Injustice For LB.

Tags

#107days, #justiceforLB, (un)accountability, Connor Sparrowhawk, High Ordeals, learning disability, preventable deaths, Sloven Health

The MPTS hearing concerning the fitness to practise of Valerie Murphy, the psychiatrist who was the (ir)Responsible Clinician at STATT during LB’s (Connor Sparrowhawk’s)  time there, finished on Wednesday 21 February.

Having made a determination of facts in August 2017 and a determination of impairment in the November of the same year, the Tribunal reconvened on 19 February to deliver its decision on sanction.

It’s worth remembering that when Murphy appeared in person at the August hearings of fact, her attitude was the mixture of disdain and belligerence she had manifested at LB’s inquest.  She did not appear in person at the November impairment hearing. Questions were put to her counsel, Richard Partridge, who answered them as best he could in the absence of his client, which was not terribly satisfactorily, as it turned out.  There was quite a lot of ‘I will have to ask’ and ‘I will find that out for you, Madam’ from Mr. Partridge.  Some documentary evidence of her remediation was produced.  The Panel seemed to consider her moves towards insight and remedy pretty perfunctory:

So three months later, Murphy’s counsel presented a bundle of additional evidence by way of mitigation, consisting of

• Emails regarding the ‘yellow card’ (actually an A4 form for recording details of epilepsy);
• An audit of Epilepsy In Psychiatric Inpatient Settings (a ‘baseline’ audit);
• An audit of the epilepsy ‘yellow card’;
• An email regarding epilepsy care;
• An email regarding Directions for Future Research; and
• Testimonials;
• A reflective statement, signed and dated 15 February 2018 (the Thursday before the sanction hearing began);
• A certificate of attendance at ePEX (An Electronic Computerised Record Keeping System) training;
• An ePEX Manual and Index;

The more I re-read the @JusticeforLBGMC tweets, the more sickened & disgusted I feel.  Murphy has never apologised to or shown any consideration for Connor’s family, but she has used his death to set herself up in southern Ireland as an expert on epilepsy in learning disability care.

She claims to have had an epiphany after Connor’s inquest & begun her ‘yellow card’ epilepsy recording scheme.  She says she was open with other health workers about her failures, in order to emphasise the importance of epilepsy care and the dreadful consequences of her failure to provide it.  But until the 19th of February, she hadn’t ever publicly acknowledged the full extent of her failings.   Even on Monday, she was giving deflective answers to questions about the extent of her responsibility for Connor’s death and skirting round her previous efforts to displace blame onto the nursing team.  How can she possibly have been honest with colleagues about her errors at a conference in June 2017, when in August 2017 she was stoutly refusing to be accountable for them?  From here, the ‘yellow card’ scheme and the conference look like something cobbled together as extenuation, just in time for the first MPTS hearing.

Murphy’s submitted email featured three other clinicians, showing, she claimed, that she was ‘driving the (epilepsy) scheme forward’.  I’m not sure you can call this bunch a steering group for the scheme, as the participants mentioned have never met as a group and there didn’t appear to be any formal agreement on working to ensure that the scheme is uniformly implemented.  In fact, it turned out that of 3 other people mentioned in the emails, she’s not seen one since 2014, and another since around 2015.  However, she said, she sees the third person frequently.  How frequently? asked the GMC barrister.  Oh, all the time, said Murphy.  (He’s her husband.)

Moving on to the ‘yellow card audit’ data provided, this came from Ireland’s Midwest health region.  The Midwest region, for those whose Irish geography is a little sketchy, is Limerick and its hinterland.  As it happens, the University of Limerick is where Murphy’s husband is based, as an Adjunct Senior Clinical Lecturer in psychiatry with an interest in research.  In fact, he is the one who appears to be running the whole Midwest ‘yellow card’ project.  Murphy did not make an upfront, public, competing interests disclosure about his involvement in the audit process.
The abstract of the poster presenting the Midwest audit says that the introduction of the ‘yellow card’, coupled with ‘an intervention to improve awareness of risks’, significantly improved documentation of considerations concerning assessment and risk assessment, but did not significantly improve documentation of PRN (as-required) epilepsy medication.

In Cork, no auditing was done because Murphy has been off work since August 2017.  She did, however, claim that “I’ve had verbal feedback that shows 100% use and completion of yellow card for a patient in the unit there, the feedback I get is that it’s working.”
I don’t see how such claims can be considered evidentially admissible in the absence of robust numerical data, especially if – as I suspect – this was oral, i.e. unwritten verbal feedback.  Murphy’s word for it was, at best, hearsay.  There was no way of verifying the accuracy of either her understanding of what was said or her transmission of that understanding.  She produced nothing to corroborate her story.

Having been castigated for failings over recording notes on STATT’s RiO electronic system, Murphy has taken a course on e-notation. She still doesn’t use electronic notes, but if she did, she would hand-write notes & then transfer them onto computer.  I can see more than a smidge of potential in that for transcription errors and omissions.

Murphy ducked directly answering questions about her failures in leadership , leading to dialogues like this:
GMC barrister: You just explained a moment ago this document was your reflection following (LB’s) inquest, is that right?
Murphy: Yes
GMC barrister: You outline leadership as one of the aspects.
Murphy: Yes.
GMC barrister: Do you accept you were trying to blame the nursing (staff) for deficiencies?
Murphy: This is a reflective document about my thoughts and feelings of why I struggled with leadership, this is very personal, part of reflecting on things was thinking what was stopping me, why, this was more a reflection of my difficulties with the environment.

Ah, that inconvenient, uncongenial environment.  Of course.

Chloë Fairley, for the GMC, pressed on:
Fairley: Do you accept that you don’t at any stage identify your own failings in this document?
Murphy: Yes.
Fairley: Do you accept you’re attempting to lay some of the blame on the nursing (staff)?
Murphy: No, someone has to take charge.  Sorry, I’ve got a bad headache.  It was the inquest that was helpful for me, for it to sink in that (the care system) was siloed and there was no-one tying it together, and it should have been me that was doing that.

Murphy claimed to have questioned Southern Health’s interdict on contacting Connor’s family.  I don’t doubt that Sloven imposed just such a prohibition on direct contact.  Yet  doctors have a duty of candour, so Murphy’s abiding by that embargo was dubious, to put it mildly.  Moreover, even after leaving Southern’s employment in 2014, she made no attempt to contact or comfort LB’s family.  Instead, Murphy continued to treat his mother in particular in a hostile and aggressive manner, via her legal representatives at both inquest and tribunal

She contradicted her own evidence: having previously claimed she was distracted by a multiplicity of clinical roles, she then admitted she was no longer doing them when Connor died.  She also made statements that contradicted the submissions made on her behalf by her counsel: she claimed to be a ‘young consultant‘  while her counsel talked of ‘a single clinical incident in a long career.’
Nobody acknowledged that the failings in this ‘single clinical incident’ had stretched out over a span of #107days.

