An Inquiry into Quality and Practice within the National Health Service arising from the Actions of Rodney Ledward

Terms of Reference: 1. To consider why the serious failures in the NHS clinical practice of Mr Rodney Ledward at South Kent Hospitals NHS Trust were not identified and acted upon earlier and to consider the action taken when those failures came to light. In doing so, to review the role of the management and staff of the Trust (and its predecessor body) and other external bodies concerned with the quality of patient care and to consider the adequacy of systems, including clinical audit, to ensure quality.

2. In so far as it is relevant to the inquiry into 1 above, to inquire into the care of the NHS patients treated by Mr Rodney Ledward at South Kent Hospitals NHS Trust between 1990 and 1996, but including earlier events where appropriate.

3. To make recommendations for the NHS arising from the case, particularly in respect of the development of clinical governance within the NHS locally and nationally.

4. To report to the Secretary of State as soon as possible from the commencement of this inquiry.

The Inquiry will be conducted in private and the Inquiry Panels Report to the Secretary of State will be published.

Chair: Jean Ritchie QC

Dates:

· Establishment: 17 March 1999

· Hearings: First public meeting 31 March 1999

· Report: 1 June 2000

Link to website and or download report:

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4093337

Description of the events which caused the public concern:

Clinical misconduct by a Consultant Gynaecologist, Mr Rodney Ledward.

Litigation

None from the inquiry.

Summary of reports recommendations

Detailed recommendations relating to:

Clinical governance in the NHS, including:-

  • Incident reporting
  • Audit
  • Complaints and claims
  • Appraisal
  • Use of data
  • Liaison between NHS Trusts and GPs
  • Whistleblowing
  • Clinical governance in the private sector
  • Disciplinary procedures
  • Alert letters
  • The General Medical Council
  • References
  • Chaperones
  • Consent forms
  • Occupational health
  • Medical students
  • Dealing with a major incident
  • Organisation in the NHS