Last summer Sara and Rich asked me if I was willing to be their lay representative on Verita 2. This investigation was expected to build on Verita 1, which found LB’s death to be wholly preventable, and look at the wider system aspects at play in the lead up to/at the time. I’d never been involved with an NHS investigation before but was totally up for the experience, as someone with a professional interest in getting knowledge to people who can use it, learning from a preventable death seemed like a good thing to work on.
Over the last 14 months Verita have made (slow) progress and their second report Independent review into issues that may have contributed to the preventable death of Connor Sparrowhawk, was published this morning. A couple of months ago the first draft of the report was shared with us. I was lost for words, something that anyone who knows me will know is an incredibly rare event, I’ve seen the interview transcripts, had sat in meetings with the project group and just could not understand how the evidence they have amounted to the conclusions they have drawn.
I discussed my concerns with Sara and Rich, who had a very similar response. We agreed that there was little point to my further involvement with the process, the simple fact is that no-one could explain how these conclusions were reached, or if they could they certainly didn’t try to explain them to us. There comes a point where ‘going along’ with something (even if you fundamentally challenge the findings) gets wrapped up into an acknowledgement of support for it, a risk we were not prepared to take.
Chris Hatton has already produced a brilliant blog that highlights some of the inconsistencies in this report, so I’ve tried to avoid repeating him where I can. At some stage I’ll blog about the experience and the process of being a lay representative, but for now the focus of this is the final report. I am (quite rightly) bound by a confidentiality agreement so these reflections are purely based on the publicly available material.
1) How independent is this Verita investigation? We heard a lot of evidence and opinion at LB’s inquest over the last fortnight, you can see it all on the twitter feed here. Some staff members were very unhappy with Verita’s investigation approach first time around and having read Verita 1 and sat through the inquest I can see why they may feel that way.
If you scoot through the report to paragraphs 5.3 and 5.4 you will see an incredibly obvious challenge to the investigators independence, or will power, as Southern Health try, and succeed, to dictate the terms of the interviews with their senior staff.
Yup, you read that correctly. 5.3 we told interviewees they could not have a legal representative with them, 5.4 Southern Health’s senior executives and clinicians were allowed. How’s that candour working out? 100% independent, I don’t think so. You could probably stop reading now if you’ve got this far, but I’ll carry on with a few more thoughts.
2) When is a contribution not a contribution? I had understood it to be an investigator’s role to make judgements on the evidence available, on the balance of probabilities, rather than have to unearth a smoking gun, a couple of years after the event (once those involved had plenty of opportunities to ‘lose’ records and agree their statements). Verita started off with a judgement of ‘substantial contribution’ to the poor care Connor received [para 4.6], it is still unclear to me what counts as evidence and where the baseline is for making a ‘substantial’ contribution, or in actual fact any contribution, to substandard care. What I do know for sure though is that there is little point in conducting a stakeholder meeting to share your interim findings, receiving strong feedback, removing the word ‘substantially’ and carrying on regardless as you were before.
3) What is the point of a guiding test if it doesn’t guide you? I was pleased when I read the first draft of the report to see that Verita were drawing on Sir Robert Francis’ guiding principle from the Mid Staffs report [see para 4.8]. This principle seeks to identify whether people knew something and failed to act on it, or whether they didn’t know in the first place. My relief at it’s use was based on the evidence I’d seen, it is clear throughout the report that Southern Health had a lot of information available to them on which to base their decisions, even if they then took their eye off the ball/focused elsewhere/got a little distracted by a shiny award that needed applying for.
4) Situating Verita 2 within the existing evidence base At the first project meeting I attended I was pleased to be able to give a brief introduction to myself and my background (that includes a PhD in profound learning disability and a professional interest in knowledge transfer and evidence use in practice). I now know that this was just because the Verita team were polite, rather than because they were interested, because despite my skills being freely offered, they were never drawn upon. I therefore feel conflicted about this point and the next one.
It is great that Verita attempted to situate their report within the existing evidence base. It is not so great that the research they focused on was old (over a decade old) and they couldn’t even spell the author’s name correctly [para 4.11]. It’s Kieran WalshE with an E if you’re interested.
5) Situating Verita 2 within the wider learning disability context Again this is an approach that I think had great potential, except I’m not sure that anyone on the Verita team had up to date enough knowledge to do this. They do say that they ‘endorse’ Stephen Bubb [Finding 4] but I’m unclear why or in what context that is appropriate in an investigation.
6) If the data doesn’t fit, keep searching until you find some that does In an attempt to be open and responsive, Verita held a stakeholder meeting in May 2015 to enable local stakeholders to feed in their thoughts on their interim findings. We have already seen that some of these were (sort of, not really) taken on board (see 2 above) but in a remarkable show of brass neck Southern Health didn’t like what families had told Verita and sought to discredit it with the inclusion of their own data, collected by their staff, when they asked people who rely on their services whether they liked them. It’s all in paragraphs 8.14 onwards, I’ve no idea why Verita included it, other than some odd sense of wanting to appear fair I suppose.
7) A throwaway naturally!
6.24 The Winterbourne View exposé focused attention on the abuse that had happened there and on restraint in particular. From Oxfordshire’s point of view, commissioners had concerns about services in Wiltshire and Buckinghamshire, some of which related to restraint. Their attention was naturally* focused there. By contrast, Oxfordshire services had experienced fewer incidents so they received less attention.
*this is my focus, to help you spot it.
Go on, have another read of this paragraph and ask yourself what this throwaway naturally is for! This is amongst the oddest logic on show in Verita 2, a national exposure of the shit and shoddy care of learning disabled people allowed OCC and Southern Health staff to take their eye off the ball, naturally. I have no words.
8) It’s co-production Jim but not as you know it This probably isn’t the time or the place for a blog post on coproduction, suffice to say if Verita were serious about genuinely producing this report in a collaborative fashion you’d think that the lay representatives would at least get a name check! Appendix A contains no less than four sides of A4 introducing the investigation team (sales pitch anyone) but can’t even be bothered to name the lay reps, Bill Love and myself. Nuff said.
9) Death by words Oh the complete and utter irony of writing that, over 1000 words into a blog post, but that aside, it really appears to me that Verita have mistaken quantity for quality. Verita 2 is an exceptionally dense report with nothing but words and a handful of tables thrown in for good measure. There are typos, errors and inaccuracies that bely a lack of care and attention to detail, which one suspects goes farther than the (lack of) proofreading. The executive summary is buried deep into the report, not at the front, I very much doubt anyone will get past it! All of this wouldn’t be half as irritating if I hadn’t been reassured at a project meeting long since past that our views would be welcome on how to present the information, once the drafting was done. Here’s a clue, if you want something other than too many words, you need to consider who your audience is and how best your messages can reach them before you have words down on paper.
10) It really doesn’t matter anyhow Luckily this story has somewhat of a happy ending. It really doesn’t matter what conclusions Verita drew, or how much they are at complete odds with the information gathered and presented elsewhere in their report [unless of course you’re interested more broadly in investigation systems, value for money or candour].
Luckily for us all a jury of nine Oxfordshire citizens have already decided that Southern Health *were* responsible for what happened to Connor. They attributed his death to neglect and very serious failings in the systems and care provided by Southern Health. If it wasn’t for their judgement, I’m not sure where we’d be left. As it is I really think there are some serious questions to be asked about ‘independent’ investigation within the NHS.