The Lampard Inquiry is an independent statutory inquiry investigating the deaths of 2,000 mental health inpatients in Essex between 2000 and 2023. The inquiry has had a number of public hearings now, that you can view on the inquiry’s youtube channel.
I’ve followed a number of the hearings, dipping in and out, listening to the heart breaking evidence from bereaved families at the start. Today I wanted to write briefly about the evidence of the EPUT CEO Paul Scott on Prevention of Future Death Reports.
I don’t live tweet from courts any more because of how unreliable that platform is, but I do still think there is a real power in sharing people’s words directly, without my commentary, so that’s what follows (tiny reflection at the end). Paul Scott is being questioned by Nicholas Griffin KC, counsel to the inquiry.
NG: Can we now turn to incident investigations and responses please? Dealing first with the Prevention of Future Deaths reports issued by the coroner. Do you know whether NEP [North Essex Partnership] had any mechanism or framework for sharing issues arising from records of inquests and PFDs and indeed the findings of Serious Incident Investigations and action plans across the Trust, so as to identify recurrent issues of concern and to prevent future deaths?
PS: I don’t know.
Mr Griffin KC then asked for core bundle page 1407 to be displayed, expanding paragraph 62.
NG: Thank you very much. So you say here “In addition, the Prevention of Future Death Reports from inquests into patient deaths, which occurred since the date of merger have been analysed thematically to identify systemic issues. The systemic themes identified included:
- Communication, including failures in joint working and information sharing, and the involvement of family members or carers
- Training and supervision, including criticism of Oxevision training and failure to convey its limitations or use of the tool as a substitute for in-person observations and care
- Record keeping
- Discharge planning, including the inadequate assessment of patients
- Care planning and
- Failures to assess risk and manage risk adequately”.
When did the analysis that this paragraph talks about take place?
PS: Well I will have to, I’m really sorry I will have to get back to you on that.
NG: And do you know what purpose that analysis was for?
PS: It was trying to understand, umm, urgh, what kind of things were emerging from the PFDs, a thematic review as you’ve already said, and how that informs our safety plans or our strategy.
NG: Was that done specifically for this inquiry, do you know?
PS: No. No, no, no, no.
NG: It would have been done prior to this inquiry? Or for a separate purpose in any event?
PS: It’s a separate purpose.
NG: Thank you. Would it be fair to say that the Trust’s systems for responding to and learning from coronial reports have been slow or inadequate?
PS: I think they have been slow, yes. And I think there’s, there’s been a gap, I think, in the oversight of those.
NG: Have they been inadequate?
PS: Um… I don’t know.
NG: You don’t know?
PS: I don’t know if they’ve been inadequate or not. I think there’s been gaps. So the reason I’m saying that is that the oversight at a central level that is different. So they were overseen and delivered at care unit level, clinical level, but we didn’t have the reporting mechanism in the oversight to make sure that the actions we were committed to were delivered. And that’s why I said I don’t know if it’s inadequate or not, because I don’t know.
NG: Looking, we can still see it on the screen, looking at the themes there, do you accept that the pattern of failings repeated in multiple PFD reports reflects systemic and ongoing failure of the Trust leadership?
PS: Urgh, I don’t accept that, no. And I think there’s quite, there’s a, there’s a, there’s a, there’s a, there’s a, quite an interesting conversation here. If you look across, um, many NHS organisations, particularly mental health organisations, you’ll see repeated themes. And that’s because it’s learning, and we need to do more, but it’s also because they’re the points of risk and failure in a system. And so when we talk about learning, we have to continually cycle round to say, has that learning worked? And you heard from Dr Ian Davidson there’s a lot of things that need to be in place to guarantee safety. And urgh these are the areas we’re going to have to continue working on time and time again, I think, to get to a point where we improve safety.
NG: Thank you. We understand from the witness statement of your EPUT colleague Ann Sheridan that the Trust does not hold a central record of all PFDs and records of inquest issued for the entire relevant period. So we’re going back to 2000.
She also says that since May 2023, the Trust has in place a central record of PFDs and ROI’s, records of inquest, which consists of a catalogue and the storage of key documents within the Inquest Team shared drive. What was the reason that there was no such, no such central record in existence before May 2023?
PS: I think it was an oversight and an omission, and we’ve created that now.
NG: Is there any reason why it took six years post-merger to set it up?
PS: No.
NG: Are you aware of any reason why older pre-merger records couldn’t also be incorporated into this central record?
PS: Urgh, no, there’s no reason, no.
NG: Do you think that might be a good idea?
PS: Possibly, yes.
Nicholas Griffin KC then took Paul Scott to PSIRF, the Patient Safety Incident Response Framework. If you wish to watch today’s hearing you can find it here. Mr Scott appeared part apathetic, part defensive.
In a defence reminiscent of Katrina Percy at Southern Health when the Mazars review found they’d failed to investigate the deaths of learning disabled people and those using mental health services, the inference was that EPUT aren’t an outlier, and this stuff is just complicated and difficult.
Whilst simultaneously being forced to admit that they just didn’t seem to try too hard to learn from Prevention of Future Deaths reports and inquests, or even to compile all the relevant evidence in one place.