STOKE MANDEVILLE HOSPITAL NHS TRUST 1994-2000

  Stoke Mandeville Hospital is situated near Aylesbury in mid-Buckinghamshire. It is home to the National Spinal Injuries Centre and is an Acute General Hospital serving the needs of the population of mid-Buckinghamshire and parts of the adjoining counties of Bedfordshire, Hertfordshire and Oxfordshire. It hosts the Regional Burns Unit as well as well-established sub-regional specialities of Plastic Surgery, with clinics in Northamptonshire, Bedfordshire and Hertfordshire, and ophthalmology, rheumatology and orthodontics. It has about 520 beds and 2,170 wte staff. Around a quarter of a million patients attend the hospital each year.

  Its site was, until 1999, approximately 90 acres and its buildings include wartime huts that suffer from subsidence, (six wards had to be taken out of use as a result in 1997-98) and are in constant need of repair. Backlog maintenance across the site is a significant issue. The Remaining buildings are 1970s Oxford method frame buildings, the National Spinal Injuries Centre built in 1995 as a result of the Jimmy Savile Appeal and some recent modern buildings such as the Maternity Unit. The most recent Cancer Care and Haematology Unit opened in 2001 was, like the Spinal Injuries Centre, built by charitable donations raised locally

  Stoke Mandeville Hospital became a Trust in 1994. On 27 June 1994, Tom Sackville, the Minister for Health wrote to the then Chairman of Stoke Mandeville Hospital NHS Trust saying that the Business Case for capital development had Government approval. In June 1995, in a written answer to a question from David Lidington, the MP for Aylesbury, he replied "this scheme (Stoke Mandeville Redevelopment) has received Full Business Case Approval and is planned to start from 2 December 1995."

  Later that summer, the Trust was informed that their scheme needed to be tested against a potential PFI option and that they should run the Treasury funded scheme in parallel with a PFI scheme. This was done, though the field of potential consortia was not strong as this was a scheme which had already been approved for Treasury funding. In October 1995 Stoke Mandeville was informed that there would be no Treasury money for the scheme and the Trust would need to pursue a PFI solution. In 1996 following the collapse of the consortium the Trust advertised again and by July 1997 the Trust were just about to go to Preferred Bidder status with a second consortium. Meanwhile approximately £3,500,000 had been spent on the infrastructure required such as roads, drains, a roundabout etc. In 1997 the General Election took place and the Labour Government was elected. A stop was put to all PFI schemes whilst the new Government assessed the position and despite heavy pleading, SMH was not one of the 12 schemes, which were considered sufficiently advanced to gain approval. In 1998 SMH advertised for the third time for a PFI partner. That scheme has now reached the point of moving to Preferred Bidder status but has been temporarily on hold, as it has been one of the three pilot schemes involved in exploring alternative options for the management and future employment of Facilities Management staff.

  There are three elements to the Stoke Mandeville Hospital site. About 40 acres to the south which belong to the Trust, the remainder being split into two tranches which were leased to the Trust but stayed in the Secretary of State's ownership in 1994 when Stoke Mandeville Hospital gained Trust status. The presumption then was that, as the hospital was about to be redeveloped and would not require its full site, the surplus land would be sold and the proceeds would go some way to funding the Treasury approved scheme. Of the two tranches leased to the Trust but remaining in the Secretary of State's ownership, the middle tranche currently has the North corridor wards, the Coronary Care Unit and the Gastroenterology Unit all in wartime huts, and an operating theatre. The most northerly tranche accommodates a number of doctor's residences and three nursing accommodation blocks.

