PART 1:  SILENCING THE WHISTLEBLOWER

`Virtue, truth and justice are irrelevant to the prince who wishes to conserve his power. He must be willing to murder any subject who dares oppose him… yet it is often wise to represent to the people that the death is a suicide.' 
Machiavelli: 'The Prince'

This saga of psychiatric abuse, cover-up and now Government whitewash has run for forty years and still - despite Chairman Pleming's wish for 'closure' - the end is not in sight. He must fool himself if he imagines that The Report does not betray its bias and implausibility when, in the face of the mass of the evidence which it publicises, it asserts that that there was no conspiracy to protect the abusers Kerr and Haslam. The representative of a group of abused former patients has expressed her bitter disappointment with this unwarranted and bizarre conclusion, whereby 120 patients were criminally abused and dozens of complaints were made, yet only three officers of the NHS are to blame, and they only get a verbal smack on the wrist. Yet it is worse than that. So as not to publish further and conclusive evidence for a conspiracy to ignore the patients and protect the abusers, The Report also deliberately suppresses crucial evidence. It is also outrageous in its dissemblance of the harassment and victimisation of the only determined whistleblower in the whole history of the abuse and cover-up.

To show this we make public much information that The Panel is careful to omit. The central event which the Committee was charged with investigating was 'the mismanagement' of the complaint brought by Deputy-Sister Linda Bigwood against Kerr, Haslam and the managements of Clifton Hospital and the York Health Authority, in 1983. Lin Bigwood's campaign to 'blow the whistle' proceeded for four years. Pleming is careful to hide the full nature of the cover-up by providing only a reluctant, partial and incoherent account of her attempts to stop the abuse, and of her harassment and victimisation by various managers in various NHS institutions. Although two Chapters are given to her complaint, the Report is far from describing everything which happened, and the reader is only able to construct even a partial account if he is determined enough to pick out the odd isolated reference scattered over the 955 pages. Pleming knows that if the public was permitted to hear Lin Bigwood's well-documented story, as a coherent narrative and in full, it would be impossible for him to bluff that there was no conspiracy to protect the abusers Kerr and Haslam.

No-one can understand this Report without knowing its pre-history. I begin with the narrative of the central and most blatant cover-up in the quarter of a century of abuse.

In 1983 Clifton Psychiatric Hospital served York and North Yorkshire. Lin Bigwood ran an acute admission ward on the shift opposite the Charge Nurse. This was very taxing, but Lin always tried to find time to talk to the patients. One day, an anxious female patient from another ward told Lin that she had 'had an affair' with her psychiatrist, the senior consultant William Kerr. He had since 'dropped her' and now he threatened her so as to shut her up. The patient didn't know what to do because she felt she still needed psychiatric care. She said that Kerr had had sexual relations with many female patients, and that this was common knowledge amongst some of the hospital staff, many female patients and the GPs in Harrogate. She said that Kerr's abusive behaviour towards women seeking psychiatric help was also known by at least some of the Harrogate Samaritans. She said that another consultant, Kerr's wife - but known as Beryl Bromham - knew about Kerr's behaviour. She said that she knew of one girl who had been admitted to hospital under Bromham's care after the girl had attempted suicide because Kerr had sexually assaulted her when he was her psychiatrist. Bromham knew the details but 'hushed it up'.

Much concerned, Lin told the patient that for her sake and for the sake of all the other patients she had to pass on what she had heard, and that she would be protected. As soon as she could, Lin informed her Nursing Officer, John Monk-Steele. His response was: 'Right. Let's get the bastard!' Having reported to management, Lin expected a discreet but proper investigation and protection for the patient. This did not happen. Days passed and Monk-Steele seemed to avoid Lin. When she caught up with him he refused to discuss the matter. She then started asking around and heard that Kerr was to have a private meeting with the patient, with no third party as a witness. She left the ward immediately to get this meeting stopped, but Monk-Steele told her that it had already happened. Apparently, the meeting was arranged by 'senior management'. (The Report reveals that it was organised between the Senior Nursing Officer, Ann Tiplady, junior psychiatrist Ann Mortimer and Kerr.) Kerr was now in possession of a signed note from the patient which stated that what she had told Lin was untrue. Whether or not Kerr had actually had sexual relations with this patient, in itself this meeting was exactly the sort of possibility that had caused the patient such anxiety. It was disgraceful exploitation of a vulnerable patient. By the time that Lin caught up with events the patient had already been discharged from the hospital.

Of course Lin was angry about this unethical and abusive behaviour. She asked Monk-Steele to arrange for her to meet SNO Tiplady. Three times Monk-Steele said he would do so, but he never did. In the end Lin phoned Tiplady. She said they could meet, but she was not prepared to discuss anything about Kerr. However, Lin was not happy about that and anyway went to see her. SNO Tiplady refused to discuss either the issue of Kerr's possible sexual abuse or the intimidating 'interview'. Instead, she told Lin that she was very disappointed with her general performance - although she was unable to specify any faults and it was only a matter of weeks since both she and NO Monk-Steele had praised her work. Tiplady said she had decided to move Lin to a geriatric ward. This was a demotion. She also said that Lin was now on a probationary period, 'to see how she coped' because she had 'failed' on the acute ward. She said that NO Monk-Steele had already counselled her about this. He had not.

Soon after this encounter Lin discussed the patient's allegations with a colleague, Sister Barbara Wearing. The patient had named her as someone she had previously informed. Sister Wearing said that she believed the patient, and she believed that Kerr had abused many other female patients. She said she would support Lin's pursuit of the proper management of the matter. Shortly after she was moved to the geriatric ward, Lin was approached by Meg Jones, Head of the Hospital's Social Work Department. Lin had worked with her on the acute ward. Jones asked Lin why she had been moved. Lin told her what had been going on, and was careful to refer only to 'a consultant', since all she knew was that the patient had alleged that Kerr had abused her. Jones replied: 'Oh, you mean Haslam.'

Although Lin was already unhappy about how callously he treated one of his patients, the assumption that she meant Michael Haslam came as a surprise. Lin said that she meant Kerr. Jones replied: 'Oh, him too.' She said that the Social Work Department knew about a number of instances of sexual abuse perpetrated by both Kerr and Haslam, and that some years before she had taken a patient to see a solicitor in order to pursue a complaint against Haslam. On the grounds that it was just the word of a mental patient against that of a doctor, the solicitor had advised her to drop the complaint. Meg Jones said she would support Lin. Without specifying what she had been told, Lin now began to ask others if they knew anything. A few patients on the ward immediately gave her details about Kerr assaulting other female patients. One said she had witnessed an assault, others had heard from female patients who reported his abuse. A local social worker put a former patient in touch with her; this woman phoned to tell Lin how Kerr had sexually assaulted her when she was his patient, but at the time she did not feel able to make a complaint.

Meanwhile, Lin had been demoted and derogatory comments were entered on her record. It was intolerable to have to work with doctors and management who connived to abuse the patients. In the heat of the moment, she wrote a document setting out everything she knew. This was written so as to collect her thoughts and to express her concerns to those colleagues who she thought ought to know what was going on and ought to do something about it. She circulated copies of this note to various staff at Clifton Hospital. Another consultant, Tony Rugg, was the first to respond to this circular. He came to see Lin in her new ward, but only to tell her to drop the complaint or she would be sacked. He said he would not support her actions, and that anyway she had got some facts wrong. This was untrue. Rugg's intervention was very upsetting. Since he offered her no support, sympathy or understanding, and since he did not intend tackling Kerr or the management - even about Kerr's unethical 'interview' with the patient - Lin felt that Rugg's only intention was to scare her off. Because he was young and known amongst the nurses as 'a liberal' and 'one of the boys', it felt to her as if Rugg had been sent to intimidate her, and that, if needs be, he could later dissimulate his visit as 'only giving friendly advice'. (The Report reveals that when Rugg spoke to Lin he was already well aware of complaints about Haslam. He did not tell this to Lin, and neither did he ever do anything about the complaints he had heard. It also reveals that Rugg was on the Hospital Management Committee at the time. It now seems likely that he was a messenger from that body.)

Social worker Jones also reacted to Lin's report. Lin met her to discuss it. Jones was angry and blurted out: 'I've got to work with these people!' Lin asked her why she had never reported to management what she heard or knew. She did not answer. Since management had responded so inappropriately to what Lin had told them, she took the matter to her trade union, COHSE. She was being victimised, the members had a right to know what was going on, and through collective action they might persuade management to do the right thing. At first, the nurses at the local branch were somewhat non-committal because they didn't want to 'make waves'. However, some of the porters and kitchen-staff were outraged that they were supposed to serve such a despicable regime. And the branch gave Lin its full and ongoing support.

Through the union branch, a meeting was then arranged with the York District Nursing Officer, Mr Corbett. He told Lin and her union rep, the Yorkshire Regional Officer, that nothing could be done because management at Clifton had now received a second written statement from the patient, again denying what she had said to Lin. Lin asked the DNO how that statement had been obtained. He said that the patient had written an unsolicited letter to the hospital. At the end of this meeting he told Lin and the union rep that York's Director of Nursing Services, Ray Wilk, would enquire into all the events.

It did not take Lin long to discover that DNO Corbett had lied. It turned out that after the 'interview' with Kerr, and although much distressed, the patient was immediately discharged from the hospital. Management obviously then had second thoughts, for Lin learned that a week or so later two members of the York Health Authority had been to visit the patient at her home, so as to extract the 'unsolicited' letter. (The identities of these bullies did not emerge until the Report, in 2005. They were Dr Wintersgill, Specialist in Community Medicine, York HA, & psychiatric nurse Celia Armitage. The Report fails to consider who decided to cover-up the abuse by further intimidation and the extraction of another rebuttal. It is also shameless enough to assert that Wintersgill and Armitage were 'invited into the patient's home'.) Now Lin was even more concerned for the patient's welfare. She went immediately to find Kerr, but he was not around. So she marched into SNO Tiplady's office. Lin insisted that management had deliberately failed to follow proper procedures with respect to the information she had given them, and now they were colluding to harass a patient so as to protect Kerr, Haslam and Bromham from a proper investigation.

By now it was clear that Clifton and York managements would be unscrupulous in their defence of the abusive consultants, suffer who may. Since she had barged into the office of the SNO, and had raised her voice at her, Lin quite expected that management would try to throw the blame on her by making her face an internal disciplinary hearing. She would have welcomed that: then she could raise all the issues. In fact the only response she heard about was that Tiplady phoned the COHSE Branch Secretary to tell him to 'bring Nurse Bigwood into line'. After working uneasily for several months on the geriatric ward, Lin applied for a post as a Nurse Tutor in Wakefield. As far as she was concerned, her complaint against the Clifton management was still active, but she wanted to get out of the York Health Authority where there was obviously no future for her. Since she could not do this without a reference, and her employment record now held false information, she went to see DNS Wilk. He was feared by most nurses and well-known as a bully. Lin told him that if management lied about her in their reference she would tell Wakefield Health Authority about the circumstances. Wilk replied: "I'm not frightened of you, like some people are." Lin asked him what he meant, but he would not say.

Lin got the post of Unqualified Nurse Tutor at a psychiatric hospital in Wakefield. Just before she left her job at Clifton Hospital, York, she was interviewed by DNS Wilk, as part of his 'investigation'. Wilk sat with a York HA nurse whose name Lin cannot remember. Lin was accompanied by the COHSE Branch shop steward. The interview took the form of nothing more than trumped-up accusations against Lin, such as: that she had failed in her duty by not originally reporting the patient's allegations about Kerr in writing - which she was not required to do, and which she anyway did in full detail, in her own time, several days later. Lin asked to see her nursing record. Wilk refused to let her representative read it with her, but showed it to her in private. Every entry for the time she had worked in York expressed management's satisfaction with her performance - until she reported what the patient had told her about the abuse. At that moment there appeared a false and defamatory entry about her general performance, written by NO Monk-Steele.

Ten months after Lin first heard about the abuse she started a new job at Wakefield. She was happy in this work and popular with the student nurses. The manager of the Nursing School, David Passey, was pleased with her. He thought she was an excellent tutor with a promising career ahead. Her contract with Wakefield HA required secondment for nurse tutor training. Since she still lived in York and a course was run just across town, she elected to go to the College of Ripon & York St John. The course would take ten months, and together Wakefield HA and the English National Board of Nursing were to pay her salary. This choice of college was unfortunate: it played straight into the hands of those who wished to terminate her complaint against Kerr, Haslam, Bromham and the management. For in the meantime Lin had got the York Branch of COHSE to agree to send to the Yorkshire Regional Health Authority a report of what was now the union's complaint. During 1984 and 1985 Lin occasionally met with the Yorkshire Regional COHSE officer, Glyn Robinson. All this time she had the impression that he was her ally, and was working on the report. Once Robinson told her that he had met Kerr who had told him to pass on the message that if Lin continued with her complaint he would 'crucify' her.

In January 1985 Lin began her secondment to the Nurse Tutor Course at the College of Ripon & St John, York. The Head of Department was Peter Birchenall. In March she went off sick with flu. She phoned in, and a tutor told her: 'Take as much time as you need.' Yet during the week she was off sick she received from Birchenall a letter headed: 'Final Written Warning'. He cited as the reason her 'non-attendance' of the course. In fact, this was the first written warning, she had notified the college, she had been told to take her time and she had a doctor's note. Besides this, the College Regulations specified a number of formal verbal warnings prior to any formal written warning: no prior warnings had been given about any aspect of her conduct. This 'Final Written Warning' was endorsed by a letter from the College Registrar which arrived the same week. Lin wrote back to both Birchenall and the Registrar to protest, to inform them of the facts about her absence, to institute a complaint against their failure to follow legal procedures, and to ask them to act properly. 

When she returned to College the following Monday she was immediately called to Birchenall's office. He told her: 'We have taken steps to find out about you, and we have discovered that you are a troublemaker and a danger to the nursing profession.' Lin tried in vain to get him to admit that his 'Final Warning' was invalid in form and lacked proper grounds. He terminated the meeting with the threat: 'We have to be very careful about who we let qualify out of this Department.' The Registrar also ignored her request that his formal letter be rescinded. Since the charge was obviously trumped to give weight to the 'Final Warning', so that she could be pushed off the course whenever they wished it, Lin asked to speak to the College Principal, Dr G McGregor. He wrote to say that he would only see her to discuss 'her difficulties in fulfilling course requirements'. Yet she had no such difficulties, and McGregor failed to respond to her argument that the so-said Final Written Warning contravened the statutory procedures of the College.

