Big week this week, after months of delay the #Mazars report into deaths at Southern Health was finally published at just gone 2pm on Thursday 17 December. You can download/read the Mazars report here and you can download/read the easy read version here. I’m not going to blog about the findings here, others have done that including Chris Hatton who focused on the deaths of people with learning disabilities:
337 lives, all different, all irreplaceable. If we held a minute’s silence for each of the 337 people with learning disabilities who died, we would be silent for almost six hours (and this is just one NHS Trust). And once this period of silence is over (as we have seen, there is too much silence, too many whisperings behind closed doors) we must not, cannot, return to business as usual. Business as usual is killing people [and there’s the rhetorical excess…]
Rob Greig who focused on equality and rights, (non) leadership and the action required:
The Regional Health Authority Chief Executive said to me, “Rob, you know and I know that I will not lose my job if I don’t deliver on the learning disability agenda”. He was right – then, in 2003. It is about time that changed. If accountability and responsibility is not accepted by senior people for these failures, the NHS will not be taken seriously by people with learning disabilities and their families.
Gary Bourlet whose response on behalf of People First England was far and above the best organisational response I’ve seen. Gary covers what went wrong, why its a problem and also acknowledges the unfair burden placed on bereaved families who have to try and campaign to get answers and improve things:
I think the leaders of Southern Health Trust like Katrina Percy should be sacked.
Their job is to keep people alive and well and they failed to do that. They then failed to properly investigate their deaths.
I’ve not seen any blogs that touch on the appalling failures to investigate deaths of people using mental health services, especially older people, but I’m sure they’ll come. Now, back to sleazy read (hat tip to Richard Humphries for the phraseology there).
As well as a duty of care (you’d be forgiven to think this doesn’t exist any more in some spaces), the NHS has a duty to ensure that disabled patients receive information in formats that they can understand and that they receive the appropriate support to help them communicate. There’s more information on the Accessible Information Standard here. As ever I’m not sure whether the focus is right, I suspect that the real issue is with the NHS failure to listen, rather than patients not being able to communicate, but as of July 2016 this duty will be legally enforceable.
The Easy Read versions of the Mazars report and the Southern Health response to it that I noticed on Friday made me feel distinctly uneasy. The links in the last sentence allow you to download/read the documents in full. I’m just going to discuss a few points.
1) A significant focus of the Mazars report and accompanying investigation was in relation to the lives, deaths and investigations of learning disabled patients. It’s therefore reasonable to expect easy read versions of both documents, I don’t think that’s something that’s laudable, it’s the bare minimum. So please don’t read the rest of this blog post thinking, even a little bit, ‘at least they did easy read documents’, these should be standard now.
2) The NHS England Easy Read version of the Mazars report is ten pages long, not bad for a 254 page document! I’m no expert in these matters but there still seem to be a lot of words, but the document tries to explain the findings of the report.
3) Next up is the Southern Health response to the Mazars report. This is where those responsible for the Accessible Information Standard might want to give this some thought. It seems that the same picture/image bank is used by all NHS organisations, regardless of whether they are presenting fact or fiction, sorry whether they are presenting facts (like the Mazars findings) or spin (like the Southern Health response to the findings).
It’s good to see that the NHS managed to get Camilla to pose for some stock photos, glad it has royal approval, however it’s a little confusing when the same woman is used for two parallel and related documents. Slightly surreally, if you look at Camilla in the Mazars findings she’s saying that finding out who should investigate a death can be difficult (for healthcare staff presumably, never mind those pesky grieving relatives) however she’s saying there needs to be clarity. In the Southern Health response she is clearly saying ‘we investigated all the deaths we needed to’.
4) Hmmmm, did they? I’m not so sure. If we pop along to page 5 of the Mazars findings it seems that they’re not so sure either:
I’m fairly sure that if it wasn’t clear to Southern Health what death should be investigated (see shrugging shoulder’s man above) then Camilla is telling porkies in the Southern Health response. Given that these documents are produced by NHS organisations and are primarily aimed at learning disabled patients in their care (337 of whom died under Southern Health’s non-care during the period in question), these confusions really aren’t helpful.
5) I can’t write this post without picking up on Southern Health’s use of the jolliest of jolly families ever… to represent a grieving family and the fact that in two thirds of the investigations carried out into unexpected deaths families were not involved in any way. Again the Mazars findings use the same cheery family, although alongside different words. Given the findings within the Mazars report, maybe the NHS needs to invest in some new photo images of bereaved families, I’m sure they know of a few families they could approach.
6) One of (the) most significant finding in the Mazars report was about the utter failure of the CEO, the leadership team and the Board at Southern Health. This is touched upon in the Mazars document. Despite the incredibly significant finding that the Board knew that the quality of the reporting of deaths was not good, no mention of this appears in the Southern Health document, instead they skip over that altogether.
7) The Mazars report was also clear that Southern Health failed to learn (adequately, enough, anything) from the one and a half thousand ‘death incidents’ that took place. Southern Health don’t mention this failure in their response document, instead they talk about reporting and care.
8) Southern Health don’t touch on their failure to learn, or the broader implication that a failure to learn means it’s reasonable to assume some of the later unexpected deaths may have been preventable, if they had learned from their earlier mistakes. Instead their focus is on reporting. Like what matters here is just paperwork. Not the lives lost, just the record keeping and bureaucracy.
9) This is made crystal clear on the next page when Southern Health make the quite remarkable statement that the report was not about the quality of care that they provide.
I’m a simple soul, and no doubt there is some subtlety or nuance that I’m missing here, but the report is everything about care, or rather the lack of care, for people in their lives and their deaths. The first principle of the NHS Constitution is:
The NHS provides a comprehensive service, available to all
That’s irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status. Yet we know at Southern Health this wasn’t the case. We know that some unexpected deaths were paid more attention than others. We know that if you had a learning disability or were an older person with a mental health problem, the chances of your deaths being investigated were less than one in a hundred. Not such a comprehensive service really.
10) Finally, I have to address the bare faced peddling of what I’m beginning to think can only be described as modern-day eugenics by Southern Health. Yes really. I’m so often lost for words in our dealings with Southern Health, but their response to the Mazars findings is quite something else. This is what they say towards the end of their response:
We are not any different from other hospitals. Really? As Rob Greig says in his blog:
To be clear, this is an NHS Chief Executive stating that other NHS Trusts also fail to equally investigate the deaths of people with learning disabilities and older people. The evidence to support this claim needs to be provided, and NHS England, the NHS Confederation, the DH and indeed the Minister need to be aware that this claim has been made and take action accordingly – either to investigate all NHS Trusts because of similar failure or to disprove this claim in the interests of the reputation of other NHS Trusts.
Not our problem, everyone breaks the law, we just got caught out. That my friends is at the heart of the Sloven Health Sleazy Read. We can do/say/neglect/spin as we like, because we can get away with it. Or maybe not, guess time will tell.