How many ‘learning opportunities’ in epilepsy does Southern Health need?
LEARNING OPPORTUNITY 1
The first known incident relating to epileptic-type seizures was in September 2011. A Southern Health Consultant Psychiatrist misdiagnosed the after-effects of a seizure as mental illness and sectioned CRASH, carting him off to a remote psychiatric unit – without advising the unit of the very recent seizure or a suspected TIA.
CRASH was forcibly restrained by two police officers, who were not made aware of his physical illness. A senior officer offered to give evidence to Southern Health’s ‘independent’ investigator but the Trust withheld his offer from the investigator and ‘accidently’ lost a body-map of CRASH’s injuries, which the police had requested.
Four day’s later, a junior Southern Health doctor recorded in CRASH’s notes:
“I did not see any documentation from [A & E] and therefore contacted them. They have faxed across his notes from the ED which state: They have referred [CRASH] to the First Seizure Clinic for a possible grand mal seizure – 1st. Unfortunately, it does not seem that they have performed a CT brain.”
So a patient, at risk of another seizure and/or a TIA, was in Southern Health’s ‘care’ for four days (despite not being mentally ill) and its staff were oblivious to the conditions and thus the risks. Dr Lesley ‘Slippery’ Stevens knew about this in December 2012 (if not before) as Adjudicator of CRASH’S complaint.
Dr Stevens also believes it is lawful to detain patients, who are not mentally ill, under The Mental Health Act, despite that detention without lawful justification has been a tort of strict liability (in which the defence of ‘reasonable care’ is not available) since the Magna Carta. The fight for justice goes on 5.5 years later.
LEARNING OPPORTUNITY 2
On 4 July 2013 Connor Sparrowhawk, a young lad commonly known as Laughing Boy (“LB”), passed away. A known epileptic, Southern Health staff allowed LB to have an unsupervised bath … the rest is entirely predictable even by non-medics. Read more here→.
Here is an answer to a question at the Inquest by Dr Stevens (from twitter-feed):
Key here is not the date of the Inquest per se but that Dr Stevens knew of the need to ‘up-skill’ (train in normal language) staff in relation to epilepsy in 2013 after LB died.
LEARNING OPPORTUNITY 3
In February 2014, in its first report on LB’s death, independent investigator, Verita recommended inter alia:
- The trust should undertake a review of the epilepsy care it provides to ensure it complies with local and national guidance.
- The trust should ensure that trust staff working with patients with a history of epilepsy have access to appropriate advice and support from epilepsy specialists.
- The trust should ensure that all relevant staff are competent to manage an epileptic seizure.
“We have reviewed the training our staff receive in relation to writing care plans and developing risk assessments for patients with epilepsy. All staff across the Learning Disabilities Division will undergo enhanced training and this will be mandatory. “
LEARNING OPPORTUNITY 4
Three months’ later in May 2014, 18-year old teenager Edward Hartley died following complications from an epileptic seizure. Allegedly, Southern Health has not formally acknowledged that Edward’s carer had not been epilepsy-trained. His family believe he hadn’t but have no proof. However, the Trust acknowledged that the career hadn’t received BLS² training, so it is unlikely he was epilepsy-trained too.
Astonishingly, three years later his parents say they are no closer to finding out the truth. We are constrained about what we can say by a second investigation report, which has not yet been issued. Read more→
LEARNING OPPORTUNITY 5
Following Connor Sparrowhawk’s Inquest, on 2 November 2015, the Oxfordshire Coroner issued a Regulation 28 Report – Prevention of Future Deaths to Southern Health raising serious concerns relating to epilepsy care and recording.
The response to the Regulation 28 Report by Katrina ‘Teflon’ Percy is full of more duck-billed platitudes and re-assurances, including details of how staff would be informed of required improvements in relation to epilepsy.
Download the full Regulation 28 Report and Southern Health’s response on the web site of the Judiciary for England and Wales here→.
OUTCOMES BY 22 NOVEMBER 2016
So, even 11 month’s after Katrina Percy’s undertaking to the Coroner, are all relevant staff trained and competent in epilepsy? The answer is in November’s Board Papers.
Extracts from Agenda Item 10 – Board Assurance Framework dated 22 November 2016: pdf file page number 162.
Southern Health itself doesn’t actually know what percentage of relevant staff have attended training or are competent in epilepsy. It hasn’t even allocated an ‘Assurance Group’. ‘Action’ is required but they have not even allocated an ‘Action Owner’
OUTCOMES BY 19 APRIL 2017
And the April Board Papers reveal that the only progress made in five months (16 months after Katrina Percy’s letter to the Coroner) is the allocation of a ‘Risk Owner’ – Bobby Moth³ – obvious one might think: she is Associate Director of the Leadership Education and Development Team and co-author of a paper, ‘Nurse Revalidation‘.
Indeed, in that role, why is she not be keeping figures for her own information anyway?
Extracts from Agenda Item 10 – Board Assurance Framework dated 25 April 2017: pdf file page number 266.
And look at the slight of hand – whilst risk scores are unchanged from November, the assurance strength appears to have improved from “weak” to “partial assurance” even though, on epilepsy (and other) risks, there appears to be no assurance at all!
SUMMARY OF ‘LEARNING’
In short, despite all these ‘learning opportunities’, over five years after the first known incident; three years after the CEO promised to ensure trust staff were trained and competent in managing epileptic seizures; and over 16 month’s after the CEO’s letter to the Coroner, its Medical Director, Dr Lesley Stevens cannot tell the Board, patients, families what percentage of relevant staff are trained and have competency in epilepsy. Perhaps she uses her mystic powers.
OTHER OBSERVATIONS FROM THE STRATEGIC RISK REPORTS
- Two of the major public health concerns currently are dementia and diabetes. The training and competency records on these are no better than those for epilepsy.
- Not all staff hold signed competencies in their personal portfolios.
- Clinical Supervision Policy – records of compliance are not 100% and some teams are not formally recording supervision.
AND MOST SHOCKING OF ALL?
Despite two Board and Council of Governors Meetings and Care Quality Commission inspections, not a single Director, Governor or CQC Inspector has challenged these failures.
CRASH makes no apologies for the ‘mouse print’ – it is how the Trust publishes its reports, probably to disguise its failings. Lucy la Zouche commented:
As for the Risk Analysis – they always seem to have documents like this in the smallest possible print and with a three-way risk assessment in full colour, But, they still consistently screw things up. Perhaps they need to get some good managers and get rid of some of the analysts, strategists and other hangers on.”
Even using the original Board Papers, it is necessary to use the pdf zoom facility! Read all the pages in both (total 697) and recall the adage – excreta tauri cerebrum vincit.
Misleading – learning apparently never starts for Dr Stevens and Bobby Moth.
And what does this say about their leadership?
³Moths: Quite frightening as they tend to appear at dusk!