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.

April 6 2021

First – a definition.

“Lessons learnt: lessons which are never learnt by those who need to learn them.”

Today we learn that Credit Suisse has lost 4.4 billion Swiss francs following Archegos’ failure. This comes on top of its problems with Greensill, now in administration. This will result in a first quarter loss of ca. 900 million Swiss francs and has already led to the departure of its Head of Investment Banking and Chief Risk Officer.

A world of pain awaits.

– There may be more departures. Others will be nervous about the scrutiny now being given to past decisions.
– There will be internal investigators, internal audit, external investigators, lawyers, accountants and regulators crawling over thousands of internal documents.
– The remediation costs will be horrible.
– Clients whose money was invested in these ventures will need to be pacified if legal action is to be avoided.
– Enforcement action from regulators may follow. Scrutiny by them certainly will.
– It will be urgently looking to see where else it has made similar mistakes.

And a number of other banks also involved with these two entities will be undergoing something similar, though with less publicity. They have either had – or will have in due course – their turn in the sun.

Still, it’s not all bad news. The Chief Executive has said that “Serious lessons will be learnt.”

Would it be unkind and/or tactless to say that if it had learnt any of the serious lessons that were available to be learnt from the many similar disasters over, ooh I don’t know, the last couple of decades or so, they might not have had to learn them now and that £3.4 billion would still be in the bank?

It would. Oh well. Never mind. Let me update the definition instead.

“Lessons learnt: lessons which are never learnt by those who need to learn them, until it is too late.“

Photo by Tom Pumford on Unsplash

February 14 2020

In March 2017 PC Keith Palmer was killed while defending Parliament from a terrorist. In August 2019 PC Andrew Harper was killed while investigating a suspected burglary. These are only 2 of the 50 police officers killed between 1990-2010. Few of us face the risks ordinary police officers run. This does not excuse what is set out below. It does explain why it is so necessary, if their work and sacrifices are to be worthwhile and the public gets the policing it is entitled to, that the issues raised below be properly addressed.

What follows is not a comprehensive list of every scandal affecting the police. But it is an overview of their range over five decades.