Lin continued to try to get a meeting with a senior member of the College management. Eventually she was allowed an audience with the Vice-Principal, Canon Batey. He would not listen to any of her points about the College's abuse of its statutory procedures. Instead, he offered her 'pastoral counselling'. He also suggested 'a compromise': putting all the complaints they had about her into a sealed envelope in her personal file, to be opened only if she caused more problems. (Of course, there was no mention of this strange device in the College Statutes.) Batey refused to show her the purported complaints and she declined his cynical offer. Then, late that evening, suddenly and uninvited, this bully phoned her at home to demand that she reconsider her decision. Batey threatened her with dire consequences if she would not comply with the College's wishes. After about half an hour of this invasion of her privacy, Lin told him to stop. He wouldn't, and she put the phone down on him. He phoned back twice to continue the harassment. Finally, a friend took the phone and told Batey that if he did not stop the next call from the house would be to the police.

In the weeks after this Lin continued to write to Birchenall and Batey, asking them to apply the proper complaints and disciplinary procedures, as set out in the College Rule Book and mandated by Parliamentary Statute. They always refused to respond to her concerns. She wrote to McGregor with the same request, and to the same effect. Meanwhile, Lin and most of the nurse-students were upset by one particular tutor's demand for inappropriate intimacy during an encounter-type exercise. And in his capacity as their teacher and assessor, Birchenall advised the class that under certain circumstances they should act in breach the UKCC Nurse's Code of Conduct. Specifically, he said that if they thought they witnessed malpractice whilst on teaching practice 'you must remember that you are the guests of that facility', i.e., do not intervene or complain. Most of the students had at least fifteen or twenty years of nursing experience, and many of them found this injunction very disturbing. But none dared say anything because if they failed to satisfy the requirements of the Department their career in nurse education would be at an end.

It was at about this time that Lin happened to meet Rugg who told her that 'two people' had been sent to see the patient who originally alerted her to the abuse, and that afterwards 'Kerr had been assured that the matter would not be taken any further'. Lin also chanced on a one-time colleague from Clifton, Student Nurse Ann Davis. This contact informed her that since Lin had left Clifton Hospital her former Charge Nurse had reported a complaint about the sexual abuse of a female patient by Haslam. Management had responded by victimising the Charge Nurse. Of course this was hearsay, but this contact also told her that the Deputy-Sister who had replaced Lin on the acute ward, Kath Little, had tried to find out what was going on and had pursued the issue as far as DNS Wilk. No-one knows - or admits - what she was told. However, soon after this York HA management were involved in having Kath Little committed to a local private mental hospital. She committed suicide soon after she was released. This contact told Lin that Kath had been in a relationship with Rugg. Lin knew Kath was a good nurse, and her own experience of the distress which could be caused by the senior doctors and management of Clifton Hospital persuaded her that it was entirely possible that the terrible affair of Kath Little was connected to that unfortunate nurse's opposition to abuse and cover-up at Clifton Hospital. (Whilst this is the only sequence of events Lin cannot document, the Inquiry could have investigated. Kath Little appears in the Inquiry Report, but there is no mention of what Lin heard about her fate, or the preceding events.)

Meanwhile, Lin's complaint against the abusers and the Clifton Hospital management appeared to have been shelved by the Health Authority. But she was determined pursue it, and in June 1985 the union branch secured a meeting with Stuart Ingham, District General Manager for York HA. DNS Wilk was at the meeting. Lin took with her two union branch reps. Together they asked Ingham and Wilk to honour their promise to show them a copy of the report of Wilk's 'investigation'. They said they would. (But they never did). The union delegation reiterated its complaint about Kerr being allowed to see the patient and extract a retraction of what she had told Lin. They also asked management to set up proper procedures so that such a thing would not happen again. And they demanded that the false and defamatory entries on Lin's nursing record should be removed. The delegation received a reply to only one point: Ingham stated that it was perfectly fair and reasonable for a consultant to see a patient alone after she had made allegations against him, although this would certainly not do for a nurse. He later confirmed this extraordinary opinion in a letter.

Two days later, out of the blue, Lin received a letter from the College. It suspended her from the Nurse Tutor course. The Orwellian grounds for this decision were that 'she had failed to withdraw an allegation against the College that they were refusing to hear her complaint against them'. Not only was this a travesty of the truth, but the letter contravened the College Rules, which stipulated a number of prior warnings. Apart from the so-called Final Warning - actually the first, completely unwarranted warning, in March - she had received no other formal warnings, verbal or written.

Never mind, on the day that he suspended her, Principal McGregor came to address all the students and staff on the Nurse Tutor course. He told them that he had been forced to suspend Lin because she had made false allegations against the College, she had refused to meet him, and she had used violent and abusive language. The truth was that he had refused to meet her; and how would he know that she had used such language if he had never allowed her to speak to him? He told the assembly: 'There are enough psychiatric nurses among you that I don't have to spell out what she is suffering from.' Lin knows this because afterwards she was phoned by a group of the student nurse tutors who were upset by this bizarre address. They all understood that this almost certainly meant the end of Lin's career as a nurse, let alone as a tutor.

It did not occur to her at the time but only fifteen years later, when Kerr was the subject of criminal proceedings, Lin was alerted to the fact that Dr McGregor was a medical doctor. This meant that he worked, and was likely to socialise, within the close-knit fraternity of York medicine and management. If that were so it would be highly unlikely that he was not acquainted both with Kerr and Haslam and with the fact that Lin was bringing a complaint against Clifton Hospital management with respect to the abusive activities of those two psychiatrists. Later still - almost twenty years after the event - she discovered the stark truth: College Principal McGregor, who had always refused to see her or to instruct his officers to carry out for her the statutory complaints or disciplinary procedures, was at that very time a member of the Executive of the York Health Authority. District General Manager Ingham reported directly to that Executive. And in order to re-activate the complaint against Kerr and the Clifton management, Lin had met Ingham only two days before her illegal suspension. The Head of the Nurse Tutor Department had already told Lin that 'they had taken steps to find out about her'. It is inconceivable that McGregor was not in communication with Ingham and had not been informed (or misinformed) about Nurse Tutor Bigwood and 'the danger' she presented - but not to the nursing profession, only to Kerr, Haslam and the Clifton and York Health Authority hierarchy.

Leeds University governed the course for the Certificate in Nurse Education at the College in York. Therefore Lin immediately phoned the Registrar's Department at Leeds University. As advised, she sent a letter summarising the situation, along with a copy of her file on the events. She requested the Deputy-Registrar at Leeds University to instruct the College to follow the statutory procedures with respect to her case. Despite follow-up phone calls, there was never a reply to this request. Her former patron, Passey, The Head of Department at Wakefield, had by this time left to take up the post of Education Officer at the English National Board of Nursing. Over the months since the bogus 'Final Warning', Lin had written several letters to those funding her, her then current employers: Mr Saunders, Director of Nursing Education at Wakefield & Pontefract School of Nursing, and David Passey, at the English National Board. She wrote to explain what was happening and to ask for their help to get the College to abide by its statutory Rules. Neither Saunders nor Passey answered her letters. Saunders wrote to her for the first time towards the end of October 1985, but only to terminate her employment. He cited as 'reasons': failing to finish the nurse tutor course at the College and 'failure to report to [him] as an employee'.

In 2004, so as to participate in the Inquiry, Lin applied for a sight of the records of her employment, as held by York and Wakefield HAs. The new HA for York claimed that, as a matter of routine, everything had been destroyed in a reorganisation. Wakefield sent no correspondence or comments, only two pages of bare facts - name, address, NI number, etc. Under 'Reason for Leaving' is written the false information: 'Voluntary'. She also retrieved her personal file from the College of Ripon & York St John. There she found a copy of a letter sent to the Registrar of the University of York. This was from Dr E. Bendall, Chief Executive Officer of the English National Board, and dated November, 1985. She had had no dealings with this person, who had never consulted her about her relations with the College of Ripon & York St John. And yet the letter falsely accuses her of not attending the nurse tutor course at the College and of failing to inform her employer. It also warns York University that she misuses public funds. There was no administrative necessity for this letter.  It reads as a deliberate attempt to jeopardise Lin's place on the MA course at York University - that is to say, to further jeopardise her career.   

Meanwhile, through her union representative, and by letters, Lin continued to pursue Principal McGregor. This went on until March 1986. She simply asked for a fair hearing, according to the College Rules, and with the representative of her own choice. McGregor doggedly ignored this request. In April 1986 she received a letter from solicitors acting for the Wakefield HA and the English National Board. This informed her that since she had failed to attend the Nurse Tutor course she was sued for the recovery of ten months salary and college fees: this amounted to about one year's salary. Fairly predictably, Mr Heron of the Legal Department at COHSE National Office refused to respond to her request for help with this demand, or with the whole issue of her illegal treatment by the College. He told her that the union would not help and she should repay the salary and fees.

This had been the worst year in Lin Bigwood's life. She had dedicated her working life to psychiatric nursing, including attending night classes in order to improve her skills, to get qualifications and to further her career. Her employment record now debarred her from nursing, she was being sued for a year's salary, and she had nothing in the bank. Would she have to sell her house? There were severe consequences for her health. Already slim, she lost a stone-and-half in weight. She was made anxious and experienced difficulty sleeping. At this time she was sent for a medical test which indicated a life-threatening illness. Due to the way in which almost everyone in authority in the NHS had dealt with her she was deeply suspicious of the local doctors and she kept refusing surgery. (She put her life at risk by only submitting to surgery two years later. She was also right to be suspicious: when she retrieved her medical notes in 2004 there was a surgical consultant's letter from 1986 which indicated that in York medical circles she was known as a troublemaker.) She consulted a Registered Naturopath who was also a qualified doctor. He told her that she was seriously mentally and physically exhausted and that if she would reduce her anxiety and begin to eat and sleep properly it would still take two years to repair the damage to her health.

In May 1986 Lin approached a London solicitor who worked on mental health cases. This woman immediately recognised the injustice. So clear was Lin's case for wrongful dismissal that two brief letters from her solicitor persuaded the Wakefield Health Authority and the English National Board to drop their action for Lin to repay them. But this solicitor did not feel sufficiently experienced to make a counter-claim and take it to an Industrial Tribunal.  In September 1987 Lin urged her union Branch Executive to submit a report to the Yorkshire Regional Health Authority. This had been agreed by the Branch many months before and had been discussed with the COHSE Regional Rep. But there was no sign that Robinson had ever submitted it. Suddenly Lin and the Branch found out why. Robinson came to a COHSE York Branch Executive meeting to say that if they submitted the report to the Regional Health Authority he would use the rules to get Head Office to suspend the whole Branch for 'bringing the union into disrepute'. This was a surprise. Yet the Branch refused to be cowed, and at the end of 1987 it submitted a report to A M Stokes, Regional General Manager, Yorkshire Regional Health Authority, with copies to the Chairman and the Regional Medical Officer. The Branch Secretary later told Lin that the RHA acknowledged its receipt. But neither she nor the union ever heard anything more. (The Report of the Inquiry reveals that, as he had in 1983, the Legal Officer for the Yorkshire RHA advised York HA to call in the police. YRHA took no further action when this advice was ignored.)

By mid-1991 Lin's file for redress or compensation was, in civil law, within a few months of 'going out of time'. She was determined on this last chance to get the whole matter of the abuse and the cover-up aired in court. She went for an interview with a York solicitor. After a few minutes, whilst she was still outlining the matter, he stopped her to say that he could not handle the case because he 'regularly drinks with these people' - Kerr, Haslam, Wilk, McGregor. He said he was quite willing to believe what she was telling him, but she had to find another solicitor. He advised not to bother with York or Leeds since all the solicitors would know the principal actors and would not wish to appear for her and jeopardise their business with the big local institutions. He suggested a firm in Sheffield. That firm of solicitors refused to help and she could find no other. She ended up trying to pursue the matter with her London solicitor, who still felt it was not her field of expertise.  Finally, in late 1991, one week before the case was due in court, her efforts to mount an action were let down by her QC, who changed his mind and said that she had no case. (The QC did not say why. Although she seemed to have a strong case in employment law, perhaps it was because Kerr and Haslam were still not prosecuted, let alone convicted.) This made Lin's action go 'out of time' and effectively brought her pursuit of the whole matter to an end.

It was not until 1997, with the police investigation into Kerr's abuse, that Lin felt sufficiently vindicated to try to return to nursing. However, she did not expect ever to get a job in the NHS in Yorkshire, and she took a post as night-sister at a private nursing home. In 2001 Kerr was found guilty and Lin had moved to Bristol. At last she felt secure enough to take up a post as staff nurse in the NHS. Lin Bigwood was the only NHS employee to blow the whistle again and again and again - and far shriller than a feeble 'peep'. Management finally shut her up and the abuse continued. Nowhere does the Report acknowledge this simple fact. This account and the Report together provide proof that all those officers or agents of the NHS whose names are highlighted above are guilty of negligence that amounts to a conspiracy to cover-up abuse, and that the Report of the Inquiry is a whitewash of that conspiracy.

 

PART 2:  THE CRIMINAL TRIALS OF THE ABUSER S

 `You win some, you lose some.'   Old adage.

 Psychiatric power concentrates into the hands of the doctor, while the patient is doubly vulnerable. Not only does she suffer from emotional and mental fragility, but the myth of mental illness permits any callous person to dismiss airily as 'only another symptom of the mental illness' whatever the psychiatric patient says when it is not what he wishes to hear. The ill-founded 'medical model' of mental disorder is a veritable Abusers' Charter.

The trashing of Linda Bigwood's nursing career was a successful exercise in discrediting her and thereby terminating her persistent efforts to have Kerr, Haslam, other consultants and the Clifton and York HA managements investigated and the abuse stopped. Consequently, Kerr and Haslam continued to abuse patients - although it transpires from the Report that by 1987 management must have been worried because they did then suggest to Kerr and Haslam that they had best retire. Finally, in 1996, one of Kerr's former patients went to the police and made a complaint about the sexual abuse she had suffered at his hands. The local MP, Phil Willis (Social Democrat) took up her case. The police, the Health Authorities, The Royal College of Psychiatrists and the General Medical Council were all uninterested. The Health Minister Alan Milburn (Labour) stone-walled Willis. In the end Willis threatened to expose Kerr and the lack of official concern by using his privilege to bring the matter up on the floor of the House of Commons. This meant he could not be sued by those he named, and there would be publicity at the national level.

This did the trick. In March 1997 the police were instructed to make a thorough trawl of hundreds of Kerr's previous patients. 726 people were interviewed, including 157 doctors. Of 1200 known former female patients, 120 complained of abuse. This abuse ranged from sexual suggestions and threats through uninvited touching and perverse intimacy to outright assault and rape. About 30 former patients also complained of sexual abuse by Haslam. However, only fifteen victims felt brave enough to stand up in court to admit their psychiatric past and tell of their experiences at the hands of their powerful and protected abuser. Towards the end of 1997, Kerr was arrested. He was charged with four counts of rape and fifteen of indecent assault, committed between the 1960s and 1980s.

