Epilepsy Rage 2

4559220 - short sighted man needs binoculars to read his book

Director reading Strategic Risk Assessment

 

On 29 April 2017, we identified five ‘learning opportunities’ in epilepsy, from which Southern Health failed to learn. The ‘learning’ continues … or does it?

First, a simple eye test. Body text in Strategic Risk Assessments is CIDFont+F1, size 4.

 

 

SIZE MATTERS

Having spent so much time reading Southern Health’s ‘mouse print’ – see previous post –  your scribe decided it was time to visit his optician.  Now try this test:

Font Size4

This image is CIDFont+F1, sizes: 4 to 14 in 2pt steps. Which can you read comfortably?

 

Optician astonished that NHS is producing important documents in font size 4. There is no statutory limit but guidelines indicate that print should be legible to someone with normal eyesight, or with glasses, which correct to normal. 4 is the lowest possible limit.

In short, a good, comfortable font size is necessary for readable text. This rule is old news but clearly not for Southern Health – unless they don’t want people to read it.

LEARNING OPPORTUNITY 6

Following the Care Quality Commission’s decision on 6 March 2017 to prosecute Southern Health for an incident in December 2015, the BBC has reported the Health and Safety Executive’s decision to prosecute the Trust under Section 3 of the Health and Safety Act in relation to the ‘preventable death‘ of Connor Sparrowhawk. Read more here and here. A ‘bitter-sweet moment‘, one might think, for his mother Dr Sara Ryan – who has fought for justice for four years with formidable dedication and energy. 

11763603 - what can i do? picture about regret

What can I do? I’m just a Director?

Or it might have been a learning opportunity if Southern Health had not responded with its usual crass comments and non-apology.

The ‘apology’ was part of a statement Southern Health was sending to journalists!

 

 

They didn’t get in touch with Connor’s family to say sorry. They got in touch with the press. A purely bitter moment. Read more on Sara’s distressing blog→

LEARNING OPPORTUNITY 7

It was alleged at an Inquest into the death of Sasha Taylor (a known epileptic) that a Consultant Psychiatrist had increased the dosage of Olanzapine, an antipsychotic drug, during a telephone conversation to higher than the recommended maximum guidelines. Amongst the side-effects of Olanzapine are seizures – with a specific recommendation:

“Tell your doctor or pharmacist if you have any medical conditions, especially … if you have a history of seizures.”

It makes clear also that there are a number of other drugs that, if used in conjunction with Olanzapine, will increase the risk of side-effects. It is alleged that Sasha was also taking Amisulpride, which has a precautionary warning on epilepsy too, and anti-depressants, which are known to lower the threshold for seizures.

The Consultant said he wanted to lower Sasha’s medication but, in order to do this, he had to briefly raise the level of Olanzapine! We bow to his professional expertise but this offends common sense.

Senior Coroner Grahame Short recorded a verdict of a drugs-related death and said:

“It is worrying for us to learn that these high levels of anti-psychotic drugs, which can have serious side effects, were not monitored over 12 months.”

Naturally, Southern Health responded with the usual platitudes. Clinical Director, Professor David Kingdon said:

“We have carried out our own internal investigation and made a number of improvements to the way we support people on higher doses of medication.

“For example, all our teams now have a nominated physical health lead to monitor the physiological effects of psychiatric mediation, and a review of patients receiving high-dose therapy now takes place at every clinical team meeting.”

Oh really, Professor Kingdon! After dishing out a mountain of drugs (often justifiably) for treating psychosis, schizophrenia, depression etc., many of which have very serious side-effects, Southern Health still didn’t monitor patients’ physical health properly four years after its formation … and the percentage of trained staff is unknown to this day.

15413127 - angry doctor holding telephone

And this is not the first ‘distance diagnosis’ – on 8 March 2017 Coroner Grahame Short heard of an outpatient talking of suicidal feelings but being told by phone just to take a diazepam and have a cup of tea – shortly before falling to her death: read more→.

 

And in 2013, Dr  ‘Mystic Meg Lesley’ Stevens, then Clinical Director, Mental Health Division, used psychic powers to diagnose a patient she had never met or spoken too – even by phone.

And now? We will not use images of barely readable text again but the Trust’s Strategic Risk Assessments for physical health training for November 2016 and April 2017 show:

“New Physical Training programme available for all staff: Attendance % not reported. Course content and attendance recording being reviewed.

“Board Reporting: Attendance accurately not reported.”

Back to School

SUMMARY – STILL NO LEARNING.

And who was successively Clinical Director, Mental Health & Learning Disability Director and Medical Director during this time – Dr Lesley Stevens when will she join the seven

 

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