At the time of writing, the Mazars report into the deaths of patients of Southern Health NHS Foundation Trust, although ready to go, is still unpublished. The BBC news stories on Wednesday 9 December were based on a copy of the final draft of the report, leaked to them by person or persons unknown to #JusticeforLB. The House of Commons Urgent Question to the Secretary of State for Health, on Thursday 9 December, was based on the same unpublished final draft.
As a general rule, I find televised Parliamentary proceedings an irritating bore, epitomised by that baying bearpit of ritualised smuggery and yah-boo-sucks non-addressing of the issues, that is Prime Minister’s Questions. The UQ was very different: sober, even appropriately sombre.
Heidi Alexander (Lab., Lewisham East, Shadow Health Secretary) was suitably urgent in putting the question: “To ask the Secretary of State for Health if he will make a statement on the report of the investigation into deaths at Southern Health NHS Foundation Trust. “
Health Secretary Jeremy Hunt (Con., South West Surrey) would, at length. He is obviously a bright boy. He realised long ago – as soon as Verita 1 came out in early 2014 – that any attempt to dig a bomb-proof shelter on this issue would simply end up with him in a massively embarrassing hole, and he promptly came out with his hands up. He adopted the same approach for the UQ, displaying cast-iron courtesy and resisting the temptation to yield to snark, even when asked awkward questions several times over. Indeed, his responses were so cordial as to take on a slightly surreal air, as Members on all sides of the House heard the Minister telling them that they were ‘absolutely right’ ‘quite right’ and ‘completely on the same page’. There were, of course, several places where he failed to answer the question despite replying at some length. He is, after all, a politician. Although the Mazars report states clearly that Southern’s major problem was a dreadful lack of adequate Board-level leadership, Mr. Hunt diverted to issues around individual health professionals and whistleblowing. He did at least have the decency to look faintly embarrassed by his own equivocations, and at other times a slight hoarseness in his voice betrayed either a consummate actor, or else genuine feeling behind his words. Watching him through the dispassionate microscope of television, the latter seemed more probable.
Ms. Alexander and many of the other MPs present also did themselves credit. They had grasped that the point of the report was not the number of unexpected deaths, but that the overwhelming majority of the unexpected deaths had not been investigated. They asked pertinent questions about informatics, mortality statistics and the prospect of independent Medical Examiners. They pressed the Minister on when the finalised report would be published and pushed for it to be while the House was still sitting. Mr. Hunt said NHSE had promised ‘before Christmas’, but not ‘before the Christmas Recess’. (The Justice Shed promptly debated when actual publication would be. Consensus was definitely in favour of 24 December, but 4pm or 5pm?) Nobody in the Chamber was questioning the general validity of the Mazars findings, but outside, things were otherwise.
Health Service Journal (which named Katrina Percy, Southern Health’s CEO, ‘NHS Chief Executive of the Year 2012’ at one of their glitzy, pricy awards dinners) followed the line of a part-disclosed Southern-Health-commissioned review-of-the-Mazars-review (do keep up at the back there!) in dissing the Mazars findings by trash-talking their methodology. The review review, written by Mohammed Mohammed, Bradford University Professor of Healthcare Quality and Effectiveness, picked out two items from page 5 and page 26 of the Mazars report and focussed on these as though they were the main thrust of Mazars findings.
The other query that came up was on the definition of ‘unexpected’. I had already heard my Dad’s voice in my mind’s ear, asking, ‘What is meant by unexpected? What constitutes a sufficient investigation?”, so I paid attention to these questions.
NHSE’s Serious Incident Framework says an unexpected death is one ‘where natural causes are not suspected.’ Posting that definition online got a near-apoplectic response from a medical practitioner, who said the definition should be ‘where unnatural causes are suspected’. Initially, it sounded reasonable, but I could feel a niggle. What if there was no reason to expect a person to die, but equally nothing to instantly give rise to suspicion of unnatural death? Would those deaths just go into a limbo? Could they be classified as ‘nothing obvious’?
The BMA guidance to doctors issuing a Medical Certificate of Cause of Death (MCCD) suggests that an ‘expected death’ is one where the person has a current illness or condition from which they have been unable to recover despite appropriate treatment. Other deaths are called ‘sudden or unexpected’ and fall into two categories: those where there is prima facie (obvious) evidence of violence or other unnatural causes, and those where despite the death being sudden or unexpected, there is no such prima facie evidence of unnatural cause. The BMA adds that doctors
“are advised to be cautious in making or attempting to make this distinction unless they are forensically trained and experienced in clinical forensic medicine. It is too easy to wrongly classify a sudden or unexpected death.”
In other words, where the death is sudden or unexpected, the decision about its ‘naturality’ is medico-legal and not purely medical. The BMA says,
“English law, contrary to popular belief, does not, at present, place an obligation upon a doctor to report all sudden deaths to the Coroner. In practice, the wise practitioner will report a sudden death to the Coroner, normally through the agency of the local police… In all but very exceptional circumstances, even where there appear to be no suspicious circumstances, the doctor would be wise to notify the coroner.”
It appears that the principles around investigating deaths are of the precautionary variety – deaths are to be investigated, unless there is obvious good reason not to do so. It’s a much lower bar than ‘investigate only if there are immediately obvious reasons to do so’. It also means that it is reasonable to ‘expect’ some sudden or unexpected natural deaths to occur. People do die suddenly, like the jogging guru Jim Fixx, who dropped dead at 52, but equally, they don’t die for no reason. The causes of the death must be determined. Mr. Fixx had a genetic predisposition to heart disease, possibly exacerbated by previous lifestyle factors.
Not until cause of death has been investigated, can the questions of preventability and accountability come into play. And this is where Southern Health, despite their protestations, have failed. They are not keen on accountability, particularly when it appears to be encroaching on the ivory towers of upper management. In order to evade accountability for preventable deaths, they have avoided doing death investigations thoroughly, or at all. They are complaining bitterly and loudly that people are conflating ‘unexpected’ deaths with ‘preventable’ deaths, that the Mazars report did not look at quality of patient care, and that it’s all so unfair.
It’s true that no-one can say that the uninvestigated deaths were all preventable. Indeed, it’s certain that a proportion of them could not have been prevented by any efforts. But there is equally no way of knowing whether that proportion was big or small, because Southern Health didn’t make any effort to find out. They did not do the preliminary sifting to see what the causes of death were, or to see if those causes might be linked in any way to Southern Health’s care. They are now pointing out the gaps in the data and saying ‘No evidence of wrongdoing’. But an absence of evidence is not evidence of absence. Other evidence – such as their eagerness to classify Connor’s death as ‘natural’, such as their treatment of the Reed family, and their attitude to the father of David West, suggest that some of the uninvestigated deaths might well have been preventable, and that a truly ‘learning organisation’ would have wanted to evaluate causes and circumstances of death, to see what could be done better in future.
We’ll never know. Because Sloven couldn’t be bothered to look.
Who By Fire 