Kerr denied it all and his lawyers spent the next 28 months delaying. They played the same game as the butcher-dictator Pinochet, coming to court nine times, mainly to say that Kerr's medical evidence wasn't ready. Phil Willis claimed that Kerr's defence team were making a mockery of justice. In the end, a top doctor made Kerr a favourable diagnosis, and in April 2000 he appeared in court. The jury was persuaded that the ill-looking, old-looking and pathetic-looking Kerr was unfit to plead 'due to organic mental impairment'. It was then decided that there should be a hearing before another jury, so as to 'find the facts'. Kerr's defence continued to delay, on the grounds that he had made an appeal to the European Court about the prosecution's abuse of his human rights - another leaf out of Pinochet's book. The hearing finally began at Leeds Crown Court in December 2000. So far as anyone seems aware, in the history of British psychiatry no abused patient had ever sought or won redress in a criminal court. This was an important test case.

Although the detectives told the women involved to expect a three-month trial due to the number of witnesses and the amount of evidence, when the judge came into court he said: 'I want this all done and dusted by Christmas. I have to go on my holiday.' Appearing at court would be harrowing for the former patients. Unlike his victims, Kerr was not forced to appear in court and face cross-examination. However, he was brought in briefly, mid-way through the proceedings. This, said the judge, was so that the jury 'could put a face to the person whose activities you are considering'. Of course, the face was fifteen or forty years older than that of the perpetrator: it was the face of a timid, decrepit-looking, harmless old man, not that of the powerful and assured consultant who, as a matter of routine, spent his entire career threatening, assaulting and sexually abusing young female psychiatric patients.

The court heard that Kerr committed the abuses at his base in Clifton Hospital, in clinics and at the women's homes in North Yorkshire. At the time, each of the victims sought or was being given psychiatric treatment for severe depression. Many appeared initially to have complied with Kerr's demands because of his 'forceful personality' or his power to administer or withhold the medical treatment they so desperately hoped would help them. Early in the hearing a witness reported that when she threatened to report Kerr for abusing her he replied: 'There's no point. The state you are in, who would believe you? Would they believe you or me?' Other victims independently reported that he taunted them, saying that no-one would believe them because they were psychiatric patients, whereas everyone would believe him because he was an important doctor.

The details of many of Kerr's abuses are well-documented in The Report. Many of the victims did complain at the time, usually to their GP. Only one patient was believed - or, at least, only one GP took any action. By ill-chance, he took the complaint to Bromham, Kerr's fellow consultant. Bromham aided and abetted Kerr by always using her maiden name and not disclosing that she was Kerr's wife. When this ex-patient viewed her medical records at the time of the police investigations she found that Bromham had done nothing about the complaint except falsify her medical records so as to make her out as severely mentally ill: this would discredit her if her complaint about Kerr ever reached more responsible hands. Of course, when they were first referred to Kerr the women all suffered from feelings of vulnerability and inadequacy. They were desperate and imagined that he would help them. However, after Kerr had done with them they were frightened, embarrassed, unclean, ashamed, humiliated and mentally and emotionally much worse. Each witness said she had lived with such feelings ever since. Each had felt that no-one would believe them if they spoke out against Kerr. And in the event, many years later, all but one was proved right.

The women were all surprised that the prosecution failed to present much of the evidence it possessed. It failed to call all of its available witnesses, some of them eminent experts. It also failed to produce any of the evidence and witnesses it had for the widespread official cover-up of Kerr's abusive activities for at least seventeen years: in particular, Lin Bigwood's well-documented police statement. If it could be shown that there was an official cover-up this would have provided a strong argument for the actuality of the abuse: nobody is likely to try so hard to cover-up what doesn't happen. The jury consisted of seven men and four women. From the point of view of the abused women this was probably not a favourable ratio. It retired after just over two weeks of the hearing, and it returned after seventeen hours deliberation. The jury wanted more time to discuss twelve charges, but they found Kerr not guilty on six and guilty on one charge: indecent assault. The only difference between the one and the six seems to be that in the one case the victim was timid and visibly distressed in court, whereas in the other cases - and although their lawyers had advised them to show their distress and to shed tears if they felt them - the victims refused to be intimidated by the aggressive interrogation of Kerr's QC. Unfortunately, they were determined to be brave and they reacted angrily to his accusations about their honesty and their mental capacities.

A previous jury had already found Kerr unfit to plead through mental impairment, so he was not convicted and sentenced. To the astonishment of the public gallery, rather than send it back to decide the outstanding charges - most of them, and including two charges of rape - the judge dismissed the jury. Kerr was given an absolute discharge and the remaining charges would 'lie on file'. The judge said: 'I have little doubt that there are those in this court who feel this is not an adequate order. That is not for them to decide, it is for me. Dr Kerr has not been convicted of a criminal offence and he does not present a danger to the public'. He ruled out an alternative option, such as a hospital order. The prosecution then reminded the judge that Kerr must nevertheless go on the sexual offenders list. Oh yes, ruled the judge, under the Sexual Offences Act of 1997, Kerr 'had taken advantage of one of his patients for his own sexual gratification' and must go on the register of sex offenders for a period of five years. The prosecution said it would not seek a retrial to decide the remaining serious charges. As he had wished, the trial was over before the judge's Christmas holidays.

The women were shocked. Once again they felt abused, this time by the judge and the ineffectual prosecution. They wondered about the judge. Arthur Myerson QC was a 72-year-old former York Circuit judge who was brought out of eleven years retirement. He lived near Kerr. Psychiatry routinely interfaces with the law. It is most unlikely that a local judge of the same generation as Kerr would not know him. It would be unusual in North Yorkshire if he had not met him professionally and socially. If so, the judge should have declared the fact and stepped down - as, indeed, did one member of the jury. In his summing-up, and despite the absence of any evidence, the judge called into question the reliability of the memory of all of Kerr's accusers. He also confused events to the degree of misdirection. He cut short the trial in less than three weeks. It was unreasonable of him to demand that the jury make a decision on the twelve outstanding charges - most of the charges - in one day. The witnesses and various members of the public were also surprised that the prosecution, led by Paul Worsley QC, put up such a mediocre case. Worsley consistently failed to press the advantages given him by witnesses, and he failed woefully to use in court all the available witnesses and evidence. Due to the normal lack of a direct witness in cases of sexual abuse, any corroborating evidence is vital. And why did the prosecution agree to the gender ratio of the jury?

Aggrieved witnesses often feel they have undergone a kind of assault under the aggressive and often insulting interrogation of an unscrupulous and determined QC - and Kerr's QC pulled no punches. However, a local reporter got the impression that the prosecution really could have tried harder, and that in his directions to the jury there were hints of the judge's partiality for Kerr. Why did the judge terminate the whole trial when the jury had been out only seventeen hours trying to decide on 19 counts? Why, in this most crucial test case, and when most of the charges were unresolved, did the prosecution not seek a retrial, at least to decide on the majority of the charges for which there was no decision?

Are we really to believe that sixteen middle-aged women, nearly all former psychiatric patients, would each risk humiliation, shame and ridicule to stand up in court and independently tell almost exactly parallel stories about their abuse by Kerr? Why should they each, after all these years, if ever, simply 'have it in for him'? The defence offered no motives. Some suspected the work of the masons or the North Yorkshire professionals' old-pals network in several of the decisions of both the judge and the prosecution. But perhaps both were simply insensitive functionaries who were in a hurry. In any case, this historical trial ended with a considerable amount of dissatisfaction on the part of the aggrieved women and some impartial observers. Some of the victims of Kerr who had been willing to go to court formed a group. Supported by Phil Willis, they used to meet once a month. They wrote to Lord Chief Justice Wolf to complain about the bias of Judge Myerson. He replied that he wouldn't intervene unless they spent more money on another legal brief. And that was that.

However, Phil Willis and the group kept together, and ten of the women who had been willing to testify began a civil action for negligence against the NHS. Although Kerr was only found guilty on one charge, each former patient received an apology for the way complaints against Kerr had been handled in the 1980s, and they shared compensation to the total of £300,000. Knowing that there was much more than what had been revealed in court, they also pressed the Minister of State for an official Inquiry. Kerr was careful to sell his car before the trial, but almost immediately afterwards he was seen playing golf near his home. He was also elected President of his golf club - not bad for a man who suffered from 'organic mental impairment'. His misconduct was at last referred to the General Medical Council for its judgement. It made no investigation. Kerr accepted the offer of 'voluntary erasure' from the Register of Doctors, on the grounds of ill-health.

 In 1988, due to the number of complaints about his abuse of patients, the York HA also encouraged Haslam to take early retirement. He then successfully applied for another senior post in psychiatry, outside of York. (The Report shows that Dr Kennedy, a psychiatrist who used to be a colleague of Haslam but who was by then General Manager of York HA, was happy to write him a good reference.) By 1993 Haslam was back in the NHS, at Durham. Complaints of his abuse continued until 1996.  In 1998 the authorities finally caught up with Haslam. There was an NHS Inquiry into allegations made by some of his former patients at York. This Inquiry was chaired by the QC Manzoor. Four ex-patients were called to give evidence, as were four representatives from the local NHS trust. The Inquiry was held behind closed doors and took two-days. It seems to conclude that there was substance to the complaints of abuse. Manzoor also heard that none of the patients' complaints had been dealt with properly - in other words every NHS official who heard about the abuse failed in his or her duty. All the same, Manzoor concluded that although 'practice fell short of what would now be considered good practice', no-one who failed to act on the complaints of Haslam's abuse was really to blame: it was 'the culture', you see. (I discuss this fashionable excuse in Part Four of this review.)

Haslam was referred to the GMC at about the same time. There was no investigation and, despite the complaints of a number of ex-patients and even a psychiatrist, he was also offered 'voluntary erasure due to ill-health'. Then, at the end of 2003, and after much delay and a prolonged and bombastic attempt by Haslam to sue the Sunday Times, he was brought to trial at Leeds Crown Court. Once again a few brave ex-patients stepped forward to testify. This time a jury found Haslam guilty of one count of rape and four of indecent assault, on three patients, at Clifton Hospital on occasions between 1981 and 1988. He was sentenced to three years in prison for each lesser offence and seven for the rape, to run concurrently. Naturally, he appealled, and on a technicality the rape charge was rescinded. After 18 months he was free.

 

PART 3:  PREPARATIONS FOR THE WHITEWASH

`What makes it so plausible to assume that hypocrisy is the vice of vices is that integrity can indeed exist under the cover of all other vices except this one. Only crime and the criminal, it is true, confront us with the perplexity of radical evil; but only the hypocrite is really rotten to the core.'  Hannah Arendt

 As I understand it, together Phil Willis and the ex-patients group pressed the Department of Health for a public Inquiry into the mismanagement of the abuse. The Committee always gave the appearance of great solicitude to the ex-patients, but it certainly did nothing to encourage the participation in the Inquiry of the one person who could provide it with extensive documentation on the central cover-up. In fact, it discouraged and deceived her. As soon as Lin Bigwood heard there was to be an Inquiry she phoned its office to explain her part in the events. This was in the Autumn of 2002. Whoever answered her call had heard of her, but he seemed to have no comprehension of how anxious revisiting the events might make her and what a great drain it would be on her energies. (For the next nearly two years, no-one on 'the team' ever seemed to get it.) He blithely suggested that she should send all her documentation. Apart from it being foolhardy to hand over her papers to some anonymous person on the other end of a telephone, this was easier said than done. The documents were not to hand and there were hundreds of pages: it would take time, energy and expense. Anyway, what was this Inquiry? What were its terms of reference? What guarantee was there that it would not selectively use whatever she sent them, once again, to discredit her? She requested proper information.

Information concerning The Inquiry to Investigate How the NHS Handled Allegations about the Performance and Conduct of William Kerr and Michael Haslam arrived in a 'pack'. On top were brief biographies of the three members of The Panel. And Lin's heart sank. The first paragraph was taken by the Chairman, and it was monumentally insensitive. Were the recipients of his fluffy little bio supposed to feel assured when they read that Nigel Pleming QC is happily married, has two children and loves cricket and playing the guitar? This added insult to the injuries of everyone Pleming was supposed to serve. For while he was busy having a successful career and a secure and happy family life, one hundred-and-twenty abused patients and former patients and at least one nurse (Lin) were abandoned to struggle through, coping with abuse or victimisation, many of them with a damaged life and a wrecked career, very often isolated within a community of relatives, acquaintances and officials who disbelieved them and stigmatised them as troublemaking nuisances. It had been happy family people with lovely careers who had failed in their duty of care by acting as accessories and even positively protecting and aiding and abetting the abusive psychiatrists.

Pleming's bio failed to mention anything which might really interest most of these victims of abuse and NHS corruption: Why should he be trusted? Who elected him chairman, anyway? (And who chose the other two on the Panel?) Is he sympathetic to us? (It would appear not.) Or does he have much more in common with the senior doctors and managers he is supposed to investigate? And would he rather please his political paymasters than publicise the uncomfortable truth? Ministers of Health had already opposed attempts to get Kerr and Haslam brought to justice. Why would the abused and aggrieved women suppose that this PR smoothy and well-heeled choice of the Minister really had their interests at heart? The substance of the proposed terms of the Inquiry was not reassuring. First of all, it would not be open to the public and the press. Lin felt that the only real guarantee for the safety of her reputation and for full weight to be given to all the damning evidence would be a public hearing. Next, she was invited to send in everything she had on the abuse and the cover-up, and this material could then be shown to anyone - including those she accused. And yet she was offered no protection from being sued for libel or slander. These terms would place her in the same degree of jeopardy she was in during the 1980s. And while she could justify everything she said, she had absolutely no wish to reawaken the anxieties she was caused when she blew the whistle on Kerr, Haslam and York management back in the 1980s. It was also clear that without the power of subpoena - without the ability to compel witnesses to give evidence and be cross-examined - the Committee would be toothless: any guilty party could simply refuse to co-operate. Lin also assumed that since the Committee asserted that it would pass her statement around to all and sundry she would get the reciprocal right of a sight of any statement in which she was mentioned. And she wanted to be present at the hearings when those she accused were giving evidence, so that she or her representative could cross-examine them. Otherwise, she felt, they would just wriggle away again. Finally, she was not offered funds for a solicitor when once again she felt that she needed one.

This looked like an Inquiry which lacked teeth, not designed to reveal the truth, the whole truth and nothing but the truth. This was either bureaucratic incompetence - as if any Government Inquiry did not employ well-established procedures - or laying the grounds for a whitewash: a public relations exercise with all the appearance but none of the substance of justice. Moreover, it was all too familiar. It already did reawaken the old anxiety that Lin would once again play the patsy while all the guilty got off scot free.

After this, and for the next twenty months, Lin Bigwood began a constant series of phone calls and letters to the Inquiry team and its Chairman, in ever more despairing efforts to get them to stop causing her anxiety by their refusal to acknowledge her points and to respond honestly and fairly to them. These are the issues which concerned her, and the Committee's response:

A Government Inquiry behind closed doors is notoriously a sop thrown to public opinion, the appearance of justice but the reality of a public relations exercise which selects only the evidence and declares only the conclusions that The Government wishes to publicise. Even though patients had made complaints which were ignored by every official of the local NHS, in 1998 The Manzoor Inquiry into Haslam's abuse by was held in private, took just two days and found that, except for Haslam, no officer was culpable. As recently as 2001, there had been outrage when the public (i.e., the press) was not permitted access to an Inquiry into another local scandal: Dr Neale had been struck off in Canada and yet he was hired for North Yorkshire and permitted to commit at least 60 horrific surgical blunders on female patients.

