Scandals that need not have happened

DISASTERS and scandals that could have been averted if concerns had been raised or acted upon include:

In August it was announced that 2,000 bone cancer cases were being re-examined after an inquiry launched in May discovered that a senior pathologist at Birmingham's Royal Orthopaedic Hospital had misdiagnosed 42 cases. The inquiry, headed by Archibald Malcolm, found that two consultants had expressed doubts about the diagnosis over several years but failed to speak up through official channels.

In July 1992, the report of a committee of inquiry chaired by Sir Louis Blom-Cooper revealed that patients at Ashworth special hospital had been subjected to a brutalising regime of physical and mental abuse by staff. The inquiry uncovered 'a developed pattern of intimidatory behaviour against staff and professionals who were brave enough to speak out'.

Investigations into the closure of BCCI in July 1991 uncovered fraud estimated at pounds 2bn worldwide, which had evaded exposure for 19 years. The inquiry revealed an autocratic environment in which no one dared speak up.

The official inquiry following the conviction of Frank Beck and two other men for assaulting and sexually abusing children in the care of Leicestershire council revealed that over 13 years at least 30 concerns had been raised about Beck, but no effective action was taken.