Independent investigation into governance arrangements in

136 Pages·2015·1.45 MB·English

Independent investigation into governance arrangements in
the paediatric haematology and oncology service at
Cambridge University Hospitals NHS Foundation Trust
following the Myles Bradbury case

A report for Cambridge University Hospitals NHS Foundation Trust

October 2015
Authors:
Lucy Scott-Moncrieff
Barry Morris

© Verita 2015

Verita is an independent consultancy that specialises in conducting and managing
investigations, reviews and inquiries for public sector and statutory organisations.

This report has been written for Cambridge University Hospitals NHS Foundation Trust and
may not be used, published or reproduced in any way without its express written
permission.

Verita
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Contents

1. Introduction 1
2. Terms of reference 3
3. Approach and methodology 5
4. Executive summary and recommendations 9
5. Timeline/narrative 20
6. Paediatric haematology and oncology services at the trust 23
7. What happened once a concern was raised about Dr Bradbury’s behaviour 30
8. Governance arrangements and Dr Bradbury’s compliance 43
9. Other behaviour by Dr Bradbury which did, or could have, facilitated abuse 63
10. Safeguarding 77
11. Changes made by the trust 95
12. Learning from elsewhere 107
13. Meeting with Dr Bradbury 127
14. Conclusion 131

Appendices

Appendix A List of interviewees 134
Appendix B Documents reviewed during investigation 136
Appendix C Questionnaire to families that contacted Verita 139
Appendix D Myles Bradbury curriculum vitae 142
Appendix E Layout of paediatric day unit 152
Appendix F Letters sent to families by Cambridge University Hospitals 153
Appendix G Cambridge University Hospitals chaperone policy, updated April 2014 154
Appendix H Revised appointment letter with chaperone policy sentence 159
1. Introduction

1.1 Dr Myles Bradbury was employed as a paediatric haematologist in the paediatric
haematology and oncology service at Cambridge University Hospitals (CUH) NHS
Foundation Trust (the trust). In November 2013, the family of a patient raised a concern
about possible inappropriate behaviour by Dr Bradbury. Senior staff were alerted at once.
He was immediately removed from clinical duties, then excluded from clinical duty the
following day, and did not return to the trust. Following investigations by the police, Dr
Bradbury was formally charged in July 2014 with 11 offences against children under his
care. Following further investigation, he pleaded guilty in September 2014 to 25 sexual
offences against 18 children who had been his patients, as well as to charges of voyeurism
and possession of indecent images. He was sentenced to a total of 22 years’ imprisonment,
with the judge emphasising the seriousness of the breach of trust that these offences
displayed.

1.2 Dr Bradbury appealed against the length of his sentence, and on 12 June 2015 the
Court of Appeal, while upholding the length of the sentence, restructured it to 16 years’
imprisonment and six years on licence.

1.3 Following the conviction of Dr Bradbury, the trust commissioned Verita, a
consultancy specialising in public sector investigations, reviews and inquiries, to carry out
an independent investigation into governance arrangements within its paediatric
haematology and oncology service.

1.4 The investigation team was led by Lucy Scott-Moncrieff, supported by Barry Morris
and administrative staff from Verita. The team is referred to as “we” from this point on in
the report. We were assisted by advice from Donald Findlater director of research and
development at the Lucy Faithfull Foundation, Dr Mike Bewick, former deputy medical
director NHS England, and Jane Held chair of both the Leeds Safeguarding Board and the
Birmingham Safeguarding Children Board.

1.5 The purpose of the independent investigation is to establish how Dr Bradbury was
able to carry out his activities, how his offending behaviour went undetected for so long,
and what lessons there are to be learnt for the service, the trust and the wider NHS, with
the aim of ensuring that services today are safe and appropriately governed so that
children are safeguarded.
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1.6 The trust has remained in contact with the local safeguarding children board
(LSCB), the body responsible for recommendations for serious cases reviews (SCR). LSCB is
of the view that the investigation undertaken by Verita was sufficient for the lessons
learned to have been identified without the need for an SCR.

