Reply to Ombudsman's draft report
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Suzanne Ryan 6 Mole Close Public Services Ombudsman for Wales Bettws Estate 1 Ffordd yr Hen Gae Newport Pencoed Gwent CF35 5LJ NP20 7XR 20 June 2006 Dear Sue Ryan, Thank you for your draft report on your investigation into my complaints against Gwent Healthcare NHS Trust and its chief executive Mr Martin Turner. As you will remember when we met, I told you that I had no faith in the Ombudsman ever supporting my complaints because I considered that any government quango (you corrected me on that terminology) was set up solely for the protection of government organisations and departments against complaints made by the general public such as myself. So your findings come as no surprise to me even though the evidence you have collected clearly supports my complaint. I remember about two years ago when the Ombudsman for local council authorities was interviewed live by Jamie Owen on BBC Wales evening news. The first question that Jamie Owen put to this Ombudsman was and I quote… “It is highly unusual for the Ombudsman to uphold a complaint against a local council, so why did you with this one?” Now that question spoke volumes about any complaint that Joe Public may make and the so called independent review of complaints made by any Ombudsman. So I will now go through the various sections of your report starting with section 5.
Section 5The newspaper article in question was the South Wales Argus edition dated 8 December 1999 and written by the Argus health correspondent Andy Rutherford who is still today their health correspondent. The article consisted of , which you have glossed past, a headline in one high inch bold letters that stated, “Pledge to parents” this heading also had a sub-heading stating, “Our hospitals don’t do autopsies on children”The section of the article that you do quote, “The majority of our autopsies are conducted on behalf of the coroner; we do not perform paediatric autopsies. Hospital autopsies are only performed with the full and informed consent of the patients relatives and in these cases we do not retain whole organs for teaching or research” Well to name just three families of many that were not fortunate enough to be asked for this “fully informed consent”, myself, Jocelyn Davies AM and Rhosalyn Hawkings of Abergavenny and with respect to the other part “we do not retain whole organs for teaching and research”, why did they retain them then? In my own case my sons organs were cut up into seven blocks and therefore could not be considered to be a ‘WHOLE’ organ even though they kept all seven blocks and then just stored them away for no useful purpose for 28 years!!! In Jocelyn Davies case, they retained 25 separate body parts of her child and that also could be described as ‘not keeping WHOLE organs’ but the facts is they did but in pieces!!
Sections 6 and 7In these paragraphs you describe the action I took when I read the article in the SWA and indeed I immediately wrote to Gwent Healthcare NHS Trust, contacted Andy Rutherford of the SWA who told me that he would contact Gwent Healthcare NHS Trust put my concerns to them and let me know their response. I am still waiting for him to get back to me! Even though you state that I contacted the Trust for a second time on 11 January 2000, you clearly have either forgotten deliberately or omitted the full facts that the only contact that I then received from the Trust was via telephone and not one word, take special note of this, was put in writing to me, thereby NO tangible evidence was put on file to come back on them years later. The ‘cover up’ had begun!! By arrangements made by telephone only, my wife and I were visited by Mr Keith Hamilton and until your draft report I was unaware of his position with the Trust. Now you quote Mr Hamilton as saying, “However, there was no report of a post mortem being carried out on Brendan and he could only assume that one had not, infact, taken place: since there was no post mortem, then the issue of body parts did not arise” Those words were in fact written by Martin Turner in a letter sent to me after Mr Hamilton’s visit even though Mr Hamilton had told me that he could find no record of a post mortem and with the passage of time, 26 years previously, finding out the truth would be difficult and after listening to him and his failure to answer simple questions I put to him, I told Mr Hamiliton that he was telling me a pack of lies. Now considering there were no records of a post mortem being carried out on my son Brendan then how come a couple of years later when the Trust did own up and finally told me the truth and still I am not yet totally convinced that they have told it all to me, did they then send this mortuary log of my sons post mortem.
The mortuary report clearly showing that a post mortem was performed on my son and being the entry in the mortuary log, would have been the first place for any research to have taken place on whether my son had under gone a post mortem or not. And it was!! And they covered up that fact and told me a pack of lies for years causing myself and my family totally unnecessary distress and anxiety which I still suffer from. I will repeat again, Martin Turner and Gwent Healthcare NHS Trust are a pack of liars and knew from the moment that they received my very first letter that a post mortem had been carried out not only on my son but many, many other children without the fully informed consent of the relatives. They deliberately encouraged the publication of the article in the South Wales Argus not to allay any fears of relatives of the deceased but solely only to save their own skins from possible legal action against them due to the adverse publicity surrounding other UK hospitals and organ retention. The only mistake Martin Turner and Gwent Healthcare NHS Trust made was to tell ME a pack of lies.
