision between June and December 2013, Eljamel was able to carry out surgery on Jules Rose – twice. 

The report says the period of indirect supervision was “inadequately monitored” and that the health board was not adequately supervising Eljamel “despite having identified that there was a potential concern”. 

“The level of supervision that was decided upon was not proportionate to the concerns being raised at the time and once implemented was not monitored effectively,” the report states.

“Specifically, the supervision was indirect when, due to the nature of the concerns, direct supervision would have been appropriate.”

Jules Rose (centre) joins campaigners calling for a public inquiry | Credit: Alamy

The health board says it has now identified 98 complaints against Eljamel, the vast majority of which were received after his suspension in December 2013. However, there were three complaints received in 2011 and a further three in 2012. A whistleblower had previously told the BBC that the board was aware of serious concerns about the surgeon as early as 2009. 

While Eljamel was finally suspended, it came too late for Rose who believes she was the last person to be operated on by the disgraced surgeon and claims health bosses allowed him to carry out the second operation knowing they were going to suspend him the following day. 

“I’ve had prevarication, I’ve had arrogance from their medical director at the time…I have just been treated with utter contempt by the health board,” she says. “Not just me but other patients as well.”

But while the failures in the Eljamel case are truly shocking, they are by no means unprecedented. Since the early 2000s, the NHS across the UK has been struck with a series of scandals made no less harrowing by the passage of time. If there’s one thing that unites them, it’s the apparent inability to make meaningful lasting change in their wake.

The last decade has been sheer hell. It’s been psychological torture.

The recent conviction of former nurse Lucy Letby for the murder of seven babies and the attempted murder of six more led to renewed calls to overhaul whistleblowing within the health service. It emerged after Letby’s trial that concerns were raised about her in October 2015, but no action was taken, and she went on to attack five more infants, killing two. Dr Stephen Brearey, the lead consultant at the neonatal unit at the Countess of Chester Hospital, said senior managers had failed to investigate allegations and attempted to silence doctors who spoke out. A BBC Panorama investigation found hospital bosses demanded doctors write an apology to Letby and ordered two consultants to attend mediation with the nurse, now confirmed as Britain’s most prolific child serial killer.

Following the Letby conviction, the charity Protect, which provides legal advice for whistleblowers, wrote to MPs calling for the law around whistleblowing to be improved and backing calls for NHS managers who attempt to suppress whistleblowers to be barred from their roles.

“Forty per cent of NHS callers to our advice line this year alone said they were ignored when they raised a concern,” says Sybille Raphael, Protect’s legal director. “Often whistleblowers are made to be the problem and then bullied, dismissed or reported to their professional body. It’s a real issue; it’s a real problem.”

Raphael says there is no “silver bullet” to improve whistleblowing in the health service but says change must start from the top. 

“We need a law that says not just that your workers may go to a tribunal if you punish them when they speak up but a law that says employers need to take this seriously – they have to listen to whistleblowers, they have to give feedback as much as possible, because there is nothing more dispiriting than to raise a serious concern and feel that nothing has been done and it just fell into a black hole.”

An academic analysis of whistleblowing in the NHS, published in 2021, found that while those raising concerns were often the start of a process which ultimately led to a formal inquiry, they were more than likely overlooked in the recommendations or lessons learned – the “dog that didn’t bark,” the report’s authors said.

Published in the journal Public Money and Management, the report’s authors looked at scandals such as the case of Harold Shipman and the failings at Stafford Hospital where years of abuse and neglect led to the unnecessary deaths of hundreds of patients, describing the NHS is an organisation “without much of a memory”. 

The report concluded: “It seems that despite the burgeoning academic literature on whistleblowing, there is relatively little on developing effective whistleblowing policy. It is therefore ironical that the inquiries considered in this paper did not appear to blow the whistle loudly enough and that the UK Government failed to listen and act appropriately when they did.”

Under reforms enacted in 2020, Scotland now has an Independent National Whistleblowing Officer for the NHS which falls under the remit of the Scottish Public Services Ombudsman (SPSO). However, a recent survey by BMA Scotland found around half of doctors are still frightened to raise concerns about patient safety or inappropriate behaviour, a situation the organisation described as “shameful”. 

There are now calls to go further, with Tory MSP Stephen Kerr putting forward plans for an Independent Officer of the Whistleblower for Scotland which would be accountable to parliament and would protect those raising concerns while fining those responsible for suppression. 

If there’s a case that highlights the complexities and sensitivities around raising such concerns, it’s the ongoing investigation into the Queen Elizabeth University Hospital (QEUH) campus in Glasgow which includes the Royal Hospital for Children. The construction of the hospital, which is now the subject of a public inquiry, has been blamed for a series of infection outbreaks.

In 2021, a case review into the death of 10-year-old cancer patient Milly Main in 2017 concluded her death was “probably related to the hospital environment”. Senior clinicians who were among the first to raise the alarm about the hospital have accused the health board of failing to listen and treating them like “troublemakers”, a suggestion denied by NHS Greater Glasgow and Clyde.

Louise Slorance’s husband Andrew, the head of the Scottish Government’s Resilience Response and Communications Unit, died at the QEUH in 2020 after catching Covid while receiving cancer treatment. It emerged after his death that the 49-year-old father-of-five had been treated for an infection caused by a common mould called aspergillus which can lead to health problems in those with weakened immune systems. Despite former First Minister Nicola Sturgeon telling parliament in 2021 that she would “not tolerate cover-ups or secrecy”, Slorance is still searching for answers over her husband’s death and says she’s been unable to properly grieve for him. 

“It feels like a daily fight to get answers,” she says. “With every avenue you try exploring, you realise how powerless you are. I’ve had to come to terms with the fact that due to things that didn’t happen at the time, there is now pretty much no chance of getting total answers. The answers I may receive will be on the balance of probability.”

And while the parallels between what happened at the QEUH and the Eljamel case initially appear limited, Slorance says there are similarities in a health board culture “that allows things to go unanswered for so long”.

Louise Slorance has been campaigning for answers since her husband Andrew's death | Credit: Alamy

“What we need to introduce is not only a way that whistleblowers can report concerns but that they are totally and utterly protected from the detriment they suffer afterwards and that there is a mandatory process of investigation for those concerns,” she says. “I’m hopeful that the total shock caused by the Letby case has brought the issue of whistleblowers into focus and we can use that momentum to move forward.” 

As the NHS prepares to enter another winter where pressure will be brought to bear on A&E departments, cancer waiting times and mental health provision, it’s easy to see the issue of whistleblowing again falling down the agenda. But these recent high-profile cases, not least the Letby tragedy, have shown why that cannot be allowed to happen. 

Raphael says the scandals will keep coming unless substantive changes are made. “There is a real cultural issue [in the NHS] and we’re in a time where resources are scarce. I do think this is something that’s not going to stop any time soon.”

It feels like a daily fight to get answers. With every avenue you try exploring, you realise how powerless you are 

While hospital bosses may have once considered the scandal of Eljamel over when he left their employment, many of his former patients continue to suffer to this day. But while the pain, both physical and mental, remains they are now at least a little closer to getting the answers they seek after many years where it felt like they were screaming into the void.

“We’ve still got a long way to go yet,” says Jules Rose. “I feel like we’re now on the first step of a long, long road to recovery. 

“It’s a positive first step but we’re under no illusion that it’s going to be an extremely harrowing sequence of events. What gets uncovered in the public inquiry will be traumatic and there will be anger. We’re going to have to sink down more before we can rise back up.” 

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