Note: Alan Ogilvie is a campaigner within the Eljamel and NHS Tayside Patients’ Action Group and allowed his feedback to Lord Weir to be archived here. Alan was operated on by Eljamel, in thec are of NHS Tayside, in 1995 at Dundee Royal Infirmary. Alan started this website and continues to support the campaign and the former patients, their friends and families.
Alan submitted a response to the call by Lord Weir for feedback on the Draft Terms of Reference that were published in the Eljamel Public Inquiry in which he is the Chair. His first submission was on 1st October 2024. He then attended the virtual meeting that Lord Weir and team set up for the 10th October. He reviewed his original submission and added additional clarification based on the meeting, and added responses to the topics raised during the meeting – this submission was on the 22nd October.
It is this last submission which is archived here as it contains all of his points. It is available as a PDF, and the text has been included on this page.
Alan refers to the Draft Terms of Reference sections in his submission – this document is available on the Scottish Government website. And archived here as a PDF in case that becomes no longer available.
Firstly, this document contains my feedback from the Virtual Meeting held on the 10th October which I attended and asked questions. (Please note that where I’ve put a timestamp like “~1815” that just means ‘at around 1815’ on the clock later realised things started a little later and were interrupted by the technical blip so it may have been around this time)
Secondly I have included my previously submitted notes which I have improved with layout to make it clearer the areas referenced in the Draft Terms of Reference. I have also tidied up these and expanded on some of the comments.
I provide this feedback as a former patient of Eljamel and NHS Tayside and my contact details are held on the form attached.
1. Response to Virtual Meeting with Lord Weir and team – 10th October
1.1. Use of the term “The Eljamel Inquiry”
I understand the comments you made about the reasons why this is used. However – I do feel that this again singles out the individual – which, in many eyes, is no longer the only thing being scrutinised. Those that enabled him, failed to scrutinise, are equally at fault. I also feel, somewhat begrudgingly, that it potentially victimises the individual Eljamel. Perhaps something more encompassing : “The Eljamel and Healthcare Inquiry” or something slightly different like “Scottish Patient Safety Inquiry” or something. Equally – I also realise, that the choice of my website’s domain put Eljamel front and centre (https://www.eljamelinquiry.org.uk) so I’m perhaps thinking that it makes sense to continue on given the coverage and the space held by this in the Public perception.
1.2. Lord Weir @ ~1815 – need to confer with SG with regards to possible changes to the PI ToR
Whilst I understand the person responsible for holding the purse perhaps has a say in anything which might impact the budget for the PI, it came across as suggesting that the SG were able to ‘control’ the ToR far more. This perception perhaps tarnishes the ability for the PI to be seen as truly independent – especially when the purse holder (and the purse holder’s predecessors and colleagues) should be investigated as part of the PI.
1.3. Lord Weir @ ~1823 – broadcast and accessibility for the PI
I wholeheartedly agree that the PI must have full access for those unable/unwilling to attend in person – having also seen what has happened to other PIs who have done this, it is vital that an official archive is kept and also made available to anyone wishing to review what happened. In the case of the Post Office ‘Horizon’ PI at least there were problems where individuals on Social Media were posting video from the PI but having edited it significantly. There should always be an official archive, and I believe you should make it clear how any recorded material deriving from it should be kept intact.
1.4. Lord Weir @ ~1824 – regards the Individual Clinical Reviews
This came up here and in the Draft ToRs. I just wanted to remind you that original the Clinical Reviews were supposed to answer questions for the individual patients (and families), not only to be a source of information feeding into the PI somehow. Please see the press release (with citations to media coverage) by the patient’s action group responding to Michael Matheson’s announcement of ‘clinical reviews for individuals’ on 20th April 2023. https://www.eljamelinquiry.org.uk/news/press-release-response-to-micahel-matheson-4th-may -2023-0600/
It would perhaps be prudent to acknowledge the main aim of the ICRs in the ToR, perhaps seeking Prof Whigmore’s input. The main aim for patients was to get them help first, and quicker than the PI could be set up and run – so far it’s still head-to-head as to whether the ICRs can beat the PI to starting up!
1.5. Jamie Dawson @ ~1850 – use of Media Coverage to help draft the ToR
As the maintainer of the website https://www.eljamelinquiry.org.uk I have quite an archive of media coverage in PDF and other formats. Not all of them are published to the website, specifically I have been unable to find the time to post several years of coverage early on in the activities of Eljamel and NHS Tayside. I am happy to provide my archive as files to the PI should you feel this useful. Please just ask. Also the website is being archived by the British Library’s archival service should that also be useful.