Section 8Again Sue Ryan in this section you gloss over this newspaper article in the South Wales Argus dated 20 September 2001, some 18 months + after I first made my inquiry with the Trust. A Trust spokesperson states to the reporter about my particular case “We can find no record of a post mortem examination being carried out and it was and never has been our policy to retain organs for medical research” Then in a further article dated January 2002 only four months after the previous article they state, “Our investigations were carried out in accordance with the strict guidelines issued by the Assembly. The initial stage has now been completed and validated by a team from the Assembly… We are now in contact with all families who have made enquires, we are offering our full support to them and will continue to do so.” You also failed to state the Trust spokesman said, “that a letter explaining comments made by the Trust official during the home visit was sent to Mr McGuire on January 31 last year” Now only having a quick glance at your report previous to going through it now as I am now, I seem to remember further on you are telling me the Trust are now saying that they FORGOT ALL ABOUT ME! and failed to contact me under the guidelines as issued by the Assembly even though the newspaper article in September 2001, some 18 months after I first contacted them, clearly shows that they were totally aware of me and my concerns. Now who are you trying to kid saying that you fully accept the Trust stating “They forgot to contact Mr McGuire”!!!! Section 10Firstly I am fully aware of the differences between a Coroners and hospital post mortem and if my sons post mortem had been conducted by the coroner, then I would not be responding to your report today. Its very good of the Trust to now clarify that when the original article giving “Their pledge to parents” was published in December 1999 they again seem to have “forgot” to add that they were referring to AFTER 1990, very convenient to say the least. I’m getting the impression that ALL employees of Gwent Healthcare NHS Trust suffer from Alzheimer’s or a similar short and long term memory losses. They seem to have forgot the South Wales Argus article about Rhosalyn Hawkins whose child was born on 13 June 1993 and 8 years later she found out that her son had gone through a hospital post mortem (remember the Trust categorically state that they have never carried out hospital post mortems since 1990). Now your investigations into my complaint should have investigated exactly how many hospital post mortems had been carried out after 1990. We know that there is at least one and my suspicions are there were numerous more and even based just on the one case we know about Gwent Healthcare NHS Trust have told a pack of lies
Section 11Not much in this section other than Mr Keith Hamilton conveniently retired but it seems he was not approached in any way to ask him about his involvement in this matter. To thoroughly investigate any matter, them ALL witnesses should where possible be asked to be interviewed whether retired or not, that is if you want the truth to come out. Matters like that though may be rectified in the future in any legal action I may bring and Mr Hamilton amongst others may be asked to attend court and where necessary subpoenaed. “Due to the stringent checking mechanisms now in place, we have established that a post mortem was undertaken. Mr Keith Hamilton would have previously been unaware of this” What a load of rubbish this part of the statement is.!!! Mr Keith Hamilton that you keep referring as the Board Secretary would have been very well aware that the first place to find a record of a post mortem taking place would have been at the mortuary. You know the place where post mortems take place. He would also have been given some help, assistance and advice by other individuals as to where to begin his search. Keith Hamilton knew when he visited my wife and I at home that a post mortem had taken place on our son Brendan, I knew it had, and I very much knew that Keith Hamilton was telling me a pack of lies and told him so there and then! Also many other records concerning my wife’s stay in hospital now turn up but no records of my son other than an outpatients card showing his entry into the Royal Gwent hospital and his exit as DEAD! How very convenient again!
Section 13I very much and thoroughly object to my sons or for that matter anyone else’s internal organs being referred to as ‘tissue samples’, they are body parts and when you put the parts together you come up with the WHOLE organ and NOT a sample!! Yes, I did ask for a meeting with Martin Turner and the time of the meeting would be of MY choosing and not his. When I requested that meeting, remember I was told that I could request a meeting ‘at any stage in the future’ and which it would now be part of my complaint under HM Governments National Health Complaints procedure, Martin Turner and Gwent Healthcare NHS Trust flatly refused to meet with me!! So Martin Turner, by refusing my request, effectively refused to meet with me twice, once when previously he had agreed to meet with me and secondly under the complaints procedure. Why? Did he think that I was now well armed against the codswallop that he had and would dish out since I first wrote to them in December 1999.
Section 14 - 18At a meeting of the Retained Organs Commission in Cardiff on 13 March 2003, Professor Margo Brazier, Chair of the commission and Steve Catlin, chief executive listened to my story of the way I had been treated by Martin Turner and Gwent Healthcare NHS Trust and it was they that told me about community health councils and their role. No one previously had ever mentioned them to me and the last people who would have wanted me to know about them would have been Martin Turner and the Trust. Because of the RTOC advice I contacted Gwent Community Health Council via telephone and they sent me a complaints package which I duly sent back with my full complaint on an attached separate piece of paper. When a couple of weeks later when I received no reply, exactly the same as when I asked Gwent Healthcare NHS Trust in December 1999, my suspicions were aroused and with good reason. I then telephoned GCHC and asked about my complaint and whilst I was on the telephone, the person I was speaking to told me that GCHC had NOT received any complaint from me. She then made a search of the computer and confirmed that no complaint had been received and tried other options in trying to find my complaint and eventually had to give up and said she would look into the matter further. Then miraculously either the following day or the day after, I get a letter from Colin Hobbs of GCHC and from his reply it was obvious to me that GCHC were NOT going to represent my complaint in a fair and unbiased way. I replied to Colin Hobbs to that effect and did receive another reply containing a letter of very few lines to the Trust about my complaint and I knew from that moment, I was beating my head against another brick wall. I heard no more from Colin Hobbs about this matter and didn’t press the matter further with GCHC because of Colin Hobbs attitude and I believe he was in collusion with Gwent Healthcare NHS Trust and I am right about that also!!! Since then I have been informed that it appears that Colin Hobbs was forced to resign from GCHC as he left under a cloud, although I don’t know the full details and I suspect that in some way he was up to no good in other matters. Subsequently when GCHC took up my complaint again, some 18 months after it was originally made and only after they read my website and found out about it, it now appears that ALL the records and documents that they held concerning my original complaint have been destroyed and I wonder by whom? Because GCHC had no records of my complaint, they were forced to download those records off the website I set up about my son and my ordeal, a website that I immediately made known to the Trust, GCHC, MPs, AM’s, newspapers and any other party that I thought would be interested, in my fight to get at the truth. A fight that I have not yet succeeded in. Now as regards Colin Hobbs. I made an official complaint under HM Governments NHS Complaints Procedure and I consider the destruction of all documents relating to my complaint as being a criminal act. When the Ombudsman publishes his ruling on my complaint, then I intend to make a complaint to Gwent Police about the destruction of those documents as I consider that a criminal offence has occurred. If that is the case then no one will be able to hide under the excuse of ’he’s retired!’ Since Mr Ralf James of GCHC has been involved now the second time and since his reading the website and copying the original documents, I have no complaints against GCHC since then. It’s unfortunate that a “gentleman” like Colin Hobbs was ever put in the position he had as there are probably many other persons that went through the same procedure as I had to endure under his control. I wonder what the reasons were that he had to retire?