Finally, her counsel submitted for Murphy that she was ‘emotionally broken by these events’.  Given that plural, ‘events’, I don’t think it was Connor’s death that broke her.  I believe it is being held (repeatedly) to account, that she has found shattering.  Had Connor’s death affected her, she could not, would not, have countenanced her barristers hounding his mother as they did.  If she had come to realisation after the inquest, as she claimed, she would not have permitted the same specious attacks on Dr. Ryan to continue at the tribunal.  As with the Tribunal’s finding on impairment (page 15, paragraph 69) when it considered the extent of Murphy’s remorse,  the brokenness of Valerie Murphy seems ‘limited to the consequences these (Tribunal) proceedings have had upon her.’

Despite the dubiety of some of her evidence, despite being granted an extra seven months in which to work up a show of remorse that was still unconvincing, despite the bad faith she displayed in the way she allowed her lawyer to batter LB’s mother, despite the inapt-to-the-point-of-grotesque intervention of her witness Prof Ted, despite her inability to use health information technology, despite one-minute-to-midnight reflections extruded four years and eleven months after Connor went into STATT – her sanction is a 12-month suspension, (which may be extended at a further review before it expires).  The tribunal accepted Murphy’s assertion of a ‘sea-change’ in her attitude.  It even quoted her own marine-metaphor description of herself, verbatim.

I can’t give this change much credence and I really don’t know how anyone can ever place confidence in her again. Her character seems entirely unsuited to responsibility for or authority over disabled persons.  Its salient features appear to be cowardice and dishonesty.  Her behaviour towards Connor’s mother during his time in the unit reeks of both.  Murphy would neither confront Dr. Ryan with her own view of events, where her view and Dr. Ryan’s were in disagreement, nor would she keep Dr. Ryan apprised of what was actually happening to Connor.  After Connor died, Murphy didn’t act on her duty of candour and she made repeated proxy attacks on Dr. Ryan via her lawyers.

One of the reasons I don’t believe that Murphy has overcome either her cowardice or her dishonesty is embodied in this thread of live-tweets from the sanctions hearing.  Dr. Murphy explained she was honest with people about her learning before describing the ‘yellow card’ scheme.

What would ‘honesty about learning’ look like?  Well for a start, it would have to acknowledge the trigger for the learning: the death of Connor Sparrowhawk and Murphy’s responsibility for that death.  True honesty would have to be along the lines of the penitential act:

I confess…to you, my brothers and sisters
that I have greatly sinned
in my thoughts and in my words
in what I have done
and in what I have failed to do
through my fault
through my fault
through my most grievous fault…

So we come again to the ‘insight’ and accountability question: Did Valerie Murphy admit to the professional colleagues to whom she presented the ‘yellow card’ scheme, that, through her ignorance, arrogance and failure to fulfil her duties, an eighteen-year-old-boy for whom she had clinical responsibility came by his death under her care, drowned in a hospital bath?   I beg leave to doubt it.

The original article proposing the scheme, a letter to the editor of the Irish Journal of Psychological Medicine, dated January 2017, doesn’t mention Murphy’s experiences at all.  Connor is expunged from the narrative.  What we have here is a detached, academic suggestion from our cogitative clinician, worrying about what appear to be non-specific risks of ‘higher mortality rates, particularly in those with recent seizures‘ and ‘psychiatric medication (that) may interact with anti-epilepsy medication‘ or ‘seizures could be mistaken for evidence of psychiatric illness‘ and – a real kicker here – the fact that ‘from a risk-related viewpoint, those with comorbid epilepsy have specific risks to consider including but not limited to areas such as bathing…‘
Every individual statement is neatly referenced, either to an academic paper, or to some other authoritative publication.  Far from presenting the ‘yellow card’ scheme as an act of atonement, Murphy is presenting herself as a paragon of farsighted benevolence who has sagaciously synthesised all this disparate observation into a coherent and philanthropic whole, to improve the welfare of the afflicted.  In the case of the risk consideration, Murphy has the gobsmacking neck to refer to the UK National Institute of Clinical Excellence epilepsy management guidance.  You know, that commonsense stuff about deep water and seizures that she fatally ignored when Connor entered her orbit.

Of course, Murphy would have needed to seek permission from his mother to talk about Connor.  She would have had to approach her humbly and frankly: “I realise I did a terrible thing – a series of terrible things – when your son was in my care and after he died.  I was neglectful towards him and I’ve been vile to you.  I am sorry, although I know mere words are not enough.  Nothing I can do will bring him back.  I wish beyond anything that I had done things differently.  I have had this idea for trying to help other doctors do things differently, I hope it might prevent failures like mine in future and avoid deaths.  May I send my ideas to you?  I won’t do anything without your agreement or approval….”

But it’s beyond Murphy.  She doesn’t have the guts, or the integrity, to go beyond mere remorse to contrite action.  She’s happy to wallow in regret, to which she now appears to have added a splash of guilt (I don’t believe the tribunal’s interpretation of her demeanour to mean that she is ‘wracked with guilt’, is correct.  Wracked with regret – for herself – sure; guilt-wracked: No.)   She has made no amends to Connor’s family.  She hasn’t even apologised to them for inflicting some of the deepest hurts one human being can cause another; she’s half-apologised – after prompting – to the Tribunal.

There comes a time when apologies and amends are no longer acceptable. They are too late to be credible.  I don’t know if Murphy has reached Connor’s family’s Too Late, although given that Murphy’s barrister harried Connor’s mother into breakdown and illness at the MPTS fact-finding hearing, I wouldn’t be surprised if their Too Late were last August.

On the other hand, I don’t foresee Murphy ever making true effort at apology.  As I say, she has, in my estimation, neither the backbone nor the probity for it.  She’s interested in (self)-justification.  Not justice.

The Irresponsible Clinician.

Tags

#justiceforLB, Connor Sparrowhawk, GMC, High Ordeals, JusticeforLB_GMC, learning disability, medication, mothers, NHS, preventable deaths, Sloven Health, true stories

Revolting reminder yesterday of the complete lack of empathy and human kindness manifested by LB’s so-called Responsible Clinician, via her brief, at his inquest.