A public Inquiry would have let the reporters in. In this instance it would have resulted in weeks of front-page headlines and detailed revelations about the true extent of the abuse, corruption and cover-up. It would have made it impossible for the Chairman to cobble-together a Report which exonerated all those GPs, consultant psychiatrists, nurses, ancillaries, managers and executives who were complicit to the abuse. This would have caused a whole new crisis: the suspension of a number of still-serving GPs, psychiatrists, nurses and managers; the criminal or civil prosecutions of all those who were accessories or aided and abetted the crimes committed by Kerr and Haslam - including many retired NHS staff; the likelihood of claims for substantial compensation from perhaps over one hundred former patients… No, the Inquiry had to be held in private. If the public was prevented from hearing the evidence this would permit Pleming to 'spin' the Report away from the horrible truth of the widespread guilt and conspiracy to protect Kerr and Haslam, and into the sweet-smelling, well-tended garden of a multitude of excuses and 'liberal and enlightened' recommendations - as if there never had been very clear professional Codes of Conduct before Pleming arrived to put everything right.

The ex-patients group also pressed for a public Inquiry. They were thrown the crumb of permission to attend the hearings. They took the offer and attended every day, perhaps thereby limiting the distortions and omissions in Pleming's Report. (Although this is not noticeable. At the hearings they were immediately ordered to stop taking notes.) Lin Bigwood was also offered the option of attending. But she lived and worked 230 miles from York. She suggested that now she was once again an NHS employee, and since her whistle-blowing and victimisation must constitute the most significant topic in the Inquiry, she might be granted paid leave to attend. This suggestion was put to the Committee more than once. It was ignored. 

Protecting the whistleblower is supposed to be a priority within the NHS. Since the Public Interest Disclosure Act of 1998, workers who 'blow the whistle' about wrongdoing are protected by law. One or two victimised whistleblowers within the NHS have since made successful claims for compensation. Since the Act does not apply retrospectively it could not benefit Lin Bigwood. All the same, NHS guidelines were quickly introduced, according to which all employees are directed to report wrongdoing and to protect and support anyone who reports it. For almost two years Lin Bigwood expressed her anxieties to the Committee and its 'team'. Even though she received letters from Pleming expressing his 'wish not to cause her anxiety', none of 'the team' ever seemed to get what it was like to have lost one's career for trying to stop abuse. Participating in the Inquiry created a heavy load of paperwork, much writing and phoning, and considerable disruption and stress. There was the possibility of being made notorious by the press: two reporters already wanted Lin's story. Almost two years after the Committee was set up she was still trying to negotiate with them about the points she raised. First of all, the patients or ex-patients were granted protection. She, too, as the whistleblower, had also suffered - at the hands of those who protected Kerr and Haslam. If she passed 'the team' all her documentation she needed immunity from vindictive prosecution for libel or slander by those she accused. The Committee would not give her this guarantee. Instead it gave itself the right to pass on her documents to anyone it chose, and to publish any accusations she might make about those involved in the cover-up and her victimisation.

Lin only asked for the same rights and protection as the abused ex-patients. In fact, her position was actually worse than the ex-patients: it was proved that Kerr and Haslam had committed assaults, and the abused women had been (more or less) vindicated in a court of law. That was not the question before the Inquiry, and Lin supposed that nobody would subject the ex-patients to aggressive, disbelieving cross-examination. The issue facing the Committee was the cover-up by many other NHS staff. That issue had not been before a court, and Lin was not yet vindicated. Therefore she was especially vulnerable. In the end, not long before the hearings, and in exasperation, Lin wrote a letter threatening to refuse to participate in the Inquiry. She said that she would tell the press and involve the two local MPs in what was going on. At last the Committee granted her the same protection as any witness in a court of law.

The power of subpoena is the only way to compel a reluctant (or guilty) witness to attend a hearing and undergo cross-examination. Lin pointed out that since almost every other member of staff who had information about Kerr and Haslam or the cover-up would have to explain why he or she had failed to act on it properly at the time - as is and always was required by both the professional Code of Conduct and criminal law - under the terms proposed by the Committee there was absolutely no incentive for them to make a statement and submit to cross-examination. This absence of the power of subpoena was very worrying. Except for various current NHS staff who would think that for form's sake they had better show their faces, it meant that most likely she would be the only NHS employee from that period who would participate. The Committee would then be able to argue that it lacked the evidence to come to any uncomfortable conclusions. Getting the Inquiry to admit this anxiety and do something about it was just as hard as getting herself protected from those Lin would have to accuse. Perhaps Willis and the group of women put pressure on the Committee, but this point, too, was only conceded after Lin sent the letter threatening to withdraw from the proceedings and tell the press.

The victimised whistleblower wished to attend the hearings when those she accused were to give evidence, so that she or her representative could cross-examine them. The Committee denied her this right. With increasing desperation, for nearly two years she had tried to negotiate this point by phone and letter. She was always blanked. Late in the day, in response to the letter in which she threatened publicity, she was finally 'welcomed and encouraged to attend the hearings'. Although her complaint and her victimisation should have constituted the very core interest of the Inquiry, as the only sustained effort to stop the abuse, her plea for paid leave from work to attend the many days of hearings fell on deaf ears. So did her request for the right to be able to cross-examine all those witnesses who she had named as accessories and abettors to abuse, and those who had acted to discredit her and, by unlawfully wrecking her nursing career, had terminated her attempts to stop the abuse. These witnesses were unlikely to be honest, and only she knew the details of the events they would misrepresent to the Committee. Was the whistleblower denied access to witness statements in which she figured? When Lin Bigwood contacted the Inquiry Office in 2002 she was told that any statement that she made might be circulated to any other party to the Inquiry. She made it clear that her statement would amount largely to accusations of serious misconduct on the part of about twenty NHS personnel. It seemed that those she accused had access to what she said about them, but the Inquiry did not accord her reciprocal access to their statements. It was likely that some, if not all of those statements would contradict hers, and perhaps accuse her.

Despite her request to be kept informed, the Committee did not tell Lin if it had taken statements from the all actors who figured in her statement to the Inquiry. If they had taken such statements (and they should have) why was she not told? And if she was mentioned in other statements, why was she not given access to this information and given the chance to respond? She was finally sent a handful of statements. Then, on the day of her appearance at the hearings, she was presented with the statements of two of those she accused: namely, two of those she could prove had conspired to have her sacked. These statements arrived at her breakfast-table at 8.30 in the morning on the day she was to undergo cross-examination. She was expected at the hearing for 9.30, to undergo a briefing and take the stand at 10 a.m. This provocative delivery sent her solicitor into a flap, but Lin was unfazed and rather cheered: since they included absurd lies in which those two agents of the NHS had clearly collaborated, the statements only provided more evidence to support Lin's case. (But the Report does not register the existence of these witnesses.)  

The whistleblower was repeatedly refused funds for a solicitor. This is one of the most outrageous elements in the whole of the Committee's dealings with the only honourable actor in the 'mismanagement' of the abusers Kerr and Haslam, the person whose complaint had been 'mismanaged' for four years, a witness who was clearly vulnerable and whose case obviously ought to have been at the centre of the Committee's investigations. In her initial contacts with the Inquiry, in 2002, and on several occasions afterwards, she communicated the anxiety and distress she was being caused by the demands of the Inquiry. Her anxiety would have been much allayed had the Committee provided her with a solicitor. This seemed reasonable enough and the refusal of a solicitor was itself a constant source of anxiety. Again and again members of 'the team', including Pleming, assured her that they did not wish to cause her distress and were doing all they could to help.

The Inquiry hearings were scheduled for June, 2004. In February it occurred to a friend to punch 'Kerr-Haslam' into the Google search-engine. This fetched up the website of the North and East Yorkshire and Northern Lincolnshire Health Authority. Since the Inquiry was set up, in September 2002, this HA had offered free legal advice to any NHS employee or former employee who was to make a statement or to face cross-examination. So the guilty parties in the matter could have representation by an NHS funded solicitor: they were referred to a firm of solicitors in Leeds. Another firm was available for the abused ex-patients. There was also a Helpline. Why was this hidden from Lin, for eighteen long months? Instead, all 'the team' and Pleming would repeat was that they would not pay for her access to a solicitor.

This was an appalling deception. And yet the Committee was unembarrassed when Lin told them what she had discovered: it still resisted her. Lin pointed out that she could hardly use the same solicitors which represented all those she accused, and neither was she an ex-patient. She demanded a solicitor of her own choice, one she could trust, not some good old boy who might be pals with Kerr, Haslam and the Yorkshire 'mafia'. She also demanded a sight of the finalised terms of the Inquiry. This revealed that all the while it had denied her any help, the Committee was actually empowered to apply to the Secretary of State for funds and could 'appoint a solicitor for any witness, at its own discretion'. Now the Committee conceded that 'her situation was unique'. But it still continued to make difficulties, arguing that she should contact her union for legal help and explain the whole matter to them, from scratch. Yet Lin had long before made it clear that her union's national legal officer had refused to help her when she was sacked for blowing the whistle on the abuse and cover-up. Moreover, explaining the whole thing again to another stranger was an onerous prospect that would tie up her free-time for weeks

Lin made two more phone calls in which she pleaded for some proper understanding of her situation. Once more she threatened to withdraw from the Inquiry and go to the press. The solicitor she had used in the 1980s now intervened - she was as yet unpaid. Finally, a year and a half after Lin had first contacted the Inquiry office, and less than six weeks before the hearings, the Committee agreed to fund her own chosen legal representative.  Besides this disgraceful deception and harassment of someone the Committee of Inquiry was mandated to help and protect, on the first day of the hearings the Panel betrayed its arrogance and contempt for the abused former patients.

At some time during 2003 Lin was contacted by Kathy Haq, the leader of the group of women. They kept in touch, exchanged information and encouraged each other. Before the hearings Kathy had already complained to Lin that the solicitor assigned to them, Rachelle Mahapatra, was arrogant, overbearing, rude, obstructive and negligent; she failed to keep her clients informed and she misrepresented some of the facts. Kathy said that she had altered the material facts of at least one witness statement, and she suspected that she had deterred prospective witnesses from making statements. None of the group trusted this solicitor. On their behalf, and as the processes unfolded, Kathy had already resorted to by-passing Mahapatra and going straight to the Inquiry's solicitor for information. Then, on the first morning of the hearings, the group of ex-patients were suddenly made very anxious. The first abused former patient to give evidence was not a member of the group and they did not know her. She testified that when she complained of sexual abuse by Kerr she had been transferred to a psychiatrist called Mahapatra. One of Kathy's group looked into this. It turned out that Mahapatra was indeed the daughter of that psychiatrist: her father was directly involved in a matter which concerned the Inquiry. It was likely that he had heard about the abuse. If so, what had he done about it? Was he guilty of negligence, too? Had he worked directly with Kerr and Haslam, or socialised with them? 

Rachelle Mahapatra had not disclosed this relationship to her clients. The Committee's chosen firm of solicitors was Irwin Mitchell of Leeds. They must have known that Mahapatra's father was a local psychiatrist. This failure to disclose an interest was surely unethical, and the information they suddenly received caused Kathy and her group much anxiety. Moreover, Mahapatra had only just upset Kathy by telling the aggrieved former patients that they could not be present when their GPs give evidence before the Committee. Kathy had to go to a representative of the Committee to find out that this was untrue.

Nobody with a secret link to a psychiatric interest should have been selected to represent women abused by psychiatrists. And Mahapatra's link was highly suspicious. After the hearings the women somehow found out that the Committee was aware, or at some time became aware, of this solicitor's family connection. The group was told that Mahapatra had declared a possible conflict of interests to the Committee. And yet the Committee had not bothered to tell the women. Anyway, why was Mahapatra not replaced? Whether or not she acted well for her clients - and they were not at all happy that she had - they could not trust her after the accidental revelation of her family connection. That the solicitor Mahapatra was selected and permitted to continue as the women's representative is yet another instance of the arrogance of too many professionals, and the contempt in their cynical gaze upon psychiatric patients or ex-patients. The Committee of Inquiry was supposed to help remedy this attitude, not perpetrate it. More than this, the deliberate deception by Mahapatra and the Committee raises the suspicion that she was 'planted' by the local establishment - as a spy and a saboteur, serving interests opposed to those of her clients and of justice.

 

PART 4:  THE WHITEWASH

 `The great mass of people will more easily fall victim to a big lie than to a small one.'
Adolph Hitler

However much it oozes liberal 'concern', The Report of the Inquiry to investigate how the NHS handled allegations about the performance and conduct of William Kerr and Michael Haslam is not a full and honest reflection of the evidence laid before the Panel. It hides vital evidence, the judgements are biased, and it provides such a litany of excuses that it amounts only to a whitewash of the widespread professional negligence and criminal cover-up. Flick to almost any page and I could show you the 'spin': even the list of witnesses, at the back of the Report, is spun. (Two witnesses, at least, are 'disappeared' - along with every sign of their statements which prove conspiracy.) In all, the investigating Panel[*]  manages to match the level of deceit and corruption achieved by all those NHS employees who originally heard about it and yet chose to be complicit with the serial abusers Kerr and Haslam.

The Inquiry took the form of a judicial hearing. Just as it is incumbent on any witness to tell the truth, the whole truth and nothing but the truth, so it is for the Inquiry Panel. Yet the Report makes it very clear that this was only an exercise in damage limitation by means of a £3.2 million public relations hoax. It is so biased and deceitful, so excessively forgiving to all those who protected the systematic abusers Kerr and Haslam (thereby laying every young female patient open to continuing abuse), and so unsupportive to the one whistleblower in the whole long and sorry affair that it will surely give great comfort to both future abusers and any future witness who would 'rather not get involved'.

This whitewash was only made possible by the device of an Inquiry closed to the public. On page 67 Pleming tries to justify a private Inquiry as the need to protect former patients. Yet the hearings could have been made private for those former patients who did not wish to testify in public (video-links, etc.)Neither does he mention that nineteen former patients had already appeared in open court, at the trials of Kerr and Haslam, and that the women's group pleaded to him for a public Inquiry. Privacy appears to have made the Panel's overall deceit entirely successful. According to Pleming there was no conspiracy to cover-up well over twenty years of reported abuse, and only two or three NHS officials were slightly to blame for making innocent - even understandable - mistakes in the management of the multitude of complaints. The Report is so successful a whitewash that its release wasn't even mentioned by the national media, and it only briefly made the local news.