  In 1998 the Anglia and Oxford Regional office sold, on a single tender basis, the most northerly tranche of land to Persimmon Homes for housing development, without advertising the site and without any reference to Stoke Mandeville Hospital who were in occupation of the site. It was a transaction that the Trust Board considered did not comply with guidance or best practice. When it learned of the sale, the Trust Board raised the question of the probity of the Regional Office's action with both the Regional Chairman and Chief Executive. NHS Estates (Leeds) later commissioned an Independent Enquiry by solicitors into the transaction. The Trust Board was not allowed to see their Report, which we understand criticised both individuals and the process that had been followed by the Regional Office. The Trust Board was, however, told by both the solicitors and NHS Estates (Leeds) that no blame attached to Stoke Mandeville Hospital, its Board or its employees. At a meeting held with representatives of NHS Estates (Leeds) and a Regional representative of NHS Estates in May 2000, the Board was promised an immediate letter for the record exonerating the Trust. Despite many reminders and much pressure, no letter was forthcoming until very recently, when a letter was, we are told, received by the new Trust Chairman.

  As a result of the sale, the Trust was required to replace both the doctors' and nurses' accommodation that were on the Persimmon site. Negotiations took place with a number of Housing Associations and separate PFI bids were made for their replacement. In 1999, the Trust Board selected the Beacon Housing Association as the preferred bidder. However, the SE Regional office, who had taken over from the Anglia and Oxford office, stopped the deal going ahead, on the basis that the Trust should consider building on the site sold to Persimmon or the site still in the Secretary of State's ownership, options which had never before been offered to the Trust. Indeed, the Trust had been requested to clear the Persimmon site as soon as possible so as to give vacant possession to Persimmon. The Trust was told that the NHS Estates wished to renegotiate the deal with Persimmon. Because of the delay, substantial sums of money had to be spent on the old nurses' accommodation to make it acceptable for existing nursing staff and also fit for the nurses who were coming from the Philippines to ease the nursing shortage at Stoke Mandeville. As a consequence of the late intervention by NHS Estates, the scheme had to be re-advertised and started again from scratch.

  To date neither the main PFI bid for the redevelopment of the hospital nor the PFI bids for the doctors' or nurses' accommodation have, as far as we can ascertain, been signed off.

  In 1997-98 the Trust had reduced its maximum wait in all specialities to no more than 12 months. This was highly regarded by the local GPs and was in part instrumental in its success during the fund holding years. The Hospital's performance was the best in the County. The same year Bucks Health Authority decided that there was a need to equalise access across its three acute hospitals. Stoke Mandeville's income from Bucks Health Authority was reduced by £2 million. As a consequence and in order to balance the Income and Expenditure account, swingeing cuts were made, which included the closure of two wards, one surgical and one long-stay elderly, and two operating theatres, the loss of nursing posts and a tightening of the budget for management. Altogether 60 posts in nursing and support jobs were lost. Savings were made but with inevitable detriment to the waiting list position. In the year 1998-99 the Trust, as a result of very tight management, met its targets albeit with some difficulty. In 1999-2000, Stoke Mandeville was required to make a further saving of £1.6 million. There was always the underlying threat from Bucks Health Authority and the Regional Office that they would not approve Stoke Mandeville's PFI bid unless Stoke Mandeville Hospital met all its financial duties year on year. Additionally, the Regional Office and Bucks Health Authority insisted that fully worked up savings plans were in place, thus demonstrating that the PFI scheme would deliver the required savings. The Trust always held that savings at this level were unachievable given the number of patients requiring treatment and the deficiencies of the site. However, the Trust did achieve a further £1 million plus of savings in the year 1999-2000, ending with a deficit on the I & E account of £866,000. Despite this, through rigorous management, it met almost all its waiting list targets.

  The Trust was awarded a whole hospital Charter Mark for its excellence in Public Service in 1996 and again in 1999.

  Management of Stoke Mandeville Hospital was well regarded by the Region and the cost of management, as a proportion of income, placed it among the most efficient in management cost terms. From 1997-99 Ken Cunningham, the Chief Executive of Stoke Mandeville Hospital NHS Trust was appointed Chairman of the Anglia and Oxford Region Waiting List Task Force and was their representative on the National Waiting List Action Team. In 1999 he was appointed as a Member of the SE Regional Patients Access Team.