The psychiatrist, Valerie Murphy, is up in front of the GMC’s fitness-to-practice Panel this week and next.  Confusingly, the GMC has decided to refer to LB neither by his name, Connor Sparrowhawk, nor his nickname of LB, but as ‘Patient A’.  There’s probably a whole other blogpost in there about the effect and intentions of this depersonalisation, but right now I am busy with other things.

The full list of allegations runs to four pages (thanks and acknowledgement to George Julian for posting these).

On a first count, there are 55 separate allegations there, of which only the first does not allege misconduct.  But the effect of 7 (i) and 7(ii a-c) is to multiply the accusations in 7(a)-7(f).  Item 7 contains 24 separate allegations of misconduct, giving a grand total of 68 allegations of individual instances of Murphy’s care of LB falling below adequate standards.

Of those 68 allegations, Murphy has admitted 30, which are accordingly found proven, but contests the remaining 38.  Looking at the matters admitted to, they are either procedural failings (not arranging a best interests meeting, inadequate record-keeping) or related to Connor’s epilepsy.  The ones she is contesting are the mostly psychiatry-related ones: assessment, diagnosis, treatment and medication, including the whole of that multiplex Section 7.

The inference I draw from this is that she intends to assert that her treatment of Connor as a psychiatric patient was unexceptionable, that its poor documentation was down to faults in the system beyond her reasonable control, and that his physical health was not her responsibility.

At Connor’s inquest, she was already citing system chaos, for example on the morning of Day 6:

VM: I can’t remember what was seen or discussed at that meeting, but I remember it as quite chaotic..

11.05  AS asks who those minutes wld be sent to?  VM: Wouldn’t know.  AS: Do minutes of CTM meetings find themselves in patient’s medical records?  VM: Yes, they would.  AS: Would members of the team have a duty to ensure those records were accurate as medical professionals?  VM: It depends, we were struggling w RiO, the Chair would read and confirm them.  

(From @LBInquest tweets)

Now, I’m all for Southern Health management being made to shoulder their share of responsibility.  It was painfully obvious at Connor’s inquest, that the detached and indifferent nature of Southern Health’s oversight of Oxford services was itself probably well over the line of neglectful, leaving staff demoralised and demotivated.  But Southern’s flaws, however egregious, do not excuse a clinician failing in her direct duty to a patient.

The failure properly to treat Connor’s epilepsy is catastrophic on its own.  Psychiatrists are medical doctors, and all medical doctors are required first to train as generalists before they specialise.  Moreover, Murphy is a specialist in the psychiatry of learning-disabled people.  Given that epilepsy is commoner among learning-disabled people than it is in the general population, she should have been well aware of epilepsy in general. And, given the information that came into STATT with Connor and the subsequent additions to that information offered by his family, she should have focussed on epilepsy as a difficulty of Connor’s in particular.  Instead, she dismissed it, and continued to do so.

On Day 5 of LB’s inquest in 2015, she insisted that “there was no evidence of seizure activity during LB’s admission”, because “two instances that were explored as potential seizures….were ruled out”.  This was in spite of clear and urgent warnings, both oral and written from LB’s mother that she had seen signs of seizure activity – drowsiness and a bitten tongue – while LB was in STATT.  Now, it seems, Dr. Murphy has folded on the presence of epilepsy, in the face of the inquest findings, although she apparently continues to claim that its management was not her responsibility. Oddly, she also still appears to contend that she obtained a history of Connor’s epilepsy that included whether seizures made him tired and need to sleep. If she had done so, why did she then ignore that he was drowsy at unlikely moments?

My general feeling for the other contested allegations is that these are areas where it is possible for Murphy to argue that she did the things she should have done; it is merely her recording of them that is defective.  Slap-on-the-wrist stuff, not striking-off material.  Whether those arguments will seem plausible, is likely to be largely down to the credibility of Murphy herself.  She needs to present herself as competent, knowledgeable  and benevolent, but overworked and harassed.

Hence, no doubt, the utterly disgusting hounding of Connor’s mother in front of the Tribunal yesterday.  The interactions of Richard Partridge, Murphy’s barrister, with Dr. Ryan, were not so much a cross-examination as an attempted crucifixion.  He did everything he could to portray Dr. Ryan as incompetent, ignorant, uncaring, shiftless and vindictive, in order to improve his client’s chances of appearing the reverse.  It was exactly the same strategy as the one used at Connor’s inquest by Murphy’s then-counsel, Alan Jenkins.  It failed then and it failed this time, for the same reasons as before.  Firstly, Dr. Ryan is a person whom it is difficult to impugn: she has always been shrewd, informed, capable, industrious and warm; and now she is showing tremendous courage in the face of loss and grief that would overwhelm most people.  I don’t think a Panel with even a modicum of intelligence is going to fail to notice the discrepancy.  The inquest jury certainly were not fooled.  Secondly, and far more importantly,  Dr. Ryan’s personal characteristics are completely irrelevant to the question of the adequacy of Murphy’s care of Connor.  Whether Murphy found Dr. Ryan’s outspokenness uncongenial, difficult or even frankly insufferable, that was still no excuse to ignore the information she contributed about Murphy’s patient, Connor.

That both Murphy’s briefs have taken this line of personal attacks upon the patient’s mother, suggests to me that the initial steer in that direction comes from Murphy herself.  It seems like a risky strategy.  It’s going to be hard for her to come across as competent when she has so seriously misjudged Dr. Ryan as well as Connor himself; or as benevolent when she has allowed her barristers to stick so many unwarranted knives of sneer and innuendo into a grieving mother, and then twist them.

The nadir yesterday came when Partridge read out Dr. Ryan’s impression of Murphy as ‘dismissive, arrogant and distant’ and told her it was ‘very upsetting for Dr. Murphy to hear any patient’s relative describe her as such’.  Dr. Ryan asked for a recess at that point:

” ‘Dr Murphy is upset by your evidence.’ Dr Murphy is upset. Upset. ‘Can I have a break?’ I was taken to a room alone. To howl…“

Nevertheless, she returned to display the intellectual rigour that #JusticeforLB’ers have come to know and admire.   Pursuing an irrelevant line of questioning on the blog, Partridge tried leading his witness: ‘The tenor of the blog was critical, in a neutral term’.

“I don’t think ‘critical’ is a neutral term,” rejoined Dr. Ryan.  “The blog was an honest account of our experience.”

Partridge continued in a similar dismissive vein, referring to ‘the tongue-biting incident’.  When told by Dr. Ryan that it was not an ‘incident’ but a seizure, he went DefCon1 on the patronisation:  ‘I know that you feel it was a seizure.’

