The Myles Bradbury case - what do we learn and how do we change?
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The Myles Bradbury case - what do we learn and how do we change?
- 2. IMPROVEMENT THROUGH INVESTIGATION Celebrating the value of nurses in East Sussex The Myles Bradbury case: what do we learn and how do we change Ed Marsden Managing partner
- 3. IMPROVEMENT THROUGH INVESTIGATION 3 Aim • Provide a summary of the Bradbury investigation • Share thoughts about how we improve safeguarding practices following this & other cases • Role of nurses in raising concerns
- 4. IMPROVEMENT THROUGH INVESTIGATION 4 • A paediatric haematologist at Addenbrookes (CUH) • Qualified in 1996 • Previously worked as a locum consultant at CUH in 2007 • Joined Birmingham Children’s Hospital in late 2007 • Re-joined CUH in late 2008 • Employed as a consultant in the paediatric haematology and oncology service • Worked in the children’s outpatient unit: the paediatric day unit (PDU) • First arrested on 18 December 2013 • Pleaded guilty to 25 of 27 charges involving 18 victims • Sentenced to 22 years’ imprisonment on 1 December 2014 Myles Bradbury
- 5. IMPROVEMENT THROUGH INVESTIGATION 5 The independent investigation • Trust board commissioned the investigation • Lucy Scott-Moncrieff led the work • Interviewed trust staff, families, regulators, professional bodies and Myles Bradbury • Reviewed trust policies and procedures • Reviewed earlier reports of abuse by NHS professionals
- 6. IMPROVEMENT THROUGH INVESTIGATION 6 • Should the trust have identified or prevented Myles Bradbury’s criminal behaviour? • Were trust policies and processes intended to protect patients robust, understood and followed? • Were there any ways in which the trust could and should improve safeguarding in the future? Purpose of the investigation
- 7. IMPROVEMENT THROUGH INVESTIGATION 7 1. Myles Bradbury acted alone 2. As soon as concerns were raised the trust acted promptly 3. There were weaknesses in some policies 4. Improvements needed to safeguarding training 5. Ways of helping patients & families to recognise unusual behaviour needed to be developed Five key conclusions from the report
- 8. IMPROVEMENT THROUGH INVESTIGATION 8 • Weak signals – need for openness • Value of dialogue & openness in your team • Time for discussion • Talk about good practice • Talk about unorthodox practice • Start local • How do we provide for professionals ‘at risk’? • http://www.nhsemployers.org/your- workforce/retain-and-improve/raising-concerns-at- work-and-whistleblowing Lessons into practice - Bradbury, Savile
- 9. IMPROVEMENT THROUGH INVESTIGATION 9 Action • Check whether you have an up-to-date chaperone policy in your organisation • Find out whether patients & families know what to expect of professionals when they come to clinic • Talk about good & unorthodox practice • Tell staff & patients it is ok to raise concerns
- 10. IMPROVEMENT THROUGH INVESTIGATION 10 For more information please contact: Ed Marsden, managing partner Email: edmarsden@verita.net Tel: 020 7494 5670 Follow us on twitter: @VeritaUK
Editor's Notes
- Regarded by colleagues as a very good clinician Attracted a lot of accolades from families and patients Job included teaching responsibilities Excluded by the trust in November 2013 after the family of a patient raised concerns Currently serving his sentence in a sex offender prison Bear in mind that this case came on the heels of all the Savile revelations
- Trust board debated whether it should be internal or independent. Eventually decided on independent Lucy is the House of Lords commissioner of standards and a Verita senior associate Saw Myles Bradbury to discuss what others said about his behaviour & to inform our recommendations Particularly chaperoning, transition and appointments, safeguarding, safer recruitment Including David Britten, Clifford Ayling, Christopher Allison, Kerr/Haslam Final investigation was sufficiently rigorous & thorough for LSCB to agree that there wouldn’t been an SCR
- We did not investigate Bradbury’s actions as this was the responsibility of the police Rather we looked at the three points noted in the slide. Investigation was particularly probing as we thought it quite possible that staff/colleagues had had concerns. We found no evidence to support this idea.
- Bradbury carried out abuse in the context of going about his clinical work. To this day some children won’t know that they were abused. He planned his activities and exercised considerable foresight. For example, scheduling appointments, giving out personal mobile phone number, carrying camera pen. The trust dealt with the concerns in an exemplary fashion. PDU clerk. Would have been easy to invite MB to speak to family. She didn’t make this mistake. Chaperoning – not robust, not enforced, not monitored and not understood by families because no one explained it Transition – patients and families not aware of it. In no position to notice that it was being breached. Appointments – allowed for flexibility and MB took advantage of this. Safeguarding training said nothing about identifying professionals with access to vulnerable groups Importance of empowering patients and families – part of safeguarding
- Weak signals – early, often minor indicators that something is amiss. Often known about and ignored but usually come to light after the event. Big lesson of many incidents – including Savile – is promoting a culture of openness Talk about unorthodox practice may have identified Bradbury sooner e.g. no teaching, slow to read results, didn’t want medical students, slightly off-hand, seeing patients outside of clinic hours. Focus on pubertal examinations. Start with your team MB pointed out that the extent of his behaviour only became evident to him when he spoke to Lucy Faithfull. What provision do we make for professionals ‘at risk’? Useful link from NHS Employers