Table I.

Summarising the key Inquiries on doctor wrongdoing, from 2000

Inquiry	Context	Individual doctors’ shortcomings – from incompetence to criminality (bad apples)	Organisational setting and/or cultures (bad barrels)	Overall health system concerns (bad cellars)	Additional comments drawn from Inquiry reports
Kennedy (2001)	Public inquiry, set up in 1998, to examine the care of children receiving complex cardiac surgical services at the Bristol Royal Infirmary between 1984 and 1995	Incompetence: focussed on the high mortality rates of two surgeons This is “not an account of bad people” but a “tragedy born of high hopes and ambitions and peopled by dedicated hard-working people” Both surgeons and the hospital CEO (also, and unusually, a doctor) were found guilty of serious professional conduct by the GMC in 1998 The whistle-blower (an anaesthetist) found himself unemployable in the NHS; he left the UK in 1995 to work in Australia	“Club culture” and “culture of fear” both noted Local data indicating high levels of mortality was ignored inside the hospital Structural and individual elements of hierarchies prevented open discussion	Local data were shown, inter alia, to: the later President of the Royal College of Anaesthetists; the (local) Director of Anaesthetics; the Medical Director of a neighbouring hospital; and (indirectly) to the President of the Royal College of Surgeons of England, as well as two Senior Medical Officers at the Department of Health Other concerns included “territorial loyalties and boundaries within the culture of medicine and the NHS, and also the realities of power and influence”	Although there were flaws with the hospital, its organisation and culture and the wider NHS, there were individuals who “should and could” have behaved differently
Ayling (2004)	Originally announced in 2001, but change of chair announced in 2002	Criminality: GP and hospital doctor, Clifford Ayling, was arrested and charged in 1998 with indecently assaulting former patients In 2000 he was convicted on 12 counts of indecent assault, relating to ten female patients, and sentenced to four years’ imprisonment. His name was placed indefinitely on the sex offender’s register; the GMC then determined that Ayling’s name should be erased from the Medical Register Inquiry identified a number of missed opportunities from 1971 until 1998: “individuals who could and should have acted on the information then available”	No investigation occurred after an incident was reported in 1980 Incident was brought to the attention of the health authority in 1991, but was not taken sufficiently seriously by senior management. Culture that saw complaints as a challenge, rather than a source of information and an opportunity to learn	Local medical committee and Medical Defence Organisation were aware of concerns, but no actions taken Health Authority finally alerted police in 1998	The single most important barrier was the absence of any formal procedure for reporting concerns about criminality
Neale (2004)	In 2000, the General Medical Council erased Richard Neale’s name from the Register	Criminality Richard Neale was erased from the Canadian Medical Register in 1985, but was subsequently allowed to work in the UK Neale then cautioned by police for an incident at a public toilet; investigation in 1993 resulted in demotion. Subsequent disciplinary hearing in 1995 led to a negotiated severance package. However, Neale then employed by two other hospitals in NHS “Alert Letter” not sent out by NHS Regional Office to NHS Health Authority and Trust Chief Executives until 1998	Culture of complacency (“We have no complaints”) that would make it extremely difficult for patients to raise concerns An urgent need for a root and branch change in attitudes and culture within the NHS	Systems failures within the employment and complaints procedures within the NHS between 1985 and 1997, and very importantly, failures within other professional bodies upon whom the NHS was dependent The most perplexing aspect was how Neale could be struck off in Canada, but able to retain his licence to practise medicine in the UK (GMC)	Both the system and those operating in it were not operating as effectively as they should have been to guarantee patient confidence and patient safety
Kerr/ Haslam (2005)	Sexual abuse of psychiatric patients in hospitals by two doctors, William Kerr and Michael Haslam In 2000 Kerr was convicted (in his absence, on a Trial of the Facts) of one count of indecent assault, and in 2003 Haslam was convicted of four counts of indecent assault (a conviction of rape was quashed on appeal)	Criminality Many ignored warning bells or dismissed rumours and some chose to remain silent when they should have been raising their voices Some stepped forward, but those lone voices were not heard Above all it was an account of psychiatric patients, whose concerns and complaints fell on deaf ears Many staff turned “a blind eye” Rumours of Kerr’s alleged abuse of female patients were well known to GPs in Harrogate, but only in later years with a “change of culture” that GPs reported In 1964 a GP practising in Northern Ireland (Mathewson), ignored pressure that he should not give evidence against a colleague, and pursued a complaint by a young female patient against Kerr, resulting in the ending of Kerr’s career in Northern Ireland: “It is a sad fact… that once in England there was not a single GP who displayed the fortitude of Dr Mathewson”	A story of management failure, failed communication, poor record keeping and a culture where the consultant was all-powerful Internal Inquiry entirely excluded the whistle-blower’s allegation of sexual abuse, and concentrated on the messenger and the substance of the message was both lost and ignored So-called “unhealthy” culture where professionals were reluctant to take action against consultants Concluded that change of culture is at the heart of real change	In 1997, NHS Regional Office set up an Enquiry into the allegations of sexual misconduct against Michael Haslam between 1984 and 1988, who was dismissed from his post in 1998 Whatever the systems in place, if those who operate them at all levels are not focussed on patient safety, then other factors, other pressures, will prevail	Key factors explaining GPs’ lack of response: the old-boy network or professional loyalty; the isolation of GPs; tolerance of sexualised behaviour; insufficient expertise in psychiatry; confidentiality; the power of consultants; and an ambivalent attitude to relationships between doctor and patient Stressed the importance of individual “agency” explanations, as opposed to collective, structural factors