Dr. Ryan did not let him get away with that, either. “It was a seizure.”

I really don’t know what Murphy hopes to gain by permitting or requiring her counsel to act thus.  If anything could confirm the accuracy of Dr. Ryan’s negative summation of Murphy’s character, it surely has to be such a display of tone-deaf, compassionless persecution.  To  ‘dismissive, arrogant and distant’, most observers would probably add, ‘egocentric, devoid of empathy, disrespectful and cruel’; in short, thoroughly unsuited to being a consultant psychiatrist.

An irresponsible clinician.

LB: Another Day…In Court.

Tags

#justiceforLB, Connor Sparrowhawk, preventable deaths, Sloven Health

It was confirmed yesterday that the Health and Safety Executive are going to prosecute Southern Health for the failings that led to Connor’s death.  To paraphrase Norman Lamb: Good, and about bloody time.

Still can’t get my head round why the Crown Prosecution Service did not pursue a corporate manslaughter charge: the inquest jury found that serious management failures at Slade House contributed to Connor’s death, so presumably the resulting breach of Southern’s duty of care towards him was deemed insufficiently ‘gross’.  Call me naïve or thick but I can’t see how much grosser it can get, than having systems which allow a clinically vulnerable person, carelessly, in defiance of known diagnoses and of recent events confirming clinical risk, to be put into a situation with a high potentiality of death.  Especially given that the risk, and the death, actually eventuated.

However, the Health and Safety Executive seems to have a good track record of holding companies, and their directors and senior managers, to account.  More slog for LB’s family, seeing this one through, on top of the wildly inappropriate General Medical Council (GMC) and Nursing and Midwifery Council (NMC) approaches to involving families in disciplinary proceedings.

I watched the news coverage of the announcement.  But as Huw Edwards launched into the introduction:  “…Connor Sparrowhawk, who was eighteen….” and the familiar images of LB as a giggling toddler and an ice-cream-eating teenager played over, I had an almost physical sensation of a bit of my mind slipping sideways.

Eighteen.  That can’t be right.  LB is three years older than E; he was in Year 13 when E was still in Year 10.  LB was a young man and E was still a baby-faced, coltish boy, lanky and spindly, with what appeared to be more than the standard complement of knees, elbows and shoulder-blades; still in school uniform, still to sit GCSEs, still to graduate into a ‘business dress’ chain-store suit and Sixth Form, still to choose and sit his A-Levels, still to make decisions about where to go next.

Now, E is an undergraduate. At nearly 20, with a full set of whiskers and (following a recent student-prank-gone-wrong) a No. 1 crop, he looks nearer 30.  He’s playing sports three times a week and hitting the gym in between, and even if his sixth-form suit hadn’t developed peculiar pinkish patches after repeated dry-cleanings, he still wouldn’t be able to wear it, as his chest and shoulders have packed on an extra six inches of muscle since he left school.  He’s revelling in having left behind the write-a-mark-a-minute constraints of A-levels, in being able to pursue his academic interests and do the research needed to back up his hypotheses, in finding a circle of like-minded mates for study and leisure, in being responsible for his own schedules, meals, laundry, and employment for spending-money.  So if E is this mature young man, Connor, surely, is approaching his mid-twenties?

Of course, he isn’t.  And it hits me all over again.  While LB has been an ongoing presence in so many lives, and while I have continued to think of him as older than, and therefore somehow growing up ahead of, my own son, Connor has in fact stopped.  Stayed as he was on that brilliantly sunshiny morning, forever an eighteen-year-old schoolboy, about to visit the Oxford bus company.

It’s not that I don’t know.  It’s just that the enormity and awfulness of the realisation seems new and raw, every time.  And as I remember to gasp in another breath, and blink away the prickle of tears, the screen is filled with an image of Connor’s mother, talking to the BBC’s Michael Buchanan.

“He should never have died.  And I… just miss him so….He’s left an unimaginable hole in our lives.”

*****

Appallingly, Connor is not the only one remaining in the same place.  Southern Health is still, still, overclaiming (otherwise known as outright lying) about its actions. “Tonight,” said Huw, “the Trust has apologised again to his family”.  However, and to whichever bit, of Connor’s family the Trust apologised, it didn’t include doing so, in words, to Connor’s mother.

Earlier @Southern_NHSFT told BBC News they have apologised again to us. Odd. Not heard a dicky bird. #JusticeforLB

— Sara (@sarasiobhan) May 9, 2017

If Sloven can’t get that right, after nearly four years, they can’t be trusted on any of the alleged improvements they’ve made, either.

Oh dear. @Southern_NHS, apologising to us unreservedly through a statement to the media ain't an apology. Seriously. #JusticeforLB

— Sara (@sarasiobhan) May 10, 2017

No learning. No honesty. No Trust.

Dear @Southern_NHSFT, can you please stop telling journalists you have apologised again to us. You haven't. Thank you. #JusticeforLB

— Sara (@sarasiobhan) May 10, 2017

See you in Court, Sloven.

 

I.Can’t.Even.

Tags

#justiceforLB, (un)accountability, Connor Sparrowhawk, institutions, learning disability, NHS, preventable deaths, Sloven Health

This latest #JusticeforLB development is almost beyond comment.  It does, however, throw into sharp relief the siege mentality obviously operating within Southern Health; and speaks volumes about Sloven culture and the messages purposefully circulated within, and outwith, the organisation.

The transcript below comes from a message left on LB’s mother’s office answerphone from someone claiming to work for Sloven.  It doesn’t much matter whether the caller is a member of management, a lower-ranking staff-member, or just an unconnected crank; she has obviously absorbed and internalised an execrable attitude to LB and to his mother, and feels justified in spewing it out.  A toxic attitude that aligns precisely with Sloven’s dealings with LB and his family, all through the more-than-three-years since LB was admitted to STATT.

And Sloven’s response?  Of a piece with their previous form, and with the call.

Sloven are not setting up an enquiry, actively seeking the culprit and requiring staff to disclose information.  They’re not even setting up an internal enquiry and asking for all available information.  Oh no.  They will, apparently, set up a ‘full internal investigation’, if and when they receive ‘any information’ in response to their ‘urging’.

Pathetic.  As always.