The Impact of Alder HeyNow a part of this section I found very interesting, why? Because I found out something that I didn’t know and which I consider fully supports my complaint. At the time I made my first request about the post mortem carried out on my son, 9 December, 1999 the publicity surrounding organ retention had been in the public domain for 18 months and not just a couple that Gwent Healthcare NHS Trust refer to often. But on 3 December 1999, 5 days before the original newspaper article, “PLEDGE TO PARENTS” remember, the Coroner for Liverpool PUBLICLY suggested that organ retention was unlawful!! It was that, that set Gwent Healthcare NHS Trust knowing full well that they were holding the body parts not only of children but adults as well, taken at hospital post mortems without the full and informed consent of relatives to go into damage limitation mode and have that article published in the South Wales Argus to deliberately and maliciously deceive the people of Gwent and save their skins from any legal action that may take place in the future. I now know the reason why the South Wales Argus article was published on 8 December 1999!! Very much to their surprise this was followed a day or so later by my letter and they then told me a pack of lies. Now to come to my letter of 9 December 1999, Gwent NHS Trust have never ever acknowledged receiving that letter, never ever denied receiving that letter and never ever have stated what action the took on receiving that first letter and why they never ever immediately replied to it. I now want a full and detailed answer to those questions!!!
The impact of Alder Hey (chronology)3 Dec The Coroner for Liverpool remarks that organ retention was unlawful was obviously the catalyst for Gwent Healthcare NHS Trust to contact the South Wales Argus and give an interview to their reporter Andy Rutherford and gave their ‘Pledge to Parents’ that they had never carried out autopsies on children. They were the only NHS Trust in the UK to have an article published and it was entirely composed to deliberately and maliciously pre-empt any query by the families of the deceased. The Trust and its management at the highest level knew that their hospitals contained many thousands of body parts taken at hospital post mortems without the fully informed consent of the relatives and the really sad thing is that they still have many body parts and have not the slightest intention of informing the families concerned so that they can make a decision about what should happen to the remains of their loved ones. Now if as stated that Gwent Healthcare NHS Trust had ‘no control’ over the editorial content of the article published on 8 December 1999 and especially after receiving my letter by the 10 December 1999, they should have immediately contacted the SWA and had a retraction published. They didn’t because the article stated 100% of what they wanted it to say and was to deceive the relatives of the deceased.
2001 Now all this section I find very interesting because this is the first time that I have seen any documentation relating to the guidelines laid down by the Assembly and it is clear that I was not informed or was the correct procedure carried out under these guidelines. Now the moratorium was lifted on 23 May 2001, yet on the 20 September 2001, the Trust when asked by the SWA reporter Ben Tuner for their comments about my claims state, “a letter was explaining comments made by the trust official during the home visit was sent to Mr McGuire on January 31 last year” Now this statement issued by the Trust 4 months after the moratorium was lifted clearly shows that 1 The Trust were aware of me 2 The Trust knew that my concerns were about ‘organ retention’ 3 The Trust couldn’t be bothered to follow the guidelines and reinvestigate my claims
What the complainant had to saySection 22 Your comments here about the article published on the 4 September 2001 and my assumption that the SWA reporter Ben Turner had spoken was assumed by me are totally wrong. I was in contact on a number of times with Ben Turner and he told me that he had contacted Gwent Healthcare NHS Trust, so there was no assumption about it. I strongly object to your inference that the Trust spokesman as quoted in the article of 8 December 1999 that they did not carry out post mortems on children meant only at the time the article was published, ie 8 December 1999. I would assume then, that you consider that the Trust were carrying out post mortems up to and including 7 December 1999. Even Martin Turner himself in his letter of 24 March 2002 said that “The article in 1999 outlined the practices that were current at the time. In as since 1990 all Hospital post mortems on Paediatric cases would have been referred to the University Hospital of Wales” This statement shoots down in flames your consideration that the statement in the 1999 article referred only to the time when the article was published and which I disagreed with you during our meeting. That statement in itself is also a blatant lie as has been proved by the only case that WE are aware of, Mrs Hawkins whose child’s body was robbed of his body parts at the Neville Hall hospital in June 1993. As I will be coming to later, you are basing your report solely on conjecture and supposition and not on the hard facts.