I also have amassed a timeline of important or notable events in Eljamel and NHS Tayside’s activities. I can include this in the archive should that also be useful to you.
1.6. Jamie Dawson @ ~1904 – positions held by Eljamel
There was a discussion regarding whether we knew of any other positions held, and I point you to my previous feedback (which is also included below with some expansion to my prior comments – you find this in my Section 2 below.
1.7. Jamie Dawson @ ~1905 – statement about GMC regulations
It is exactly these quoted regulations that, to me, mean that they need to be investigated by this Inquiry. See my comments below in the Q&A session.
1.8. Jamie Dawson @ ~1907 – statement about Private Healthcare
The comments suggest no attempt to investigate the role of Private Healthcare in regards what happened and how to stop it happening again. However, you’ll find comments below that I made in the Q&A session and in my previous feedback why I believe it is vital to include Private Healthcare in this inquiry, and why I feel it should be legally possible to do so.
Jamie Dawson @ ~1917 – statement about the ‘limitations of the Scottish Inquiry’
I have gather my response to this in the general points raised through Q&A Session below. I believe that there cannot be the limitations as suggested.
1.9. General points I raised during the Q&A session
1.9.1. Public Inquiry is suggested to be unable to investigate organisations ‘outside’ of Scotland
I wish to raise a concern about the scope of the Inquiry – earlier it was explained that the powers were limited to it being a ‘Scottish Inquiry’, restricting to things only that the Scottish Parliament functions within.
Jamie Dawson said that “no stone will be left unturned” – yet the statements suggest that important stones will be left unturned.
As someone operated by Eljamel in 1995 at Dundee Royal Infirmary, before devolution, why should there be such a restriction. Further – if this is suggesting that the General Medical Council and the Health & Safety Executive are somehow out of reach for investigation – both these organisations are operating within Scotland (before and after Scottish devolution) so I do not understand why they might be two organisations which cannot be investigated.
Organisations like the General Medical Council, the Health & Safety Executive, and the Royal College of Surgeons (several chapters of it) are all key organisations that are involved in what has happened and operate in Scotland and have done so before and after Scottish devolution. If you can’t look at these when these organisations’ actions (or inactions) are key to various aspects of the failures that led to these outcomes, then there is little point having a Scottish Public Inquiry – this needs to be a UK Public Inquiry.
If the a ‘Scottish Inquiry’ is unable to investigate these things then that would bring into question why these organisations of interest are able to operate unregulated in Scotland – I say unregulated because being unable to investigate them in a Scottish Public Inquiry, to me, suggests that there is no oversight of these organisations by the Scottish Executive/Government.
1.10. Public Inquiry is suggested to exclude investigation of Private Healthcare
In several statements earlier it was clarified that the team felt it was unable to investigate Private Healthcare. However I propose that it must be investigated, the former patients are either fully NHS, part NHS + part Private, fully Private – plus the need to investigate this Private Healthcare activities in relation to impact on other NHS service deliverables. Plus ‘independent healthcare’ (Private) is regulated in Scotland by NHS HIS –
https://www.healthcareimprovementscotland.scot/inspections-reviews-and-regulation/regulati on-of-independent-healthcare/
Since we are investigating NHS HIS and the various NHS Boards linked to NHS HIS activities, and that private healthcare cannot operate in Scotland (similar in other parts of the UK) without regulation by an NHS board – then it is, I propose, perfectly legitimate to include investigation of Private Healthcare.
Note that Circle Health Care is on the NHS HIS list of independent healthcare providers and I understand they are the current group that owns the old BMI Fernbrae (Dundee private hospital where Eljamel operated) records – Circle acquired BMI Healthcare Limited in January 2020
(acquisition information available https://assets.publishing.service.gov.uk/media/5e8d8c30e90e07077b526ab6/Summary_of_the_d ecision_updated_8_April_———.pdf ).
Who knew what when? Well – if you don’t investigate the Private Healthcare organisations and help the ‘private’ patients – it will feel like another stone left unturned and deprive patients of answers (consider if they are hybrid public and private patients!).