 – – – – –

Good morning, hello. Hi, I believe this is a message for Dr. Sara Ryan, um, I’ve been seeing on the media about your son, your poor son that died under the care of Southern Health.  I work for Southern Health and I’m, it, it’s awful that you’ve lost him, I’m so sorry that you have done, um, ’s tragic, and … I hope you find some closure after the report, the, um, issue of the GMB … CQC report today, but I do think you are being reall- very vindictive.  I think you are a vindictive cow.  On TV all the time, ummm, slating the NHS Southern Health.  With your intelligence background, you know, as much as anybody else knows, that Southern Health only took over those units in Oxfordshire recentl-, you know, the recent months before your son died.  You know, with your background, it takes a while to make changes in anywhere, and I think now you’ve just become a bitch and you want some attention, but you are vindictive, you are unpleasant, and you are a nasty cow.

This message was recorded at 9.33am on Friday April 29th.  To save this message press 1.  <beep> To-  Message saved.

– – – – –

Reassurance.

Tags

#107days, #justiceforLB, #justiceforNico, #Mazars, preventable deaths, Sloven Health

News today that the Hampshire All Party Parliamentary Group is to ‘quiz’ Southern Health Chief Executive Katrina Percy.

The piece is not very clear on exactly what is expected to happen. Initially we are told that Ms Percy will be ‘scrutinised’, which sounds promising, and would be a novel experience for the Trust CEO, who is accustomed to being deferred to and lauded. But then it appears that Ms. Percy will be ‘addressing the meeting’, which sounds, depressingly, much more in keeping with her preferred style. On the other hand, local MP Suella Fernandes is expecting some ‘frank questions’ to be put. But there again, the said Member for Fareham is only wanting ‘reassurance’.

Ms. Fernandes, I can tell you now, you will get reassurance by the syrupy bucketload. Reassurance is a Sloven speciality, to be poured generously over concerns until they disappear under the sticky golden tide of sugary sweetness. And the recipe for this elixir of reassurance seems to be one part sparkly mendacity to two parts emollient obfuscation, spun into impenetrable thickness in an expensive PR machine.

The New Forest East MP, Julian Lewis, however, has shown himself in the past highly capable of subjecting Sloven spin to truly rigorous, data-based scrutiny (thank-you, @59kemppaul, for the heads-up). I hope Mr. Lewis is able to attend the meeting and give Ms Percy a thorough in-person grilling. Because while a few may be content to swallow syrup of reassurance, what everybody else wants is knowledge: knowledge that crunches like an crisp apple with the sharply acid taste of factual truth.

Nadirs, Smoking Guns and Silver Bullets.

Tags

#107days, #justiceforLB, #Mazars, Sloven Health, true stories

Just when a one might think one has well and truly scraped the bottom of the pond-mud at Southern Health… it turns out one hasn’t.  A hundred days went by after the publication of the Mazars report, in which next to nothing happened, apart from the Sloven CEO getting back into her spin-doctor groove.

On 2 April, Simon Hattenstone wrote a superb in-depth piece on Connor and Justice for LB for the Guardian’s Saturday magazine.  It was like someone had stirred an ant’s nest with a stick: much activity for no discernible outcome.  The CQC gave Sloven a warning to improve within the and NHS Improvement (the erstwhile Monitor) put an additional condition into the organisation’s licence, allowing it to make Board-level changes… but Sloven had another 6 months before any draconian action would be taken, which would mean the CQC/NHSI would have given the Sloves a three-year run for the public’s money. Katrina Percy repeated once more, blank-faced and empty-eyed, yet with contemptuously unconcealed ego, that she would not be resigning.

Once again Connor’s mother and his cousin pulled apart the NewsSpeakery of Sloven statements to show that these had a complete lack of meaningful content.  George Julian applied her considerable skills of academic research and analysis to finding out from the numbers if Sloven actually were ‘outliers’ or not in how they responded to patient deaths (to no-one’s surprise, Sloven were and are amongst the worst performers).  It seemed impossible that the current Sloven Board could be allowed to continue for one month, never mind six, and yet, and yet…

Then someone anonymous sent the 2012 Sloven due diligence report on STATT to Connor’s mother via My Life My Choice.  Maybe that someone works in Sloven Towers, saw the Guardian article, and decided that in decent common humanity, they’d rather stand with Connor and his family than with Katrina Percy.  Maybe they could simply see that nothing was likely to change in another six months and thought it was time to put a stop to the fake-improvement farce, rather than waiting for someone else to turn up the relevant paperwork.  Maybe it was just coincidence that they came across this report at this time and had an opportunity to take a copy.  Whichever, it told Connor’s mother for certain that all the failings at STATT that were identified by the inquest jury as contributing to his death, all the appalling carelessness that led to STATT failing its September 2013 CQC inspection, all the things that had bothered Connor’s family while he was still alive and sequestered in the Unit – all those problems had been flagged to Sloven before they took over STATT from Ridgeway.  Flagged by – and here is the fact which makes it inconceivable that the burial of this document was an oversight – flagged, it appears, by the very same person who was charged with doing the initial investigation into Connor’s death.  That’s a gun that’s not just smoking, it’s red-hot and liable to set a few things on fire.

Years ago, I watched the Angela Cannings ‘Real Story’ documentaries.  Mrs. Cannings lost three of her children to cot death, and lost her marriage and her surviving child after she was prosecuted – and convicted – for murdering the younger two of the children who died.  No-one could say for sure how the children had died, much less that she had killed them, but despite the lack of evidence, Mrs. Cannings fell victim to the American aphorism, imported as ‘Meadow’s Law’ by the eponymous paediatrician, that ‘One is SIDS, two are suspicious and three are murder’.  Her lawyer, hearing that her young brother had as an infant stopped breathing on a number of occasions, possibly due to a cows’ milk allergy, began researches aimed at basing an appeal on the likelihood of a genetic cause of sudden infant death in the family.  With commendable tenacity and significant help from the BBC, he researched her family history and discovered a number of infant deaths on her father’s side. Mrs. Cannings had been kept informed of these developments, but after the first programme was broadcast, her lawyer got a call from a young woman who turned out to be Angela Cannings’s previously unknown half-sister.  The half-sister’s children had also suffered incidents of respiratory collapse similar to those that had affected the Cannings’ babies.  In the solicitor’s view, it was the piece of evidence that would tip the scales of justice in Mrs. Cannings’ favour.  “He said, ‘That’s it, Angela'”, Mrs, Cannings recounted in the second documentary, filmed after her conviction was quashed and she was freed. “‘There’s your silver bullet'”.

It appears that this week’s smoking gun comes with a few evidential silver bullets of its own.  Good.

Reparations and Resignations.