1. 1972-1977: Sir Robert Mark’s campaign to root out corrupt officers within the Flying Squad and CID, resulting in more than 500 officers being dismissed or “resigned”. He memorably stated: “a good police force is one that catches more crooks than it employs”.
2. 1974-1989: The West Midlands Serious Crime Squad – eventually wound up after allegations of incompetence, malpractice and abuse of power, leading to over 100 cases collapsing or being overturned on appeal. An investigation into its activities led to some disciplinary action but no prosecutions, a decision for which the DPP (Barbara Mills) was severely criticised.
3. 1970’s: The activities of various police forces in the Irish miscarriage of justice cases – the Guildford Four (1974), the Birmingham Six (1975), the Maguire Seven (1976).
4. 1978-1982: Operation Countryman – an investigation into corruption within the Met and City of London Police in the late 1970’s. Information was released in 2018 about efforts made by the Met and the DPP (Sir Thomas Hetherington) to cover up the scale of wrongdoing and obstruct the investigation by the Hampshire and Dorset police.
5. 1979: The death of Blair Peach during an Anti-Nazi League demonstration against the National Front in Southall. In 2010 a police report stated it was likely that a Metropolitan Police officer “struck the fatal blow” and attributed “grave suspicion” to one unnamed officer, who may also have been involved in a cover-up with two colleagues.
6. 1981: Operation Swamp, the subsequent Brixton riots and the Scarman report into how the police used their “stop and search” and other powers.  Numerous recommendations were made.
7. 1980’s – 2010: South Yorkshire Police’s failures in the Rotherham child exploitation scandal. The Jay Report described how the police failed to investigate adequately or at all the reports they were receiving over at least a decade of child sexual grooming.
8. 1989: The Hillsborough stadium tragedy. Two reports – the 1990 Taylor Report and the 2012 report by the Independent Panel – described the extent of South Yorkshire Police’s negligence, attempts to shift blame on others and pervert the course of justice.
9. 1993: The investigation into Stephen Lawrence’s murder and the resulting 1999 Macpherson Inquiry which found that many Scarman recommendations had not been implemented. Macpherson, unlike Scarman,  described the police as “institutionally racist”. Subsequently it was revealed the police had spied on the Lawrence family.
10. 2003-2020: The failures of the Greater Manchester Police in relation to Operation Augusta and child sexual exploitation, described in the Newsam report published this week. The report’s statement that: “The authorities knew many were being subjected to the most profound abuse and exploitation but did not protect them from the perpetrators. This is a depressingly familiar picture and has been seen in many other towns and cities across the country.” could apply to a number of places and police forces round the country.
11. 2006-2011: Allegations were made during the News International inquiry that the police were selling confidential information to journalists. This was to be looked at in the second stage of the Leveson Inquiry which never went ahead.
12. 2009: The death of newspaper seller, Ian Tomlinson, as a result of police assault during G-20 summit  protests.
13. 2011:  It’s revealed that various undercover policemen had infiltrated environmental groups for a number of years, entering into deceitful relationships with activists and fathering children. In 2015 the Met apologized to women “tricked into relationships” over 25 years, closed the units and made financial settlements of circa £3 million. An “Undercover Policing Inquiry” into “appalling practices” in undercover policing was set up. It has yet to report.
14. 2012 onwards: Cleveland Police has 5 Chief Constables in 6 years, the first in this list being dismissed for deceit and misconduct. In 2019 it is put into special measures following an independent report describing it as “inadequate” in all fields, “directionless, rudderless and clueless”, “putting the public at risk” with some officers “not acting with honesty, integrity and competence“.
15. 2014: Operation Midland into child abuse allegations made by Carl Beech against politicians and others is launched. In 2019 following his conviction on multiple counts of perverting the course of justice, the Henriques Report identifies extensive failings in the original investigation.
16. 2015: Police Scotland are criticised by a judge for breaching data privacy laws and the ECHR when spying on journalists and their communications with their sources. Similar breaches were committed by Cleveland Police.
17. 2018: The Met’s anti-corruption unit is under investigation for corruption in relation to allegations of assault, racism, child abuse and child grooming.
18. 2018: Cliff Richard is paid £400,000 by the South Yorkshire Police for its behaviour over the raid on his home in relation to historic child sex abuse allegations, including informing the BBC about the raid.
19. 2005 to date: there have been 4 Metropolitan Police Commissioners. Ian Blair resigned after falling out with the London Mayor; his successor resigned because of his links with one of the journalists implicated in phone hacking; Hogan-Howe lasted 6 years. Under his leadership Operation Midland is set up and people arrested under Operation Yewtree and bailed for lengthy periods without charge, a practice later banned. His replacement in 2017 is Cressida Dick, the senior policewoman in charge when a blameless electrician was killed in 2005 following terror attacks.
20. 2020: The Met refers itself to the police watchdog for its failure to act on recommendations made by Sir Richard Henriques to investigate two others for perverting the course of justice in relation to abuse allegations arising from Operation Midland.
21. 2020: A review led by a former Met Police Commissioner states that the police are unable to deal with a huge increase in fraud cases.
22. 2020: This month a report by HMICFRS on all 43 police forces states that the public has lost faith, having “rumbled” that the police are unable to investigate most crimes. The charging rate in the year to March 2019 fell to 7.8% of all reported crimes in England and Wales.

It is a dismal list. It could be twice as long.

To a financial investigator, this picture is very familiar. Despite innumerable inquiries, changes in the law, disciplinary proceedings, recommendations, new procedures, training, apologies, compensation paid, some prosecutions and that perennial favourite – “lessons have been learnt” – bad, criminal behaviour (which all the people doing it would clearly have known was wrong) and incompetence have repeatedly occurred in forces all over the country over decades. Not one or two “rotten apples”; whole orchards of them. There has been a culture of poor leadership, cover-up or the truth only coming out many years later and of other key agencies turning a blind eye, aiding and abetting or failing to set or demand high standards of probity and professionalism.

Above all, there has been a failure to ask why such problems keep on happening, despite all the remedial steps taken and all the apparent learning of all those lessons.

It is irrelevant that there are many policemen, possibly even the majority, who don’t behave in this way. The same could be said of banking. The professionalism, hard work and good name of the honest good guys are tarnished by the bad, useless ones. The bad drive out – and demoralise – the good.

Policing depends on consent. Trust is essential to that consent. Scandals and incompetence erode that trust. How can our cherished system of policing work then?

Perhaps – like banking – it is time to realise that there is something systemic and deep-rooted and toxic in police culture which allows or encourages or does not stop officers from behaving badly. Perhaps – like banking – it is time to make the hard cultural changes needed if training and rules are to work. Perhaps – unlike banking – it is time for senior leaders to take real responsibility not merely talk about it. Perhaps – like banking – it is time to realise that even successful or vital sectors or professions can in reality be really rather more second-rate than we like to pretend. Perhaps we should stop deluding ourselves that our key institutions are as good as we sometimes rather vaingloriously claim. The police are not the only body of which this could be said, of course.

Law and order are the most basic functions of the state. But the police should not be treated as a sacred cow. A comprehensive, dispassionate and ruthless look at how the police operate and real tough action to change it for the better are needed.

What are the chances?