Of course, the Report certainly has the appearance of a thorough investigation. Perhaps it was, up to a point. 91 witnesses were called, and there were thirty days of hearings. A further 134 witnesses were 'put into evidence' without being called to the hearings. Thirty-five GPs gave written responses, and 23 of them also gave oral evidence. 120 former patients testified that the two consultant psychiatrists Kerr and Haslam had abused them, with behaviour ranging from inappropriate sexual suggestions through groping to outright assault and rape. By 1983 at least 30 'concerns or complaints' had been raised with at least 11 different GPs and 11 hospital staff. In all, it appears that by 1988 more than forty patients had reported the two psychiatrist's inappropriate or abusive behaviour, to at least 11 GPs, 16 nurses, various ancillaries, and some other psychiatrists and managers. The Report finds that except for one, each GP failed properly to pursue any disclosure of abuse, and each still refuses to accept the responsibility. Moreover, between 1965 and 1988, when they retired, the York Health Authority gave Kerr and Haslam a free rein to continue their abuse: although a few complaints of the abuse were reported to responsible officers by other NHS staff who heard them, no report ever led to a proper investigation.

However, it is not without reason that the Inquiry was held behind closed doors. The apparently thorough investigation actually serves no final purpose but the masquerade of truth and justice. For if the reader was excluded from the hearings (which everyone was, except for a few of the former patients), or is not otherwise privy to pertinent information, he can never know that the Report simply fails to mention a number of the most vital items of evidence, and that its conclusions are unwarranted and biased in the extreme. The many former patients who had suffered abuse were happy that at last they had been heard, but otherwise the Report did not please them. The women's group heard the evidence and the cross-examination of the witnesses, and they could not believe it when they read that 'there was no conspiracy' and that none of the guilty are to be disciplined. Lin Bigwood spent a day reading the Report and fell quiet. After another day or so she suddenly said, 'You know, I don't think the Committee ever wanted me to give evidence.'

The price and inflated length of this Report will deter all but the most dedicated from reading it. Luckily for Pleming and his paymasters, how many NHS officials, let alone members of the public, are ever going to read all the way through the evidence and argument which lies beyond the first 36 pages of summary and recommendations? And how many have access to the evidence which Pleming is so careful to 'spin', or simply fails to record? It is true that the Report documents about sixty different former patients' accounts of abuse at the hands of Kerr or Haslam. This is laudable and in the public interest, but not the main point. We know Kerr and Haslam are guilty: the abuse was aired in courts of law. The question which faced the Committee was that when each abused patient turned to an NHS official for help almost invariably the response was negligent, corrupt, abusive and self-serving. And when, over the years, a dribble of NHS employees did report to a responsible officer what they heard, their reports were invariably ignored. Moreover, when Deputy-Sister Bigwood made a sustained attempt to get what she had heard properly investigated, management responded with an equally sustained campaign of lies, obstruction, harassment and victimisation.

The problem facing the Committee - which it not only fails to address forthrightly but positively dissembles - is that those who wish to protect patients by standing up against abuse and corruption are not protected and encouraged. On the contrary, if Pleming's Report is the latest word on the matter, the would-be caring, dutiful and lawful NHS employee had better watch out. He or she will be not be encouraged, protected and commended, but only denigrated, harassed and victimised - and, of course, this too will be officially denied.

The deception begins: 'willing witnesses' and 'structural and cultural problems'

On page 1, in The Foreword, the shameless Pleming begins his lubricous deceptions:

"I hope [the abused former patients]…will be able to feel that they have achieved some sort of 'closure' with the Report's publication. I…extend my appreciation to the present and former staff of the local NHS authorities - including clinicians, nurse, GPs. administrators and managers. Almost without exception they came forward, 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 the Panel, were extremely impressed by the level of willing co-operation we received. It does credit to the NHS and cause us to be optimistic that existing structural and cultural problems identified in the Report can be rectified."

Pleming uses the faux compassionate term 'closure': in the context of his own whitewash of the events, what he means is: 'Now we have done all this for you, will you complaining women just shut up'. Later, I devote a section to the scrutiny of Pleming's 'structural and cultural problems', which is his excuse for the corruption of all those NHS staff who heard of the abuse and failed to carry out their primary duty to protect the patients. 

But let us examine the rest of this unctuous and complacent paragraph. Firstly, the NHS witnesses were almost all accessories to criminal abuse, and there is a profusion of evidence that many of them positively aided and abetted the abusers: all of them, to some degree, had committed a crime. How does Pleming know that they were willing witnesses? Is that what they told him? Well, they would say that, wouldn't they - when they may be compelled to give evidence, how many of the guilty are likely to announce their reluctance to stand as a witness? This 'appreciation' is actually Pleming's first bare-faced lie, for it only takes on plausibility due to what Pleming does not tell us. Nowhere in the Report does he remember to inform the reader that had any witnesses been unwilling the Committee was in possession of the ability to compel them to give evidence by the power of subpoena. And that it was Lin Bigwood who forced the Committee to take-up this power, so as to give The Inquiry any integrity at all. Besides, how does Pleming's 'appreciation' square with what the group of abused former patients saw at the hearings? According to them, witness after witness from the NHS prevaricated and conveniently 'forgot' vital information, and again and again Pleming had to remind them that they were under oath: i.e., that he thought they were lying.

The lie of no conspiracy

Pleming soon declares the opinion which the Committee was always going to endorse. On page 5, in the Summary, he writes:

"The story that has emerged is not one of a deliberate conspiracy by healthcare professionals knowingly acting to conceal sexual misdemeanours (or worse) of two of their consultant colleagues. It is mainly but not entirely a story of committed and caring doctors, nurses and psychologists and others. But, for a complex of reasons that we attempt to unravel in our Report, no matter how committed and caring they may have been, many nevertheless ignored warning bells or dismissed rumours and some chose to remain silent when they should have been raising their voices."

“It is also a story of management failure, failed communication, poor record keeping and a culture where the consultant was all-powerful. While the majority stood back, there were, as in all such stories, some who stepped forward, and this account seeks to examine why even those lone voices were not heard.”

Whilst it is careful to contain elements of the appalling truth, this major spin achieves the status of a breathtaking lie. For the evidence which Pleming then proceeds to spread before us (let alone the evidence which he carefully withholds from public view) points absolutely towards a deliberate conspiracy. Throughout his Report, Pleming is careful to avoid this issue. Nowhere in the Report is the term 'conspiracy' defined. Yet it has a specific meaning in criminal law which people understand full well: it is where two or more parties communicate in secret to plan an unlawful act. Does Pleming mean that none of the dozens of negligent NHS staff ever communicated to each other so as to organise their (almost invariably negligent) responses to the steady flows of information that Kerr and Haslam were abusing numbers of patients? The Inquiry provided sheaves of evidence that this is exactly what happened. Or - when this is clearly untrue - does he mean that the negligent responses to the complaints of abuse were not unlawful: that the multitude of negligent responses did not constitute at least accessory to crime, if not always positively aiding and abetting it?

Nowhere in the Report does Pleming offer any argument to support his fantastic assertion that there was no conspiracy. He simply believes the word of those shown by the evidence to be negligent, lying and conspiratorial. And he simply offers the pathetic excuse: 'it was the culture'.

On the other hand, over and again the Report delivers evidence that clearly indicates conspiracy. At the same time, the Report suppresses evidence that is absolutely conclusive proof of one particular widespread conspiracy: the four years of machinations around the silencing of the only whistleblower in the whole quarter of a century of the abuse. For example, nowhere in the Report's 955 pages is it mentioned that the only sustained complaint against Kerr and Haslam lapsed when the whistleblower was illegally sacked by a member of the Executive of the York Health Authority, two days after she had reactivated her complaint. (Neither is it anywhere mentioned that there existed an Executive of the York HA which would have taken ultimate responsibility for all local NHS activity.)  In spite of this deliberate suppression of vital evidence, when he reports Lin Bigwood's four-year attempt to have her complaint properly heard, even Pleming has to admit that 'an impression [of a cover-up in 1983] is not unreasonable'. Yet this admission is buried at page 200 of the Report. On page 206 Pleming even writes:

"There is now evidence not only of a cultural problem at Clifton Hospital (and in the wider local NHS) that allowed concerns and complaints not to be investigated, but, arguably, of something close to conspiracy to suppress expressions of concern, disclosures of sexual misconduct and tolerance of sexualised behaviour towards patients."

Note the qualifications: 'at least an impression','close to','arguably'. In this way the oily Pleming endeavours to retract his admission of the truth even as he makes it. He is forced to be so greasy: the evidence stares him in the face and too many people know it. But then the Report proceeds by ignoring obvious leads and failing to mention that the whistleblower was made to shut up, let alone investigating how this occurred. This deception is achieved by the simple device of failing to record half of Lin Bigwood's documentation and oral evidence.  And that is the last we hear of the possibility of conspiracy (in which individuals would be to blame) and the more we hear about 'the culture' (in which, apparently, no-one is to blame). Even without the evidence concerning the cover-up of that particular complaint, Pleming's assertion that there was no conspiracy would be a joke if it were not so serious.

The myth of the system and culture of 'the bad old days'

The Foreword ends with another complacent dissemblance:

"We acknowledge in the Report that much progress has been made in many areas since the time that the incidents happened. Only when a system is in place that enables the voices of psychiatric patients and concerned NHS staff to be heard, and appropriate action to be taken, can we be confident that the situations described in our Report will not be repeated."

In other words: that was then, when there were no proper rules and procedures, but things are so much better now; and the worthy recommendations in this Report will carry us into Utopia. This is an outright lie. It was not the Dark Ages in the years 1965 to 1988. There always was an absolutely clear professional Code of Conduct, of course the staff knew that assault and rape were crimes, and there were clear lines of authority to which any health problem should have been referred. The problem facing the Inquiry was not the absence of clear rules and systems but the presence of too much perversity, bad faith, cowardice and self-serving: that was the basis to the widespread complicity in abuse.

In the same vein, Pleming has the nerve to call all the guilty actors in these despicable events 'committed' and 'caring'. Where is the evidence for this assertion? His own Report proceeds to deliver hundreds of pages of overwhelming evidence that almost no NHS employee with any seniority was committed and caring when it came to stopping the sexual abuse of a female psychiatric patient - which was really the only question before the Committee. Besides this, Pleming's 'complex of reasons' for all the criminal negligence is nothing more than lies and excuses. Moreover, it was not 'management failure' and 'failed communication': it was very successful management and communication which happened to be criminally corrupt. Again, whilst some records may have been poorly kept, at this juncture Pleming fails to mention that some records were deliberately falsified, and that, by a coincidence, when the abuse became more of a public issue the incriminating records of the old York Health Authority were deliberately destroyed by persons unknown. (Or at least, the Report never tells us who did it). And again, whilst the consultant was certainly a significant figure in psychiatry - as he still is - there were also clear procedures for calling him to account: some NHS staff did try to stop the abuse, the General Medical Council was in existence, Yorkshire Regional Health Authority did (twice) advise the York HA to inform the police, etc., etc. It is disingenuous to try to dignify criminal complicity by calling it 'a culture': it was only widespread self-serving, bad faith, negligence and deliberate protection of the abusers, put above the duty of care. 800 pages later The Report says in its Concluding Remarks:

"We accept as broadly correct the following summary from submissions made on behalf of the health authorities: 'The reason why a consultant was able to continue to practice and assault his patients…was a mixture of flawed structure, poor procedures, system failures, individual and collective failures in an institution that was created at a time when to most, if not all, people the idea that patients might need protection from doctors was unthinkable."

This is a breathtaking. There was indeed individual and collective failure - although one might rather call it great success since it is clear from the evidence in the Report that there was a series of successful cover-ups. When the entire Report shows that for thirty years they were busy protecting the abusers Kerr and Haslam, and up to their necks in corruption, why does Pleming accept the motivated lies in this paragraph, the word of spokespersons for the health authorities? Despite the prevarications and excuses of the guilty, the evidence in the Report clearly shows that the structures and procedures were only as inadequate as the individuals who held office.

Pleming over-reaches himself. The obvious hazard of abuse in psychiatry has attracted Parliamentary legislation for two hundred years: it is simply untrue that it was unthinkable that doctors were capable of abuse. Besides, if it was unthinkable that a doctor would abuse a patient, how come for thirty years North Yorkshire was rife with accounts and rumours of Kerr's and Haslam's abuse? As soon as a patient told Lin Bigwood, she easily discovered other tales of abuse. And when the union took up her complaint against Kerr, Haslam and the management, the news of this event also spread all over North Yorkshire. And yet the abuse was still permitted to continue and other NHS staff were still victimised for trying to stop it.

Systematic bias

129 pages of the Report are quite rightly given to the description of nearly fifty patients' complaints about Kerr and Haslam, all communicated to someone in authority - a GP, a nurse, another psychiatrist, etc. Few of those NHS officials ever reported the complaint on, so as to protect the patient and have her story properly investigated. However, whenever the abused former patient speaks of the callous or verbally abusive response of the official in whom she confided, Pleming tends to give the negligent recipient of the complaint the benefit of the doubt. This might appear to be a conundrum: whilst Pleming seems to think that the women were not lying when they say they were abused, he tends always to believe the negligent official when he denies that he was not solicitous. This enigma is only explained by reference to the secret politics of the Inquiry which runs, I believe, as follows: Kerr and Haslam are convicted and discredited, therefore they probably did abuse many patients, and since they did not appear before the Inquiry they are convenient targets onto which the Report can try to deflect all the public's criticism; at the same time, the Committee wishes to play down the corrupt negligence of a host of current and former employees of the NHS by inventing the myth of a culture and organisation which was once not corrupt but only ill-educated and muddled, is now so very much improved, and with the Committee's multitude of recommendations will soon approach perfection.

One expects circumspection from a QC, but this disbelief in the former patients is ridiculous - and actually biased. The Inquiry appears to have been conducted according to a certain general principle: unless they are caught-out up to their very necks in abuse and malpractice and this is already well-known, the higher the status of the witness the more Pleming is likely to believe him - even when there is evidence or another witness to dispute what he says, and even when the witness damns himself out of his own mouth. Correlatively, the lower the status of the witness, the less likely will Pleming take what is said at face value.