1.11. Public Inquiry suggests Police Investigation isn’t in scope
Whilst I can agree with the statements in response to the other person asking the question about the ongoing Police Investigation, I followed up with a point that – I understand why the Police Investigation cannot be interfered with in terms of the actual investigation; but why is it not possible to look at the role that the Police have in the wider Public Inquiry investigation. Can the Public Inquiry not look at the delay in investigating Eljamel and the patient complaints to the Police, some of which have been made public recently regarding the revelation that the Police asked the Scottish Government for help because they were ‘out of their depth’. Alongside the HSE / NHS HIS the Police are part of the body of people that patients and staff can go to… yet they seem to have failed us/them. Surely it is possible to suggest an investigation into the role the police have had, whilst still avoiding perceived interference with the ongoing investigation. Again, feels like another potential unturned stone.
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Previously submitted comments [Editor’s note: from 1st October] follow with improved referencing and expanded comments.
2.§1 – Appointment process.
In regards to the phrase “process leading to” – to what extent are these processes being investigated?
This seems to limit the investigation to only the positions (a), (b), and (c) in this paragraph. I believe there were others. For example – he was appointed the chair of the internal body “Clinical Governance Committee” according to the Tracey Gillies report 2019 (report ref: pg 3 sec 3) though disputed by NHS Tayside who claim he was chair of the “Specialist Services Group Clinical Governance Committee” (2006 to 2010). Further, NHS Tayside were unable to provide any minutes of these committees when asked under FOI, nor were they able to confirm the Terms of Reference for those committees – surprising since it was a committee around Clinical Governance yet they retained no records.
Surely it would be better that the PI ToR look at any and all employment and appointments made by, at least, NHS Scotland and the University of Dundee of Mr Eljamel rather than restrict this to only these titles? I say ‘at least’ because I would suggest that any and all employment made in relation to his medical credentials should be within scope – including employment by any NHS and UK Private Healthcare providers.
Additionally – there seems no reference to his professional memberships and investigation to those – I would propose that “processes leading to the appointment” should investigate these.
This would include Fellowship of Royal College of Surgeons: multiple country orgs including Ireland, Scotland and England; and also the General Medical Council. I suggest that the investigation process leading to his appointments will require these organisations’ actions to be investigated. It seems to me these are key to not only understanding how this happened, but also to stop it happening again.
I noted in Section 2 that other organisations may be investigated and not just NHS Tayside as the only NHS health body involved; there should be a wider review into any other NHS organisations he was involved with leading up to this point – England and Ireland reportedly. When NHS Tayside were doing their ‘due diligence’ in appointing him, what information did they receive from the NHS bodies that he was apparently involved with prior to his appointment?
3. §2 – Mr Eljamel’s professional practice with NHS Tayside
3.1. “…contributing to adverse outcomes for former patients”
Why does this seem to limit the investigations to be only about former patients, and only about
‘adverse outcomes’. Surely this should be about his impact on not only patients, but colleagues (other staff), as that may be useful to understand if it impacted others and the problems surrounding his actions. Regarding ‘adverse outcomes’ – is this an attempt to limit to only evidence logged as an adverse outcome, what about complaints (upheld or otherwise)? A cover up by NHS Tayside, if there is one, would attempt to limit things getting to a formal stage where they are written down as an ‘adverse outcome’.
3.2. “…during the course of his employment with NHS Tayside”
There is evidence he showed up in other NHS health boards to see patients. Perhaps widen this to just ‘NHS’. This also raises a question of this not just being about ‘NHS Scotland’ but also any roles in England and Ireland that may have had an impact on this and perhaps his appointment processes.
3.3. §2a – “private practice”
This should detail out the private practice or be all encompassing – he didn’t only seem to work for Fernbrae (now Circle Health Group). How did this impact his NHS Tayside position(s) also?
3.4. §2b – “professional colleagues within the NHS”
Surely this should include University of Dundee medical faculty (and any other related areas)… or is this considered part of the use of the word ‘NHS’ here?
3.5. §2b – “trainee surgeons”
And any other relevant medical students / student nurses /etc – he reportedly ‘ruled the roost’ and had a finger in many pies. What about the anaesthetists that he worked closely with?
3.6. §2c – “Workload pressures within NHS Tayside”
Why only within NHS Tayside? What about pressures outside of this – workload pressures included his private practices, his private consulting, and his authorship/publishing. How could he do all of these at once and expect to be able to be good at all of them? Equally – how could his main employer, NHS Tayside, not question the load he was placing on himself (outside of the workload they had placed on him) and discuss how he could maintain quality for his deliverables – not harming patients, etc. It seems to me to be ridiculous that Eljamel operated as a law unto himself and NHS Tayside, for one, didn’t question his other activities. Were, for example, they monitoring his compliance with ethics? Were the GMC checking things? Etc.