  As a result of his Regional Waiting list responsibilities Mr Cunningham was regularly absent from Stoke Mandeville Hospital supporting other Trusts with waiting list problems. The Nursing Director of the Trust was also the Chairman of the Bucks and Northants Education and Training Consortium and the SE Regional Office's Nurse Champion for Improving Working Lives. She too was regularly absent on Regional duties during 2000. It is a matter of record that the absence of these two senior executives caused difficulties and the Chairman of the Trust, Gillian Miscampbell, raised her concerns with the Regional Office as to the amount of Stoke Mandeville Hospital senior management time being used by the Regional Office.

STOKE MANDEVILLE HOSPITAL 2000-01

  Stoke Mandeville Hospital Trust Board always paid strict attention to the waiting list situation. Monthly reports were presented to the Trust Board by the Executive showing the overall situation against all Government targets, with specific information as to 15, 16 and 17-month waiters. Until the February 2001 Board meeting, when it was told of the Northamptonshire patient, no 18-month waiters or problems were notified.

  The policy of the Trust Board was clear and reinforced regularly at meetings, namely that no 18-month waiters would be allowed and that all steps must be taken to prevent 18-month waiters occurring. This was stated regularly at Trust Board meetings and at individual meetings between the Chairman and Chief Executive. Attention was drawn to irregularities which were taking place elsewhere. This was the subject of discussion by the Trust Board and strict instructions were given that there were to be no irregularities in the management of Stoke Mandeville's waiting lists. In parallel with this, the Trust was cultivating a "no blame" culture in its endeavour to learn from mistakes and improve safety and service.

  Regular reports were also presented to the Board was to waiting lists, the bed position, activity, staffing and the problems the hospital had in admitting elective patients. Discussion of these issues formed a major part of Trust Board meetings and very full briefing papers over and above the Board papers were provided to Board members. The Board relied on the information provided to it by the Executive. There was rigorous scrutiny of the information and data provided in which the Community Health Council representatives, who attended the Board meetings participated.

  In April 2000 the Trust was made aware of three potential 18-month waiters. In accordance with the Trust's policy of openness and honesty, these potential breaches were immediately notified to the Regional office. In the event, no breaches occurred. However, the Trust Board were assured that steps had been taken by the Chief Executive, Ken Cunningham and the Director of Operations, Sue Nicholls to ensure that there would be no repeat of the problem. In addition the Region sent a representative to Stoke Mandeville in June 2000 to verify the waiting list situation and agree the management action that had taken place. We understand that she expressed herself satisfied with the steps that were being taken.

  On 1 June 2000, Ken Cunningham was seconded for six months to Surrey and Sussex NHS Trust as Acting Chief Executive. It had major waiting list problems. Such Nicholls became Acting Chief Executive. She maintained her role as Director of Operations. Paul Martin, Chief Executive of the Two Shires Ambulance Trust joined Stoke Mandeville as Acting Deputy Chief Executive on a seconded basis to gain experience in the Acute sector. As Paul Martin was only due to be with Stoke Mandeville until November and had no experience of an acute hospital, he undertook specific projects that were time limited.

  Three of Stoke Mandeville Hospital's four Assistant Directors of Operations were absent over extended periods of time through sickness or maternity leave, putting additional strain on Sue Nicholls in her Director of Operations role.

  In August 2000, Surrey and Sussex advertised their Chief Executive post and Ken Cunningham was appointed. He gave six months notice at the end of October. It was acknowledged by the Regional office that Stoke Mandeville had a very extensive agenda and was short of management resources. The Chairman, Gillian Miscampbell, was asked to release Ken Cunningham immediately but refused to do so unless and until the Region provided additional support to Sue Nicholls. The Region gave assurances that support would be forthcoming if the Chairman released Ken Cunningham. The Chairman wrote to Barbara Stocking, the then Chief Executive of the SE Region, on 13 October, "As you know, the very strong advice that I am getting from both the clinicians in this hospital and from Non-Executive members of the Trust Board is that, bearing in mind the agenda we are facing over the next six months, we cannot continue with the present management arrangements till next April. Their strong view is that Ken Cunningham should work out his notice so as to enable this Trust to fulfil its agenda." Assurances were given that support would be forthcoming and the Board was told that it should commence procedures to find a replacement Chief Executive.

