There have been many responses to the leaked #Mazars review this week, with the vast majority being a mix of horror and disbelief. There are notable exceptions though that Sara has blogged about here Doubters, deniers and belieSHers. Sara touches on the ‘outlier argument’ which is what I want to focus on in a little more detail here.
What is the #Mazars review?
Back in March 2014, eight months after LB died, Sara and Rich were offered a meeting with David Nicholson, the then CEO of NHS England. This meeting, two weeks before he retired, resulted in his commitment to commission an independent investigation into all the deaths of people with a mental health problem or learning disability in contact with Southern Health between April 2011 and March 2015. Sara and Rich had hoped for a review of the previous ten years, but given Southern Health was only created in April 2011, the four year period seemed reasonable. The Death Review was born (the hashtag #Mazars has been used online this week so I’ll be using that term throughout this blog post – Mazars is the name of the independent auditors who conducted the review).
The #Mazars review was never (just) about LB. It was directly sparked by the speed with which #SouthernHealth dismissed his death as being as a result of ‘natural causes’ and the discomfort that this rightly left with his family, as Sara blogged in A matter of public interest:
That the Trust were so quick to try and badge this as a ‘natural causes’ jobby and that this probably ain’t unusual practice when it comes to learning disabled people dying unexpectedly, makes it hugely important that the report is made public. The apparent acceptance that a fit young 18 year old man could die in such circumstances underlines how being labelled as ‘learning disabled’ removes any of the considerations/human rights that the rest of us are accorded.
What the #Mazars review is not
I just want to put on record something thats been troubling me a little this week. The #Mazars review was never about revenge or righting a wrong. It was never intended as some sort of salve for LB’s family’s grief or LB’s death. It was not about shining a spotlight on Southern Health and revealing them as a shining beacon of abject failure, and it certainly wasn’t ever some sort of witch-hunt for Katrina Percy or the Board.
I think I’m right in saying that there is an energy and drive in the #JusticeforLB collective for some sort of accountability. Yes, personally, I’d like Katrina Percy, as the accountable officer and someone who has demonstrated woeful leadership and what I can only conclude is contempt for patients and families, to be removed from her post. I don’t really care how it happens but I think her current performance puts patients and staff at risk. At my most generous I’d say that she’s the new poster girl for the Peter Principle but I’m not sure that really matters, so much as what now happens.
[Take a look if you don’t know what the Peter Principle is, but in a nutshell it’s about people being appointed/promoted to roles based on their performance in a current position not on their suitability for the position at hand, until ultimately they rise to their level of incompetence. The Paula Principle is quite interesting too and relates to women working below their level of competence, but I think this is definitely a situation of Peter not Paula].
The focus of the #Mazars review was always about systemic failings across health and social care. It was about putting a focus on the premature deaths of learning disabled people or those using mental health services. It was about exposing and understanding the seeming societal acceptance of these behaviours, something I’m increasingly viewing as some sort of soft eugenics as time goes on. It was about making the invisible, visible.
What have outliers got to do with it?
Not very much really.
This week in a bizarre last ditch attempt to discredit the #Mazars review Southern Health went on the offensive, in a really meta way thus demonstrating why they don’t learn anything because they’re so neck deep in waters of denial and reputation management. Anyhow, I digress.
The HSJ reported that Southern Health had commissioned Professor Mohammed Mohammed to review, the independent auditors review, seemingly focusing on Southern Health’s position as an outlier, or not. None of these documents have been made public yet, and I doubt Prof Mohammed’s ever will given the selective reporting that is required for Southern Health’s purposes.
— Dr 'Dr' Sara Ryan (@sarasiobhan) December 10, 2015
However, if you are super interested you can click on the picture above for a little taster. Shaun Lintern, a journalist at the HSJ, shared this:
— Shaun Lintern (@ShaunLintern) December 9, 2015
On the whole the reaction to this development (doubters and deniers aside) has been to highlight the naivety of trying to discredit an independent report by using someone whose integrity has already been called into question:
It seems crystal clear though that this is a deliberate distraction tactic and an attempt by Southern Health to discredit the findings that highlight their failings. Not for the first time this week I wonder whether the Board are fully aware of these actions. Who commissioned Mohammed and for what purpose? I should also point out that NHS England have already reviewed the methodology and apart from a request for more information about the methods used, it was given a clean bill of health. Sara has blogged about the never ending diligence delays here. So how’s that Duty of Candour working out down in Southampton HQ?
So are Southern Health an outlier?
I don’t know, and to be honest I’m not sure that I really care. I think it’s a bit of a distraction.
What do we know is that the real issues, as reported by the BBC, go much much deeper:
- We know that there were 1,454 unexpected deaths of people with a learning disability or mental health problem in that 4 year period at Southern Health. That’s one unexpected death every day. I’ve no doubt that some, maybe even many, of those unexpected deaths may have had a reasonable explanation behind them. The fact remains that Southern Health wouldn’t know, because they failed to routinely investigate them.
- We know that the chances of your unexpected death being investigated varied hugely.
- We know that those most likely to see an investigation were adults with mental health problems aged less than 65, where 30% were investigated.
- We know that if you make it to old age (over 65) with a mental health problem and you die unexpectedly, the chance of your death being investigated was just 0.3%. So if there were 1000 unexpected deaths in this group, only three would warrant investigation (because old people die and who wants to get old right?)
- We know that only 1% of unexpected deaths of people with a learning disability were investigated. Put another way, for every hundred people with a learning disability who died at Southern Health, only one of their deaths had any sort of investigation. One in a hundred.
- We also know that in nearly two-thirds of investigations there was no family involvement. None, nadda, nothing. So on the flukey off-chance that your unexpected death did warrant an investigation, there’s every chance your family wouldn’t be involved in any way. How it is possible to build a full picture of what happened, never mind identify any learning, without this involvement is beyond me. To be fair so much of this is beyond me.
So, I’m not sure whether Southern Health are an outlier, whether they’re the worst Trust in the country, or the best to be frank, and I really don’t see how it is relevant. It feels a little bit like arguing whether you scored more or less goals than any other team playing that day, once you’ve lost the match you were playing. Or like arguing that it doesn’t matter that you got caught speeding and breaking the law, because others get caught speeding to, so you should be let off.
Or, let’s be honest and call it for what it is, trying to hide your own organisational failings (eugenic practices?) behind the generally shite treatment given to people with a learning disability or a mental health problem. That seems like a desperate strategy to me.
The #Mazars review is due to be published ‘early’ this week, alongside the NHS England response (one rather suspects that is where the current delay is coming from). Once it’s published people can read it and judge for themselves.
I have read it. I have read every draft of it. It makes me feel ill.
Everything about the #JusticeforLB campaign has been designed (or organically evolved through accident, chance and luck) to shine a spotlight into the murky dark corners of poor practice and societal neglect of some groups of people. It’s really not about outliers, it’s about the opposite. I hope that the #Mazars review will prove to be a catalyst for raising the mediocre average, to something that equates to a life worth living. For everyone.