1.7 The trust is one of the largest in the UK. It comprises Addenbrooke’s Hospital
(general and specialist care) and the Rosie Hospital, which offers women’s and maternity
care. It has about 7,600 (full-time equivalent) staff, 1,000 beds, and an annual income of
£661 million.

1.8 As well as delivering care through Addenbrooke’s and the Rosie, the trust is also:

 a leading national centre for specialist treatment for rare or complex conditions;
 a government-designated biomedical research centre;
 one of only five academic health science centres in the UK;
 a university teaching hospital with a worldwide reputation; and
 a partner in the development of the Cambridge Biomedical Campus.

1.9 Addenbrooke’s has a dedicated unit for children with cancer and blood disorders.
This treats children with solid tumours and those with malignant blood diseases such as
leukaemia. It also treats children with non-malignant blood disorders such as haemophilia.
The hospital is a tertiary centre for paediatric oncology and haematology; it sees patients
needing its specialist input from a catchment area covering the east of England. The unit
consists of an inpatient ward and a linked unit for outpatient appointments for children
needing day treatment who do not require inpatient admission.

1.10 The inpatient ward is called C2 and the outpatient/day patient part of the unit is
called the paediatric day unit (PDU).

1.11 The PDU is where Dr Bradbury committed his offences.
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2. Terms of reference

2.1 The trust started an internal investigation into Dr Bradbury’s activities but
abandoned this in favour of an independent investigation. The independent investigation
was commissioned by the chief executive on behalf of the trust board. Its terms of
reference state:

1. The investigation team will:

• Produce and comment on a detailed timeline setting out key events relating
to Dr Bradbury focusing on the period 2009 - 2013 (but will consider earlier
events if necessary).

• Set out the relevant governance arrangements in place for the paediatric
haematology and oncology department from April 2009 to August 2013 and
report on the extent to which they were complied with. This will include
reviewing:

o All relevant policies including chaperone policy, appointments policy
and case allocation policy
o The quality of safeguarding training and its uptake
o The safer recruitment practice
o Annual appraisal of Dr Bradbury and others involved in the service

• Identify and comment on what was known about Dr Bradbury’s
inappropriate behaviour, when and by whom, including review of pre-
employment checks.

• Identify and comment on any action taken in respect of Dr Bradbury’s
inappropriate behaviour.

• Inform patients/families of the investigation and engage with those
patients/families who wish to contribute.

• Comment on any changes already made to the governance arrangements in
the light of matters concerning Dr Bradbury.
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• Report on any other relevant matters that arise in the course of the
review.

• Provide a written report containing clear recommendations aimed at
learning any lessons from these events.

2. It is not the role of this investigation to review the 18 cases (used in the
criminal case) of abuse individually. Aspects of individuals’ treatment may
be reviewed as part of this investigation when identifying themes in Dr
Bradbury’s offending and whether the trust’s systems and processes were, in
any way, a contributory factor in the offences.

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3. Approach and methodology

3.1 The police investigation of Dr Bradbury and his subsequent sentencing took place
during an unprecedented period of public debate and concern about the sexual abuse and
exploitation of children. In 2012 revelations about Jimmy Savile in a TV programme led to
the setting up of Operation Yewtree, which resulted in hundreds of allegations of
historical child sexual abuse being made against not only Savile but also many other
individuals, some of them household names. Prosecutions arising from these allegations
have been taking place ever since, and some well-known individuals have been found
guilty and imprisoned.

3.2 At the same time, evidence has been emerging of organised and extensive sexual
abuse and exploitation of children and young people by gangs and groups across the
country. This sort of abuse came to national and international attention with the
publication of Professor Alexis Jay’s report on abuse in Rotherham, published in August
2014.

3.3 During 2014 and 2015 Lucy Scott-Moncrieff, with Verita’s assistance, was writing a
report commissioned by the Secretary of State for Education on the extent and nature of
child sexual abuse in schools and children’s homes, and how the authorities recognised
and dealt with the problems The risks of sexual abuse and child sexual exploitation for
schools and children’s homes post-Savile.