  No support was forthcoming from the Region until in mid-December it was agreed that Lynda Atkins would join SMH from the Regional office as Acting Director of Operations on 8 January and that Paul Martin would extend his secondment until February 2001 to enable him to complete some of the projects in which he was involved.

  For some time work had been being undertaken by clinicians on a potential clinical reconfiguration of services between Stoke Mandeville Hospital and the South Bucks Trust because of the clinical advice, which was coming from the Royal Colleges, and the training needs and working hours of junior doctors.

  In late December 2000, the two Chairman were summoned to see William Wells, the Chairman of the SE Region, and told that the Regional Office had decided that the two Trusts should amalgamate. This was just before the scheduled interviews with the shortlist of candidates for the Chief Executive's position. As a result, two of the short listed candidates withdrew. During January 2001, meetings took place between the two Chairmen and two Chief Executives and on 7 February they were all summoned to see William Wells and Ruth Carnall, the Acting Regional Director of the SE Region, and told that it had been decided that the two Trusts were to amalgamate in April 2002.

  This was always a very tight schedule and required a substantial amount of work if it was to be achieved. Stoke Mandeville expressed concern at the timescale in the light of the agenda it was already coping with and suggested that, bearing in mind the procedures that need to be followed and the consultation period required if an amalgamation was to take place, that either October 2002 or April 2003 were more realistic. However, we were told that the April 2002 date had to be achieved, notwithstanding the fact that the reconfiguration of clinical services discussions, which had been taking place for some time, between clinicians at the two hospitals, would not have been completed before the public consultation process commenced.

  We understand that it has now been admitted that April 2002 is unrealistic and that the date has been put back to April 2003.

IMMEDIATE EVENTS SURROUNDING THE IDENTIFICATION OF 18-MONTH WAITERS AND THE RESIGNATION OF THE CHAIRMAN AND NON-EXECUTIVES

23 January 2001

  A patient from Northamptonshire rang to enquire when she would be treated. Investigations showed that she had seen a consultant some 23 months previously and there had been an error between the consultant/his secretary, which resulted in that patient being omitted from the waiting list.

  The patient was immediately give a "to come in" date. The Chairman and Trust Board were told of the situation the moment the information of the breach came to light and the Regional office was also informed. An investigation was started by the Hospital into what had gone wrong.

  A thorough investigation led by Acting Director of Operations, manned by Stoke Mandeville Hospital and the local Primary Care Group staff, was established. Further breaches were identified, firstly of a similar nature with that consultant's list. Stoke Mandeville Hospital staff undertook a continuing thorough investigation of all aspects of waiting lists and daily reports were made to the Regional Office. There was no question of cover-up.

  The Hospital requested an independent review from the Regional Office.

Wednesday 7 February

  Sue Nicholls (Chief Executive) and Gillian Miscampbell (Chairman) were summoned to the Region at 9 am for a half hour meeting with William Wells (Regional Chairman) and Ruth Carnall (Regional Chief Executive), together and then separately. William Wells told the Chairman that, "she must consider her position; that she had two options—resign or be sacked." Ruth Carnall told Sue Nicholls that she could not continue as Chief Executive of Stoke Mandeville. As the Chairman was going to leave on 9 February, a meeting with William Wells was fixed for Monday 26 February, on the Chairman's first day back.

Thursday 8 February

  Stoke Mandeville Hospital Trust Board met on its regular monthly meeting. This was followed by a meeting between the Chairman and the Non-Executive Directors. The purpose of the meeting was to report the content of the meeting with the Regional Chairman, William Wells, and the option of "resign or be sacked".

Friday 9 February

  The Chairman went abroad on leave. She returned on Saturday 24 February.

