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Hidden in plain sight: patient safety and Southern Health NHS Foundation Trust #JusticeforLB

06 Dec 2015 - 5 Comments

Claims

1) Learning disabled people and those with mental ill health matter less than… [you complete the sentence, pretty much anything will do]

2) Society (that’s you and I) continually, and routinely accepts a sub-standard of care and treatment for these people

3) Sick people go to hospital, sick people die sometimes, therefore we don’t bat an eyelid when these people go to hospital and die. Even if most people who go to hospital don’t die. Sometimes they do, and let’s be honest it’s probably easier/fairer/gods will if they don’t survive, everyone’s life would probably be easier anyhow*

4) The lies, mistruths and obfuscation that are presented in plain sight, go unchallenged, creating a climate where this stuff is so blatantly irrelevant to those with power that people don’t even bother to sweep it under the metaphorical carpet any more.

Context 

Many months ago I assumed the Mazar’s Death Review would be published by now. The Death Review is looking at all the deaths of patients using mental health or learning disability services at Southern Health NHS FT over a four year period, from 2011-2015. Sara has written about the intense pain the continual delays are causing LB’s family here (the comments are educational and heart breaking in equal measure too) and I blogged my utter frustration and disbelief at the dire communications regarding the delays before going on holiday here.

At this stage I have very little faith that the NHS has any interest in learning how to do this stuff better. I can not reconcile concerns for the safety of patients with this non-progress. This isn’t an insignificant matter, we’re talking about people dying, in our beloved NHS, and not even due to recent concerns or cuts or confusion.

People dying, in the NHS.

Safety_LBQuilt

Given the Duty of Candour, the focus on Patient Safety and the relentless NHS awards and self-promotions for brilliance, you’d think this stuff would be squared off and made available as soon as humanly possible. At least that’s what naive old me believed. Relentlessly optimistic even with the metaphorical boot of ‘the NHS system’ being smashed into my face. Anyhow that’s the context.

In an attempt to look at the issue a little myself, I decided to revisit the wonderful (surely soon to be best selling) work of fiction that is the Southern Health NHS Foundation Trust Annual Report and Accounts 2014/15. The very same one that has been presented to Monitor and laid before Parliament no less. I decided just to focus on the Quality Report and Quality Account 2014/15, from page 93 onwards.

Part 1 Statement on Quality from Katrina Percy, CEO

Southern Health is committed to and passionate about continuous quality improvement.

As we do constantly, we have closely scrutinised all aspects of our work.

We have made improvements to ensure our services are of the best quality that we can provide.

Monitor’s concerns were taken most seriously and gave us an extra, welcome opportunity to improve standards for our patients and service users.

In early 2014 I strengthened the Board, with the addition of: Dr Chris Gordon, Della Warren, Dr Martyn Diaper, Dr Lesley Stevens.

Together, this refreshed and strengthened executive leadership is championing quality improvement.

Over 100 CQC inspectors visited more than 120 of our sites. The overall CQC rating for the Trust was ‘Requires Improvement’…

I confirm, on behalf of the Board and to the best of my knowledge, that the information contained in it is accurate.

Wowsers, it’s some powerful statement. Look at the credentials and passion for quality and improvement. For scrutiny and attention. That welcomed the opportunity to improve their standards when the regulator called into practice their fitness to provide services. That’s some other worldly level of spin, that doesn’t really match up to the rest of the claims of passion for quality and safety really.

The CEO believes everything that follows is accurate and that the services provided by the Trust under her leadership are the BEST QUALITY that they can provide. In case anyone is mistaken, Katrina Percy is at the helm here, it is she who has strengthened the Board, it’s a shame then that there has been a 50% turnover of those new recruits in less than two years. What questions should those with power, or those at Monitor be asking? In fact what questions should the rest of the Board be asking. This is the best that Katrina can do and it’s wholly accurate. Time to take a closer look then.

Part 2: Priorities for improvement and statements of assurance from the Board 

At this stage you’d be forgiven for thinking that an NHS Foundation Trust with such exceptional CEO leadership and explicit passion and commitment for quality would really be incisive, dedicated and even detailed in their priorities. I mean this is what drives Southern Health.

It is a requirement that each Quality Report ‘must contain a minimum of three indicators each for improving patient safety, clinical outcomes and patient experience which are to be achieved in the following year’. Of course given the focus in Southern Health we’d expect more than the bare minimum wouldn’t we. Let’s take a look:

Screenshot 2015-12-06 08.09.13

Ummm, yes all that passion and quality can be contained in the bare minimum in terms of priorities, even when I would have thought that this is the absolute rock bottom than anyone delivering health services could do. There were four indicators for patient safety, three for clinical outcomes and five for patient experience. Let’s not dawdle, let’s take a look at what is hidden beneath the surface here in relation to patient safety.

A review of Southern Health performance for clinical quality

[To save you the bother I’ve just duplicated the entire table, it’s pages 103-4 if you’re working from the original]

Screenshot 2015-12-06 08.15.03

Let’s take these one at a time.

Healthcare associated infection: Continued very low rates of infection

Good to see C Diff is under control, for now.

Never events (serious, largely preventable patient safety incidents): There have been no never events since 2011/12

Ummm, how can this be when an independent investigation (that Southern Health fully accept) found LB’s death to be entirely preventable and just a month or so ago a jury found LB’s death to be contributed to by neglect. The neglect of Southern Health. So which is it, that the death of a learning disabled person isn’t serious enough? Or that preventable only counts for certain groups? Or that Katrina and her Board didn’t know – despite them issuing this and this and this statement to the media?