For example, Peter Kennedy is a psychiatrist who was District General Manager at York HA during the 1980s, and was later promoted to Chief Executive at York NHS Trust. When this admirable fellow admits that he was aware for years that there were complaints about Kerr and Haslam abusing patients, that he never had the complaints investigated, and that when he finally decided to persuade Haslam to take early retirement and leave the York HA he wrote him a reference for a top job with another employer, Pleming finds this behaviour only 'surprising' and 'regrettable'. All the same, he obviously accepts Kennedy's excuses for his criminal negligence as indisputable proofs of his honesty, for he proceeds to quote them extensively as good evidence for 'the culture' at York at the time

The repeated tendency of the Report to believe officials, even when they are patently guilty of criminal misconduct, is astonishing. Either Pleming does not imagine that anyone will bother to read his Report or he thinks it doesn't matter because he is untouchable. I offer one more example of this bias towards the powerful: the evidence clearly shows that for at least thirty years, so as to falsify patients' records and to head off or neutralise complaints of Kerr's abuse, Dr Beryl Bromham hid her identity as that abuser's wife. And yet the Report begins one paragraph about Kerr's sexual abuse of patients in Northern Ireland (before he came to York): 'Whilst Dr Bromham could not recall any formal disciplinary proceedings…' The woman is a proven liar. An impartial account would have read 'Bromham said she could not recall…'

On the other hand, even though dozens of former patients independently repeat precisely the same story, Pleming will not necessarily believe them. Yes, he will believe that they may have been abused - after all, Kerr and Haslam are convicted of abuse, they are already discredited, and they are a useful focus for everyone's anger. But no, he will not believe the women when they say that their complaints were ignored and their medical records altered. For example, when some of the women bear witness that their medical records were falsified, Pleming reports this as 'medical records they considered to be wrong or misleading'. After all, if he supports what the women say that would put twenty-five GPs and a dozen or so psychiatrists and other NHS officials in the dock, and we can't have that. Why would the panel not wish to pursue every line of enquiry to its proper conclusion? And in the Report - for example, when there is doubt that a particular complaint was made about Kerr or Haslam - why would he always accept the word of those of higher social standing and tend to disbelieve the word of those of a low standing (i.e., the abused former psychiatric patients)? And yet at the hearings Pleming constantly had to warn GPs and other officials that they were on oath.

It seems to us that there is a conspiracy afoot to disallow the idea that anyone in authority ever positively assisted Kerr and Haslam in their abuse, since that would make the official undoubtedly an accessory or accomplice to crime, and hence subject to criminal or civil law.

The alteration, falsification and destruction of records

So as to participate in the Inquiry, in 2004 Lin Bigwood applied for sight of her employment records, held by York and Wakefield Health Authorities. Officers of the NHS authority for York claimed that during a reorganisation, and as a matter of routine, all the records were destroyed. Wakefield sent her only two pages (in which there was a significant falsification). Pleming discusses the destruction of the old York HA's records and allows that it was unfortunate. However, the Panel seem not to have taken steps to discover who authorised this convenient way of destroying incriminating evidence. Rather than accept the explanation given by the new NHS authority, the Panel might have asked who authorised a decision so convenient to all those who might wish to have the evidence of a cover-up destroyed. Anyway, are we really to believe that there was no continuity of records between York HA and its successor? As if the changeover, involving hundreds of current staff and thousands of patients, was a sort of Year Zero from which, Phoenix-like, the new organisation emerged. Obviously the destruction of records was selective. Who made the selection? Only SNO Tiplady is reproved for destroying documents, and she is only smacked on the hand.

At one point Pleming regrets that the Panel 'could not determine whether or not the medical records, letters, etc., were accurate or false'. He concludes that 'there was no clear-cut example of the possible alteration of records…' It is impossible for us to tell if this is generally true, yet Lin Bigwood gave the Inquiry sound evidence of the falsification of records. And this is simply not mentioned in the Report. Pleming's regret also rides roughshod over the fact that for page after page he records that, quite independently, many of the former patients told the Panel that their records contained false and altered information which had been passed round the healthcare system. Apparently, while Pleming appears to believe that they were abused, the former patients are not to be believed on this point: "In the light of our inability to investigate the truth of the former patients' concerns relating to the alleged fabrication of their healthcare records, we are unable to make any recommendations."

What lies behind this 'inability'? I have suggested a political motive: direct all the anger and attention and criticism towards Kerr and Haslam; the Government does not wish to have dozens of GPs or other NHS officials arraigned for falsifying records. Again, at page 643 Pleming says: "We regret is has not been possible to determine whether or not medical records, letters. etc., were accurate or false." And he goes on to excuse the panel's incompetence by asserting: "It is impossible to legislate against deliberate falsification of health records… Doctors and other healthcare professionals must be trusted to make accurate records and write accurate letters. Failure to do so will, no doubt, have severe disciplinary consequences."

This spins like a Kansas tornado. First of all, no, there will not be severe disciplinary consequences, if Pleming has anything to do with it: he has just ducked out of determining whether records were untrue or falsified, even though he was provided with good evidence. Secondly, the whole Report is biased to ensure that there are no severe disciplinary consequences for anyone at all, however much they aided and abetted Kerr or Haslam.

The Report omits critical evidence and fails to pursue crucial lines of enquiry

The prosecution at Kerr's original 'hearing of the facts' failed to present all the available evidence, including anything from Lin Bigwood's ten-page police statement, which was supported by extensive documentation. The Inquiry appears to have been conducted along the same lines and also according to an agenda other than justice. Apart from the bias or 'spin' on the facts, it is clear that the Panel acknowledged what could not be denied because it was already public knowledge or the women would not let them deny it. Otherwise, when they felt able, they refused to pursue lines of inquiry open to them from the documentation on offer. For example, the Panel was made aware of the tragedy of Deputy-Sister Kath Little. While she is mentioned in the Report, in relation to a patient who accused Haslam of abuse, there is no mention of her attempt to protect the patient and have Haslam's abuse stopped, nor of the terrible events which followed.

In the next section we will see that Pleming finds that in 1983 there was 'at least the impression of a cover-up…something close to conspiracy to suppress expressions of concern, disclosures of sexual misconduct and tolerance of sexualised behaviour towards patients.' Also that the impression of a conspiracy 'was not unreasonable'.

Thereafter, however, when it comes to a thorough investigation of all of those who may be guilty, this is simply forgotten. For example, by page 212, the Report finds it 'surprising' that Bromham was not aware of any accusations against her husband, even though there is independent evidence that she was well aware and duped patients and other NHS officials so as to protect him. Despite this, Pleming intones "…It is unnecessary for us to explore Dr Bromham's state of knowledge any further."

Why is the Panel not interested in her knowledge and activity as a possible conspirator?  Again, Rugg sought out Lin Bigwood to scare her with the threat of being sacked if she continued with her complaint. The Report takes Rugg's word for it that this was not his intention. Why is there no balance, by putting Lin's version of the event alongside that of Rugg? Moreover, it is clear from the Report that several GPs and patients had already told Rugg that Haslam abused his patients. In the whole history of the abuse Rugg never did anything about it. Instead, he pretended to Lin Bigwood that he knew nothing about any abuse, and he did not offer to help to her, as one responsible NHS employee to another. Yet the Report ignores Lin Bigwood's evidence and proceeds to recommend Rugg as one of the younger generation of psychiatrists, in whose hands we can rest assured that things will be so much better.

Neither does the Report ever mention the true extent of the persecution of Deputy-Sister Bigwood by officials of the NHS, including those at very high levels. In fact, in the whole 995 pages the mealy-mouthed Pleming cannot bring himself to utter anything more honest than this half-truth:  "Linda Bigwood…in personally raising the issue of how the complaints were handled, herself suffered professional detriment."

Yet the Inquiry was given full documentary evidence indicating a deliberate conspiracy to wreck her career. No matter, the Report fails to mention that an officer of the College she attended for compulsory in-work training told her that 'they knew about her', that she was a troublemaker and that he would finish her career in nursing; that the principal of the College soon afterwards realised this threat by ejecting her from the course, on trumped up charges and without due process; that unbeknownst to Nurse Bigwood, this thug was a member of the Executive of the York health Authority; that this event, when miscommunicated to other officials who refused to listen to her, led to her being sacked; that although they had failed to respond to her letters to them for help with the College, she was sued by Wakefield Health Authority and the English National Board for repayment of a year's salary; and that the wrecking of her career also ruined her reputation and thereby terminated her four-year struggle to stop the abuse and the cover-up. When Pleming finds that there was no conspiracy, none of this is mentioned.

Evidence of conspiracy, 1: The complaints which were ignored

The Report concludes that "[I]t is clear that many witnesses had heard a little, and some had heard a lot about his abuse of patients very soon after Kerr arrived in 1965." We know from the Report that a few of those who heard a complaint properly passed the information to whoever they thought was a responsible officer. It is hardly credible that none of the rest of the GPs, nurses, consultant psychiatrists and ancillaries who heard a complaint ever discussed any of those complaints with a colleague, and that the two of them did not then proceed to ignore the complaint. If that ever happened - and it would be ridiculous to assume that it never had - that constitutes conspiracy. In fact, in 1983 various patients and staff at Clifton Hospital told Lin Bigwood that it was well-known by many patients and at least some staff that Kerr and Haslam abused patients. Some of the staff affirmed this. When The Report documents communications between numbers of officials concerning the management of various complaints of abuse, and when these communications issued in plans and actions which were secret, negligent and unlawful, how can Pleming assert that there is no evidence of a conspiracy? This brazen lie is contradicted time and again by The Inquiry's own reported evidence.

As regards the evidence that is presented by the Report, it certainly points to conspiracy at the local level. As we have seen, buried deep within the Report, Pleming admits as much, when he writes that "… there is now evidence of…something close to conspiracy to suppress expressions of concern, disclosures of sexual misconduct and tolerance of sexualised behaviour towards patients… [and] .. such an impression [of conspiracy] is not unreasonable."

And yet he is willing to deny (and also suppress) much clear evidence and write:

"…We do not find that there was a deliberate cover-up or suppression of Linda Bigwood's written complaint…"

When we later consider that particular case, we shall see that on the basis of its proper definition, complicity and serious derelictions of duty at area, regional and national levels of the NHS also qualify as conspiracy, since they were secret and the officers were accessories and aided and abetted serious crimes.  More than this, all those doctors or managers in receipt of a patient's complaint, and who never did anything about it, are also conspirators. Very often - as with the GPs and a few nurses, and the odd psychiatrist and ancillary worker - this is conspiracy by omission: there was communication to another doctor or a manager and the two of them tacitly dropped the matter. And then there was the managerial response to the few, such as Lin Bigwood, Kath Little and Alan Greenfield, who tried to have the reports of abuse handled properly, and were confounded and victimised in turn: this involved the conspiracy of two or more managers.

Moreover, does Pleming ask us to believe that fifty or more different patients complained of abuse to a doctor or a nurse and not one of these officers of the NHS ever discussed the complaint with any other? That is preposterous. Of course NHS employees talked to each other, and of course some of them went to their manager to report, to ask what to do or to suggest action. And when this happened and the two of them decided to 'drop it' 'forget it' or cover it up, that was negligence and conspiracy. Besides, Pleming is highly economical with the truth. He names a few managers as culpable - but apparently not to a degree that demands discipline - yet he not once does he mention those to whom the managers answered. Only because Rugg was a member do we hear that there existed a Clifton Hospital Management Committee. Was there also a York HA Management Committee? There was certainly a York HA Executive, although it is never mentioned in the Report. Who served on these committees? Are we to suppose that, in over twenty years, these committees never discussed the problem of the recurring complaints of Kerr's and Haslam's abuse? That none of them ever, in four years, discussed the complaint presented by Lin Bigwood and the union? Are we to believe that none of these Committees ever formulated a single policy or plan or passed down a single instruction on the problem of the serial abuse? This simply beggars belief.

Yet of course we are not asked to believe it since it is only in passing that the Report mentions the existence of one of these bodies. I believe that many unnamed executives must have played a major part in the cover-up and the victimisation of the patient who accused Kerr, Haslam and Bromham, and the victimisation of Deputy-Sister Bigwood who tried to stop the abuse and the cover-up. It is not credible that executives were never aware of the many other complaints which all folded without such a protracted struggle. Either the members of those committees did nothing at all and they are accessories who conspired to be negligent, or they did the wrong thing and conspired positively to aid and abet assault and rape.

One way Pleming manages not get to the bottom of things is to allow so much forgetting by officers of the NHS. Generally, he appears to take the loss of memory at face value, and doesn't even suggest it could be evasion. Yet how does this square with the fact that at the hearings he was constantly having to remind witnesses - especially GPs - that they were on oath? Another reason is that he is so ready to accept excuses. Since he thinks that they are so admirably cogent, Pleming even quotes the excuses offered by the senior psychiatrist and manager Kennedy. He then proceeds to praise this model of an administrator for finally admitting that he did not deal properly with complaints of by abuse Kerr and Haslam, did not make an investigation, never reported the abusers to the GMC, never called in the police, allowed Haslam to retire, and then wrote him a good reference for another job in psychiatry. In the face of the evidence, could Kennedy have done anything other but?

admit it?

Even if we ignore most of the evidence for conspiracies which the Report readily provides, and even if we accept Pleming's outlandish assumption that York was some strange place in which patients and staff somehow remained absolutely isolated from each other and never discussed unusual nursing events such as the abuse, assault and rape of patients, we are still left with a large body of well-documented evidence of conspiracy around a particular patient's report of abuse. I refer to the case of Lin Bigwood's attempts to get the Clifton and York managements to stop victimising the patient and protecting and encouraging the abusers. That is why the Report makes as little as possible of her role in events, why it fails to tell the whole damning story of the harassment and victimisation of this whistleblower, and why it introduces irrelevant disinformation so as to try to discredit her and thereby deflect attention from the real issue: the universal complicity on the part of managers and executives, to very highest level of the NHS. We now turn to this case. 

Evidence of conspiracy, 2: Silencing the whistleblower

This was the most widespread, persistent and well-documented conspiracy in thirty years of negligence and cover-up. The star turn, as it were. However, Pleming likes to characterise the cover-up of the report of abuse by Patient A17, and the cover-up of the 'mismanagement' of her report, as a few silly mistakes which had unfortunate consequences. He knows that all the evidence points to a deliberate managerial policy to get the whistleblower before she got them. And it succeeded. Which is why Pleming suppresses crucial evidence and fails ever to mention that the whistleblower was indeed silenced by means of corrupt managers and other agents of the NHS. 

Instead, at page 20 of the Report, Pleming piously declares: "[H]ealth professionals acting as Linda Bigwood did should be regarded as people to be treated positively and given support."

This is easy for Pleming to say and only in accord with explicit current NHS policy. It is not, however, how the Committee treated Lin Bigwood, either before the hearings or in the Report. For whilst there is page after page of detailed description of the abuse suffered by the patients, and of the contempt which GPs, psychiatrists, nurses, etc. dealt them when they dared complain, the Report is most careful to hide nearly every sense of how Deputy-Sister Lin Bigwood was persecuted when she tried to stop the abuse and the cover-up.

The group of former patients told Lin that she was mentioned every day of the Inquiry Hearings, as the only persistent campaigner in the whole history of abuse and cover-up. In a fair and balanced Report the story of the whistleblower would have been properly presented as evidence. It would deserve at least a paragraph. Don't let's kid around: it would have had to run at least to the length of Part One of this review. For it constituted the key event in all the negligence and cover-up concerning reports of the abuse by Kerr and Haslam, and Pleming knows it. And yet, as a coherent narrative, rather than only a few isolated and brief phrases and comments scattered over the hundreds of pages of the Report, the campaign by Lin Bigwood and the York branch of COHSE, and her eventual sacking, are given not one single sentence. Pleming mentions only that she may have been demoted by the Clifton hospital administration, and that she 'suffered professional detriment'. In the Report there is not even a hint of the possibility that there was a successful conspiracy to shut her up. And yet the Inquiry was presented with the account which makes up Part One of this review, along with very full documentation.