Saturday 10 February

  The Non-Executive Directors wrote to William Wells, the Regional Chairman, with a copy to Ruth Carnall, the Acting Chief Executive, saying "if failures are attributable to a Board Member, then they are attributable to the whole Board: we have collective responsibility and have collectively accepted in good faith the regular reports which have been made to the Board on this important issue." The Non-Execs set out the agenda facing the hospital and their view that "Given the excessively heavy agenda that the Trust is now shouldering, the removal of the Chairman and Chief Executive would have devastating consequences for . . . that agenda"

  The replies from William Wells and Ruth Carnall were dismissive. William Wells described the letter to Gillian Miscampbell on the 26 February as "a silly letter from your Vice-Chairman."

Tuesday 13 February

  The National Patient Access Team (NPAT) visited Stoke Mandeville for one day from 7.30 to 3.30. They interviewed 12 people. They did not interview or ask to interview the Chairman or Non-Executive Directors.

Wednesday 14 February

  The NPAT report was sent to Ruth Carnall, Regional Director of the SE Region. Stoke Mandeville Hospital was subsequently told that the Report had been submitted to Ministers. No draft or copy of the document was shown to the Chairman or any of the Stoke Mandeville Directors.

Monday 26 February

  Gillian Miscampbell met William Wells. She was informed that the report was shocking; that it was the worst case ever; 160 long waiters had been identified, some going back four years. She was told that the Report was with Ministers and that there were findings of collusion in fraudulent mismanagement at the highest level. She was told that the situation was unforgivable and her position untenable. That the evidence of fraud and collusion would count against her with the Minister. William Wells quoted "this manipulation of the waiting list appears to be collusion on a wide scale and at all levels of the organisation since 1998". Gillian Miscampbell was told that both Ken Cunningham and Sue Nichols were implicated and that, whilst the Region would do their utmost to "save Ken, Sue Nicholls would have to go". She was also told that she had the choice of being sacked or could resign. William Wells said that he would not wish for Gillian Miscampbell, after her long service, the ignominy of the Minister telephoning and sacking her, but that she would be sacked if she did not resign.

  She was denied access to the Report on the questionable grounds that it was with the Minister. William Wells had a copy in his hand from which he quoted. The Chairman insisted on seeing the NPAT report before reaching a decision and it was agreed that, in common justice, she should have that opportunity. There was a Trust Board meeting on Thursday 1 March. It was agreed that she had to take that meeting and that the Report would be sent to her on Friday 2 March. She would consider it over the weekend and would speak with William Wells on Monday 5 March with her decision. On return, the Chairman informed the Non-Executive Directors of the content and outcome of the meeting with William Wells.

  William Wells wrote to the Chairman after the meeting but sent it to the wrong address so that she never got the letter and only received a copy in response to another letter on 23 April. The letter said "The National Patients Access Team has now produced its report and I regret to say that their findings are that there has been a significant manipulation of the waiting lists which appears to arise from collusion on a wide scale and at all levels of the organisation since approximately 1998. Manipulation of the waiting lists on the scale which has been perpetrated by your Trust over the last three years is completely unacceptable and I hold you personally responsible as Chairman of the Trust Board".

Wednesday 28 February

  Gillian Miscampbell wrote to William Wells, in the light of what he had told her was in the Report, which neither she nor anyone at Stoke Mandeville Hospital had been allowed to see, that it was "her intention to submit her resignation", but that she would speak to him on Monday when she had had a chance to see the Report.

Thursday 1 March

  Stoke Mandeville Hospital had its regular Trust Board meeting. The Chairman arrived home late afternoon to find a fax from William Wells saying that he had seen the Minister, who had accepted her resignation, which had not been submitted, and that her "resignation would take effect from early next week and would be reasonably contemporaneous with the publication of the report" which she had not been allowed to see.

Friday 2 March

  The NPAT Report was faxed to Gillian Miscampbell in the late afternoon. A meeting was held with the Non-Executive Directors who were apprised of the Report's findings. Non-Executive Directors have never been sent a copy, and would not know to this day of its contents unless the Chairman had shared information with them.

  Gillian Miscampbell considered the Report over the weekend.