Section 22 The head of any company, organisation or country are ultimately responsible for the actions of its employees etc. It’s where the buck stops!!! Martin Turner has NEVER accepted any responsibility and has continually avoided the issue of the incorrect information I was given and blamed Keith Hamilton, the person that he appointed to investigate my request. Remembering that organ retention was now in every news bulletin on TV and radio, in every newspaper and that they were fully aware that my letter was clearly about the subject of organ retention "I want from the Trust, assurances and proof that any organs or body parts that were removed from my sons body at a post mortem were returned to his body for burial and not kept by the Hospital Authorities" then Keith Hamilton would have been appointed by Martin Turner to implement my request. Keith Hamilton would have been selected because of his expertise in knowing which records to search and his ability to cover up the facts.
What the Trust had to saySection 24 Firstly the Alder Hey inquiry has absolutely nothing to do with my complaint so most of this paragraph can be binned. I have contrary to what Paul Flynn MP, Rhodri Morgan AM, Jane Hutt AM, yourself and others have said, ever received a sincere and unreserved apology from Martin Turner or Gwent Healthcare NHS Trust. Repeated requests to these individuals for a copy of this “sincere and unreserved apology” to be sent to me have not been answered as is my request to you. If you consider that somewhere in the middle of a letter the word sorry is placed and this constitutes a “sincere and reserved apology”, then I don’t. Now under the agreement of the multi-part legal action that was taken, Gwent Healthcare NHS Trust with the legal department they have or have access to, unlike myself, would clearly have known that my complaint did not come under that action. This is proved by the fact that Gwent Community Health Council on both occasions including the feeble attempt by Colin Hobbs took up my complaint. The GCHC would have had to refuse my request for help under those very same rules. Gwent Healthcare NHS Trust would not meet with me because the knew that from the beginning I had been lied too. Now under the same settlement mentioned in the multi-party legal action, part of the settlement is that I am entitled to a “Full” apology and in due course, in my own time I will write to Martin Turner for that apology and I will then copy it to those persons that told me I have already received one.
Section 25 and 26 Most of these two paragraphs are based on conjecture and supposition and are therefore inadmissible. The Trusts bereavement counsellor cannot possibly know what background or experience Keith Hamilton had and therefore any statement made has no bearing on my complaint or of the hard facts and I object to its inclusion. In section 26, the councillor states that she presumed it was because no one had recognised it as a retained organ enquiry. Well just to remind you, "I want from the Trust, assurances and proof that any organs or body parts that were removed from my sons body at a post mortem were returned to his body for burial and not kept by the Hospital Authorities" Now look at the words in that statement, the last paragraph that I sent in my letters to Gwent NHS Trust on 9 December 1999 and 11 January 200, Organs, removed, body, returned. Obviously anybody reading those words would have a little difficulty deciding exactly what my letter was about! I want sections, 24, 25 and 26 severely edited as most of the content is irrelevant to my complaint.
ConclusionsSection 27 This section is total nonsense, Gwent Healthcare NHS Trust because of the adverse publicity surrounding the retention of organs from the dead bodies of children and for that matter adults as well, contacted Andy Rutherford and made a statement to him for publication in the South Wales Argus stating “Their Pledge to Parents, we do not do autopsies on children” Infact the Trust still today contact Mr Rutherford with very similar information about health matters for publication in the South Wales Argus. The Trust had very much editorial control over that article, it is and was exactly what they wanted to be conveyed to the public at that time and they could have and immediately have asked the South Wales Argus for a retraction of the article in view of the sensitivity and the national news coverage of the organ retention scandals that were prevalent at the time. They did not! The other completely nonsense statement is that you considered that the Trust spokesman was speaking in the present tense, so therefore I would assume that the Trust were still removing organs from the dead under hospital post mortems up to and including 7 December 1999 and not as the Trust has stated 1990. That date itself has been proved to be untrue as in the case of Mrs Rhosalyn Hawkins. In a letter to me dated 24 March 2002, Martin Turner himself says, “The article in 1999 outlined the practises that were current at the time in as much as since 1990 all Hospital post mortems on Paediatric cases would have been referred to the University Hospital of Wales……. Prior to the 1990’s the majority of Paediatric hospital and coroners post mortems were performed by the Trust.” This statement proves a number of things, 1 That the spokesman was at least referring from 1990 and not just the present time 2 Hospital post mortems were still being carried out since 1990 as Mrs Hawkins found out, the only one we actually know about and there are probably many more. 3 That the article was designed as a total lie to deceive the people of Gwent Now it is interesting to note that you failed to ask for or interview Andy Rutherford with regards to his memories of the publication and how and why he published that article and how did he obtain his information for it.
