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Action plans: complete misnomer when it comes to learning from deaths?

21 Oct 2016 - No Comments

It’s twelve months today since the second Verita investigation into the circumstances of LB’s death was published. I wrote this blog post a year ago, 10 reasons why I can’t support the Verita 2 conclusions and sadly since then I’ve become more convinced that I was right to mistrust it, not less (which is what I hoped for). At the time I had concerns about the independence of Verita, about the required ‘smoking gun’ test that seemed to be applied to draw any conclusions of responsibility, about the relevance of the context in which they were situating the report, and the ease with which some narratives took precedence over others. These concerns have only grown in the last year as I’ve met even more families who have been bereaved by the NHS and who have had to seek (incredibly hard) to get any sort of answers or clarity, and we’ll not even mention accountability.

I’m left wondering what is the point of action plans that often don’t lead to any action and certainly more often than not don’t lead to any improvements or impact. I did a little search on Google’s Ngram Viewer which looks at the frequency of use of phrases or words over time. This searches the English language books that they’ve scanned that were published from 1800 to 2008 for the phrases ‘action plan’ and ‘lessons learned’:

It’s possible to see a flurry of ‘lessons learned’ after the Second World War and it gradually grows in popularity until the early 80s when it explodes; conversely no-one wrote about an ‘action plan’ before the 70s and it’s been growing in parlance ever since.

I’m at a stage where I can only believe that they’re words, just management speak to cover up for inaction and to falsely give the impression of actually doing something. Action plans have never been more popular, and yet action has never been more absent from the agenda. We have had years and years and years of people promising to act, with nothing but more reports and more words and more action plans to show for it.

Last week Southern Health was found to require improvement at another CQC inspection. Another one, following failings published a week after LB’s inquest last year. In their report the CQC inspector states:

At the last inspection carried out on 6 and 14 August 2015 we found three breaches of the regulations. Staff had not received supervision and appraisal support, and the provider had failed to notify the Care Quality Commission (CQC) of incidents. The service did not have an effective system in place to assess, monitor and improve the quality and safety of the services provided. At this inspection we aimed to see what measures had been taken to ensure the quality of the service had improved and check if these measures had been effective. The provider had told us that all the corrective actions specified in their action plans would have been implemented by the end of March 2016. During our inspection on 31 August and 1September 2016 we found that not all of the recommended actions had been completed (my emphasis).

The provider had told us…. we found not all had been completed.

Also this week a report into homicides at Sussex Partnership Trust was published, it looked 10 homicides committed by patients under the care of the trust over the last five years (2010-2015). This review looked at the independent investigations to identify whether there were any common themes emerging. The findings that jumped out for me were in relation to action plans:

8.1 We requested evidence that recommendations and action plans had been implemented. We wished to fully assure ourselves and, by extension, the Trust, NHS England and the general reader. In most cases, we, therefore, required more than confirmation by the Trust that an action had been implemented. We needed to see the evidence. For example, the Trust might confirm that there is a policy, or that training has been delivered, but we needed to see the policy or details of the training or the number of people who have attended. The exception was where the action and evidence referred to named individuals.

8.4 The investigations generated a sizeable number of action points in total (100). The Trust provided evidence of a level of implementation in the great majority of the actions, including evidence that over one-third of actions were being embedded within the organisation.

8.7 The first observation which we can make is that, although relating to incidents spread over a number of years, there are a relatively large number of separate actions (100). In addition, actions arise from less serious incidents and from complaints. This number raises the question for us whether it is reasonable to expect this (or any other) mental health Trust to implement all actions/recommendations fully and to be able to provide supporting evidence of that implementation.

8.8 There was some repetition in the action plans. For example, several recommendations related to care planning and implementation; several related to risk assessment and management; several related to noninvolvement of families and carers. In these cases, this suggests that, over the period and homicides reviewed, the Trust had not fully implemented changes in practice across all their services.