Sunday 4 March

  Gillian Miscampbell wrote to William Wells "Firstly may I make it absolutely clear that I have not yet resigned. Your letter and discussion with the Minister was somewhat premature". The letter stated that she was not prepared to resign and refuted any question of any charge of collusion or involvement in wrongdoing. "You really cannot expect me to resign and at the same time publish an unsubstantiated allegation." The letter went on to say that Gillian Miscampbell recognised that, "as Chairman, I am accountable to the Secretary of State for the performance of the Trust and I understand the political imperatives of having someone to blame. If, however, I am to be required to resign, I should tell you that any question of implied dishonesty on my part will be vigorously disputed by me and that this matter must be resolved before I am asked to take a decision. I am not prepared, after 20 years' service to the NHS, to have my good name brought into question by an unfounded allegation."

Monday 5 March

  William Wells telephoned Gillian Miscampbell and agreed that she was justified in her concern and it was agreed that William Wells would write a letter exonerating the Chairman and Non-Executive Directors. His letter said, "I can confirm absolutely that the allegations as to how waiting lists were mismanaged bear no implications as far as the Chairman and Non-Executive Directors of the Trust are concerned. The details of the management of the waiting lists are not the responsibility of the Chairman or Non-Executive members of the Board; as a consequence any allegations that are made in the report do not apply to the Chairman or Non-Executive Directors.

  However, as you realise and agree, the fact that there are a significant number of over 18 month waiters at Stoke Mandeville is the responsibility of the Chairman and Non-Executives and it is for the failure to deliver an essential plank of Government policy that the Chairman should resign".

  The Region gave no publicity to this statement.

  The briefing from the Region led to radio and television items and articles in the media of "mismanagement of the waiting lists, cover up, Chairman resigned".

  (It should be noted that William Wells' letter of 5 March said that the Chairman "should resign". In a fax to her dated 1 March, he said "I have discussed this with the Minister and he accepts your resignation". Subsequently, the Minister confirmed 6 March as a matter of record as the date on which the Chairman resigned).

Tuesday 6 March

  Resignation of Gillian Miscampbell took effect.

Wednesday 7 March

  Three of the four Non-Executives resigned. Their offer to meet the Regional Chairman had been ignored and their advice dismissed out of hand. A further reason was the process and treatment of the Chairman, Gillian Miscampbell.

Thursday 8 March

  The replacement Chairman was introduced to Stoke Mandeville Hospital.

Monday 5 March

  Sue Nicholls attended a meeting with Ruth Carnall and was again told that she could not remain in post. She was shown a letter from the Director of the NPAT Team saying that reference to collusion should be dropped from the NPAT Report. She agreed to step aside pending an external enquiry.

12 April 2001

  Gillian Miscampbell wrote to Ruth Carnall asking to see the letter from the Director of the NPAT Team, "As Sir William quotes that statement as the basis on which my resignation was required, in common justice, I believe I am entitled to see that letter and to know if the current version of the NPAT Report still includes that statement, or if, as I have heard, there has been some amendment to the Report dated 14 February."

April 2001

  Gillian Miscampbell received a copy of the final version of the NPAT report which excluded the sentences "On available evidence, this manipulation of the waiting list appears to be collusion on a wide scale and at all levels of the organisation since approximately 1998" and "Staff at all levels of the Trust either colluded in the inappropriate suspension of patients or should have known of the problem." These two sentences had been in the NPAT Report that had been sent to Ministers in February and as William Wells told Gillian Miscampbell on the 26 February "The evidence of fraud and collusion would count against her with the Minister".

26 April 2001

  Ruth Carnall, Regional Director wrote to Gillian Miscampbell saying that "As a former Chairman you were not involved in day-to-day management and will not therefore be expected to know about detailed management arrangements. Copies of the Report . . . include the full text . . . The only change is in the reference to "collusion". This has been deleted as it is an inference, rather than established fact".

THE DISTRICT AUDIT INVESTIGATION

  District Audit was asked to do an investigation by the new Chairman of Stoke Mandeville Hospital. They took evidence from a number of people including the past Chief Executive, Ken Cunningham, and produced a Draft Report, on which comments were made by most of those who had been given a copy. As far as we can tell, no account was taken of any of the comments made by the previous Chairman, Non-Executive Directors, Mr Cunningham, or Miss Nicholls; as a result the Report is, in our view, significantly flawed.