Section 28 Now here we ago again! From the time we had the first interview with Keith Hamilton we have been fobbed at every opportunity with the “passage of time” Its funny how an NHS Trust in North Wales are tracing all of the patients of an employee of theirs going back 30 years or more but Gwent NHS Trust suffer a severe case of amnesia only going back to yesterday! Unavailability of witnesses? Did you ask Keith Hamilton if he would be prepared to be interviewed? Did you tell Keith Hamilton that he was being the scapegoat in this “Turnergate” affair and tell him that his incompetence is being brought into question and his former boss Martin Turner is bringing all the blame on the mis-information and destruction of all documentation concerning my request to the Trust on him? Just to remind you what that request was… "I want from the Trust, assurances and proof that any organs or body parts that were removed from my sons body at a post mortem were returned to his body for burial and not kept by the Hospital Authorities" See, clear as the day, ORGAN RETENTION! Now most of the rest of this section has no bearing on my complaint other than Keith Hamilton was chosen to investigate my complaint based on his expertise. I firmly believe that he found out a post mortem HAD been carried out on my son and when he visited my wife and self and told us different, I knew he was lying because he could not answer the most basic of questions and invariably used the two most common statements used repeatedly by Gwent Healthcare NHS Trust… 1 The passage of time, “We do not know what happened all those minutes, weeks, months, years, decades, centuries ago” 2 We do not do post mortems and retain organs because we do not have teaching hospitals or do medical research. So how come all the Gwent Hospitals are full of body parts, where did these come from, were they given with the full and informed consent of relatives? I very much doubt it so and why did and do they keep all these body parts if from their statements they clearly do not need them?
Section 29 There needs only to be one line here. “That said, I am concerned that there appears to have been no material from Mr M’s 1999/2000 enquiry held on file by the Trust” Oh! And that is a surprise to you? The answer to that question is, they are still there and they will not let you see them or they were all deliberately destroyed so that no tangible evidence would ever remain in the archives of Gwent Healthcare NHS Trust. These are the only two options. The rest of that paragraph is rubbish also other than after the moratorium being lifted there was no way that the Trust were going to contact me and immediately admit to me that they had told me a pack of lies from the start!.
Section 30 Before the article in September 2000 was published, Mr Ben Turner the reporter for the South Wales Argus contacted the Trust and asked them for a statement about my concerns. The Trust replied that they told me everything they knew back in January 2000. There was no point in the Trust reinvestigating my concerns as they already knew the truth and were not prepared to open themselves up to accusations of lying which they were very much doing. It still hasn’t stopped those accusations has it? For my own part in this, when asked by friends and family has to how my search for information about my son Brendan Séan was going, the only thing I could say and I still remember saying the same words to a number of other people as well, Alzheimer’s hasn’t set in with me yet as it seems to have with all of the Trusts employee’s, “My hands are tied; I can go no further as they hold all of the cards and evidence” So I think that answers that question as to why I didn’t press the Trust then or at other times but when other evidence was published like the newspaper articles, I wasted no time in coming back at them except with a short delay when the last article published before the truth was finally admitted by the Trust. On that occasion I didn’t even read the article thoroughly and took little notice of it and even though I was told to read it by my family, I told them there was little point for the reasons stated above and it was only at the insistence of my wife a week later before she threw the paper out did I read it completely. It proved that for the last two years I had been right and Martin Turner and Gwent Healthcare NHS Trust were and are liars!
Section 31 To be quite honest and frank about this, Martin Turner and Gwent Healthcare NHS Trust didn’t give a shit about me and my family. They had only from the beginning, been interested in saving their own skins and I can rephrase that completely different if so desired. They were fully aware of the Assembly guidelines and by now would have followed them with other families who have gone through the same ordeal as myself and my family and some of those other families had a far worse experience than I had. Over six years later, I still suffer from the opening and reading of that letter, no warning what so ever and did they care? Did they hell!
Section 32 I did pursue my request for a meeting with the Trust and I did at a time when I was good and ready too. There was no time limit set as to when I could request that meeting and as it could also be part and parcel of my complaint under the NHS complaints Procedure, I requested it then. It was refused point blankly! The rest of Section 32 and most of Section 33 is irrelevant to my complaint as the Ombudsman had at that time no jurisdiction over Gwent Community Health Council other than the statement by Martin Turner that it had not been possible to use the complaint procedure because of the legal action. Well that’s poppycock because they will have a large legal department or access to one and they did know that my complaint did not come under the legal action that was taken then. They were and are also aware that the Community Health Council would also have had to operate under the same conditions and would if my complaint was part of that legal action have to refuse my request for their help. Just another lie, by the Trust.
Section 34 When you look at the wood behind the trees in your report you will find that ALL the factual evidence fully supports my complaint and my complaint must be upheld. You have failed to fully investigate my complaint by not interviewing important witnesses or asking them if they would be interviewed namely…. Keith Hamilton Andy Rutherford Rhosalyn Hawkins Jocelyn Davies AM My daughter Shelley, came into my home near to the end of our meeting with Keith Hamilton and remembers him holding documents in his hand that he was referring too. The documents that were destroyed And finally one of the most important witnesses that you or anyone else has ever yet to consider, the lady who gave birth to Brendan, the lady that had to carry Brendan for 9 months and then suffer the loss of her child, the lady that believed every damn lie told us by Keith Hamilton, something I only found out the day the letter arrived telling us that he did have a post mortem and his body parts were retained and the Lady that had to go through a second funeral for her child. Your report Ms Sue Ryan is based on conjecture, supposition, memory loss and superfluous information disguising the true facts of my complaint. I reject it in its entirety and I expect it to be rewritten based on the actual hard facts. A report like this will be torn to shreds in a court of law by even the most half baked lawyer far better than I can do and is unacceptable. You have at no time taken into account or fully investigated the missing and deliberately destroyed documents. It seems that because I made this complaint, certain departments both in Gwent Healthcare NHS Trust and the Gwent Community Health Council went on overtime to destroy a lot of documents that would have helped my complaint. Is it coincidence that both these organisations are unable to find those documents? I think not!
