Given the overwhelming amount of evidence of failures already we’ve no idea why another inspection is required, or what it is truly meant to uncover, but if the Sloves can’t perform for one day, in an (un)announced inspection, surely someone will step in and do something?

What is unannounced about an announced inspection? JusticeforLB, Jan 2016

Maybe, just maybe, we’ve seen the first action towards someone being held accountable at Southern Health for the hundreds of uninvestigated deaths of people with a learning disability or using mental health services. This week CCQ issued a warning to Southern Health and NHS Improvement (what was Monitor) taking the first steps to remove the management of the Trust,

A month ago now, at the start of March 2016, I decided to have a look at how other NHS mental health trusts had responded to the Mazars report. I checked all the December, January and February Board Papers for all 58 mental health trusts. If Mazars or Southern Health was given even a cursory mention it was included in this analysis.

41 out of the 58 Boards made some mention of the Mazars report and Southern Health’s performance. Think it’s probably safe to say that those that didn’t must be in some sort of denial of the importance and relevance, or living in some sub-human slipstream. They were: 5 Boroughs; Avon and Wiltshire; Birmingham & Solihull; Bradford; Calderstones; Cumbria; Devon; Leeds & York; Northumberland Tyne & Wear; North East London; Oxford Health; Rotherham, Doncaster & South Humber; Solent; Somerset; Staffordshire & Stoke on Trent; Tavistock & Portman. Worcestershire Health and Care get a special mention for being impossible to access, despite requesting papers and having the inaccessible version emailed to me.

So, what of those who did discuss the Mazars report. In the spirit of brevity [postscript: apologies, this is obviously a relative concept, this is not a short post but it is quicker than reading 41 sets of Board Papers] and knowledge translation, I’ve read all of the papers and picked a few highlights to share with you to save anyone else having to ‘deep dive’ into the murky, stinky revolting pool of spin and obfuscation. First thing to say was I was pleasantly surprised at the number of Boards and Trusts who appear to have taken the report seriously, and proactively used it to help them learn, reflect and improve their patient care.

Cultures of honest, evidence-informed assessment of own performance (with humility) are possible

There were numerous examples where Board papers clearly showed the processes in place for investigations were robust, and evidenced the learning from them happening regularly. Lincolnshire Partnership Trust commissioned a small scale review of deaths to gain assurances about their investigation and reporting processes:

‘The Quality and Safety Team therefore reviewed a random sample of 55 cases of patients who died between 1st April 2011 and 31st March 2015 drawn from CAMHS, Adult, Learning Disability and Older Adult Services. Findings evidenced a varying quality of recording at the point of death across the cases. The cases reviewed that met criteria for Serious Incident (SI) investigation were cross checked and all were found to have been escalated for SI investigation. From the sample, and based upon the evidence within the records, no cases from the random sample were identified as having been missed as requiring SI investigation’.

The Lincolnshire paper goes on to examine their own performance further and compare it to that at Southern Health:

Within SHFT NHSE found no comprehensive, systematic approach to learning from deaths as evidenced by action plans, board review and follow-up
LPFT has a comprehensive and systematic approach to learning from deaths….

Within SHFT NHSE found no effective systematic management and oversight of the reporting of deaths and the investigations that followed
LPFT has an effective system for the management and oversight of the reporting of deaths via Datix reports, which are scrutinised daily by the Quality and Safety Team….

Within SHFT NHSE found a lack of Board oversight and lack of Board challenge to the systems, including how decisions were made on whether to investigate deaths
LPFT has Board oversight of serious incidents, receiving a monthly related Board paper. All SI investigations level 1 are reviewed and approved by an Executive Director….

Within SHFT NHSE found an ad-hoc and inadequate approach to involving families and carers in investigations, with only 35% of investigations engaging families
Duty of Candour is evidenced in all Trust SI investigations, with compliance reported quarterly to commissioners within the Trust’s Quality Schedule….

You can see the greater detail in the paper on Lessons Learnt from Southern Health. Lincolnshire’s response is thorough and honest, they are not claiming to have everything right, but they are clear that they are committed to improving their provision and ensuring learning is identified from deaths.

Likewise Sussex Partnership minuted their discussion of their January discussion as follows:

There is more detail in the February minutes here. There is a real sense of importance and seriousness, care and attention to the local implications and a reminder not to be complacent.