  The Trust treated 22,000 elective patients each year. Of the 131 patients identified as long waiters, systems errors, where patients were wrongly classified or legitimate suspensions had not been lifted, accounted for 35 patients. This represents 0.19 per cent of the patients successfully treated. Administrative errors accounted for 29 patients, 0.13 per cent of those patients successfully treated. Whilst any errors in administration or systems are to be deeply regretted, it is difficult to know how that would compare with any other Trust, which underwent the same degree of scrutiny. Twenty-four patients are unclassified owing to the "unavailability of their notes as the patients were receiving treatment". Neither Stoke Mandeville Hospital's new management nor District Audit have been able or been prepared to give detailed information in respect of the 43 suspended patients. It has been impossible to ascertain how many of them were patients waiting the second of a bilateral procedure, patients who self deferred having declined a reasonable treatment plan or those patients who were suspended without reason.

  There can be no excuse for this third category, which we understand amounted to 15 to 20 patients. They should not have been suspended and why Sue Thornton, the Business Manager for General Surgical Specialities, inappropriately suspended them will never be known. She was not given instructions to deal with these patients in this way by either her immediate superior, Nigel Pearce or by the Director of Operations/Acting Chief Executive, Sue Nicholls or Ken Cunningham. On previous occasions when she had problems admitting a long waiter, she had brought the matter to the attention of her superiors for resolution. The Trust Board policy was clear. Patients had to be treated before 18 months and no irregularities in management were allowed. We understand that she has now retired. Despite the criticisms that may now be properly made as to her actions in relation to 18-month waiters, it should be noted that she was a good theatre sister and had done excellent work for the hospital in helping to set up the Day Surgery Unit, before being promoted to the position of Business Manager, General Surgical Specialities.

  As to the first category, the patients who were awaiting the second of a bilateral procedure, the practice employed at the Trust was in common use throughout much of the South East Region. A second procedure was suspended until such a time as the patient was medically fit to undergo the procedure. This policy has, we understand, now been enshrined in the Trust's new Waiting List Policy, which has been signed off by the Modernisation Agency.

  The second category was patients who could not be treated under their named consultant if the 18-month deadline was not to be breached. These patients were offered alternative treatment plans that included treatment by their consultant in the local private sector, treatment by another consultant within the Trust or treatment within a neighbouring Trust. Many patients accepted one of these alternatives but those who did not were suspended on a self-deferral basis. Prior to suspension, the patients gave their informed and written consent to this course of action, preferring to wait for their named consultant to treat them. Post suspension plans were agreed with them and their GPs were informed. District Audit counted both these categories of patients as breaches of the 18-month rule.

  Some of the breaches arose because District Audit opted to apply Patient Charter definitions for calculating the total wait rather than Korner definitions, which have always been used at Stoke Mandeville and many other Trusts in the Region. All Trusts are required to base their monthly performance reports to the Regional Office on Korner definitions and as a result it has been common practice to manage waits using the same definitions. As previously stated, neither the Trust nor District Audit have been able to provide information to support their declaration of 131 18-month plus waiters and as a result it is not possible to ascertain how many of the alleged breaches have arisen for this reason.

MATTERS WHICH SHOULD BE TAKEN INTO ACCOUNT

  It is to be deeply regretted that Stoke Mandeville Hospital failed in its duty to treat all patients within the 18-month target but some consideration needs to be given to the problems the Hospital faced:

—  The agenda the hospital management faced was enormous. Through no fault of its own, it had had to manage three attempts at a major PFI redevelopment with all the attendant problems and workload.

—  It was also running separate PFI proposals for doctors' and nurses' accommodation, which because of the land issues had to be re-worked, and a separate project for a Private Patients Unit.

—  There were major land and building problems because of the elderly nature of the estate, and the dubious arrangements for the sale of the leased land.