Tags

#justiceforallthedudes, #justiceforLB, (un)accountability, institutions, Local Authorities, Sloven Health

After several days of carefully-worded prevarications, the Prime Minister has finally had to admit that in claiming he had nothing to do with offshore tax havens, he was in pants-on-fire territory.

Media coverage appears to agree that not coming clean at the earliest opportunity was a particularly stupid move. “It’s never the offence, it’s always the cover-up“, says one headline.  Cameron doesn’t appear to have helped himself by sounding plummily and defensively irritated when being questioned.

Worse than merely causing offence, or laying himself open to the most caustic ridicule, it also leaves the PM under ongoing suspicion that there may well be more revelations to come.

It’s not that he participated in legally permissible, if morally questionable, financial dealings.  It’s that he didn’t tell the truth when asked.  Even if he didn’t outright lie, he was evasive and shifty.  The public are not daft.  They can spot shiftiness when they see it; while for the media, a squirm is catnip and the scent of a buried bone: all the incentive they need to keep on digging. Cameron’s failure of candour is what has led to calls today for his resignation; for many, he has forfeited the level of public trust considered necessary for him to continue in office.  He could confess every little peccadillo he’s ever committed, and still people would wonder if there were more.

In the same newsfeed as the multiple pictures of the beleaguered PM, came this report, on how the Oregon State University has changed the way it handles sexual assault cases linked to the college or its students.  In 1998, Brenda Tracy was gang-raped by four men including two U of O students on sports scholarships.  Despite the accused men’s admissions, the investigation was mishandled and dropped.  But in late 2014, after sports journalist John Canzano wrote a piece on the incident, the president of the University, Ed Ray, contacted Ms. Tracy to apologise.  Ray had only joined Oregon State in 2003, five years after the assault.  Ms Tracy considered his apology genuine and is now working with the University to improve its approach to the problem of sexual violence by or towards students.  In contrast, Kristin Samuelson and Laura Hanson, who were also badly treated by the University following student-linked rapes, are still without proper apologies or closure.  Both were discouraged from reporting the rapes, and Hanson later discovered that the University had taken possession of her supposedly confidential counselling records without her permission.

Back in the BC days (Before Children), I worked at one time for a Local Authority, and every election day (which was most years, as our councillors retired by thirds rather than in one fell swoop), I would end up in a school or community hall with an electoral register, some rickety plywood booths and some very battered black tin boxes, as Presiding Officer of a polling station.  The duty was mostly mind-numbingly and bum-numbingly tedious, and often foot-numbingly cold as well, but on this particular day, the station was in the community hall of an old people’s home, so it was at least warm.  I arrived at 6.30, set up the booths, the tables and the notices, and nipped through to the loos, which were opposite the day-room.  They were nicely kitted out with modern fittings, and discreet stacks of incontinence supplies in each cubicle.  However, when I next paid a visit around elevenses, there was a large blob of shit in the middle of the floor, with a trail of smaller blobs leading to one of the cubicles.  I went to find the day manager, who thanked me and said it would be dealt with.  At lunchtime, around 2pm, the blobs were still there, each dried to a darker crustiness on top.  I spoke to the manager again.  “It’ll be dealt with!”, she said, sharply.  But by 5pm, the shit was still there – only someone had trodden in it, and a trail of stinking footprints and zimmer-frame skid-marks led back across the corridor carpet towards the day-room.  This time, the manager was nowhere to be found, and although I mentioned it to someone in a uniform dress, the smears and lumps were still in evidence when I paid a final visit at 10pm before taking the boxes to the count.

The following morning, I went to find a colleague on Community Care to ask if there was anything that could be done.  “It’s not about it being unpleasant for me,” I explained, feeling close to tears.  “It’s that if they are that way in front of outsiders, what are they like to the people who can’t get away?  I wouldn’t want my Granny or Grandad in a place where nobody cares if shit gets tracked all over, and I don’t think it’s acceptable for anybody else’s Granny or Grandad, either.”  My colleague hugged me.  “Don’t you worry, I’ll see to it.”

A few days later, I was accosted by the Electoral Registration Officer.  “What do you think you’re doing, complaining about E House’s treatment of residents?  That’s none of your business.  The manager’s threatening not to let me have the hall for elections in future.”  I suggested that we could take it to the Chief Executive, as Returning Officer.  The ERO declined; we both knew which way that would go.

One of my responsibilities at the Council was Ombudsman cases.  Underlying causes of complaints were routine, even trivial matters; what got them taken up by the Ombudsman was maladministration: a failure to ‘do it right’, often compounded by an obstinate refusal to recognise that the aggrieved had just cause for complaint, and frequently aggravated by attempts to blame the complainer for ‘causing’ the situation complained of.

One of the earliest cases in the files concerned a disabled tenant of municipal housing, who had been asking to have repairs and renovations to her home accorded a higher priority, as her condition was being worsened by the current conditions in the house.  The housing officer seemed to have treated the request with extreme jobsworthiness, interpreting any discretion in the housing regulations to mean, “although we could accede to your request, we don’t absolutely have to, – so we won’t”.  It was not until the tenant, after over two years of patient pleading, went to the Ombudsman, that an officer from the Council actually went round to see the state of the place, which, as it turned out, was shocking.

The officer’s report outlined the work to be done, with costs and timescales, detailed the considerable extra costs the tenant had incurred as a result of having to live in an unsuitable property and outlined the weekly amount needed to cover her living expenses in alternative accommodation until such time as the work was finished.  The Chief Executive’s handwritten note in reply was brief. “DO IT. Start NOW. I want a weekly update.”  A further, typed, letter to the tenant apologised fully for the specific failings of the Council, explained the arrangements proposed to remedy them and asked for the tenant, if she agreed, to telephone her approval to the Chief Exec’s office so that delays could be kept to a minimum.  It also requested permission for the Chief Executive to visit the  tenant once the works were done, so that he could satisfy himself that everything had been sorted out.

The final document in the case-file stated that the reporting officer had visited the tenant after the Ombudsman’s case had been closed.  The tenant had had no further problems, was fully satisfied with the way her case had been handled. The officer added, somewhat smarmily, that the tenant had had a number of complimentary things to say about ‘a certain Chief Executive’, for having visited to present her with in-person apologies from the Council, a cheque reimbursing her previous expenditure and flowers and chocolates to accompany a ‘New Home’ card.