Some Trusts have reporting cultures where staff aren’t afraid or discouraged from reporting deaths 

The Board at Nottinghamshire Healthcare have had two detailed discussions of the Mazars report and the implications for them locally at the time the review was conducted. The January paper can be viewed here and the February one here.

The comparison between Southern Health and Nottinghamshire Healthcare provides clear evidence that when it comes to reporting deaths on local (Ulysses) and national (STEIS) systems, Southern Health are performing worse than their peers. Hopefully the CQC and NHS Improvement action will start to change the culture at Southern Health. The Mazars report (pg17) raised grave concerns about the poor reporting culture at Southern Health:

There was a high level of attrition, from the level of deaths initially recorded on the Trust’s systems to those subsequently reported and investigated. This attrition varied across care groups (for instance, there was a greater likelihood of a Mental Health death which was a suicide being investigated than the death of someone with a Learning Disability due to the interpretation of national guidance). It is also reflected in the fact that the Trust reports a low number of deaths to StEIS under death and suicide categories in comparison with other regional NHS Mental Health provider Trusts and in absolute terms to the National Reporting and Learning System (NRLS) under ‘degree of harm death’.

From our review of the evidence, too few deaths were investigated in Learning Disability and Older People Mental Health services.

It is therefore reassuring to see other Trusts have healthier reporting practices and lower levels of attrition.

Unexpected deaths are investigated elsewhere – Southern Health are an outlier

Following on from this point about culture, there were also examples in the various Board papers of higher numbers of investigations happening. For example, Cheshire and Wirral Partnership January Board Papers, pg 170-176 reported:

‘CWP takes learning from external recommendations very seriously and uses such learning as an opportunity to review and improve its own systems even further. It has benchmarked its own position and has confirmed that all reported unexpected deaths during the same time period were investigated’

Another Trust that were impressively pro-active in their response to Mazars report were East London FT. They arranged a meeting with the authors of the Mazars report, submitted FOIs to other Trusts to try and secure some comparator data, and examined their performance and practice against Southern Health’s:

There is a lot of information in the paper (all detailed here) suffice to say East London appear to be much more open and interested (and better performing) than Southern Health. The glaringly obvious difference is that all deaths in the Trust’s learning disability services are investigated, as opposed to 1% of deaths at Southern Health.

It was crystal clear that not only were processes better elsewhere, the numbers were vastly different. Despite this, just this week Katrina Percy was barefaced lying again on BBC News stating that Southern Health are no worse than anywhere else.

The outlier argument is irrelevant anyway 

I have already blogged about this back before Mazars was published. It was a relief to see the same point echoed throughout Board papers, such as this from Hertfordshire’s January meeting. The Integrated Governance Committee hit the nail on the head in a discussion about what the data collected told them:

It was more important to note actual numbers given the overall pledge to reduce suicides to zero. Southern Health haven’t done anything as aspirational as pledged that they would reduce suicides in their Trust to zero, but the point about the value of comparative data stands.

A similar attitude of proactive and desire for improve was demonstrated at Pennine Care. The first discussion of the Mazars report took place at their December 22nd Board Meeting. They were even able to demonstrate what lesson they’d already learned by adding additional data to their governance dashboard:

Perhaps more reassuringly, the Chair of the Board at Pennine pushed the discussion, asking whether they should have been more proactive previously, questioning whether changes coming off the back of Mazars should have happened without the need for the report. January’s Pennine Board meeting saw an in depth comparison of Mazars findings and what happens at Pennine in their Risk Department Assurance Report (pg 28-31)

Similar number of deaths reported onto Ulysses and similar number of unexpected deaths, but look at how many more warrant investigation at Pennine Care. Yet further evidence that Katrina Percy’s ‘we are not an outlier’ refrain is growing ever more hollow.

Timely, considerate and accurate reporting is possible 

I have to say that South West London and St George’s shone like a beacon of hope through this process. The document Summary Report of Trust processes to investigate deaths prepared in December for January Board meeting was exceptionally clear and gave cause for much optimism.

They have clear processes, clear governance, they have consistently met the 45 or 60 day time requirement for investigations since December 2012 and they even have a family liaison officer nominated for each death investigated. This is a world away from Southern Health’s treatment of Connor’s family. The proactive approach to investigating and learning also extends to preventing deaths in the first place, compare and contrast their 2014/15 quality report and it’s focus on embedding learning from Francis and Winterbourne View, with the work of fiction reported by Southern Health discussed here.