Shipman (2005)	Harold Shipman was a GP who was convicted in 2000 of murdering 15 patients, and of forging a will. However, the Inquiry identified 215 victims, but “the true number is far greater and cannot be counted” In 1976 Shipman had been convicted of offences of forgery, of unlawful possession of pethidine and of obtaining pethidine by deception, but was allowed to return to unsupervised general practice in 1977	Criminality In 1994, Shipman gave a gross overdose of diamorphine to a 46-year-old patient, who later died in Tameside General Hospital. The report noted that both consultants in charge who did not report the event “must be criticised” for their failure to report Shipman’s actions, but that this is “tempered” because the culture within the profession at the time was that to report a colleague was “not done”, and many doctors throughout the country would have failed to act, as these two doctors did	The culture was that it was “not done” to report a colleague, and even today, after the Kennedy Inquiry, that culture survives in some quarters The culture in medicine inhibited the proper reporting of concerns by nurses about doctors	Smith ended her review of the Shipman case by stating she was “driven to the conclusion that, for the majority of GMC members, the old culture of protecting the interests of doctors lingers on”. The GMC, she said, was “doctor-centred”. It appeared to assume that all doctors were good, competent and conscientious until proved otherwise. It would deal with the profession’s “bad apples” for the sake of the profession [but] it would do so in its own way and it did not welcome scrutiny	Contributory factors included: fear of accusations of disparagement; the insufficiency of evidence; ignorance of procedures; fear of being seen as a troublemaker; fear of recriminations or reprisals; a concern that making a report might lead to proceedings for defamation; a feeling of impotence and that nothing will be done
Francis (2010)	Concerns about high mortality rates at the Mid Staffordshire NHS Foundation Trust, and an increasing public outcry led by a group of patients and patients’ relatives who had had experiences of poor care Resulted in an investigation by the Healthcare Commission (HCC), which published a highly critical report in March 2009, followed by two reviews commissioned by the Department of Health	Incompetence Deficiencies in staff performance and governance Evidence of a worrying acceptance of poor care, of poor behaviour among colleagues being condoned and of potentially dishonest behaviour being tolerated or even encouraged Insufficient attention to the maintenance of professional standards Some of the treatment of elderly patients could properly be characterised as abuse of vulnerable persons	The culture of the Trust was not conducive to providing good care for patients or providing a supportive working environment for staff An organisational culture which included: a culture of bullying; target-driven priorities; disengagement from management; low staff morale; isolation; lack of candour; acceptance of poor behaviours; reliance on external assessments; and denial The most important remedying factor is the fostering of “a culture of openness, self-criticism and teamwork”	Report focussed on Mid-Staffordshire Trust, but: Local confidence in the Trust and the NHS is unlikely to be restored without some form of independent scrutiny of the actions and inactions of the various organisations to search for an explanation of why the appalling standards of care were not picked up	Organisational culture of the Trust regarded as most important factor
Francis (2013)	The Conservative Secretary of State for Health in the Coalition government, Andrew Lansley, decided that this Inquiry should be a public inquiry under the Inquiries Act 2005	Incompetence The primary responsibility for allowing standards at an acute hospital trust to become unacceptable must lie with its Board, and the Trust’s professional staff	Reported a culture of fear in which staff did not feel able to report concerns; a culture of secrecy in which the trust board shut itself off from what was happening in its hospital and ignored its patients; and a culture of bullying, which prevented people from doing their jobs properly Primarily caused by a serious failure on the part of a provider Trust Board. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities A culture “focused on doing the system’s business – not that of the patients”	Second and third volumes of the Inquiry are concerned with the wider NHS The NHS system includes many checks and balances which should have prevented serious systemic failure of this sort A system that ought to have picked up and dealt with a deficiency of this scale failed in its primary duty to protect patients and maintain confidence in the healthcare system The extent of the failure of the system shown in this report suggests that a fundamental culture change is needed Aspects of a negative culture have emerged at all levels of the NHS system	Primary cause: failure of the Trust Board Secretary of State for Health in announcing inquiry: this was a failure of the Trust first and foremost, but it was also a national failure of regulatory and supervisory system As in the first inquiry, the evidence shows that an unhealthy and dangerous culture pervaded not only the Trust, but also the system of oversight and regulation as a whole and at every level Echoes of the cultural issues found in Stafford can be found throughout the NHS system