The conclusion the reports authors draw are:

8.10 The Trust has demonstrated that some 80 percent of the identified actions had been implemented. In over one-third of cases, the Trust had demonstrated that learning was being embedded across the organisation, through the audit and re-audit of practice.

There is no 8.11 in the final report, my hunch is that it was edited out at some stage before the report was made public, perhaps because it was too challenging? It is safe to say that no report ever gets published before it has been through the associated trust for ‘factual accuracy checking’ that often seems to water down findings.

8.12 We made several request requests to collect the supporting evidence which would demonstrate that actions had been implemented. We were concerned that this indicated that the Trust’s administrative systems were not fully fit for the purpose of demonstrating learning from investigations into homicides and other serious incidents. We recognise that these investigations reported over a number of years during which organisational structures and administrative procedures have changed, making it more difficult to retrieve information. We understand that, in light of this experience, the Trust has introduced new methods for linking actions with evidence electronically – this will make it easier in the future for the Trust or those it commissions to review learning to access the necessary evidence. We have now seen an action plan, which uses this electronic linkage.

8.13 We recognise and fully support the principle of delegating responsibility to clinical directors and service managers, to enable local services to develop and have ownership of service and care delivery improvements. However, the Board of Directors retains overall responsibility for the care and treatment provided and for reducing the risk of similar incidents occurring in the future.

To be fair to Sussex Partnership Trust, as far as I can tell they were actively involved in commissioning the review, so I must quieten my inner cynic long enough to say that the point of this exercise will of course be reflected in the actions (and the inevitable action plan) that follows.

What is striking though is that 1 in 5 actions weren’t actually actioned and that the reviewers had to make repeated requests for evidence, even though this review was known about and conducted with the full cooperation of the trust. They knew that they were going to be looked at and still didn’t manage to action 20% of what had been required. Additionally in about a third of cases actions could be seen to be embedded, which means that in about two thirds it couldn’t. What is the point?

Back in April I wrote a blog post for JusticeforLB called ‘An apathy of action plans‘ after Southern Health were inspected by CQC following the publication of the Mazars report. It clearly showed that despite knowing the inspection was going to happen, and despite the Board having access to the report and being aware of the failings months before it was published, CQC still found:

  • Trust had not put in place robust governance arrangements to investigate incidents
  • Trust had missed opportunities to learn and take action to reduce likelihood of similar events happening in future
  • Trust had not put in place effective arrangements to identify, record or respond to concerns about patient safety raised by patients, their carers, staff or by the CQC
  • Where the Trust and others, including CQC had identified risks to the delivery of safe care arising from the physical environment, the trust had not ensured that these risks were mitigated in a timely and effective way.
  • Trust had also failed to identify, record or respond effectively to staff who expressed concerns about their competence to carry out their roles.
  • Key risks, and actions to mitigate them, were not driving the senior management or board agenda.

At the time Paul Lelliot, Deputy Chief Inspector at CQC said:

In spite of the best efforts of the staff, the key risks and actions to address them were not driving the senior leadership or board agenda. It is clear that the Trust had still missed opportunities to learn from adverse incidents and to take action to reduce the chance of similar events happening in the future…. I am concerned that the leadership of this Trust shows little evidence of being proactive in identifying risk to the people it cares or of taking action to address that risk before concerns are raised by external bodies.

To return full circle to the Verita 2 report, one of it’s main objectives was:

To undertake a review of the delivery of the action plans of this independent investigation, six months after it is published and share the report (to be published) with the family and stakeholders

Twelve months post publication there has been no review, or if it has happened, it has not been shared with LB’s family, with stakeholders and it certainly has not been published.

Families have already suffered so much, they offer so much of themselves and they place their trust in the NHS system to find out what happened to their relative, and to prevent it happening to any other family.

Yet time and again the reports, and the action plans that follow, appear to be no more than an exercise in going through the motions, managing damage to reputation by being seen to do something, apathy, performance and little more.

I’m left wondering what the real point is?

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