Reflections on working with CQC on #CQCDeathsReview

In mid December 2016 the CQC Deaths Review was published. To coincide I published my own scoping review Family involvement in, and experience of, death investigations by the NHS and I blogged some initial thoughts about it here and some thoughts on potential learning here and here. I promised that I’d blog some thoughts about the experience […]

How can we improve things 2 #CQCDeathsReview

A couple days ago I posted How can we improve things #CQCDeathsReview and wandered off twitter and email for 36 hours. It’s been a roller coaster week, bizarre in many ways, trying to keep on top of the media coverage since the review published, wanting to engage with people who offered their perspectives, and reeling […]

How can we improve things #CQCDeathsReview

This is a bold title on this blog post, and I’m sitting her before 7am, before coffee, the day after the #CQCDeathsReview published tapping my keyboard – so bear with me, hopefully the discussion and comments will add to whatever I can offer. At the last ERG (Expert Reference Group) someone raised the concern that once […]

No learning, no candour and no accountability #CQCDeathsReview

The CQC Deaths Review publishes today. You can download and read the report here. It makes for a gut churning read. The headline message is that the NHS is failing to identify deaths that need investigating, failing to investigate properly (when investigations happen) and failing to learn lessons, improve care or prevent future deaths. It […]

What the Donkey Sanctuary could teach the #NHS and #socialcare

Disclaimer: this blog post may just be a very simple cover to share pics of donkeys, but hopefully the words might make sense too, if not enjoy the donks  I am very fortunate to live about half an hour from the Donkey Sanctuary headquarters at Sidmouth and consequently when I’m looking for a day out, […]

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

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 […]

Unofficial #NHS guide to all things inquest

Alternative title, not to be used publicly: how to protect your reputation at all costs When a patient dies  Don’t bother apologising or the family might get the wrong idea and try to sue us. Assign as much as possible to ‘natural causes’, especially if they’re using mental health services, have a physical disability or are learning […]

Inquest reflections #JusticeforLB

Last week I wrote a post reflecting on the first week of LB’s inquest last year. It focused on some of the themes that emerged in that first week, the sprinklings of candour, the constant undercurrent of mother blaming, the contradictions and flaky knowledge of epilepsy, even then, years after LB died, years after Southern […]

A year on from LB’s inquest: candour, contradictions and mother blaming #JusticeforLB

All week we’ve been sharing some of the lowlights from LB’s inquest a year ago. Sara has blogged about how this strange anniversary feels for her and the utter despair at the complete absence, still, of anything vaguely resembling accountability: I think my new tear configuration has (re) emerged because of the utterly shameful banality […]

Exit stunts #JusticeforLB

I’m not one for conspiracy theories, however, as the news spread that Katrina Percy has ‘reflected’ (it’s only taken her three years) and decided her employment at Southern Health was no longer tenable (Trust statement here), something just didn’t smell right. We’ve been around Southern Health long enough to know that very little smells right, but […]