3.7. §2d – “research undertaken”
This item seems to be limited to only where it (employment/appointment) is related to University of Dundee. He clearly had private consulting and other research (he had published articles, written text books) – surely the investigation shouldn’t be excluding the full picture?
4. Clinical Governance
In general – this section doesn’t specifically mention things like SAER (Significant Adverse Event) or M&M reports (Morbidity and Mortality meetings) – are these included in the clinical governance, perhaps they should be mentioned explicitly?
4.1. §4 – “complaints and feedback process operated by NHS Tayside”
This item only looks at NHS Tayside, why exclude complaints to private practice (Fernbrae Circle Health Group, for example)? There are reported cross over complaints between those treated privately, then picked up by NHS Tayside for corrective surgery. Surely to get the full picture, complaints made against him or the teams he ‘ran’ should be reviewed? In §3 you mention private providers, but not here in §4.
4.2. §4 – possible confusion over if §3 is before and if §4 is after his employment
As I read here I see that §3 is during his employment, but §4 is outside of this. Before or after?
Maybe this could be clearer to anyone reading this?
4.3. §5 – “feedback process or systems of oversight”
What about whistleblowers… these aren’t explicitly mentioned here. They may not appear in the catchment of formal complaints and feedback. If feedback processes were working there wouldn’t be the need for whistleblowers to blow those whistles. So perhaps worth explicitly mentioning them in the appropriate points to encourage those that wish to speak anonymously could do so? Perhaps emboldened by the Public Inquiry legal protections?
4.4. §6 – “including by not limited to NHS Quality Improvement Scotland (NHS QIS) and Healthcare Improvement Scotland (HIS)”
I know you have said ‘including but not limited to’ – but could I suggest adding in the other agencies… the ‘Scottish Health Advisory Service (SHAS)’ the precursor to NHS QIS. The latter was only formed in January 2003. (NHS QIS was formed of the Clinical Standards Board Scotland, Scottish Health Advisory Service, Health Technology Board Scotland). The Clinical Standards Board Scotland itself was only created in April 1999.
Equally – why only investigate ‘health agencies’. What about the GMC (or are you classing that as one of these)? Also the Health and Safety Executive needs to be investigated about their relationship with NHS QIS and the ongoing back and forth finger pointing over their responsibilities in this case.
And why stop there? Pre-devolution in May of 1999 – the UK Government, via the Scottish Office was responsible for the oversight of NHS activities in Scotland. Eljamel was employed by NHS Tayside from late 1995 so there was at least 4 years of time when it wasn’t only about the Scottish Executive’s (as it was called) responsibilities.
4.5. §6 – “care provided by Mr Eljamel to his former NHS patients”
I wonder again why this is only about care to patients, what about how he worked with teams, colleagues, etc. It’s mentioned in some of the other items here in Clinical Governance. Why not here?
5. Candour
5.1. §7 – “concealed or failed to disclose evidence”
I agree with this, but I do feel it’s somewhat limiting. What about his concealment of success rates of proposed surgeries to patients and families? It has been reported that he concealed things perhaps so that he could do the surgery. I also personally have evidence of him concealing key details of my operations to the lead consultant neurosurgeon at Queen’s Square in London – he told him that only one operation had been done, it was completed successfully and no one else touched me – totally failing to advise the consultant that a second operation had been done by his then boss, head of neurosurgery, Mr Varma, as a corrective measure.
Also – what about his advice to private healthcare providers (there’s a lot of ‘NHS’ only words here).
6. Restrictions relating to Mr Eljamel’s practising privileges
6.1. §10 – “came to resign from his position”
I think it would be helpful if we could understand how he left… how he ‘resigned’. My own feeling having reviewed reports, like the Tracey Gillies 2019 report, was that it was perhaps a ‘severance’ – whereby he held out for some money, and once all was agreed it was presented as him having ‘resigned’. I think this is important as this is public money being used to cover up something where he should have been sacked for gross misconduct or similar. (i.e. there would be no money as part of a severance agreement, and potentially legal actions with consequences)
7. Reviews and investigations
7.1. §12 – “(a) by, on behalf or on the instructions of NHS Tayside or (b) the Scottish Executive/Scottish Government”
Why just these two bodies? What about the GMC, what about RCS (yes – I see the report by the England facet, what about RCS Ireland for which GMC published his credential, what did they all report internally about this), what about NHS QIS/HIS, what about HSE? What about other health bodies, what about private healthcare (Fernbrae / Circle). Though the list in this section is a good start, as you said… I feel it should be a slightly wider scope than just restricting it to NHS Tayside and SE/SG.
