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Failures of whistleblowing governance which led up to the passing of the Public Interest Disclosure Act in 1998 included:1987 - Herald of Free Enterprise capsized off Zeebrugge. 193 people died. The inquiry found that staff had warned middle management five times before the disaster about the ferry sailing with its bow doors open but had been ignored.Sheen Report on the loss of the Herald of Free Enterprise, Department of Transport, 1987 1988 - Piper Alpha oil platform exploded 110 miles off the coast of Scotland. 167 people died. The inquiry found that workers did not want to put their jobs in jeopardy through raising a safety issue which might embarrass management. Report of the Public Inquiry into the Piper Alpha Disaster, Department of Energy, November 1990. Cm 1310 1988 - Clapham rail crash. 35 people died. The inquiry found that a supervisor had noticed the loose wiring a few months earlier but did nothing because he did not want to "rock the boat". Hidden Report of the Investigation into the Clapham Junction Railway Accident, Department of Transport, 1989, Cm 820 1991 - BCCI collapse. The Bank of Credit and Commerce International closed as a result of a 19 year old fraud causing estimated losses of over ?2 billion world-wide. The inquiry found that BCCI had an "autocratic" environment in which no-one daredto speak up. Bingham Report on the Supervision of the Bank of Credit and Commerce International, HC 198 1992/93 1992 - Ashworth Hospital scandal. The inquiry into a brutal three year regime of physical and mental abuse at a special hospital found that the few staff who had been brave enough to speak out were attacked, received death threats and their property vandalised. Blom-Cooper Report on Complaints about Ashworth Hospital, Department of Health, 1992, Cm 2028 1993 - Cancer misdiagnosis. 2,000 bone tumour cases had to be re-examined after an inquiry discovered that a senior pathologist at Birmingham's Royal Orthpaedic Hospital had misdiagnosed 42 cancer cases. Two consultants had expressed doubts over the diagnoses over several years, but they had failed to speak up through official channels. Report on the errors in pathological diagnosis provided to the bone tumour service, Royal Orthopaedic Hospital 1985-1993, South Birmingham Health Authority, 1993 1996 The Scott report into the Arms to Iraq affair revealed that a Matrix Churchill employee wrote to the government to raise concerns but that this was not acted upon by civil servants.The Matrix Churchill whistleblowerSince PIDA was passed, the following well known failures of whistleblowing governance have occurred:There have been many individual whistleblower cases that have had extensive press coverage. Any brief internet search will reveal that the flow of cases of suppression and reprisal has not slowed.Some of the larger scale scandals in which failures of whistleblowing governance were implicated are provided below.2000 The Commission for Health Improvement published its investigation report into elder abuse at North Lakeland Healthcare NHS Trust where whistleblowers’ warnings were ignored, and where there were poor relations between staff and a distrusted cohort of senior managers. The Public Inquiry into paediatric cardiac surgery deaths at Bristol Royal Infirmary reported that there was double the expected mortality between 1988 and 1994, when 1,827 children underwent surgery, but that this was not addressed quickly enough, and concerns were not taken seriously.2001 Report of the Public Inquiry into paediatric heart surgery deaths between 1984 to 1995 2002-2004 The Public Inquiry into the murders by Dr Harold Shipman reported in five successive reports. The second report on ‘The Police Investigation of March 1998’ noted how a GP colleague of Harold Shipman blew the whistle, but the police investigation was insufficiently rigorous because the police struggled to believe that a doctor might kill his patients. The Shipman Inquiry reports (1) to (5)2006 A Healthcare Commission investigation into widespread institutionally abusive practices by Cornwall Partnership NHS Foundation Trust against Learning Disabled people, including physical abuse, unlawful detention and financial abuses, found that multiple staff concerns had not resulted in appropriate management action to stop the abuses. The Serious Case Review on the Winterbourne View Hospital scandal reported that whistleblowers had been repeatedly ignored by both the employer and regulator The joint Parliamentary Commission on Banking Standards reported on the LIBOR scandal and concluded that there had been widespread wilful blindness by leaders in the industry who ‘benefited from an accountability firewall between themselves and individual misconduct’.Changing Banking for Good. Report of the Parliamentary Commission on Banking Standards2013 The joint report by the police and NSPCC into Operation Yew Tree, insofar as it looked into historic allegations of child sex abuse by Jimmy Savile, reported that 214 criminal offences had been recorded across 24 police forces, with offences taking place in relation to Savile’s activities at the BBC, the NHS and a school, with 450 people coming forward to give evidence about Savile. The report observed: “The questions asked by victims were how was Savile able to offend over so many years, why wasn’t he stopped and could it ever happen again?” and noted “the reluctance to confront abusive behaviour, particularly that of dominant figures in positions of authority or influence.” Giving Victims a Voice, Metropolitan Police Service and NSPCC2013 The Public Inquiry into the Mid Staffordshire Hospital disaster reported on widespread neglect, avoidable deaths and harm, and noted both whistleblower suppression and staff fear of speaking up despite grave breaches of fundamental standards of care.Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry2014 Report of the Independent Inquiry into child sex abuse in Rotherham concluded that approximately 1400 children were sexually exploited and violently abused over the period from 1997 to 2013. Frontline staff repeatedly flagged the grave problems but their concerns were minimised and suppressed. Report of the Independent Inquiry into Child Sexual Exploitation in Rotherham (1997 – 2013) 2015 The Morecambe Bay maternity deaths investigation reported and noted evidence that the trust had failed to collect whistleblowing data for the material years, and that the staffside view was that trust whistleblowing governance had been poor. Trust whistleblowers gave evidence of poor experiences of speaking up.The Report of the Morecambe Bay Investigation2015 The Freedom To Speak Up Review into NHS whistleblowing reported that it had received approximately 600 submissions, mostly from whistleblowers, who had mostly negative experiences and that there was a compelling pattern of poor handling of concerns and reprisal.Report of the Freedom To Speak Up Review ................
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