It is true that Pleming does finally admit that 'the effect on the morale of the nursing staff who knew of the Patient A17 story (and the outcome for Linda Bigwood) must have been devastating.' Yet this is hidden on page 246. The Report does also document much of the four year campaign by Lin Bigwood and COHSE to stop the abuse and cover-up. But the Panel is forced to discuss this since the participation of COHSE made it such a public event; besides, this does not prevent Pleming from applying much 'spin' in his interpretations. At this point the Report even discusses at some length two items of Lin Bigwood's 'detrimental' treatment, but not with much sympathy. And the real outcome for the whistleblower is never described.

The Report also concludes:

“With our advantage of hindsight, the Patient A17 saga looks like a half-hearted attempt to go through the motions of responding to an irritant - Linda Bigwood.”

Note the qualifications: 'with our advantage of hindsight' and 'looks like'. Pleming is careful never to give without taking. He had the evidence; he knows it was going through the motions. Yet it was much more than this. Pleming's thoroughly well-spun conclusions can only be sustained by ignoring the collusion of a large number of managers and psychiatrists in the deliberate harassment of both the patient and Lin Bigwood. The Report simply erases from the record all the evidence of the deliberate wrecking of Lin Bigwood's career, which thereby discredited and shut-up the only whistleblower in the whole history of the abuse. That evidence shows the participation of higher levels of NHS management.

Moreover, it is preposterous for Pleming to suggest, at the outset, that there was no conspiracy. Managers are employed to deal with problems. They do this by calling together the interested parties, having discussions and directing a course of action. When they do this lawfully, all well and good. But when they communicate in secret, as accessories to a crime and in order to aid and abet crime, that is the crime of conspiracy. Of course, it is unlikely that all the conspirators met together in one room, but a chain of communication is all that is necessary, and even managers can pick up a telephone. It is simply inconceivable that, over the decades, each individual NHS manager only ever kept to himself each complaint of sexual abuse, and only ever took a (criminally negligent) decision on each complaint without ever discussing it with any other manager. Pleming's assertion that there was no conspiracy is incredible even with respect to those patients' complaints which were only ever passed on by the odd isolated GP, nurse, or psychiatrist from outside York. However, Lin Bigwood's report and complaint was pursued for four years and with the backing of her union. Her employment record was falsified. She was demoted. And then she was sacked by agents of the local and national NHS.

As well as being free to add bias or 'spin' to any of the evidence he reports, the Chairman of an Inquiry which is closed to the public is also afforded the totalitarian luxury of ignoring every line of investigation which he does not wish to follow, and of failing to report vital evidence - as if it never existed - which does not suit his prejudices and purposes. To an extent, we are able to gauge the awesome degree of spin Pleming puts on the evidence which he does report. But we can never know what he fails to tell us or what line of enquiry he failed to pursue - unless we possess information which we know was delivered to the Committee of Inquiry yet suppressed. Luckily, the reviewer has a sight of the information delivered by Lin Bigwood.

Pleming is forced to deal with Lin Bigwood's complaint because it was the only determined and fully documented attempt to pursue Kerr and Haslam and stop their abuse. At last, on page 64 of the Report, Pleming allows that: "…the most striking example of "missed opportunity" [to stop the abuse]…relates to Linda Bigwood's complaint… in 1983…" Deeper still into the Report he writes

" …What is revealed by the Patient A17 story is a disturbing picture of inaction, or part action, amounting in the end to a total failure by hospital staff and administrators to investigate the allegations against William Kerr (despite Linda Bigwood's dogged pursuit of the issue)… Patient A17 was a vulnerable person suffering at the time from mental disorder - she deserved a better hearing. As is now recognised by the health authorities in written submissions to the Inquiry, Linda Bigwood was 'courageous, persistent and determined in her fight to have a proper investigation in Patient A17's allegations to her'. Linda Bigwood deserved a better hearing."

All well, and good, although Lin Bigwood has still not had one word of apology from any NHS officer, let alone a commendation or the offer of compensation for a lost career. Such was the weight of evidence already in the public domain that an admission like this could hardly be avoided. What Pleming does avoid here - and hopes to get away with - is any suggestion that it was not 'inaction' or 'part action' but deliberate conspiratorial action, the positive determination of managers and executives to protect Kerr and Haslam, and thereby to continue to lay female patients open to abuse. And this deliberate action could only proceed by somehow discrediting the whistleblower. Pleming cannot buck reporting the initial attempts to discredit and victimise the whistleblower. Yet nowhere in the Report is there any mention of the later and successful attempt, which culminated in a member of the York HA Executive illegally terminating Lin Bigwood's nursing career, just two days after she had reactivated her complaint against Kerr and  Haslam's abuse and the cover-up by the York HA management. 

The Report reveals that, in 25 years, Lin Bigwood's action (with her union) actually constituted the only determined attempt to stop the abuse. The outstanding example of the mismanagement which the Committee was set up to investigate was the response to Lin Bigwood's campaign to stop the abuse and cover-up. Except for her campaign, the Inquiry would have had little more to consider than a scatter of isolated and ineffectual complaints. All the same, nowhere in the Report can Pleming bring himself to admit that this is so. And neither does he give Lin Bigwood 'a better hearing'.

For, as we have seen, the Report gives 129 pages to accounts of how patients were mistreated and abused and their complaints ignored. And yet in the entire Report there are only oblique and scattered references to this most determined attempt to stop the abuse. Pleming ought to have commended this champion of the patients, but he cannot bring himself to do it. Lin Bigwood is the fly in his ointment of excuses. Whilst seventy pages are given to the details of the four-year complaint and the corrupt responses, nowhere in the Report is it mentioned that Lin Bigwood was persecuted by NHS officials to the point of losing her career and livelihood, her health, and at one time it seemed perhaps even her house. The Report fails to name her persecutors, it barely acknowledges that her career was affected, and there is no mention that she was sacked due the illegal machinations of a member of the York HA Executive and various other senior functionaries.

Pleming's complacent but crucial conclusion - while he admits that the counter-conclusion is not unreasonable - flies in the face of the evidence, and it is unargued. This is outrageous. Even the evidence which the Report publishes clearly shows that Kerr and various doctors and managers deliberately and secretly collaborated - twice - to harass the patient and coerce her to withdraw her allegations about Kerr's abuse. Even more outrageously, as if it does not exist and was not presented to the Inquiry, Pleming suppresses the half of Lin Bigwood's evidence which shows without a doubt that there was a conspiracy which, in 1987, effectively stopped her campaign by annihilating her career and reputation. The Report prefers to amble complacently along a much more pleasant path:

"[T]he impression we are left with is of something akin to maladministration, almost an institutional moral failing or a widespread failure of the system. We are unable to ascribe responsibility to individuals…" [and there follow excuses.]

'Akin to' maladministration? 'Almost' a moral failing? The evidence in the Report often makes it absolutely clear who is to blame. Why is Pleming unable to assign responsibility? He speaks of the negligent as if they, too, were the poor victims of the unfortunately abusive and negligent 'culture' at the time. This is unashamed spin. The story of the efforts of Lin Bigwood and the local branch of COHSE to combat the abuse and cover-up is told in Part One of this review. With reference to that account, whereas Pleming reprimands just three of the officers at Clifton Hospital and York HA, he flouts the clear evidence to declare at least seventeen other negligent NHS employees absolved of any dereliction of duty, let alone conspiracy. And who knows how many members of HA Administrative or Executive Committees were involved? Pleming does not know and does not care to investigate - or will not tell.

For, in this instance, the problem was not simply the managements of Clifton Hospital and York HA, but also officers of The Yorkshire Regional Health Authority, the Executive of York HA, The College of Ripon and York St John, the University of Leeds, Wakefield HA, and The English National Board of Nursing. And yet, so as to conveniently omit the small matter of the deliberate and illegal termination of Lin Bigwood's nursing career (and thereby her reputation and her campaign against the abuse and cover-up), the Yorkshire Regional HA is mentioned only cursorily, while the York HA Executive, the College at York, Leeds University, Wakefield HA and the English National Board - all party to the conspiracy to trash Nurse Bigwood - are never even mentioned. Although the Committee of Inquiry was fully informed about them and the role they played, and presented with full documentation, according to Pleming these key players in the silencing of the whistleblower did not exist.

In sum, and contrary to what Pleming wishes everyone to believe, the documents show very clearly that there was an extensive and deliberate conspiracy to silence the whistleblower as well as the patient. Of course it unlikely that everyone sat together in a big room to work out a plan. But it is obvious that some of them, at various times, did co-ordinate a plan. What is evident - if only Pleming would not suppress the evidence - is that a whole series of officers of the NHS communicated with each other and then refused to respond properly to Lin Bigwood's report of abuse, cover-up and her own persecution. Of course they talked to each other and wrote to each other, and formulated plans of action on the basis of their discussions. That is what managers and executives do. And when their decisions and actions are secret, negligent and illegal, and serve to cover-up abuse and protect the abusers, it is conspiracy.

In the case of Patient A17's account of abuse by Kerr and complicity by Bromham, first of all, there was a swift and illegitimate response to Lin Bigwood's report. NO Monk-Steele, SNO Tiplady, DNO Corbett, DNS Wilk and DGM Ingham conspired to falsify Lin Bigwood's employment record and subject her to demotion. Next, we know that SNO Tiplady, junior psychiatrist Mortimer and Kerr conspired to intimidate and extract a written retraction from the patient who accused consultants Kerr, Haslam and Bromham. DGM Ingham later wrote an extraordinary letter in defence of this action. Only in passing does the Report mention the existence of the Management Committee at Clifton Hospital, and it appears to fail to investigate whether it participated in the decision to intimidate the patient. We are told that Consultant Rugg was a member of the Committee and knew what was going on. Who else was on that Committee? If other members knew and approved, by way of active policy or consequent inaction, they were also party to conspiracy.

Since they performed the deed, we know that Specialist in Community Medicine, Wintersgill and nurse Armitage conspired to intimidate and extract another written retraction from the patient who accused Kerr, Haslam and Bromham. We are also told that this action was arranged by 'senior management'. We know that DNO Corbett, DNS Wilk and DGM Ingham all knew about this harassment and none of them took any disciplinary action. It would be extraordinary if the Clifton Management Committee knew nothing about what was going on. Whoever was involved is guilty of conspiracy.

We know that all of the following were in communication, either directly together or in series, to have the whistleblower Lin Bigwood illegally ejected from a mandatory training course, and hence from her job and from the nursing profession. We know that most of them knew full-well that this ruination of her career would discredit her and thereby terminate her campaign to get the abuse in York and North Yorkshire stopped: At the College of Ripon & York, St John, Head of Department Birchenall, the College Registrar, College Principal Dr G McGregor (who was also on the York HA Executive), Vice-Principal Batey; at Wakefield HA, the Director of Nursing Education Saunders; the Deputy-Registrar at Leeds University; and at the English National Board, Educational Officer Passey and Chief Executive Officer Bendall. All of these officers or agents of the NHS are guilty of conspiracy.

We also know that in 1983 and again in 1987, after communications from (respectively) York HA and the York branch of COHSE, the Legal Adviser at the Yorkshire Regional Health Authority, Hugh Chapman, advised York DGM Ingham to inform the police about Kerr and Haslam. York HA never followed this advice. Even though they knew that York HA had already ignored the advice in 1983, no officer of the Yorkshire Regional HA checked to see whether York HA told the police in 1987. The other officers involved at Region were General Manager Stokes, Medical Officer Turner, and the Chairman. By their negligence the YRHA officers are effectively also conspirators.

Finally, it is impossible to believe that York HA Executive was oblivious to the activity stirred up by the four-year-long campaign of Lin Bigwood and the York branch of COHSE to stop the abuse and the cover-up. Although the Report suppresses this information, we know that DGM Ingham was immediately responsible to this body. We also know, accidentally, that College Principal McGregor - who so effectively terminated Lin Bigwood's career and reputation - was a member of the York HA Executive at the time. The Report never mentions the existence of the York HA Executive. Neither does it say whether there was a York Management Committee. Who were the members of the York HA Executive? What did they know and what did they decide? If there was a York HA management Committee, who were its members and what was their part in the conspiracy? But of course, Pleming cannot afford to mention the existence of bodies like the York HA Executive. That would force him to name the membership and reveal its decisions. What pack of spitting cats might that let out of the bag? It would certainly flush out Dr McGregor, the Principal of the College, who effectively destroyed Lin's reputation and career in nursing - which Pleming fails to report. And were those who took the decision to destroy the records former members of York HA? Surely it must have been the new Executive that made the convenient decision to destroy the records of York HA in the reorganisation?

The attempt to discredit the whistleblower

Not content to misinterpret and suppress evidence - for he is indeed on a sticky wicket, and knows it - Pleming wastes several pages trying to discredit the whistleblower. Lin Bigwood was mentioned every day of the Inquiry hearings, and scattered through the Report, as the only person who made a sustained attempt to stop the abuse and the cover-up. The former patients at the hearings told her that, in thirty days, hers was the only fully credible testimony that they had heard. Even the stenographer came over to thank her. Yet Pleming could not bring himself to crack his face at Lin Bigwood, let alone commend her for the action she took in defence of the patients.

In the Report, Pleming is unable to contain his resentment of Lin Bigwood. He makes a transparently vindictive attempt to 'get back at' her for being the only honourable actor in the whole history of the cover-up of the criminals Kerr and Haslam. He trawls the evidence given by her enemies (those who colluded with the abuse) and the folder of unedited notes and documents which she was honest enough to deliver to the Inquiry. And, in order to discredit her, he comes up with - nothing.Yet he calls it something, so as to throw the spotlight off of the real issue and onto irrelevancies. In this attempt to 'do a Hutton' - to shoot the messenger so as to distract from the message - Pleming only shoots himself in the foot. He only leaves the reader with a gut feeling that, in 955 pages, nothing he says can be trusted.

Pleming is actually unable to fault Deputy-Sister Bigwood. She faced overbearing obstruction, threats and victimisation, and her actions were exemplary. In the whole sorry saga, amongst all the NHS employees who knew about Kerr, Haslam and Bromham - which is to say, fifty, sixty or more - she was the only one to do entirely the right thing and pursue a proper complaint against those consultants and managers who protected the abusers and so miserably failed the patients. All the same, in amongst the documents, narratives and correspondence furnished to him by Lin Bigwood - amounting to at least 150 pages, and maybe twice that - Pleming is sure enough to extract and quote in his report nothing at all that she says except one 'unprofessional' phrase from one set of informal notes. (She uses the word 'bullshit'.) 

