Earlier this month Mike Dean a hitherto respected and highly experienced football referee now retired acknowledged that he intentionally overlooked an incident and neglected to use the VAR technology to protect his "mate"during a match between Chelsea and Tottenham Hotspur last season. The new technology was introduced to provide fans and the players with as much information as possible in cases where line of sight decisions proved to be difficult for the on field officials. A decision visible to all spectators live and on TV to overrule the VAR was disgraceful and has brought the whole system into disrepute notwithstanding the financial implications for the clubs involved. The referees` supervisory body will be unlikely to take cognisance of his opinions ever again and fans will have further cause for disgruntlement when a debateable decision goes against their team.
Football is a game and big business but murder is murder and one of the most distressing facts to emerge from the Letby case is the failure of several supervisory bodies and individuals to take action when eminent qualified personnel presented prima facia evidence of malpractice by Letby. But this failure was not an isolated misfortune within the NHS. Between 2005 and 2008 at Stafford Hospital the regulator condemned "appalling" standards of care and reported there had been at least 400 more deaths than expected between 2005 and 2008. It listed a catalogue of failings, including receptionists assessing patients arriving at A&E, a shortage of nurses and senior doctors, and pressure on staff to meet targets. The Alder Hey organs scandal involved the unauthorised removal, retention, and disposal of human tissue, including children’s organs, during the period 1986 to 1996. During this period organs were retained in more than 2,000 pots containing body parts from around 850 infants. These were later uncovered at Alder Hey Children's Hospital, Liverpool, during a public inquiry into the organ retention scandal. In the 1990s at the Bristol Royal Infirmary, babies died at high rates after cardiac surgery. An inquiry found "staff shortages, a lack of leadership, a unit 'simply not up to the task ... an old boy's culture' among doctors, a lax approach to safety, secrecy about doctors' performance and a lack of monitoring by management". The scandal resulted in cardiac surgeons leading efforts to publish more data on the performance of doctors and hospitals. One could say that the cover up of scandal is endemic within the NHS.
Between 1970 and the early 1990s, an estimated 26,800 people in the UK were given contaminated blood transfusions and blood products infected with hepatitis C or HIV. People with haemophilia, a condition that affects the blood's ability to clot, were particularly affected. The then government and those following knew of contaminated plasma long before it admitted it. A minister privately expressed concerns that Aids was being transmitted by contaminated blood products while the government publicly insisted there was no “conclusive evidence”, newly uncovered documents from 1983 show. Once again the cover up is equal to or more sinister than the original disaster.
Perhaps the scandal involving the Post Office is the most revealing of all. Over many years the Post Office, aided by its lawyers, engaged in what looks like a cover-up due to repeatedly failing to disclose what they knew about problems with Horizon across a number of court cases. Hundreds of innocent people lost their livelihoods, their homes and some were imprisoned as a result. Some committed suicide. In April 2021 39 former subpostmasters had their convictions quashed at the Court of Appeal. The court concluded that the Post Office should not have prosecuted them in the first place and found the Post Office’s conduct “an affront to the conscience of the court”. Such comments by the Court of Appeal are damning and rare. The Court of Appeal’s judgment in 2021 built on findings in a High Court case in 2019 where the failings of Horizon were exposed. The judge in that case also found the defence by the Post Office to be aggressive, excessive, misleading, and otherwise unsatisfactory. It included an application to unseat the presiding judge whom the Post Office considered was biased. Even in those High Court proceedings, the Post Office failed to disclose critical information about the problems with Horizon.
In all those matters those charged with the supervision of systems and personnel not only failed in their task but were active in the suppression of evidence which was contradictory to their interpretation of the investigation. And so to the magistracy with its internal supervisory system no different in its structure from those in medicine or football. Secrecy surrounds most complaints both from without the system and within. Individual complaints by magistrates are met with obstruction and obfuscation whatever the rights or rarely the wrongs of the matter. Advisory committees, if matters progress that far, are generally obstructive. Delay in investigation is the norm. Threats are commonplace. Investigations which reach the Judicial Conduct Investigations Office are just the tip of the iceberg. But what is common in all the above instances is the failure of supervision in one form or another. My point today is that the real failure is of those who appoint the supervisors. It has been estimated by those more knowledgeable than I that there are about 10,000 individuals who are this country`s decision makers. They are colloquially known as "the great and the good". A definition might be "worthy, distinguished or important people especially when gathered together." These are the members of interviewing panels for the likes of the General Medical Council and/or its disciplinary committee. These are the people who appoint government commission members. These are the people who appoint members of investigatory committees. These are the people who are responsible for the repeated instances of supervisory failings in so many areas of our lives.
There is no civic duty more important that being a member of a crown court jury. Life and death, innocence or guilt is in the hands of ordinary people with few caveats. 18 is the minimum age; being a British citizen is not a requirement, lack of fluency in the English language is not a bar and even a person with a serious criminal record can be a jury member. It is my opinion that a cadre of ordinary citizens be assembled from which cohorts should be entrusted with the choosing of professional supervisors in various trade and professional areas. Ordinary citizens with ordinary lives, interests and hopes for the future able to sift the often uniform education, backgrounds and aspirations of wannabe supervisors. Certainly the iniquitous results from current practice are now way beyond mere chance. They are a direct result of current system failure. When the cry in so many areas is more "diversity, diversity, divercity" where is it when actually needed? It`s not for more brown, black, tall short, trans this or trans that people. It is to salvage the confidence of British people in their form of government and its tentacles which reach right down to the nitty gritty of all our lives. The pitifully repeated excuses of who? what? where? when? should no longer be even remotely acceptable. Failure to do so will be a catastrophe: it bodes ill for all of us.
No comments:
Post a Comment