Recommendations set out in Bewick report

A SERIES of recommendations are set out in the 39-page Bewick report.

Among them it calls for a review of deaths in haematology, including a retrospective review of deaths first analysed by whistleblower Dr Emmanouil Nikolousis, a former consultant at the trust.

He raised the alarm about a series of deaths in 2017, in a report which he said was later shelved without action.

The trust now needed to revisit his findings and, in addition, review all deaths in haematology in 2021-22, said the report. There should also be a probe into how well integrated the haematology departments of Heartlands Hospital and UHB are following their merger in 2018, widely seen as a catalyst for problems.

There also needs to be an external review into a series of “Never Events” – so called because they should never happen – linked to haematology transfusions.

This follows seven incidents when patients received the wrong blood or other avoidable errors occurred.

In addition, the report calls for a further external review into the hospital’s mortality rate, which is 10% higher than comparable trusts. Claims that this is explained by a difference in coding need to be investigated and future mortality statistics closely monitored. Other recommendations include:

A “reconciliation” unit should be set up to improve relationships within the organisation and prepare for “recovery” which is needed to allow staff and patients to feel secure, overseen by a non executive director.

The trust should also commission a partner to deliver awareness training on how to identify bullying, coercion, intimidation and misogyny.

The role of Freedom To Speak Up Guardian should be reviewed and offer all staff confidential and secure environments to report any past or current issues they have been reluctant to speak about

Adopt a “no blame” culture, reinforced when whistle-blowers report concerns

The Council of Governors – set up as an extra layer of scrutiny involving local residents – needs to develop a more active role in holding senior leaders to account.