The Kerr/Haslam Inquiry Volume 1 of 2 The Kerr/Haslam Inquiry (Volume 1 of 2) Cm 6640 – I £97.50 The Kerr/Haslam Inquiry Volume 1 of 2 Presented to Parliament by the Secretary of State for Health by Command of Her Majesty July 2005 Cm 6640 – I £97.50 © Crown Copyright 2005 The text in this document (excluding the Royal Arms and departmental logos) may be reproduced free of charge in any format or medium providing that it is reproduced accurately and not used in a misleading context. The material must be acknowledged as Crown copyright and the title of the document specified. Any enquiries relating to the copyright in this document should be addressed to The Licensing Division, HMSO, St Clements House, 2–16 Colegate, Norwich NR3 1BQ. Fax: 01603 723000 or e-mail: [email protected] Contents Foreword by the Chairman of the Inquiry Executive summary and Recommendations Section One: The Background Chapter 1: Establishing the Inquiry Establishing the Inquiry Chapter 2: The conduct of the Inquiry Form of Inquiry Delays to the Inquiry process Involvement of William Kerr and Michael Haslam Scope of Terms of Reference Part one: oral hearings Part two: seminars Preliminary issues Chapter 3: Introduction to concerns and complaints The range of concerns and complaints Defining a concern or complaint Establishing whether a concern or complaint was in fact communicated Assessing the response to concerns and complaints Chapter 4: The Report in context The vulnerability of psychiatric patients The effect of the passage of time Gaps in the story and the loss of documents The nature of the allegations The benefits and the limitations of a private inquiry Chapter 5: The factual background to the Inquiry The organisation of the NHS in North Yorkshire NHS organisation structure – North Yorkshire NHS personnel organisation structure – North Yorkshire Section Two: The William Kerr Story Chapter 6: William Kerr – The Early Years Qualification Marriage Northern Ireland Appointment to North Yorkshire Chapter 7: The expression of concerns and complaints by patients Introduction The rumours A summary of concerns and complaints raised by patients, 1965 to 1988 The detail of the concerns and complaints 1965 to 1988 Introduction Uncertain disclosures Confrontation with William Kerr Disclosures after William Kerr’s retirement Other non-complainants Conclusion Survey of concerns and complaints raised by patients, 1965 to 1988, at a glance Chapter 8: The Bigwood concern: A written allegation of serial sexual misconduct Introduction The Bigwood story in detail Conclusions Chapter 9: The response to complaints/concerns about William Kerr Introduction The response to the Linda Bigwood complaint Dr Turner The Patient A17/Linda Bigwood story – an end piece Chapter 10: Patients who made no contemporaneous complaint Introduction The patients who did not complain at the time Chapter 11: The retirement of William Kerr and voluntary erasure William Kerr’s retirement William Kerr’s ill health Voluntary erasure Chapter 12: The Trial of William Kerr 1997 police investigation The Trial of the Facts Outcome of the trial Chapter 13: Overview and timeline Overview Timeline Section Three: The Michael Haslam Story Chapter 14: Michael Haslam – The early years Qualification and early career Arrival in North Yorkshire Chapter 15: Treatments and procedures carried out by Michael Haslam Introduction Somlec Carbon dioxide inhalation therapy Kirlian photography Massage Hypnotism Recommendations Chapter 16: The expression of concerns and complaints by patients The detail of the patient concerns and complaints Chapter 17: Michael Haslam leaves the NHS Circumstances of his retirement The honorary consultancy and the provision of references The Inquiry’s conclusions on the retirement of Michael Haslam Recommendations Chapter 18: Michael Haslam in Private Practice (the Harrogate Clinic) The Harrogate Clinic and the South Durham NHS Trust Suspension, termination, and Employment Tribunal Chapter 19: Michael Haslam Investigated The Manzoor Inquiry GMC proceedings Voluntary erasure After the voluntary erasure, including oral evidence and panel comment Chapter 20: The trial of Michael Haslam and libel proceedings Introduction and early police investigations Second police investigation and trial Appeal Libel proceedings Section Four: The response of the GPs Chapter 21: The response of the GP community at large Introduction Dr Simpson Contributing factors Key factors explaining GPs’ responses Chapter 22: GPs who passed on the complaints Introduction Dr Wade Dr Moroney Dr Moran Summary Chapter 23: GPs who did not pass on the complaints Introduction Dr L H Moss & Partners – Kings Road, Harrogate Leeds Road Surgery, Harrogate The Surgery, East Parade, Harrogate The Health Centre, Knaresborough Road, Harrogate Park Street Surgery, Ripon North House Surgery, North Street, Ripon Picks Lane Practice, Thirsk Conclusion Section Five: Barriers to making complaints Chapter 24: Introduction – understanding the issues Introduction What went wrong? Awareness, predisposition and knowledge Responding to disclosure: a practical toolkit