I will now write the report to the Ombudsman for you based solely on the facts.
Draft report to the Ombudsman In June 1998 an inquiry was established into the care provided by the paediatric service at the Bristol Royal Infirmary. During this inquiry it became clear that the BRI was not the only hospital that was being investigated for the practise of retaining organs taken at a hospital post mortem without full and informed consent of the deceased relatives. Some of the other hospitals were the Alder Hey Children’s hospital and hospitals in Birmingham, Southampton and others and as it transpired probably every hospital under the UK’s NHS service. The scandal’s that were now evolving from the inquiry soon became national headlines in the press and on TV and on the radio, infact you could not get away from it as it was in the forefront of the news media not for just months but years. Now each and every hospital trust in the country were very much aware of the situation and watching the outcome of any inquiry with intense interest because they all knew that their hospitals contained thousands of body parts taken at hospital post mortems without the fully informed consent of the relatives. So when the Coroner for Liverpool on the 3 December 1999 publicly suggested that the removal and keeping of these body parts was unlawful, panic set in with the NHS trusts and none more so than by Gwent Healthcare NHS Trust whose chief executive is Martin Turner. Martin Turner with probably some more of the upper management of Gwent Healthcare took the unusual step and I say unusual because no other trust in the country did so, of contacting the local newspaper and their health correspondent Andy Rutherford and gave a statement to Mr Rutherford for publication in the South Wales Argus on 8 December 1999, 5 days after the Coroner for Liverpool statement. The newspaper article headline was “Pledge to Parents, we do not do autopsies on children” Now Mr Shaun McGuire of Bettws, Newport read the newspaper that evening and on reading this particular article immediately knew that the content of this article was untrue as he had, under extreme pressure from the doctor concerned, signed a post mortem consent form for his son Brendan Sėan on 30 May 1974. Mr McGuire remembered very well the pressure he had been put under by the doctor at the Royal Gwent Hospital on the 30 May 1974 when he had just been given the news that his son was dead and the doctor would not accompany him to tell his wife that the child she had given birth too the previous day was dead, not until the form authorising a post mortem had been signed. So with the memories starting to flood back and knowing the content of this article was untrue, Mr McGuire wrote the following day to the Trust with a request,
"I want from the Trust, assurances and proof that any organs or body parts that were removed from my sons body at a post mortem were returned to his body for burial and not kept by the Hospital Authorities"
Mr McGuire also that same day telephoned Mr Andy Rutherford and told him that his story the night before was untrue as Mr McGuire’s son had undergone a post mortem by the Trust. Mr Rutherford said he would make enquiries with the Trust and get back to him. Mr McGuire is still waiting for that contact. On or about 11 December 1999, the Trust received Mr McGuire’s letter and request, something they did not anticipate as the article was supposed to quell anyone’s suspicions that a post mortem had been carried out on their children or for that matter on an adult. The upper management of the Trust and in view of the high publicity that organ retention was having in the news which had now been going for many, many months now, met and this meeting would have included Martin Turner and decided they would do nothing about Mr McGuire’s letter and probably destroyed it there and then. Now the South Wales Argus sold more than the one copy that Mr McGuire had read that evening and so the possibilities are that all the upper management had read that article also. The Trust knew Andy Rutherford very well and still do today, they still feed him story’s for his health column in the newspaper, so the Trust as they have said had no editorial control and knowing full well of all the body parts that they have in draws, cabinets and on shelves in their hospitals should have immediately contacted Mr Rutherford and the South Wales Argus and ask for a retraction of the article. They did not, because it was they that gave Mr Rutherford the content for the article and a retraction would have instantly meant that they were lying, which they were. Some weeks went by and again suddenly out of the blue a second letter was received by the Trust from Mr McGuire, I should point out here that both letters were directly sent to Martin Turner and both would have ended up on his desk, and this time the letter basically said “If you ignore this letter then Mr McGuire will take his story to the press” Martin turner and other unknown management figures conferred to discuss what to do next and they decided that this time they had to contact Mr McGuire but in a way that would leave no traceable and tangible evidence for the future Trusts records. So contact with Mr McGuire was done by telephone, no letter was sent, not even to acknowledge receipt of his letters and Mr McGuire was told that an investigation had been started. Some weeks later another telephone call was made to Mr McGuire to arrange a meeting with a representative of the Trust, Mr Keith Hamilton, one of the Trusts most highly experienced and respected employee’s with all the necessary qualification’s to carry out the search of the Trusts records and to be able to give Mr and Mrs McGuire a truthful account of what happened to their baby son, Brendan Sėan in 1974. The appointed day and time arrived and Keith Hamilton assured Mr and Mrs McGuire that no post mortem had ever been carried out on their son Brendan and therefore there was no possibility of organs being retained from him, He stated that the Trust had NEVER carried out post mortems on children and backed the newspaper article of 8 December 1999 up to the hilt. It should be remembered here that the date that was being talked about was 1974 and not as subsequently when the truth or partial truth was admitted by the trust, after 1990. No other dates such as 1990 were brought into the conversation. When questioned by Mr McGuire, Keith Hamilton insisted that the Trust had never ever carried out post mortems on children and when asked why Mr McGuire was pressurised into signing a post mortem form if they never carried out post mortems on children would only answer, he did not know why because it was 26 years previously. He kept repeating that the Trust did not have any teaching hospitals or did any medical research and therefore there was no reason for the Trust to perform post mortems on children and each and every time Mr McGuire asked why he was then pressurised into signing a consent form, he unable to give any reasonable answer. Mr McGuire after failing to get any satisfactory answers to his questions and only being met with the usual answers that the Trust still use today, “we do not have any teaching hospitals and do not do medical research and the passage of time quotes”, told Keith Hamilton that he did not believe one word he was saying and that he was lying. This has subsequently been proved true. Other than the statements said to