That was the Chief.  He was a wily political operator and undoubtedly autocratic, but his fundamental concern – above his staff and beyond the councillors – was the people, whether as a collective, as small groups, or as individuals, whom the Council was there to serve.  I liked and admired him and was very sorry when, a few years later, the Council found itself mired in a scandal whose origins predated his appointment; and, after it all ended in the inevitable disaster, he felt obliged to resign.  Although the causes of the scandal were nothing to do with him, he had been unable to make it go away, and he recognised that someone else needed to take over in order to allow a fresh start with a clean slate.  Like Ed Ray, the Chief accepted that although he had had no power over what had gone wrong, he did have the power to help right it for the future, and he took the necessary action, however unpleasant it was for himself.

The original administrators dealing with Brenda Tracy, and with the Council tenant, were incapable of seeing that they had got things wrong, and badly.  In both cases, there needed to be a change of administration before the people affected by the wrongdoing could be satisfied that they would get redress.

It’s a pity a scandal and an outrage that the current Chief Executive and Board of Southern Health can’t see that they need to go for exactly the same reasons.  They are part of the problem, so they can never be part of any satisfactory solution.  However many times they repeat, “We have made changes”, the people affected by their failings will not, cannot, have confidence in these pronouncements, as long as they are spoken by the same old faces that have already proved themselves untrustworthy and two-faced.

For people to have any confidence in Southern Health, Katrina and the Sloves need to resign. Now.

The Wood And The Trees.

Tags

#justiceforallthedudes, #Mazars, NHS, Sloven Health

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I still haven’t got my head around the Mazars review. Partly because it takes even me some time to read 254 pages of dense text packed with excruciatingly painful stories behind each digit in the statistical content, but mostly because – as NHSE and Sloven no doubt calculated, by releasing it at the very last gasp before Parliament rose for Christmas – most people, including me, have had one or two other things to occupy our minds for the last 10 days or so.

Because the report wasn’t available in its final form until after the House of Commons had closed for the holidays, it has gone into limbo until Tuesday 5 January 2016 at the earliest.  I hope it gets picked up and thoroughly aired as soon as possible thereafter, floods notwithstanding.  Meantime, there are a quite few things from the Urgent Question on the leaked report that I have filed for future reference and review. In no particular order:

• ‘Parity of esteem’ there is not, even within lowly mental health services: 30% of working-age adult deaths were investigated, but only 1% Learning Disability deaths, and an even smaller proportion of deaths among people above retirement age.
• There needs to be a focus on Southern Health’s particular failings but, as noted by the MP for Stafford, the findings have implications for the wider Health Service in relation to mental health and learning disability services.
• The lack of family involvement was shocking.  The full report cites families who were not merely ‘not involved’ but were actively excluded from investigations.  I suspect that this is a function of power and control.  The patients were not seen as real people with a context, but as mere ‘cases’, so their families could be readily dismissed; and this view also played to Southern Health’s narrative whereby the service was the sole repository of knowledge about the person and their condition, the sole possessor of wisdom as to how to manage them, and the sole wielder of the power to treat and cure.
• A Public Enquiry along the lines of the Francis enquiry is warranted, although “Fast action to change culture now” is also needed.  The conclusions of the Francis enquiry, if implemented immediately at Southern Health, could do no harm and could potentially do much good.
• The scrutiny of Southern Health needs to be ‘intense & ongoing’.
• The Secretary of State placed an inappropriate emphasis on clinicians as the main actors in the present state of things at Southern.  At the root of problems at Southern Health was a massive, protracted and embedded failure to manage.  Facilitating whistleblowing by individuals is only a partial solution of the problem.  It can make no difference until senior management & Boards are held to account for their response to problems.
• That the problem with inquests whereby interested public bodies are entitled to unlimited state funding, but the dead person’s relatives have personally to fund their relative’s representation, has been noted, with 2 MPs asking about it. The Secretary of State replied as though the crowdfunding was a matter of relatives’ choice or was to fund civil litigation for pecuniary compensation, but of course this was not true.  Inquests are not non-adversarial proceedings in practice, whatever they may be in theory, and the question of funding for families at inquests should be put to the Secretary of State for Justice, Michael Gove.  In turn, the unfair and invidious position of families at inquests raises wider questions about legal aid and access to justice.
• A system of independent medical examiners could do much to assist with transparency and openness.  Oddly enough, the creator of probably the best-known fictional Medical Examiner, the author Patricia Cornwell, was on the radio in the week before Christmas, talking about how her Kay Scarpetta character, like the real ME who inspired her creation, views the bodies she examines as patients: real people who are just as entitled to proper care postmortem as they should have been in life.
• That there are questions to be asked of organisations beyond Southern Health about people’s care as patients, but also questions to be asked beyond the NHS about how to support people with mental ill-health or with learning disabilities to make a life.  Alongside the Health Secretary and the Justice Secretary, the Secretary of State for Work and Pensions also needs to be put firmly on the spot, over the closure of the Independent Living Fund, the reduction of Employment and Support Allowance paid to people in the ‘Work Related Activity Group’ (that is, people who are unwell or disabled but have the potential to move towards work, with proper support), the reduction of support to Local Authorities which in turn has meant the cutting of social care budgets, and the forthcoming transfer of Attendance Allowance to local authorities, which is likely further to reduce the support available to older people.

A dense and extensive forest of thorny problems, and just to add to the thickets of unpleasant underbrush, there is the matter of Winterbourne View and the Joint Improvement Programme, which seems to have died  the death with no results.  The number of people spending long periods of time in supposedly short-term Assessment and Treatment Units has reduced only marginally; around half of the current inmates are people who were also incarcerated a year ago.  The biggest difference is that the average distance between home and place of stay has increased.  There are many reasons to worry that the whole Mazars review could follow Winterbourne view into the long grass and the wilderness, even though, unlike at Sloven, at Winterbourne View nobody actually died as a result of the non-care and neglect.

As I say, much of this got lost for a few days in the Christmas run-up.  Lots to do, and we miss my Dad especially at this time of year.  My parents were married just a few days before Christmas, so it was an extra-special festival in our family.  Dad always did the cake, with his special home-made marzipan that is a million times nicer than anything that ever came out of a shop.  On Christmas Eve, after we went to bed, he would arrange some of Frederik Bramming’s cardboard Kravlenisser, which he and Mum had purchased in Denmark on the way back from a snowy Scandinavian honeymoon, on the curtain rails and picture frames. There they would sit, laughing at us and each other, for the full Twelve Days.

Without Dad, it’s difficult.  As it is for lots of people, whether because they have lost someone, or are alone, or are ill, or don’t celebrate for other reasons.  It’s a time when it’s easy to feel excluded or overwhelmed.  After she posted this, I sent Nico’s mother a picture of a tree decorated with sunflowers.

