Former Ward 22 manager not called as a witness says trust is lying over events that led to patient’s death

Francisca Holmes, a 61 year old staff nurse, had worked happily at the Queen Elizabeth Hospital, Woolwich since 2019. She is a black person of African ethnicity.

But during the Covid pandemic she was shocked to go into Ward 23 on 17 May 2020 after a frail elderly patient, who had not been admitted with Covid, but with a lower respiratory condition, was found to have died and nobody had noticed.

As I reported earlier, after the document was released by the judge hearing her tribunal case, the investigation into her death has been sparse. Just one page recording a ” patient incident” for a woman who died alone in a ward full of Covid patients after vomiting, with her mask resting on a pillow and a nebuliser with no oxygen.

Ms Holmes had a five day tribunal hearing this week under judge Eoin Fowell claiming detriment over whistleblowing, constructive dismissal, and age and race discrimination. All this was challenged by the Lewisham and Greenwich NHS Trust who employed a junior barrister, Camille Ibbotson, from the law firm, Old Square Chambers at great expense to press their case.

Her discovery of the body of the patient was reported to staff nurse Mr. Rey Malabuyoc. According to her witness statement she blames a Filipino nurse ,Ms Chenee Coronado, who was looking after her, for negligence that lead to her death. She has never been asked for a statement about what happened by the trust.

The death of the patient is described more fully in her witness statement:”

“According to Biftu Ali {the day nurse on duty) , the patient had been sitting out in the chair eating yoghurt when she aspirated and peri-arrested.  A crash call was put out and patient was seen by the team.  She added that patient was in bed, settled and being nebulised.

“After handover, my colleague  went into the bay but came straight back out to call me.  The known COPD patient was found lifeless with a nasopharyngeal tube in her right nostril.  She had a face mask on and nebulised on air via an air driven machine.  There was no sight of a nasal cannula, meaning she was not getting the required oxygen.  It is note worthy that a 40% (red) venture mask laid on top of her pillow while the flow metre was on at 60%. The patient had a nasopharyngeal tube in her right nostril.”

The trust’s argument is the hospital was in the middle of the Covid pandemic and nurses could not devote the time needed to look after every patient because of staff shortages. Mr Rodney Katandika, the matron, on the ward, who first investigated the situation, said in evidence to the tribunal initially there was “nothing untoward in her death”. He also resolutely denied any age and race discrimination on his part.

After the event her witness statement says the trust ” appointed Lucie Kabatesi, Matron on and sent her a list of my complaints in a letter purporting to set out my grievances. The letter specifically omitted any reference to the patient death incident and my whistleblowing complaint which I had raised. I was not advised of any other procedure to raise my concerns and it appeared that the respondent was covering up the circumstances of the patient death and my allegations.”

She says she repeated her allegations when she met Ms Kabatesi on 27 April 2021. Ms Kabatsi told the tribunal this was the first time she had raised this with her and it was added to her investigation.

Francisca Holmes claims that since reporting the death she has been subject to detriments and ” set up to fail ” including being put on inconvenient shifts, left in charge of the ward without a matron, passed over for courses, had a pay cut just after a pay rise, and being accused by Mr Katandika of leaving without handing over her patients to the next staff shift putting patient safety at risk contrary to the nurses’ code of conduct.

She seems to have had a bad relationship with Jean Firaza, a Filipino manager, describing in her statement an incident where during a handover. In her statement she says: “She was very angry, arms akimbo and leaning back and forwards. There was a discussion about the treatment we were giving to a patient.”

Jean Firaza was not called as a witness by the trust, though she attended the hearing every day.

The investigation by Ms Kabatesi was scheduled to be completed in four weeks but took six months. She was described as an expert investigator but like Mr Katandika, and Ms Ann Marie Coiley, director of nursing, had no experience of investigating whistleblowing cases. I find this strange they were chosen since the same hospital must have postgrad experience of investigating whistleblowing since it is still fighting Dr Chris Day for over ten years over his whistleblowing claims over the avoidable deaths in the intensive care unit.

Ms Holmes was never informed of the progress of the investigation and eventually frustrated resigned.

Ms Ann Marie Coiley blamed Covid problems for the failure to sort out Ms Holmes’s request for flexible working and said she had bought a ” shopping list of complaints” against the trust.

In her closing submission Camille Ibbotson for the trust said all her claims of unfair treatment and age and race discrimination were ” wholly unfounded.” She said all the trust witnesses who were called had provided credible evidence while she had been ” evasive” when questioned by her. She downplayed the death of the patient describing it as ” a patient incident” which seemed to me to be a rather callous dismissal when you heard the facts about the death.

Winston Brown, Ms Holmes’ solicitor, in summing up her case placed great emphasis on the fact that she been the victim of constructive dismissal by being kept in the dark about the investigation into her grievances and the trust hiding behind Covid to avoid detailed questioning about how she was treated.

He pointed out despite Covid the trust did not suspend its policy of treating staff with dignity and compassion because of the Covid crisis. As a result he thought it was in breach of the code and therefore she should be compensated. He also raised why the tribunal had not heard from Thurdy Campbell, one of the managers involved

After the publication of my blog over the trust’s failed attempt to ban me from seeing Ms Holmes’ witness statement and the ” investigation” into the patient’s death I was contacted on Linked In by Thurdy Campbell myself. She blames the death of the patient on an unplanned reconfiguration of wards 22 and wards 23 just two days before the patient died

She told me: ” I was the manager of Ward 22 at the Lewisham  and Greenwich NHS Trust who reported patient safety concerns  (via clinical incident) and sent email to senior managers  regarding  the unplanned reconfiguration process of 15 May 2020 that led to that incident (I was blindsided of the  patient’s death until Francisca Holmes raised the incident with me sometime in 2021).

” I supported FH as the ward manager during her complaint  but was dismissed from office during the investigation procedures conducted at the Trust . I was subjected to unlawful disciplinary sanctioning after reporting. “

She goes on: “I have sent Fran the info on this incident this morning . They are lying. I was slapped with a conduct letter by the DDNG (Divisional Director of Nursing Governance) for raising concerns about this incident. It has nothing to do with staff shortage. There should be a shift log book detailing activities of that day. Mr Brown should request a copy of that booklet..”

This seems to throw new light on events that were never told to the tribunal. The judgement will be given Monday afternoon.