News

The only lesson

August 18 2023

7 murdered babies. Attempts to murder 7 more.

A hospital’s reputation in ruins.

(Oh – and another inquiry to report on all the lessons to be learnt. Like the ones not learnt from previous inquiries. Just as these ones won’t be.)

It is not too cynical to say that care for the hospital’s reputation – rather than investigating serious concerns about staff responsible for babies in their care – was almost certainly one of the main reasons why senior NHS managers, many of them trained doctors and nurses, sought over a year to dismiss and disregard repeated concerns and red flags raised by doctors about Lucy Letby, the nurse found guilty of those murders.

They didn’t just ignore them. According to this Panorama report, they warned off the doctors, threatening them with “consequences“, including possible referral to the GMC. A line had apparently been crossed by daring to criticise a nurse described as “nice Lucy“. After two triplets died, duty executive Karen Rees, who refused to take Letby off duty against the wishes of 7 consultant paediatricians, was asked if she would take responsibility for anything that might happen to other babies and replied “yes“. We will learn now, won’t we, what value to place on that “yes“.

Why do senior executives do this? To protect the institution’s reputation is the usual reason. It never works. When you fail to look into concerns when first raised – and it really doesn’t matter which sector you’re in – the NHS, the police, banks, the press, Parliament, the army, the Guides, churches, the Post Office, oh just about anywhere, let’s face it – these are the consequences:

  • A small problem turns into a bloody big crisis.
  • You trash your reputation
  • You lose trust.
  • You’ll be clearing up the mess for years.
  • It will take longer than you can possibly imagine to rebuild that trust. Do not fool yourself into believing that quickly shuffling some people around (even out), some shiny new procedures and training, no matter how brilliant, will do it.

It is not the first time the NHS has got itself into these sorts of difficulties. Its treatment of whistleblowers has long been appalling. Similar events happened – and for many of the same reasons – at the Gosport War Memoral Hospital (see my commentary here on the report issued in June 2018). And that is only one of many. NHS management seems utterly oblivious to The Public Interest Disclosure Act 1998. The NHS – like the police – is one of those sacred cows that confuses the importance of its function with the importance of the institution and the egos of those running it, focused on their Key Performance Indicators (none of which would have included “murders solved“). This is a fatal flaw, inimical to the establishment of a healthy work culture. Politicians – those available in the foreseeable future anyway – are unwilling or unable to challenge or change this.

There is another reason why senior staff behave like this.

Cowardice.

Taking a concern seriously means exercising judgment and taking action. The judgments to be made will be difficult. There is no procedure which can act as a substitute for good judgment. The actions will often be tough. So it is easier – much easier – to do nothing (or the minimum you think you can get away with) and tell those bringing unwelcome news to keep quiet.

Senior staff would do well to remember these words:

All organizations have bad apples but what an organization ….. also has is well paid and exquisitely educated bosses, part of whose job is to spot these bad apples and, if they are spotted, deal with them.”

Who said this? Andy Webb, the BBC journalist, who uncovered the story of how Martin Bashir and Panorama (oh, the irony!) got that interview with Diana, in May 2021. He said about the bosses who failed to do anything about the ethical breach they knew had happened: “It’s my feeling the bosses were not brave enough …. and it prompted the cover up.”

Not brave enough. That’s the only lesson to learn right there.

The Acid Test

May 30 2021

Who said this, about what and when?

All organizations have bad apples but what an organization ….. also has is well paid and exquisitely educated bosses, part of whose job is to spot these bad apples and, if they are spotted, deal with them.”

It could have been said about any number of organizations over the years.

In fact, it was said last week about the BBC. It was said by Andy Webb, the journalist who uncovered the facts about how Martin Bashir got that interview with Diana and the – even worse – scandal of how this was covered up over the years by the BBC.

There is much that is familiar in this story:

  • wrongdoing – in particular, immensely profitable (both financially and reputationally) wrongdoing;
  • a “star” who can seemingly do no wrong and is protected by his bosses;
  • whistleblowers who are ignored or punished;
  • a wholly inadequate initial investigation;
  • an eventual critical external report, continuing reputational and other damage and one hell of a mess to clean up.

As always, it is the response to and cover-up of the initial wrongdoing which causes most problems.

But it was what Andy Webb said next which goes to the heart of the issue of all wrongdoing and the culture change necessary to minimise it and its consequences –

It would have been a huge ask of the Head of a News Division, having recently seen the most famous, the most significant piece of news coverage in the Corporation’s history, having gone round the world, having won prizes and plaudits, how much moral courage do you need to pull the plug on the story …. by saying that it was gained through an egregious ethical breach? Who would have been brave enough to do that? It’s my feeling the bosses were not brave enough to do that and it prompted the cover up.”

This is the acid test. A two-part test, really.

  • When a high earner, a star, a prize winner misbehaves, will the bosses have the moral courage to pull the plug?
  • And are those lower down the pecking order confident that this is what the bosses will always do?

Moral courage is at the heart of professionalism, at the heart of any successful, worthwhile, sustainable culture. It is its absence which so often allows small problems to become big ones. Building, reinforcing and rewarding the courage necessary to take difficult steps, to be open about what you are doing and why are at the heart of any successful culture change programme.

This time the BBC has been found wanting. But how many other organisations can honestly answer yes to both questions?

Photo by Varvara Grabova on Unsplash

Same old, Same Old

March 30 2021

Perhaps there was a clue in the name: Archegos. Arch. Egos. As a description of many in finance it can scarcely be bettered. A novelist might even think it a tad too unbelievable, unless you were seeking to write satire.

But why bother when reality serves it up on a plate.

The founder of Archegos Capital Management, Bill Hwang described himself in 2008 as “like a little child looking for where can I invest to please our God.” Not long after – in November 2009 – Goldman Sachs’s Lloyd Blankfein described  bankers as “doing God’s work“. Oh dear. The full extent of what bankers had been doing had yet to reveal itself, whether to God or anyone else. Still, PR advisors would do well to note that such statements do not impress. Rather they tend to bring to mind the Ralph Waldo Emerson quote:

The louder he talked of his honour, the faster we counted our spoons.”

Back to Mr Hwang. At the time of his humblebrag he was running Tiger Asia Management, which ended up being one of the largest investors in the expanding and profitable Asian market.

What God thought of Mr Hwang’s activities is unknown. What the SEC thought is, however. For in 2012 following a lengthy investigation, also involving the HK regulator, he pleaded guilty to insider trading and manipulation relating to trading in various Chinese stocks in late 2008 / early 2009. Surely not when he was trying to please God? Yes, apparently so.

A humongous fine inevitably followed. And almost as inevitably, the following year in 2013 Tiger Asia Management was wound up and Archegos rose, Phoenix-like in its place.

Now it is in trouble as a result of risky and very large investments having soured. Also in trouble are a number of banks which funded it, provided it with services and helped it trade. Questions no doubt are being asked – and, if not, they should be – about banks’ exposure to the firm, was this within risk limits, why so much leverage and so on. Other questions might also be asked: what due diligence was done? Was a fund run by a convicted insider dealer really a suitable client? How was it monitored? And so on.

Still, since bragging seems to be the fashion, might I modestly refer you to this article and my comments on what is often found when something goes wrong: “…so often, in virtually every case, there were bloody great red flags, or there was a clue that was missed.

The name might have permitted a wry smile. Mr Hwang’s track record should not have done. Does no-one ever read this stuff?

 

Photo by Orkun Azap on Unsplash