3.4 As a result of this work, as well as the reports of the various investigations
published during the past three years and the evidence at the trials arising from Operation
Yewtree, we came to this investigation well aware of the ways in which evidence of child
sexual abuse could be ignored, overlooked or suppressed. We knew that there had been no
official suspicion of Dr Bradbury before the family raised a concern in November 2013, and
we were alert to the possibility that there might have been earlier evidence that had been
ignored, overlooked or suppressed.

3.5 We considered published reports of previous reviews following the convictions of
senior health staff for sexual offences committed on their patients. We noted the tactics
they used to offend for some considerable time without detection. We looked for evidence
of such tactics by Dr Bradbury. In section 12 we set out the concerns raised in those
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reports and consider their relevance to Dr Bradbury’s behaviour and the trust’s systems
and processes.

3.6 In the course of our investigation we identified or were told of a number of matters
that, in retrospect, could be seen as clues to Dr Bradbury’s criminal behaviour. Much of
our questioning therefore focused on what his colleagues knew or deduced, or should have
known or deduced, about these matters. We have set out these behaviours and the way in
which they were seen at the time in section 8.

3.7 In writing our report we are acutely aware of the sensitivities of present and past
patients of the paediatric oncology service at Addenbrooke’s, and their families. As we
explain in section 7, some families whose children may have been abused by Dr Bradbury
have chosen not to seek clarification, to protect their children. The trust and the police
have respected this choice, as do we, and we have attempted to reflect this in the way we
have written the report. We have not given specific details of the areas from which Dr
Bradbury’s patients were drawn, nor details of the nature of the assaults carried out by Dr
Bradbury, except to say that they were presented as necessary physical examinations. For
the avoidance of doubt, we can confirm that they did not involve penetration of any kind.

3.8 Of course all these details are known to the trust and the police, who have both
told us that they will willingly respond to any query from any patient, or the family of any
patient who was treated by Dr Bradbury.

3.9 We sought an interview with Dr Bradbury, via his solicitor, to obtain information
relevant to our terms of reference: we wanted to give him an opportunity to comment on
what others had said about his behaviour, with a view to informing the recommendations
we were asked to make to learn lessons from these events’.

3.10 Dr Bradbury agreed to our request and we interviewed him in prison, after his
appeal was heard and towards the end of our investigation.

3.11 We interviewed all the consultants on the PDU, CUH’s safeguarding lead and the
other staff listed at appendix A. We wrote to all the other staff on the unit, inviting them
to contact us if they felt they had any information relevant to the terms of reference.

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3.12 We reviewed a significant number of policies and other documents (details set out
in appendix B).

3.13 We interviewed a senior nurse from the general paediatric outpatients department
to discover whether relevant practices on the PDU were similar in that unit, and, if not,
why not.

3.14 The interviewees were told that they could be accompanied by a colleague or a
friend, or a member of a professional body or trade union. With the agreement of the
interviewees, the interviews were recorded and a transcript sent to them. This enabled
them to verify the accuracy of what was said, and propose amendments to the transcript
to ensure that it reflected what they intended to say.

3.15 We wrote, via the hospital, to the patients, or the families of patients who had
been treated by Dr Bradbury since his appointment as a consultant at CUH in 2008. We
received responses from 11 families, to whom we sent a brief questionnaire (see appendix
C). We received five responses to the questionnaire, as a result of which we interviewed
the families of three patients. Where the questionnaire responses did not suggest that the
family could shed any light on our terms of reference, but indicated that the family was
looking for support or answers to questions about their child’s experience at the hospital,
we referred them to the trust.

3.16 We visited Birmingham Children’s Hospital (where Dr Bradbury had previously
worked) and interviewed a consultant in the oncology department about policies and
procedures there.

3.17 We interviewed senior staff at the General Medical Council and spoke to a senior
member of the Royal College of Paediatrics and Child Health to discuss how it publishes
information for hospitals and doctors on lessons it learns from their work.

3.18 We met Donald Findlater, an expert from the Lucy Faithfull Foundation, a
registered child protection charity which works across the UK to prevent child sexual
abuse.

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