What about definitions, it’s complicated you know

One of the responses to Mazars that I’ve found most infuriating personally, is the definition argument. We’ve repeatedly been told that it’s complicated/complex/not clear cut how deaths are defined. There has been much delay, obfuscation and excuse in relation to what definitions should be used when discussing deaths, indeed some Trusts only mention of Mazars was to say that they were waiting for more information on how deaths were defined. Arrrrrrgh, there are people at risk of dying prematurely while people argue over semantics. Yes, there are subtle, and important, differences between unexpected, preventable and premature death. The Mazars report unpicks this is great detail. Any responsible Trust should know how they themselves are recording, investigating and responding to deaths.

The Isle of Wight trust discussed the Mazars report on at least two occasions. In my opinion their key contribution is in relation to definitions:

The Trust uses the following definition of unexpected death: the death of any patient not on an end of life care pathway.

Booooooom. IOW’s brilliantly simple definition for an unexpected death, is likely to really shine a spotlight on the hundreds of people with a learning disability who die prematurely and get squirrelled away in Board minutes as ‘natural causes’. If you die from constipation, or cardiac arrest in your 30s, or choking or indeed a seizure in a bath as an 18 year old, this is likely to be picked up, because having a learning disability does not equate to being on an end of life care pathway. Or it shouldn’t, even if it does in the mindset of too many.

It’s not all hunkydory out there though

Writing this blog post was an unexpected and surprisingly positive experience. That’s not to say all is well, there were a number of Trusts who have some way to go to improve their practice. In addition to those who haven’t discussed Mazars, there were a number of pictures of poor or ambivalent practice captured by Board papers, such as the discussion in the January Mersey Care Board Papers.

The Trust does have a mortality review process that considers the causes of deaths that have been identified as being avoidable. It will request reviews into deaths as well as identify trends both from completed reviews and causative factors. It does not consider all deaths that occurred within the Trust. Out of the 549 patient deaths that the Trust is aware of which occurred last year only approximately 50 deaths were considered, those being related to possible suicide or which involved in an accident such as a fall

The Mersey Care mortality review process looks at less than 10% of deaths, and mostly those relating to suicide or falls. Not sure that will pick up much learning for preventing future deaths of people with a learning disability, or those who die due to medication errors for example. Mersey Care did acknowledge that they needed to make some changes and improvements.

The papers for Derbyshire had an almost Southern Health quality to them! The Quality Committee were tasked with looking at Mazars (page 25), they:

Considered the report and its findings and recommendations. A review of how we report deaths and a review of all deaths in the last 12 months was presented to the Quality Committee on 14th January 2016 with detailed analysis and recommendations on the Trust procedures and learning from other organisations areas for improvement.

The discussion at the January Board Meeting was minuted as:

Carolyn Green informed the Board that the Quality Committee had scrutinised the report and the Trust has a plan in place that will ensure good governance in this area and purposeful learning. This information has been shared nationally and other authorities have thanked us for this. Strong assurance on duty of candour has been obtained although there are still national reputational issues that need to be addressed as there are difficult interpretations of investigations but Carolyn Green was confident the Trust has a very strong process of control in this area.

The emphasis is mine, and I have no reason to believe that Derbyshire aren’t all over their investigations and completely on top of everything, but there was something that didn’t smell very good to me. It could just have been the way in which the meeting was reported, but it was all a little reminiscent of nothing to see here, we’re good, national problems culture elsewhere.

Perhaps the ‘ugliest’ response I happened across, was in the Leeds and York Partnership papers. They didn’t have a November or December Board meeting so the January papers included the minutes from the previous meeting held in October. There was no mention of Mazars, however the October meeting was minuted as follows:

Seems that Leeds and York are also grasping at the ‘not an outlier’ argument, not sure that answers Mrs Phipps question or would provide any comfort to the families of those four patients who died from hanging on their watch.

I’m not going to end with that misery though, I’m going to give the final word to South West Yorkshire Partnership Trust who discussed the Mazars report at a couple of Board meetings and compared themselves to Southern Health. Check out the January Board papers (Item 7.4) for the full information but I’ll just finish with the headings, a useful framework for anyone else who is interested in how to get it right: