It’s three years since I started an investigation into secrecy in some ambulance services over the deaths of patients treated by paramedics who were subsequently struck off.
As a result, investigations have been conducted by ambulance trusts and hospitals, procedures have been changed, and families have received apologies.
Lawyers have been engaged, two out of court settlements (at least) have been paid, two inquests have been held and two coroners have ruled that vulnerable patients were let down.
But had you sat through either inquest, the first in Alnwick, Northumberland in 2013, the second in Doncaster this week, you would never have known it was investigative journalism that exposed the serious failings they all agreed must never happen again.
In both courtrooms journalism – which had exposed the failings – was the elephant in the room. If the entire press bench had worn floppy grey ears and tusks no-one would have said a word. Authority had been successfully held to account for the public good, but would rather like to pretend it hadn’t, thank you very much.
The secrecy itself was well hidden – paramedics are struck off by the Health Professions Council (now the Health and Care Professions Council) in public hearings when they have mistreated patients. The paramedic concerned is named and the hearing transcripts are published online. Transparency – it would seem – at its best.
But the patients who have been mistreated are not named – and I found all too often their families had no idea anything was amiss. Just as bad, coroners were not informed of NHS concerns either – so deaths that should have been properly investigated in open court were not. The HPC relied (and still relies) on the ambulance service to inform families when the mistreatment is spotted by someone within the NHS.
It took hours of research to chase down what clues there were in the heavily redacted transcripts – any detail that could identify the patient was so carefully removed that in many cases I could get nowhere. But in some of the deaths discussed there was a reference to an ambulance station, a date of death, the patient’s age, or a landmark mentioned by a witness in passing.
In every case I successfully followed up the family of the dead patient had no idea their husband, father, daughter, wife, had been mistreated so badly that a healthcare professional had lost their livelihood. I identified three people whose deaths should have been flagged up to a coroner but were not, and another in Scotland which had not been referred to the procurator fiscal.
At each of the two inquests that have been held (so far) as a result of that investigation the coroner has found there was a failure of care. The Doncaster coroner went further: a verdict of death by natural causes, he said, “would be inadequate and improperly reflect the tragedy and seriousness of the case.”
He was talking about the death of a seven year old girl left on the bathroom floor by a paramedic who sent an ambulance away instead of rushing her to hospital where she just might have been saved.
The Yorkshire Ambulance Service admitted Sky News had “brought [the secrecy] to our attention,” before admitting they should have told the coroner and the dead girl’s family six years ago. That was the only mention journalism got.
Both inquests were told changes have now been made to procedures and the same thing can’t happen again – patients and their families are put first. The patients’ families both received apologies from the ambulance trusts – and both cases the families said they thought the NHS behaviour had been criminal.
The Doncaster coroner was keen to thank everyone by name or affiliation who was involved in the inquest which successfully brought out the facts of such a tragic and serious case. Except one.
If anyone in the NHS or the coroners court system is thankful for being alerted by investigative journalism to serious failings – enabling the UK’s biggest spender of public money to improve the way it operates – they certainly haven’t said so.