Mr and Mrs McGuire on that day, Keith Hamilton gave them some of Mrs McGuire’s hospital records and the only document concerning their son Brendan they say they have, his out patients card. Following this meeting a letter was sent to Mr McGuire by Martin Turner reflecting what Mr McGuire had been told at the meeting by Keith Hamilton and even though it shows that Martin Turner was aware that Mr McGuire did not believe one word he had been told, there was no offer of a second investigation and neither was there any criticism of the way that the investigation had been handled by Keith Hamilton or of his suitability to carry out the investigation. The questions about Keith Hamilton by Martin Turner have only arisen since the Trust had to admit that they had carried out a post mortem and had kept body parts. Since the admittance by the Trust that what the McGuire’s had been told was untrue, Martin Turner at every opportunity has heaped the responsibility of the lies onto Keith Hamilton and his ineptitude in his investigation and has never ever once accepted the slightest degree of responsibility on himself even though Martin Turner is ‘where the buck stops’. After receiving this letter from Martin Turner on the 31 January 2000, Mr McGuire was unable to do anything else about it even though he knew he had been lied too but never once did he ever think or expect that the organs removed from his sons body would have been retained and it should be remembered that he only agreed to this post mortem because the doctor told him that it may help another child. He expected that the body parts would have been returned and buried with the rest of his son after an inspection by the doctors. It should be noted here that ALL documentation relating to Mr McGuire’s letters, visit by the Trust representative and the documents that Keith Hamilton was referring too during his meeting with the McGuire’s are missing/destroyed. No tangible evidence is available for inspection by the Ombudsman at least that is what the Trust maintains and is blaming their representative who they appointed and considered a highly qualified person to investigate Mr McGuire’s request for those documents going missing. There are no records in existence even the letters Mr McGuire wrote to the Trust other than the copies held by Mr McGuire. Is it a coincidence that some year’s later documents relating to Mr McGuire’s complaint under the NHS Complaints Procedure to Gwent Community Health Council also go missing/destroyed and copies of these had to obtained by the GCHC from Mr McGuire’s website. Lucky Mr McGuire kept all these copies because otherwise there would be absolutely no proof or evidence that he had ever made any request or complaint!! Mr McGuire was just an ordinary member of the public, living in a council house on a council estate and without any formal knowledge or help to try and investigate this matter any further. He was just an ordinary “Joe Bloggs”, but not quite as Gwent Healthcare NHS Trust are finding out. As time went by and when asked by family and friends if he had made any progress in obtaining information about his son, the only answer Mr McGuire could give was, “They (the Trust) have all the information and evidence and will not give it too me. My hands are tied because without it, I am unable to do anything” The next opportunity that Mr McGuire had to tackle the Trust was when on the 4 September 2001 and some 21 months after he initially asked them if his son had been buried complete was when the South Wales Argus published another article about Mrs Rhosalyn Hawkins of Abergavenny who had discovered that body parts from her still born son were kept after his birth on 13 June 1993. It should be noted here that Gwent Healthcare NHS Trust have always denied performing post mortems on children after 1990. This again is another of their lies and it would be interesting for the Trust to actually state the date that they carried out their last hospital post mortem without the full and informed consent of the relatives. It would also be interesting if the Trust or for that matter the Welsh Assembly would publish just how many body parts are held by the Trust and a total of all body parts held in all Welsh hospitals. After reading the article about Mrs Hawkins, Mr McGuire contacted Ben Turner a reporter for the Argus and told him of his efforts to find the truth about his son Brendan. On the 20 September 2001, the South Wales Argus now published an article on Mr McGuire and his wife’s fears and concerns about their son Brendan and the article was entitled, “Parents plea 27 years on” and obviously the plea was to be told the truth by the Trust which as it turned out fell on deaf ears.
In his research Mr Ben Turner contacted the Trust and they in turn told him that they had told Mr McGuire every thing they knew back in January 2000. So at this time and after being informed of the guidelines laid down by the Welsh Assembly and especially where they had told families the “wrong” information the Trust again did not reinvestigate Mr McGuire’s claims or in anyway contact him direct to discuss the matter. The facts were that they already knew the truth and were not about to admit that to Mr McGuire and his family as they had already been told a pack of lies. They have now started using a new excuse, the latest one being that Mr McGuire’s request was not recognised as a retained organs request. Well just to remind you in case you have forgotten as the Trust say they do, "I want from the Trust, assurances and proof that any organs or body parts that were removed from my sons body at a post mortem were returned to his body for burial and not kept by the Hospital Authorities" So again after that article was published, Mr McGuire was unable to progress any further. He was unsure what to do next, it was plainly obvious to him that the Trust would not in anyway deal with him and would only hold their ground against him because they had too much to lose by admitting the truth. It was not until a further article published in the South Wales Argus on the 30 January 2002 telling the story of two cousins who both found out at the same time that body parts had been removed from their deceased children and stored at the Royal Gwent Hospital. Mr McGuire did not read that article completely when he first saw it on the night of publication. He thought that it contained much the same information as the previous articles had and there would be little point in taking any notice of it because if he did write to the Trust then he would be ignored as he had been previously. It was only at the insistence of his wife, a week later that he read it in full and realised that the hospital in question was the Royal Gwent Hospital, the hospital where his son Brendan Sėan had died and where he was pressurised into signing the post mortem consent form. He now had information that would help him and this time had had no intention of letting this matter lie. It should be noted that as part of this article Martin Turner is interviewed and his comments are written in a separate section to the main topic of the article. Martin Turner states, “I can assure you that the new arrangements now being developed and introduced nationally will ensure that others will not be subjected to the same distress in the future” Martin Turner seems to have forgotten those new arrangements himself when he wrote to Mr McGuire with the truth on 24 March 2002.