Ah, and how about some side issues to cast doubts on Deputy-Sister Bigwood, and maybe discredit her. Yes, yes, here we are - junior psychiatrist Mortimer, who at the time, and so as to protect the abuser Kerr, was busy organising the negligence and harassment of the patient who had reported the abuse - this miserable apology for a therapist suggests to the Committee that Deputy-Sister Bigwood 'was not a trained counsellor'. Aha, gotcha, Deputy-Sister Bigwood! Although there is no evidence for her inadequacy as a therapist/counsellor, Pleming is pleased to use the word of someone who is complicit to criminal abuse so he can write a number of 'points' implying that Lin Bigwood might have 'mishandled' the patient who told her about the abuse.

Oh, and here's something else, thank God! It seems that at the time of being told by a patient that the psychiatrist Kerr was an abuser, nurse Bigwood was deputy to a Charge Nurse who she didn't much like. Let's imply that Deputy-Sister Bigwood was trouble. But don't let's mention the rest of the record: that her dissatisfaction with her immediate boss was based in the fact that he was more interested in image than in nursing realities, and this had repercussions for her, for other staff and for the patients. Besides, who doesn't find the boss a bit of a problem? There is no evidence that this dislike affected Deputy-Sister Bigwood's ability or performance. And indeed it did not: in the general scheme of things it was trifling.

Yet of course, these aspersions are quite beside the point. They are simply unfounded attempts to discredit the only significant, honest and dutiful witness, on the NHS side of things, in the whole disgusting affair. Lin's disagreement with her charge nurse was so insignificant it could only be mentioned by a lawyer grasping at straws and bearing a grudge; and her counselling skills were very good: that is why she was asked to counsel patients. Even supposing her work had been affected by this 'conflict' with her boss, and supposing she was a terrible counsellor, what bearing would any of that have on the fact that she was told that Kerr and Haslam abused patients and that management should have dealt with it rather than cover it up?  Again, at another point in the Report, Pleming appears to accept a culpable manager's excuse that he didn't take Lin Bigwood's report of abuse seriously because it was 'long and wandering'. Perhaps it was, but this very soon became a complicated story with many abusers and their aides, and the manager should have paid attention. Others - such as Rugg and Jones - found the report perfectly clear. (But of course, the manager did read and understand the report. He was lying to you, Mr Pleming!).

Excusing negligence and conspiracy: 'It was the culture/system/structure'

Whenever the shameless Pleming invokes 'the culture' this is only a tawdry excuse for negligence, complicity with abuse and conspiracy to cover it up. It is outrageous to assert, on page 11:  "Our clear impression is of a system that was difficult and obstructive. It was neither 'user-friendly' nor designed to ensure that patient safety was paramount." There was a clear Nursing Code of Conduct in which all staff were trained, and clear lines of authority so as to report any problem, including abuse. It was not 'the system' that was difficult and obstructive, 'not user-friendly' and careless of patient safety, but almost every NHS functionary who was informed of the abuse.

By page 13 Pleming is busy accepting the excuses of all those who failed in their duty, and calling their bad faith and conspiracies: 'a culture'. He also blames the negligence on lack of ability or lack of training, and the lack of clarity of procedures. Yet unless one is willing to believe the excuses of the guilty, within the body of the Report there is simply no evidence for these assertions. At pages 14 and 15 of the Report the stall is set out with a whole long list of excuses which are mostly beside the point, and for which the Report anyway provides no evidence - except the whining rationalisations of the guilty. On page 16 Pleming is so carried away in his spin that he can write: "At times we felt that the structure of the NHS complaints system rendered the outcome of these events almost inevitable."

What a let off for the guilty! And what a smack in the teeth for those NHS employees who did try to stop the abuse and cover-up! Again, no evidence for this assertion is offered anywhere in the Report; there are only the excuses of the guilty. It was not 'the structure' of any system. It was widespread negligence and corruption, for which a host of corrupt, cowardly and bullying individuals were responsible. This excuse of 'structure' or 'system' or 'culture' runs as a thread through the Report. By page 660 there is another false judgement: "It becomes clear then that the current regulations exclude many people from making a complaint, who might be in possession of valuable information about poor performance, unless they have permission to act as the patient's representative. These include members of staff, relatives…" [etc., etc….]

This is absolutely untrue. There is, and always was, the overriding duty of care - not only to the individual patient who might complain of abuse, but to all the other patients at risk. Pleming prattles about 'the misplaced loyalty' of a professional to his colleagues. This is utter rubbish. The first duty of any NHS employee is quite clearly to the patient. Anyone who fails to follow up a report of abuse, or has his suspicions, fails in his duty to the patients and - if the abuse is real - ought to lay himself open to the charge of accessory to a crime. Pleming's willingness to excuse corruption means that, except for one or two scapegoats whose guilt was blatant, well-documented and already well-known, the Report tends to find that all those who failed properly to report or investigate patients' complaints, or otherwise participated in a cover-up, only made 'regrettable' mistakes. For example, on the subject of the many negligent GPs, the Report says:  '…while we do not in any way suggest collusion…' Why not? This simply flies in the face of the evidence.

Of course, Pleming has to try to justify the prejudice which runs through his Report. He does this by quoting the guilty. He is particularly impressed with what one psychiatric nurse has to say. This nurse testified that a patient told him that Kerr had assaulted her, and after he had failed to report the matter and had done nothing to protect her or the other patients, the nurse felt bad about it. Pleming admires this self-serving coward for his tardy honesty. He writes up this admission of negligence as evidence not for the nurse's failure to do his duty but for 'the culture' at the time. If he approves of a negligent nurse you can bet Pleming will give more space to a more senior figure, and even shower him with praise. Sure enough, he is happy to quote the excuses of the psychiatrist Kennedy as evidence for 'the culture'. And yet the excuses of this apparently admirable fellow are followed immediately by pages of evidence which show his dereliction of duty over at least eight years. But of course, the Report cannot afford to find much wrong in such a senior figure as Kennedy, who was Unit and District General Manager for York HA during the abusive 1980s and Chief Executive for York Health Services NHS Trust until 1999. At this point it is barely perceptible in the Report that this 'culture' - which is complicit with long-term serial abuse - is even 'unfortunate', let alone criminal.

And by page 773 this prejudice based in a wish to excuse all but one or two of the guilty expresses itself in the most bare-faced lie. Pleming is so intent on trying to make out that 'nobody really knew' about the abuse, and that it was mainly rumour, that he writes: "[T]here was general noise but little more." Of course there was much rumour. But this is largely because, as is clearly substantiated elsewhere in the Report, fifty or sixty NHS employees, from trainee nurses through to national officers, were very well informed of a patients' complaints of abuse, and they did not all keep their mouths shut. Apart from the fact that over the years there were a number of specific official complaints made by patients and some NHS staff, most of which were easily fobbed-off by the corrupt doctors and managers, this is particularly insulting to those who persevered in their attempts to protect the patients and stop the cover-up. I mean Lin Bigwood, who pursued her complaint against Kerr and management for four whole years before losing her career in the struggle; she was backed by the local members of COHSE; and Deputy-Sister Kath Little, who may have lost her life in the course of pursuing a complaint against Haslam. But of course, what happened to Kath Little and Lin Bigwood is not recorded in the Report.

The Inquiry finds that only two or three local managers are really guilty of very much at all. And even they are not blamed: when their action prevented a proper investigation and positively aided and abetted the abusers Kerr and Haslam, Pleming only finds it 'difficult to understand' that they did what they did. For the rest, Pleming spreads the blame extremely thin before he absolves all the guilty with the magical formula: 'it was the system/ structure/ culture'. Amongst the apologists for corrupt power - such as Manzoor and Pleming - it is nowadays fashionable to call any widespread complicity in abuse or corruption 'a culture'. This all-forgiving euphemism is itself a sign of the sold-out pundit's degeneracy, idiocy and arrogance, which is no doubt re-enforced by his Olympian separation from the frightening hurly-burly of real life. In institutions like prisons, care homes and psychiatric facilities the abuse of power means real perverts doing really horrible things to really vulnerable people. But what would Manzoor and Pleming really know about that - or care? 'Culture' used to mean advancement, not degeneration: it denoted the intellectual and moral aspirations and achievements of a group, the sum of its arts, science and customs. Widespread indifference, cowardice and bad faith, within an organisation run by callous managers who would much rather bully than listen, is not made dignified by calling it 'culture'. No matter. Nowadays the smooth-talking apologists for corruption like to parade their sagacity by employing the word as a mock-sociological excuse for the barbarism of individuals and conspiracies. To call widespread complicity with abuse 'a culture' just because it is far-reaching is only to give it an excuse. This sophistry, in itself, is an act of cowardice and complicity.

If he had possessed the intelligence and honesty, Pleming might have discussed the historical setting rather than employed the weak excuse: 'culture'. In 1979 a radical Conservative Government was elected. It governed for the rest of the time that Kerr and Haslam continued their abuse. When Lin Bigwood made her complaint against Clifton management Thatcher was at the height of her power. Having precipitated the highest unemployment since the 1930s, she was busy attacking the unions. York's workers were certainly anxious, and it seemed as if those managers who had job-security (such as in the NHS) felt that, after the 'permissive' 1960s and 1970s, now it was their turn. Many were arrogant and acted towards the workforce with intentional malice, as if they now felt that they could get away with anything. And in the case of complaints about the abusers Kerr and Haslam, they did.

Nevertheless, this political fact cannot excuse the complicity of all those NHS employees who were duty-bound to protect the patients by reporting possible abuse. Nor was every York NHS employee complicit. Every now and then, over the years, isolated employees quite properly passed on a patient's report of abuse to a responsible officer - although, unlike Lin Bigwood, not one made a sustained attempt to get management to respond appropriately. The members of York COHSE union branch always supported Lin in her struggle and, in fact, made it their own. This is not made explicit in the Report: nowhere is there any proper recognition of the role played by the union. This is undoubtedly because the active members of the union at Clifton subscribed to a different 'culture', one in which the Codes of Conduct meant what they said. Besides, they did not wish to serve in a regime which now appeared more like a Nazi brothel than a therapeutic environment.

Pleming might have commended all those NHS workers at York who stood up to support the whistleblower - especially COHSE branch officers Chris Brace, Mark Whyte, Jim Docherty and Tony Brownbridge. He did not. Indeed, Pleming might have commended Lin Bigwood, Alan Greenwood, Kath Little and anyone else who tried to protect the patients and ended up another victim of the managerial conspiracy. He did not. I believe that there was a personal as well as a political motivation for this reluctance.

First, the personal motive. Anyone who is complicit with abuse, and 'doesn't want to get involved', and protects the abuser, and make excuses for his own negligence - all those miserable functionaries tend to resent bitterly anyone who tries to do the right thing. It is worse if the dutiful employee dares positively to contest abuse and corruption. This is because right action throws into high relief the bad faith of the negligent and complicit. That freak - the whistleblower - is an embarrassment and an affront: she shows up the cynical sell-out of all the jobsworths who will not risk 'raising their heads above the parapet'.

Then there is politics. Were Pleming to commend anyone at all for opposing the widespread complicity that would undermine his pseudo-sociological excuse for the conspiracy to cover-up the abuse: what he calls 'the culture within York HA', or 'the structure', or 'the system'. Were he to commend the dutiful, this would immediately imply that he accuses the negligent and the conspiratorial. His employers obviously do not wish for that scandal. For that would lead inexorably to long-running bad publicity and the expense of another big criminal investigation, the suspension and trial of twenty or thirty local GPs and probably as many managers and psychiatrists (most of whom have been promoted to very senior positions), the likelihood of dozens of civil claims for compensation on behalf of the abused… No, the Inquiry was always intended as a whitewash. 

Bigging-up the recommendations so as to distract from the cover-up

Finally, I believe that Pleming hopes to distract us from the poverty and corruption of his investigation and the excuses he substitutes for just conclusions. He hopes to dazzle us with a sparkly display of his secondary research, his inclusive seminars and his wise recommendations. He insists that some of his suggestions must be implemented within the year. Who is he trying to kid? At 995 pages and with 70 recommendations, would the Minister even glance at his Report? Let's leave aside the worthy research and the seminars. And no doubt some of the recommendations are good: if you put a monkey in front of a dart board he might hit the bull once or twice with seventy throws. But here is a taste of what Pleming suggests: on page 21, as if it were a novelty which was not already high on the curriculum, and in the Nursing Code of Conduct since the year dot, Pleming announces what Basil Fawlty would call 'the bleeding obvious':

“Managers and mental health and social care professionals must be left in no doubt that the breach of professional boundaries with regard to their patients (service users) is unacceptable, and must always be treated as harmful. Every effort must be made to prevent all patient abuse.” Never mind that his whole Report is an exercise in excusing the cover-up of abuse.

Again, so as to excuse all the negligence with respect to the patients' complaints of abuse, on page 23 Pleming suggests a need for 'patient champions': someone 'readily available to step in at the outset of their concern or complaint.' Er - what about nurses, social workers, other doctors?  And - er - how about really protecting staff who try to stop abuse, rather than harassing and persecuting them and only paying lip-service to care and justice, whilst encouraging, protecting and excusing all those who are complicit? At the next Inquiry, concerning the next 'unfortunate' abuse, we'll no doubt hear about the need for 'watchdogs for patients' champions who failed in their duty' - and so it goes, in the neverneverland of NHS public relations spin.

These recommendations really do little more than indulge the usual lawyer's urge to legislate a specific rule for every conceivable circumstance, rather than rely on a general ethical principle, such as the Hippocratic Oath which enjoins doctors to 'Do No Harm'; or, if needs must, one or two obvious principles such as 'Do Not Use Your Position Of Power To Exploit The Vulnerable' and 'Always Do What You Can To Stop Any Abuse That You Encounter'. Although it is a fact which fails to register in the Report, everyone in the NHS is and always was bound by a professional Code of Conduct which already was sufficiently rigorous and perfectly well spelled-out. Moreover, even twenty and thirty years ago, when we all lacked the benefit of Pleming's wisdom, it was clear enough that assault and rape were crimes that ought to be reported and stopped.

Almost all of Pleming's recommendations are silly or would add very little to the protection of patients. However, they play a vital ideological role in the Report: they are the implicit repetition of Pleming's myth that there were not at the time of the abuse already sufficiently rigorous rules and procedures which could have been used to stop it. The recommendations serve as seventy excuses for anyone who was complicit, negligent and perhaps a conspirator. It was not the structure/system/culture of the NHS which was deficient, but only too many of those who held positions of power within the organisation.  In sum, no-one can have any confidence that this Report amounts to anything more than a whitewash of a cover-up. Since it is riddled with dissemblance and constitutes a whitewash of the original cover-up, the Report is itself evidence that the problem of the abuse of power still blights the NHS. There is nothing in the Report to persuade any would-be dutiful reporter of abuse that she would be protected, and there is much to assure the negligent and complicit that they certainly do not risk proper investigation and punishment. No doubt some people will welcome the Report as a successful exercise in damage limitation. It is actually a disgraceful document, obviously motivated mainly by cynical thoughts concerning public relations and possible claims for compensation. It is potentially disastrous for patient welfare.

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