To the Health Committee of Parliament, Dr Mark Porter of the BMA perched to give evidence and was absolutely, categorically, jaw-clenchingly certain. He said, “I have no specialist knowledge of the case of Dr Mattu… I have not been involved in any way.”
That is a grand revision of history. MedicalHarm is now publishing for the first time the specialist report into the death of one of Dr Mattu’s patients crammed into the fifth bed in a ward without oxygen and suction. That report cleared the hospital trust and was written by none other than… step forward Dr Mark Porter who worked at the same trust. Dr Mattu’s case is the most well-known whistleblowing case of this decade, costing the NHS millions. Get The File.
It was the death of this patient, and the only ever Serious Incident Report filed by Dr Mattu, which led to a cover-up, Dr Mattu’s suspension, and the millions spent on internal inquiries and a QC led inquiry.
The 35 year old patient was in the fifth bed on a cardiology ward. He suffered a gastric haemorrhage and consequent cardiac arrest, due to acute blood loss and aspiration of vomitus. Previously, Dr Mattu says he had always been successful in saving patients with this condition, by using suction to remove large clots in the airways whilst resuscitating. In this case, the fifth bed had been crammed against the window and no suction could be reached and no electricity for the resus machine. To ventilate the patient as he went blue, Dr Mattu was forced to push the clot down into the stomach. The crash trolley could not gain access when the patient arrested and the patient died in full view of other patients on the ward about 3 feet away. Dr Mattu was to fill out his only ever Clincial Incident Report, and the trust were to secretly use Dr Mark Porter of the BMA to investigate. Get The File.
The report was not shared with Dr Mattu, and we now publish it. Dr Porter’s report says the hospital cannot dispute the health regulator’s report, which was damning about a mortality rate of 160 (twice as high as Mid Staffs) and damning about stuffing five beds in wards designed for four beds. The CHI had stated in its report, “the practice of putting five beds in bays designed for four is unacceptable and must cease immeediately.”
But Dr Porter went on to conclude, in the report that we are now releasing, that “there are records of medical problems sufficient to conclude that his death may have been unavoidable..“ This will have been very welcome to the trust, who refused to investigate the death until two years after it occurred, and turned to Dr Porter, an anesthetist. This came despite the Medical Director of the trust telling the Board in minutes, “there appears to have been both a systems failure and a failure of management to take action… This is a potentially serious matter for the trust.”
When Medical Harm approached Dr Porter to ask whether (a) he had misled Parliament about his involvement in the Dr Mattu case, and (b) whether Dr Porter was a fit and proper person to talk on whistleblowing for the BMA, we received the following response.
There was no response from Dr Porter on misleading Parliament, but the BMA said, “Mark Porter’s involvement in the investigation was in no way linked to the BMA’s activities on whistleblowing, or its involvement in Dr Mattu’s case, and his report did not recommend action against any member of staff. As Chairman of the BMA’s Consultants Committee, it is absolutely right that Dr Porter speaks out on the rights of whistleblowers, and the need for a culture of openness in the NHS.”
Dr Porter might find it easier if he were open with Parliament. MedicalHarm has also spoken with Dr Peter Mulrooney, who was Mark Porter’s boss at the time of the deaths in overcrowded wards and the Chairman of the Senior Staff Committee at the hospital. He left Coventry in protest and now works in Australia.
He told MedicalHarm, “At an anaesthetic departmental meeting Dr Porter argued that the practice of returning post-operative patients into over-crowded bays should continue. He further suggested that the responsible anaesthetist could fill out a Clinical Incident form each time this occurred. I regarded this as allowing negligent and dangerous practice and I instructed that the practice would cease forthwith.”
We await full comment from Dr Porter. Meanwhile, if you feel he is the right man or the wrong man to talk about whistleblowing for the BMA, please email MedicalHarm.
Dr Porter disputed this article, claiming the Clinical Incident Form we first published related to the death of another patient in a 5 in 4 ward. That is true, and we apologise to Dr Porter. We have now published the correct death and Clinical Incident Form, filled out by Dr Mattu, that Dr Porter was called in to investigate. MedicalHarm stands by the contents of the article, and so there is no room for doubt, we are now also publishing the Board Minute in which it is confirmed that Dr Porter is looking into the death raised by Dr Mattu. Get The File.
We are also publishing the second death and Clinical Incident Form. We have no evidence of an investigation into this death. More documents are available on request. Get The File.