7.2. §13 – “to what extent NHS Tayside concealed”
Yes, and… what about private healthcare at Fernbrae/Circle Health Group? Which impacts on the responsibilities NHS has towards private healthcare provision in Scotland (and the UK). Was there any communications and knowledge sharing between the NHS and the private healthcare providers? Because it would seem to me that there should have been.
7.3. §13 – “police”
This is the only mention of the word ‘Police’. Why isn’t the Public Inquiry at least going to mention the ridiculously long Police Scotland investigation (now called ‘Operation Stringent’). Myself, and other patients who have been involved in that, will find it oddly missing from the ToRs for the PI. Surely there should at least be some mention of reviewing why that has taken so long, and whether the Police were involved during Eljamel’s time at NHS Tayside. It could inform recommendations about healthcare and police working more effectively together. It’s been ‘radio silence’ from Police Scotland, aside from very limited acknowledgments there is an investigation. Almost to the point, given the many years of waiting, where the patients involved have lost all trust in the Police over the matter.
7.4. §14 – “document management and retention systems”
Yes, and… not only look at these but also look at NHS Tayside’s inability to adhere to rules around Subject Access Requests (incl. requests for medical records), and other Data Protection Issues regarding personally identifiable information. Also check with the UK ICO and the Scottish ICO as they both have differing responsibilities. For the former I have an upheld complaint regarding NHS Tayside’s inability to adhere to rules – it demonstrates they remain a shambles to this day when asked for records regarding subjects (patients, etc).
8. Independent Clinical Reviews
I think that the ICRs also should be investigated – why did it take so long for the Scottish
Government to recognise that patients needed help, and then actually do something about it (as I write this the ICRs are still not set up – 552 days and still counting since they were finally announced in April 2023). This would allow investigating the Scottish Executive and Scottish Government handling of patients complaining to them about care at NHS Tayside in relation to Eljamel. Over the years a list of cabinet secretaries and first ministers have failed to take the problems faced by patients seriously. I believe they only finally agreed to the ICRs because they were shamed into doing so by us, the former patients. We had no support to do this… there still isn’t a Patient Safety Commissioner for Scotland appointed and previous bodies like ‘PASS’ failed to help (and were seen as to be in collusion with NHS Scotland boards). This should, in my eyes, be investigated and here is a great opportunity to do so.
9. Evidence
[no comments]
10. Lessons, recommendations and reports
§18 – “make recommendations”
I feel that only being able to make recommendations has been, for other Public Inquiries, somewhat ‘toothless’. Looking at the Infected Blood inquiry they are trying to follow up on recommendations to see that they are implemented. Perhaps being more open to doing this sort of thing in the TORs would help the public feel that this inquiry will have ‘teeth’.
There’s also no explicit mentions about potential compensation/support schemes which may be recommended. Again – another thing that patients and MSPs have been asking about.
11. Explanatory notes
11.1. Item (b) – “opportunity for public acknowledgement of the suffering of former patients of Mr Eljamel”
Yes, and… What about Whistleblowers and other colleagues? What about healthcare staff trained by Eljamel and his team, that now look back on their days as students at Dundee University and wonder if they were given the wrong training – how much ‘infection’ did Eljamel/NHST/DU cause to neurosurgery in the UK as students trained went into NHS across the country. Did anyone do corrective training for those when Eljamel was investigated by RCS and identified wrong procedures being followed!? There is an opportunity to also help our healthcare workers.
11.2. Item (c) – “are applied by Health Boards in Scotland”
Why is this limited to these? Do you also mean NHS HIS (not a ‘Health Board’ technically), why not just say “NHS Scotland”, The Scottish Government, H&SE, GMC, RCS (Scotland, Ireland, England)… surely the inquiry can make recommendations about any org/body/individual that’s involved?
11.3. Item (d) – “definitive list of every issue or every person that the inquiry will consider”
I understand that. I have tried to suggest things here that the ToR should probably talk about. These are things that I worry about as a former patient and someone with friends and family who rely on NHS Tayside to provide safe healthcare to them to this day. My trust is totally gone in NHS Tayside being able to do so. Gone is the trust in NHS Scotland or the Scottish Government to maintain any real oversight on the activities within the Healthcare system (both public and private). I was part of the former patients action group (PAG) as such I have spoken with many other former patients and I’ve tried to include common patterns of concern that they raised to me. I feel that the ToR would be better accepted by patients like myself if these things were included explicitly.