—  The re-configuration of services and the demand for the amalgamation of Stoke Mandeville Hospital NHS Trust and South Bucks NHS Trust by April 2002.

—  The increased number of referrals to the hospital over the past two years confirmed by the recent visit and audit by the Modernisation Team.

—  The increased number of complex operations, both spinal and orthopaedic eg hip revisions which can take approximately six hours if bone grafting is required, compared to one and a half hours for a primary hip.

—  The need to meet the overall target of no more than 5,101 patients on the waiting list plus the other waiting list targets, against the background of the shortage of beds, staff and appropriate theatre time.

—  A major MRSA outbreak which necessitated closing 22 surgical beds in February 2000 and prevented joint surgery for three weeks.

—  A shortage of staff which resulted in about 20 of the 100 surgical beds being closed at any one time.

—  A failure of provision in the community which resulted in a further 20 surgical beds being blocked at any one time.

—  The loss of its Chief Executive and the failure of the Regional Office to fulfil its commitment to provide support.

—  The amount of Executive management time that was being provided to the Region by the Chief Executive and the Director of Nursing.

—  The absolute requirement to meet its I & E Budget if the Region and Bucks Health Authority were to sign off the PFI proposals.

—  The cumulative cuts in Stoke Mandeville Hospital's budget over the previous three years and the effect on the Hospital as a result of those cuts by way of loss of beds, theatre time and staff.

—  The absence through illness or maternity leave of crucial Assistant Directors of Operations and the inability to replace them on a temporary basis.

—  The very substantial workload which Sue Nicholls and the management team were carrying.

  The District Audit Report did not find that there was "collusion in fraudulent mismanagement of waiting lists on a wide scale at all levels of the organisation going back to 1998", as was stated by the Regional Chairman and alleged in the original NPAT Report. It did find that "there was no indication that a major problem was developing or that concealment was taking place" and it concluded "that from the information available to them, Board Members could not have suspected any concealment. Had they done so, we are confident that a serious view would have been taken".

  As Chairmen and Non-Executive Directors of the Trust, we have complete confidence in the probity of both Mr Cunningham and Miss Nicholls. Had either of them known of the 18-month problem, we would have been immediately informed.

  One middle-ranking member of staff suspended 15 to 20 patients without any authority so to do because, as we understand it, she misguidedly thought she was protecting the reputation of the hospital. There were a number of administrative and systems errors, which should not have occurred. There were also a number of patients who, in our view, should not have been counted as 18 month plus waiters as they had either preferred to self defer or were waiting for a second procedure.

  Stoke Mandeville is an excellent hospital. The way this matter was handled took no account of the well being of the hospital, its patients and staff. No one should condone wrongdoing and no one on the Trust Board would have done so. The actions taken, apart from the real damage that was done to individuals, damaged the hospital's reputation, its ability to keep good staff, its ethos and being. It has also led to a growing concern within the Health Service generally of the "Blame and Shame" culture which has led to a number of people being required to resign though no blame could personally be attached to them. Ministers appoint and can remove Chairmen, but given that position, Ministers have a responsibility to act reasonably and fairly in the public interest. There are also questions as to whether the way this matter was handled met the standards of probity, governance, natural justice and fairness that should be mandatory in the Public Service.

  Everyone involved with the hospital deeply regrets the fact that a number of patients waited longer than 18 months and that the Government's target was breached.

  However, the hospital and its staff needed support to overcome the problems, some of which had been needlessly exacerbated by the Regional Office.

  One has to ask who has benefited from the manner in which this matter was dealt with, certainly not the NHS, patients or indeed Stoke Mandeville Hospital and its hardworking. committed and conscientious staff.

Gillian Miscampbell OBE DL
Past Chairman
Stoke Mandeville Hospital NHS Trust

Ian Taylor TD DL
Past Vice-Chairman
Stoke Mandeville Hospital NHS Trust

Alison Phillips OBE
Past Non-Executive Director
Stoke Mandeville Hospital NHS Trust

Glyn Andrews
Past Non-Executive Director
Stoke Mandeville Hospital NHS Trust

December 2001