Mr McGuire then wrote an open letter to Martin Turner and sent a copy of this letter to the South Wales Argus at the same time. He told them that they had lied to him from the very beginning and had lied to the people of Gwent. He demanded all information about his son that the Trust held, documents, names of staff who would have been present at the time and that he would only accept correspondence regarding this matter and would not entertain any telephone calls. Following sending his letter, Mr McGuire then received a number of letters from the Trust to now say that they were carrying out a second investigation to his claims, now well over two years since they should have carried out that second investigation, and on completion they would contact him with their findings. It can be hard to imagine what it is like unless it happens to you and especially when someone has to endure national publicity on a daily basis about the subject of retained organs for over two years and know that a post mortem had been carried out on your son as Mr McGuire did. And then suddenly out of the blue a letter arrives and not only did it now admit that a post mortem had been carried out on Mr McGuire’s son, which he never had any doubts about anyway, but it told him that body parts had been retained and still stored at the Royal Gwent Hospital some 28 years after his sons death. This was a tremendous shock to Mr McGuire because he never ever thought for one minute that organs had been retained because there was simply no reason too. It took Mr McGuire numerous attempts to try and read that letter in full without breaking down and it was probably days before he succeeded. Even today he has great difficulty in the reading of that letter without tears coming to his eyes mainly brought on because he was not told the truth at the time when he first wrote to Gwent Healthcare NHS Trust. Mr McGuire has always maintained that he was the first parent that asked the Trust about the retention of organs from children and they now admit that he was. As Mr McGuire was the first person to make this type of enquiry and Martin Turner would have been very heavily involved with this matter as Mr McGuire’s letter was addressed directly to him, the upper management of the Trust decided the truth would not be told even though they knew that their hospitals contained many body parts taken at hospital post mortems and some very recently compared to the date Mr McGuire was talking about. It was because Mr McGuire’s query was the first that they received the Trust went into “cover up and damage limitation” mode and so the lies started to flow. It is the above statements that are the subject of Mr McGuire’s complaint and his treatment from the date he sent his first letter to the Trust, 9 December 1999 until the admittance of the truth by the Trust and even the subsequent lies being told by the Trust and as can be seen by anyone with an ounce of sense, all the evidence directly points to Mr McGuire being told a pack of lies by Martin Turner and Gwent Healthcare NHS Trust and I uphold his complaint. End of draft statement
My Conclusions The draft report by Sue Ryan contains a lot of floss and other superfluous information designed so that the focus of the investigation is drawn away from the true facts and evidence presented by myself. It contains a chronology of events that has little to nothing to do with my complaint which is about the treatment and lies I received from Martin Turner and the Gwent Healthcare NHS Trust from the time they received my first letter dated 9 December 1999 until I received the last of their letters in 2002. Sue Ryan interviews the Trusts bereavement counselor and Sue Ryan fully accepts this counselor’s explanation of how Keith Hamilton would have investigated my request. How would she know? This is just pure conjecture and supposition, has no place in this report and should be deleted. The only person that can say how his investigation was carried out, how much experience he had to carry out the investigation was Keith Hamilton himself who Martin Turner and Gwent Healthcare considered competent and experienced enough to carry out this investigation. No attempt was made to contact Keith Hamilton to ask him if he was prepared to be interviewed or to inform him that his negligence and incompetence are being blamed on him by Gwent Healthcare NHS Trust and were the reasons that I was given the wrong information in January 2000. Sue Ryan has failed to interview other important witnesses such as Andy Rutherford of the South Wales Argus and it should be considered also that if anyone refuses to be interviewed then their refusal should be considered as supporting my complaint. It should also be noted that any refusal to be interviewed and retirement is not an excuse then subpoenas could be issued against these witnesses if this matter ever ends up in court. So we have a situation where important witnesses have been deliberately not interviewed, we have lies, we have the destruction of documents relating to my complaint, we have the character assassination of the chief investigator of my original request for information by the very people who appointed him to that position and we have even more lies and more documents destroyed later, not by the Trust but this time by Colin Hobbs of Gwent Community Health Council who I asked to put forward my complaint about the Trust to the Ombudsman. All these elements have featured in other worldwide scandals and I now call this “Turnergate” When all the rubbish in your draft report is removed you are left with only the true facts and evidence which totally prove that my complaint should be upheld. I thoroughly reject your draft report as being unfair, biased and not based on the true facts and evidence.
Shaun McGuire
Parents Hold Their Children's Hands A While, But Their Hearts Forever.
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