It wasn’t ideal  as Nico’s sunflower-tree, as it didn’t have all the right colours on it; but it was the best I could do in limited time.  We were due to gather at my youngest brother’s house, on Christmas Day, and there had been much to-ing and fro-ing over the wires and airwaves about who was getting what for whom, whether we were buying presents for the adults or only for the kids, who was contributing which component of the food, and what the theme was for the present-wrapping this year.  My sister is the queen of fabulous wrapping.  Each year she takes a theme and wraps to suit.  One year we all got parcels wrapped in brown paper and tied with buff raffia, with a trail of glitter-frosted ivy leaves wrapped around the string.  Another year, she had paper printed with sleighs and big jingle bells on top of each present.  The year my brother-in-law decorated the tree with peacock-feather baubles, she found silver bird tree-decorations to perch on the parcels and gave each one a peacock-eye tailfeather.

This year, however, Youngest Uncle and his other half had outdone themselves by completing a tree each.  Uncle’s, in the study/library, was all silver and crystal, with a few deep-red baubles as contrast, while his partner had gone for a multicoloured Victorian theme in the sitting room.  I had found some Victorian-looking cream paper printed with holly leaves for the presents from us, while my sister had wrapped this year’s parcels in metallic paper, with crystal snowflakes dangling from sequinned yarn.  Looking at the two contrasting trees, and with Nico’s sunflower tree still occupying one corner of my mind, I suddenly had a vision of a Justice Christmas Tree Festival.

I am pretty certain is is taking place somewhere in Oxford, although I’m not sure of the exact location – I didn’t really notice the sign at the entrance because I was looking at the Justice Shed banner.  It’s not a shed, anyway, it’s a big, stone-built hall, with narrow windows that allow the trees to be displayed against the walls. You might think it looks a bit like the Great Hall in the Harry Potter films.

First to greet us at the entrance is the tree that inspired the occasion: Nico Reed’s.  It is a blue spruce, decorated with, of course, wide-open sunflowers.  Their petals are edged with gold and their centres brushed with bright copper.  Copper-coloured tinsel winds round the branches, and between the sunflowers there are glittery pale-blue snowflakes as bright as Nico’s eyes, reflecting the pale blue and gold lights. At the top is the face of Nico himself, wearing his fur-trimmed red hat, a particularly beautiful nisse.

Next to it, against the north wall, stands Connor’s dark-needled fir tree, hung with a traditional red-and-green theme of untraditional miniature London buses and big shamrocks.  At the pinnacle, a huge multifaceted crystal casts rainbow splinters of light into every corner of the room, and showering down from it are many smaller drops of brilliance, each throwing out its own shards of colour, which intensify as the sun moves across the south windows, until all the out-of-the-way corners, for so long dark and unnoticed, are filled with light.

The #JusticeforLB tree has ribbons in blue, yellow and red; and crowdsourced padded fabric bauble shapes, each one appliqué’d with a George-Julian-style embroidered quotation.  In place of the fairy, a model of blind Justice flourishes her sword and scales.

Christmas Tree Festivals are usually charity fundraising events, but I am not sure that charities have a place in this one (although that tree behind the door, with the dark-pink ribbons and shiny pink pigs, might belong to @Mishap_Charity).  But this festival is really for individuals, not organisations.

Steven Neary’s tree has metallic ornaments shaped like old-fashioned microphones and miniature EPs, with candy canes and brightly-coloured sweets all round them, and a cherry Bakewell in place of the star.  Grenouille’s is almost monochrome: silver tinsel, a few dark-blue matt-metal baubles, and many dangling strips striped in pearled white, iridescent black and silver, representing chromosomal conditions.  The star at the top is actually a starfish.

Here is Ollie’s tree, hung with horseshoes and bright with bunches of glowing colour-change  fibre-optic  filaments.  Here is Naomi’s, garlanded with cut-paper festoons and button-strings.

In pride of place, at the far end, and two or three times as tall as all the other trees, is the #JusticeForAllTheDudes tree.  You can’t really see what sort of tree it is, because is is covered, smothered, in – what else? – gingerbread people.

By next year, here’s to being able to see our way out of the wood and admire the trees.

Marking Time.

Tags

#justiceforallthedudes, #justiceforLB, #Mazars, Sloven Health

Monday evening, 14 December 2015.  No sign of the Mazars report being published yet.

The Justice Shed has endured a hail of Sloven misinformation missiles and spin-stones.  The general feeling of besiegement – a curious mixture of boredom and tension – has been added to by a number of incoming hobby-horse half-bricks lobbed by various odd bods with axes to grind about NHS privatisation, Big Pharma and similar irrelevant bonnet-bees.

The “definition of ‘unexpected’ deaths” bee, first set in flight by my medical correspondent, proved to have surprisingly robust legs.  Roy Lilley, of nhsManagers.net, picked up on it and suggested that the Department of Health had leaked the report, in order to provide Jeremy Hunt with an excuse for (further) interference with the Health Service.  In his scenario, some sort of odd collusion between Katrina Percy and the Secretary of State for Health to produce poor analytics which would not prove that care at Southern Health was poor, had been foiled (or possibly facilitated) by the report being leaked by an impatient Mazars employee with a grudge.  I think.  It’s a bit hard to follow the line of the argument, especially since several of its basic premises are improbable assumptions, or just plain wrong.  Even after he had corrected his misapprehension that Prof. Mohammed Mohammed was the author of the Mazars report, Mr. Lilley was still propagating the Sloven/Mohammed suggestion that it was all about whether Sloven was an ‘outlier’ in terms of its death rates:

‘What is an ‘unexpected’ death? Broadly; a death which would not have occurred if the patient was in a similar Trust, with a similar social demographic – all things being equal.’

Meanwhile, Sloven was discovered to have been trying to minimise and explain away the Mazars figures to universities that place students within the Trust.

Chris Hatton’s magisterial blogpost on the subject expounds the CIPOLD definitions (which have got to be the most relevant for the circumstance) of unexpected, premature, avoidable, amenable and preventable deaths.  It also points out that even some ‘expected’ deaths may warrant investigation, and should have kicked the legs out from under the nonsense.  Here’s hoping.

George Julian has pointed out that the Mazars publication date was promised for ‘early’ this week, which “surely only leaves Tuesday, as Wednesday must be ‘midweek'”.  She is of course 100% right, but I am still not holding my breath.

Expected Unexpecteds.

Tags

#justiceforallthedudes, #justiceforLB, #justiceforNico, #Mazars, Sloven Health

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.