Chapter 25: External factors Introduction NHS structures The prevailing culture of the medical community Lack of governance process Supervision Chapter 26: Why patients did not complain Introduction Patients’ perceptions Chapter 27: The impact of mental illness Introduction Mental disorder The effects of drugs Contamination Impact of being a psychiatric patient Patients and culture Believing and disbelieving patients Conclusions Chapter 28: Patient confidentiality Introduction The principle Confidentiality and the Inquiry Disclosure within a therapeutic consultation Confidentiality and psychoanalysis Michael Haslam and patient confidentiality Conclusion Volume 2 contains the following material Section Six: Problematic activities Chapter 29: Sexualised behaviour and the psychiatrist/patient relationship Chapter 30: Prevalence and data Chapter 31: Chaperones Chapter 32: Record keeping Chapter 33: Dealing with rumour: hearing the warning bells Section Seven: New developments that need monitoring Chapter 34: Complaints handling in the NHS Chapter 35: Employment, discipline and regulation of doctors Section Eight: Some answers Chapter 36: Response to concerns Chapter 37: Concluding remarks Annexes Appendices THE KERR/HASLAM INQUIRY 1 Foreword by the Chairman of the Inquiry It is my privilege to present this Report, as Chairman of the Inquiry. I do so in the hope that it will assist in understanding the problem of the sexual abuse of psychiatric patients, and in the expectation that our recommendations, if taken up, will enable the National Health Service to respond more effectively to the needs of those of us who use mental health services. The Secretary of State for Health set up my Inquiry as one of three Inquiries looking at how the National Health Service dealt with concerns and complaints against four named doctors. It has surprised those of us working on the Kerr/Haslam Inquiry that it has taken so long to send our Report to the current Secretary of State, the third to occupy that post since the Inquiry was originally commissioned. A private Inquiry is a time-consuming process. We detail in our Report some of the reasons for that. We started of course with the disadvantage that we were enquiring into concerns and complaints relating to two clinicians running more or less consecutively for over 20 years. We also found that patients came forward to us in greater numbers than to either the Ayling or the Neale Inquiry, together with which we formed “The Three Inquiries”. We again give reasons in our Report on why this should be so. One common theme across all three Reports is that it was only through feeling that they were not alone in making complaints, and doing so with the support of others, that patients were able to explain why they believed the NHS had failed them. I place on record my thanks to all those former patients who gave evidence to the Inquiry. I fully appreciate how, for many of them, it was a difficult and distressing experience. I hope they will be able to feel that they have achieved some sort of “closure” with the Report’s publication. I also extend my appreciation to the present and former staff of the local NHS authorities – including clinicians, nurses, GPs, administrators and managers. Almost without exception they came forward, 2 FOREWORD provided detailed evidence and offered helpful information; and they did so knowing that they would be subjected to close examination and possible criticism. I, and the members of my Panel, were extremely impressed by the level of willing cooperation we received. It does credit to the NHS, and causes us to be optimistic that existing structural and cultural problems identified in the Report can be rectified. Another reason for the time taken, and the fact that we had to consider much more information than our sister Inquiries, was perhaps that our field of concern may also have been wider. The former patients of William Kerr and Michael Haslam raised issues involving both primary and secondary care providers perhaps in equal measure. Unique difficulties were presented by the problems of psychiatric treatment. All of these and other issues meant that it took longer to ensure that we got things right. Where we have failed to do so, it is not through lack of effort. We have tried to keep any mistakes of fact or attribution out of this Report; if, despite our best efforts, they have crept in, they are mistakes honestly made. I record here that the support of the Secretariat and Legal teams has served us well. Bruce Carr, ably supported by the skill and hard work of Clare Brown, is a first rate Counsel who tested the evidence presented to the Inquiry thoroughly and fairly. Michael Fitzgerald and Duncan Henderson got through a huge amount of work that sadly has become the lot of solicitors to Inquiries. Stephen Taylor, Tom Brennan, Karoon Akoon and David Altberg all provided us, and them, with paralegal support that could be relied upon. The Secretariat was led by Colin Phillips, supported by his team of John Miller, Kypros Menicou, Emily Frost, Philip Otton, Virginia Berkholz and Gurjeev Johal.