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Trust’s directors scapegoated psychiatrist over patient’s death, tribunal finds

Published on: 25 Oct 2021

A mental health trust ‘scapegoated’ a psychiatrist over the death of a patient amid systemic issues, an employment tribunal has found.

Judges called the conduct of two senior directors — one of whom is a current NHS trust medical director — into question after ruling they had colluded to scapegoat Bernadette McInerney for issues that would have damaged the trust’s reputation.

Nottinghamshire Healthcare Foundation Trust was found unanimously to have unfairly sacked and victimised Dr McInerney, a former consultant forensic psychiatrist at Rampton secure hospital, in a decision published last week.

The judgement was critical of both Chris Packham, a GP at Rampton hospital, and NHFT’s then-executive medical director Julie Hankin, but it also strongly condemned the trust’s former executive director for forensic services Peter Wright. Dr Hankin is now medical director at Cambridgeshire and Peterborough FT.

It said: “[NHFT] has displayed throughout a pattern of conduct which was self-serving of both [the trust] and senior employees in the form of Mr Wright, Dr Hankin and Dr Packham.

“Mr Wright, in particular, through his unreliable evidence and total lack of respect for and knowledge of the [trust’s] own policies, contrived, in our view, to use [Dr McInerney] as a scapegoat in order to avoid a prevention of future death letter from the coroner and further intervention from the CQC.”

‘Flawed’ process

A serious untoward incident inquiry was launched after a patient, referred to as CW in the judgement, took her own life in the high secure women’s service at the hospital in February 2016.

CW had “very complex psychiatric problems” and was 25 years old at the time of her death, it said.

A report by consultant forensic psychiatrist Edward Silva, who works at Ashworth hospital and was appointed to oversee the inquiry, criticised Dr McInerney for not producing paper records of her care of CW.

He also criticised Dr McInerney’s “lack of effective treatment” for schizophrenia, as well as the trust allegedly failing to “learn lessons” from the death of another patient, who was not named, six months earlier in August 2015.

The tribunal judgement said Dr McInerney could not access the paper records for “obvious ethical reasons,” while CW was not treated for schizophrenia because it was concluded she did not have it.

Judges were critical of Dr Silva, who did not give evidence at the tribunal, and denounced his investigation and report.

They added NHFT, through Dr Hankin and Mr Wright, “did absolutely nothing” to heed complaints from members of staff, and that they “remained silent” when Dr Silva blamed Dr McInerney for CW’s death “even though he could not have reasonably concluded she suffered from schizophrenia”.

A maintaining high professional stands probe, led by Fiona Mason, who is an independent practitioner and honorary consultant with NHFT, also criticised Dr McInerney for a “poor standard of care” in the six months leading up to CW’s death.

Dr McInerney had alerted to the existence of documents recording her care of CW, which Dr Mason asked Mr Wright for. The judgement said Mr Wright did not do this, nor did Dr Mason follow up her request, and so her report was completed without them.

The tribunal said the MHPS probe was “flawed,” adding: “We do not accept that Dr Mason could have carried out a fair and thorough investigation without [Dr McInerney’s report of] factual inaccuracies and the documents lately found by [NHFT].”

It suggested that Dr Packham’s “various amendments” to the terms of reference for Dr Mason’s investigation were “an attempt to focus attention on the alleged shortcomings of [Dr McInerney’s] care and away from systemic issues at the Rampton”.

“They clearly had the effect of confusing Dr Mason,” the judgement said.

An inquest was held into CW’s death in 2017, where the coroner asked NHFT to find documents that Dr McInerney had alerted it about, which related to the deceased’s care.

They were found within a “short period of time,” the judgement said, and the unnamed coroner concluded she was satisfied with the standard of care provided by Dr McInerney.

At an informal meeting in February 2018, Dr McInerney was presented with three alternatives by Dr Packham following the MHPS probe – resign, retire or face a conduct hearing – according to the judgement.

She elected to retire early.


Employment judge Michael Butler said judges’ concerns about the reliability of the trust’s witnesses grew “on an almost daily basis,” adding: “It is clear from the evidence of Dr Hankin and, in particular, Dr Mason, that there were systemic issues at Rampton [hospital] involving the care of patients.

“Despite this, there was not a shred of evidence given that these systemic issues were ever addressed by [NHFT]. However, those issues were clearly addressed in relation to [Dr McInerney].”

He added: “We had no doubt that there was extreme concern, principally in the minds of Mr Wright and Dr Hankin, that the Rampton would be heavily criticised by the coroner and might receive a prevention of future death letter.

“Given the criticisms and warnings from the [Care Quality Commission] already in place in relation to a previous death in 2015, this would have reflected incredibly badly on Rampton hospital.

“We believe it was clearly in the minds of Mr Wright and Dr Hankin to blame [Dr McInerney] by highlighting issues with her record-keeping, despite the fact they applied to other consultants.”

The tribunal formed a “very strong impression” that Dr Hankin, Dr Packham and Mr Wright were “intent upon seeing” that Dr McInerney was removed from her post “one way or another”, the judgement said.

It added that they “did this in a manner which was calculated or likely to ruin her reputation to better lay the blame for CW’s death at her door”.

NHFT chief executive John Brewin told HSJ: “The trust respects the employment judge’s decision in this case, which involved complex issues over a number of years, and we apologise to Dr McInerney in relation to the matters set out in the decision.

“The trust will work through the lessons learned and share the learning with colleagues.”

Dr Hankin became executive medical director at Cambridgeshire and Peterborough FT in March this year after leaving NHFT.

A CPFT spokesman said the trust is “aware” of the tribunal and its findings, adding: “We have started an internal process to review the outcome of this tribunal.”

Mr Wright has become a business development manager at Lincolnshire Action Trust since leaving NHFT, a charity that works with agencies to reduce re-offending. HSJ has contacted them for comment.

A CQC spokesman said: “Providers are not obliged to inform us of employment tribunals and it would not be appropriate to comment on an individual case.

“However, we will be following up with the provider in relation to the patient death outlined in the tribunal findings.”

A Mersey Care FT spokesman told HSJ the trust was aware Dr Silva formed part of the investigation and that he was not required to give evidence at the tribunal.

He said the trust would not be responding to the tribunal’s comments, but added: “Mersey Care puts a high priority on being a learning organisation and will be reviewing the findings of the tribunal.

“The trust will look at the way the SUI was handled in line with our own values and practices.”

Dr Mason responded when approached but directed HSJ to NHFT ahead of a response from the trust.

UPDATED, 27 October 2021: This article has been updated to include comments from Mersey Care FT