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Case reviews

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In June 2017, the National Guardian’s Office launched a 12 month trial of its case review process. The trial will review the handling of concerns and the treatment of people who have spoken up, where there is evidence that good practice has not been followed.

Case reviews will identify areas where the handling of NHS workers’ concerns did not meet the standards of accepted good practice in supporting speaking up and recommendations will be made to NHS organisations to take appropriate action where they have failed to follow good practice. Case reviews will also commend areas of good practice.

The National Guardian’s Office will initially conduct a 12 month pilot of the case review process, after which they will assess and refine the process, taking into account the feedback received from case referrers and others.

Case review referrals can be sent to the National Guardian’s Office by email to:

When referring by email we recommend that you use the downloadable referral form below. Using this form will assist us in promptly processing your referral.

Official documents

Published reports

Case review news

15 November 2017

The National Guardian for the NHS has published a set of recommendations following concerns raised by staff about the speaking up culture at Southport and Ormskirk Hospital NHS Trust.

The case was referred to the National Guardian’s Office as many people had spoken up at the trust but their concerns were not properly acted on. The report identified failures to act appropriately on multiple and serious allegations and a number of wide ranging issues that represented significant barriers to speaking up. These included a culture of bullying and alleged discriminatory behaviour.

As a result of the report, the National Guardian has made 22 recommendations for the trust and one for the Care Quality Commission, encouraging all organisations to reflect on these and apply the learning to their own cultures and processes.

Dr Hughes said:

“I would like to thank Southport and Ormskirk NHS Trust and all those who were involved in the review for their cooperation, willingness to work together, and appetite for learning. Many individuals at the trust said their views or concerns had not previously been taken seriously. The trust also failed to consider the needs of its black and minority ethnic staff.

“I have published a set of 22 recommendations for the trust, which are designed to improve workers’ ability to speak up and to tackle the barriers to speaking up that were present in the organisation. My review also highlights areas for improvement in the Fit and Proper Persons Test which I have recommended that the Care Quality Commission addresses in its revised guidance.

“I can, however, only act on cases that I am aware of. If any individual or organisation within the NHS feels that they have a speaking up case that has not been dealt with in accordance with best practice, I would encourage them to refer the matter to my office for consideration.”

Karen Jackson, interim Chief Executive, Southport & Ormskirk Hospital NHS Trust said:

“We were pleased to be able to work with the National Guardian’s Office to review how speaking up is, and has been, handled by the trust. We encouraged staff from across the trust to take part and they raised a range of concerns. Most of these concerns went back a good number of years.

“The trust now has a new senior management team in place. The learning from the review is a welcome and helpful addition to the robust action plan we have in place to ensure that speaking up is seen as a way to make improvements for our staff and for our patients.

Chris Hopson, Chief Executive of NHS Providers said:

“This is a constructive and valuable report. It provides welcome insight for all trusts into what makes speaking up work well and sets out the process and policies that support it.

“It highlights how openness and transparency from senior leaders are vital in ensuring staff are treated fairly at work. The focus on improving the culture for black and ethnic minority staff is particularly welcome given the concerns that exist right across the NHS.”

23 August 2017


The National Guardian’s Office (NGO) was established in 2016 to support Freedom to Speak Up in NHS trusts. It also reviews instances where there is evidence a trust may need to improve its support for speaking up. 

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust is in ‘double special measures’ (for quality of care and finance).  There is evidence that the culture and processes for staff at the trust to ‘speak up’ or raise concerns do not always work well.

The NGO launched a pilot of its process for reviewing culture and processes for ‘speaking up’.  Northern Lincolnshire and Goole NHS Foundation Trust has now volunteered to work with the NGO to use this pilot to review how it handles speaking up and concerns raised by its staff.  It will do this with reference to the recommendations of Sir Robert Francis’ Freedom to Speak Up Review (February 2016).

The National Guardian, Dr Henrietta Hughes, said: “I am delighted that North Lincolnshire and Goole NHS Foundation Trust has volunteered to work with my team to identify areas for improvement in speaking up.  The purpose of this review will be to identify learning for the trust, as well as all NHS organisations and their staff. Working together is a positive step in embedding the open and transparent culture we all wish to see where speaking up is business as usual.”

North Lincolnshire and Goole NHS Foundation Trust Chief Executive, Dr Peter Reading said: “Our staff have recently raised a number of concerns about the trust. I am therefore pleased to have the opportunity to work with the National Guardian’s Office to review whether our processes and cultures have fully supported our staff to speak up and whether there are lessons to be learned about how we can do this more effectively. I intend to use learning from this review to make improvements for our staff and our patients”.

The Trust appointed Mr Makani Hemadri, consultant in general surgery, as its Freedom to Speak Up Guardian earlier this year to act in an independent and impartial capacity, working alongside the board and executive team to help support the organisation to become a more open, transparent place to work.

Last updated:
15 November 2017


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