Serious incidents requiring investigation (SIRIs): Incidents resulting in serious harm not common. 396 out of a total of 12499 incidents.

Not common? Who is defining not common? What parameters are being used here? There has been no change in the number of incidents resulting in serious harm in four years – that isn’t exactly great evidence of Katrina’s passionate quality team being able to demonstrate any progress.

Avoidable Grade 3 and 4 Pressure Ulcers: Achieved. Reduction in numbers (of pressure ulcers recorded) partly due to introduction of new definitions.

Sort of speaks for itself. This measure means nothing. More to the point why would a team so committed to quality and patient safety have the bold ambition of ‘reducing average numbers’? Why not make the target ‘eliminate avoidable pressure ulcers’? I mean the clue is in the title, these are avoidable.

Incidents of prone restraint: Partially achieved. Annual SAFER programme to reduce use of prone restraint has seen reduction in incidents, however 20% target not reached

If you stick prone restraint into Google you’ll be deluged with a list of articles about the dangers and the places internationally where it has been banned. Prone restraint effectively means pinning someone down, face to the floor.

There isn’t room for nuance in the table above, but it’s worth remembering that the claim of reductions of use of prone restraint is reporting a reduction in the number of incidents recorded, the figure relies on people being honest, accurate and paying attention to detail. Given that this quality report of the dedicated and passionate quality staff at Southern Health has put a big fat tick in the box for ‘indicator met’ I’m not sure how any reader is meant to trust what is reported.

Let’s not forget that it became apparent at LB’s inquest not only that he didn’t die from natural causes (as Southern Health claimed in their Board minutes of July 2013) but that staff had restrained him, in the prone position, whilst he was having a seizure. The horror of that is almost not possible for my brain to compute.

Incidents of seclusion: Achieved. Focused programme to reduce seclusion with a change in reporting process to capture more accurate data.

How terribly helpful, another change in what is recorded. Moving the goalposts reduces my confidence yet further in what is reported here. While Southern Health are celebrating a big fat tick, the Care Quality Commission returned in August (2015) to re-inspect on areas flagged as concerns, following the inspection the previous October (2014) that had found Southern Health to Require Improvement. This is a return visit to look at areas flagged by CQC as a concern. This is what CQC found:

At both Ravenswood and Southfield, inspectors found that there was some confusion amongst staff about the use of seclusion, which should only be used to contain severely disturbed behaviour that poses a threat of harm to others. CQC found that patients held in seclusion were not always being appropriately reviewed.

In addition, the design of the seclusion room at Southfield did not allow for clear and effective communication between staff and patients.

Inspectors did find that staff on all wards were conducting observations of all patients, however observation results were not being recorded within patient care plans as a matter of routine.

Ummm, so recording wasn’t good (as flagged above, this sort of makes all of the numbers we’re discussing here even weaker) and still confusion about seclusion. So Southern Health identify a priority, work on it all year, claim they’ve met their targets and we’re left with an environment that is still unsafe for patients. How does that work exactly?

Medicines review within 48 hours: Not achieved. Increased number of reviews being completed towards the end of year following increase in staffing.

Not achieved. A simple target, not met. A panic when it became clear it wouldn’t be met no doubt resulted in more staff being found – it must be hard when you have such poor staff recruitment and retention rates – but still not enough to achieve the targets.

Patient safety incidents reported to National Reporting and Learning System: Improved reporting culture has increased numbers of incidents reported.

Double the number from two and three years previous. I guess increased reporting can only be a good thing, but maybe it just adds to the weight of what’s hidden in plain sight. Reporting means nothing without learning and given the performance detailed above I’m not sure Southern Health can claim any expertise in this area.

% of reported incidents that resulted in severe harm or death: % of severe harm incidents out of total incidents low

Umm, low compared to what? Based on data recorded by who? Reviewed by who? Managed and overseen by who?

Patient safety failings hidden in plain sight 

I can’t face much more of this and I’d be surprised if anyone is still reading.

To summarise Southern Health had four indicators in relation to patient safety for 2014/15. They failed to achieve two of them (that’s 50% failure rate straight up) and they claim to have achieved two, but both the indicators that they claim they achieved changed the detail and definitions of what was recorded during the period, which surely should make them null and void.

How on earth can this be acceptable? The only answer I can come up with takes us back to where we started:

1) Learning disabled people and those with mental ill health matter less

2) Society continually, and routinely accepts a sub-standard of care and treatment for these people

3) Sick people go to hospital, sick people die sometimes, therefore we don’t bat an eyelid when these people go to hospital and die. Even if most people who go to hospital don’t die. Sometimes they do, and let’s be honest it’s probably easier/fairer/gods will if they don’t survive, everyone’s life would probably be easier anyhow*

4) The lies, mistruths and obfuscation that are presented in plain sight, go unchallenged, creating a climate where this stuff is so blatantly irrelevant to those with power that people don’t even bother to sweep it under the metaphorical carpet any more.

This is simply unacceptable. Yet accepted, in plain sight. I honestly despair.

 

Disclaimer

*I obviously don’t believe all of these claims myself. I’m using them to illustrate the challenge. That said they are not fictional, they are the sort of experiences that learning disabled people and their loved ones routinely face. See this discussion last night:

see the Coroner’s Jury findings about LB’s death here, see what happened to Jack Adcock here, to Robin Kitt Callender here and this Pinterest board for many more examples.

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