Investigation of the disciplinary process that led to our dismissal of Amin Abdullah – significant actions and learning for the Trust

Today Imperial College Healthcare NHS Trust has published the report of the independent investigation into the disciplinary process that resulted in the dismissal of Amin Abdullah, a nurse who took his own life in February 2016.

The Trust commissioned independent consultancy Verita to carry out the investigation in October 2017. The investigation was overseen by a stakeholder panel including representatives of the Trust and NHS Improvement, Mr Abdullah’s partner and his partner’s representative.

This has been a thorough and fair investigation and we accept all of its findings and recommendations. Above all else, it is now clear that we let Amin down and, for that, we are truly sorry.

As you will see, the investigation has generated a huge amount of learning for the Trust that we have committed to put in place across the organisation as quickly as possible.

Commenting on the report, Imperial College Healthcare NHS Trust chief executive, Professor Tim Orchard, said:

“This has been a thorough and fair investigation and we accept all of its findings and recommendations. Above all else, it is now clear that we let Amin down and, for that, I am truly sorry.

“The investigation has generated a huge amount of learning for the Trust. Not just in terms of the specific recommendations but also by demonstrating the need to do more to build an organisational culture where concerns and poor behaviours are addressed as openly and constructively as possible. We, of course, need to do that while also continuing to act quickly to protect patients and colleagues whenever necessary.

“The report documents a series of actions — from the way a patient’s comments were dealt with on the ward to the way Amin’s disciplinary case was constructed and managed — that resulted in a dismissal that should not have happened, despite the Trust being found to have appropriate processes and policies in place.

“These errors were compounded by the way in which the executive team sought assurances about the management of Amin’s disciplinary process. This resulted in our initial review that did not tell us what we needed to know. As such, we are very grateful to Amin’s partner for pursuing a detailed review; without his persistence, we would not have generated all of this vital learning. I am also grateful to the whole stakeholder panel including Narinder Kapur for working with us to oversee the review and to Verita for undertaking the investigation.

“From just our initial reflections on the report, it is clear that our primary responsibility as the Trust‘s leadership team is to now ensure all of the learning is acted upon across the whole organisation.

“As well as accepting all of the report’s findings and recommendations, I am commissioning a full overhaul of how we support and manage our disciplinary processes, both formal and informal. In the meantime, we are immediately putting in place a set of interim measures to ensure all current and new disciplinary cases meet key standards that draw on the Verita report and other best practice. This includes:

  • a new checkpoint involving a senior staff member unrelated to the case to assess whether or not to move on to formal proceedings
  • a formal offer of pastoral care to all staff in a formal disciplinary process
  • ensuring staff undertake new training before taking up a role as an investigating officer or a chair of a disciplinary hearing
  • additional review by a senior staff member unrelated to the case at the conclusion of the investigation
  • new outcome letter template and guidance.

“There are issues to follow up with specific individuals and teams but, as this case demonstrates so powerfully, it will be essential that this is done fairly and with support and by following proper process.

“Separately, I have already initiated a major programme to be launched this autumn with staff and wider stakeholders to define and encourage the behaviours that we should all expect of one another and to understand and remove any barriers that stand in the way. It is the next step on from a similar approach we took to refresh our values and to galvanise us all around a shared promise to our patients and communities.

“The annual NHS staff survey shows that our Trust is making real and steady progress on building a more engaged and supported workforce. We know we have much further to go. The true legacy of this report into Amin’s dismissal will not be for it to set these organisational improvements back but to propel them forward. As such, we have published the Verita report in full and its learning will be the focus of discussion and reflection with staff at all levels over the coming weeks and months.

“I very much regret that Amin is not here to be offered an apology for the mistakes that we made and a personal commitment from me that we will act on all of the learning from his case. I have offered that apology and commitment to Amin’s partner. I have also offered a further apology to the patient caught up in this review.”

Click to read the full report