CRASH has experienced serious IT issues. Some suggested that we might have been ‘got at’ but we found no evidence of this. It necessitated a change to our email address.
The Pascoe Investigation re-started dramatically on 6 April 2021. Nick Ralls¹, an NHS accredited hypnotherapist, whose son has been a service user of Southern Health NHS Foundation Trust and its predecessor body for over 20 years, alleged that his experience of, “Engagement” with the Trust’s Board had, “Got worse over time“. He could not see, “Any improvement” in the complaints process, adding:
“I don’t see a cultural change…. It seems to be more problematic as time goes on, the way the complaints are handled.”
A full report of Nick’s evidence is on the BBC website here→. Others share his view.
Next were two witnesses relatively supportive of Southern Health (unsurprisingly ‘NHS-lifers’). The Chair of Healthwatch Hampshire, Anne Smith, appeared ill-informed. Dr Vaughan Lewis, S.E. Regional Medical Director, NHS England, displayed little knowledge of Quality Improvement. He admitted lack of expertise in mental health and learning difficulties and that these subjects are normally addressed by staff 1/2 steps below him. Where is the parity of esteem – enshrined in law by the Health and Social Care Act 2012?
Bizarrly, we heard from retired Judges – His Honour Judge Neil Butter CBE (rtd. 2001) and His Honour Judge Keith Cutler CBE (rtd. 2021). The former asserted that retired judges should not chair serious incident investigations (“Judges do not do empathy“) whilst the latter said the opposite because judges have (“Empty brains“). In short, they cancelled eachother out – Judges would require ‘expert’ advisors too, thereby racking up costs.
We then heard three truly independent, authoritative witnesses, whose evidence was extensive, compelling and very well-informed.
A fearless veteran of many investigations Dr Kirkup led inquiries into Morecambe Bay maternity services and Jimmy Savile’s involvement at Broadmoor. He was a Panel Member of the inquiry into the deaths at Gosport War Memorial Hospital.
Dr Kirkup asserted that Trusts need to address five issues in investigating incidents:
- They should not adopt a defensive mindset or challenge findings made against it.
- Effective leadership: especially when things go wrong. Public must trust the leaders.
- Breakdown in clinical relationships – between those with different clinical backgrounds. Once embedded, professional jealousy is hard to identify.
- Clinicians do not own up when things go wrong, especially if someone has died. They look for reasons to deny liability. There is a subculture of invincibility.
- Disconnect between senior leadership and front-line workers, which lead to ineffective clinical governance.
In rating complaints handling, Dr Kirkup rated some Trusts as very good; 70% adequate; and 10% incomprehensibly bad. 10% do not learn from incidents. He referred to the ‘We can’t make a mistake’ culture still prevalent amongst doctors and believes that overcoming the, ‘Subculture of impossible expectations’ must begin with doctors’ training. However, the General Medical Council says it has no room on the syllabus.
When asked how the 10% could be identified and improved, he referred inter alia to the following requirements.
- The Chief Executive Officer (“CEO”) and Directors must be closely engaged in patient safety issues and complaints.
- Many spend too long looking at high level figures, which do not tell the whole story.
- Many do not check learning such as by talking to people, including service users.
- Hierarchical systems and ineffective teamworking are a feature of poor leadership.
- Boards often do not have the ability to recognise what’s go on – directors should go out talk and visit places. Bad ones shut themselves behind a key card!
- Good leaders admit when they need professional help; others fool themselves and don’t tell anyone.
- There must be accountability for change: without improvement, the leaders must go.
- Current assessment of leadership by regulators is not working as well as it should.
- Changing deep-seated attitudes and culture depends on leadership.
- Does it need a change of leadership to change culture? Very difficult to change culture unless the current leadership admits to the Trust’s errors.
- A change in culture often needs a change in leadership.
- Only service users, carers and families can attest to changing culture.
Duty of Candour
- Just be open and honest – there should be no need for a legal duty.
- There must be full, immediate disclosure of evidence – families and patients must be involved throughout to avoid loss of trust. Those who recognise most incidents often the safest. If the process is not inclusive things can be missed.
- Subculture of impossible expectations and clinical denial – “We can not make a mistake culture” still prevalent.
- Needs a process and audits to ensure learning is implemented.
- Clinicians should have proper meetings with customers, not ‘edge of the bed’ talks; admit to their errors; and welcome customer involvement.
Lack of communication with families stems from clinicians not accepting that things go wrong: the reach for reputational management starts at clinical level. They do not want to sit down with people and listen.
Complaints & Investigations
- Response to complaints is not good, often dismissive/hostile. ‘Get rid of them a.s.a.p.’ – they are not linked to clinical governance and can become confrontational.
- The gold standard is that complaining should be easy. He emphasised progress made in the commercial sector in this respect.
- People should not be looking at their own incidents – will not get best learning.
- Independence of investigators must be proportional – they can be part of same Trust but not the same team. In more complex serious incidents, it is wholly wrong that Trust investigates itself; it must be wholly independent.
- Investigations should not be led by clinicians – they are not objective. Bishop James Jones is a good example of an expert in leading investigations. Educational background is immaterial – they need to understand the process.
- Families should be involved throughout: meetings should be informal with constructive dialogue, avoiding Trusts being told by lawyers not to answer questions.
- When families require legal assistance, it should be provided.
- There is no criteria for the commissioning of an independent inquiry – should include deaths or systemic failings. Dr Kirkup found a death where a simple check list was produced – 9 months later, it happened again.
- Must involve relatives and/or customers in investigations. Investigators should be open with people, not treat them as witnesses.
- Medical records often show events as they were ‘thought to happen’; they are too ‘clinical.’ This needs to be remedied.
Learning & Action Plans
- Investigations should lead to firm action plans. There can be a good process, but learning is then ignored, especially in dysfunctional Trusts.
- Needs a process to ensure that learning is implemented. For example, quality committees.
- Customer involvement in improvement and repairing ‘damage’ is essential.
- There should be an audit of action plan implementation. Directors are accountable, and Regulators should check.
- CCGs should be responsible for checking action plan implementation but this rarely happens.
Mysteriously, a Panel Member asked Dr Kirkup if his experience clouded his judgement of the NHS overall. Why does a Panel (whose own independence has been questioned) challenge a truly independent witness?
Dr Kirkup was asked how to treat families, who are not happy with the outcome of an investigation, and how to support them long-term.
He emphasised that the first time is the best chance of getting it right, adding that this often doesn’t happen and the longer it goes on the worse it gets.
Families are best experts on their own case.
Dr Kirkup sees a role for mediators – not in investigations but in mending fences. However, both parties should be willing to engage in the process with an open mind. He emphasised that they should be run by an independent professional mediator – not a clinician. At Morecambe Bay, he thought it was successful in certain cases after the investigation.
Dr Kirkup believes that the role of Medical Examiner is vital – but they only should be involved as a ‘long-stop’ and should not be an employee of the Trust.
The best compliments heard about Dr Kirkup’s evidence are expressions of regret that he was not Chair of this Panel. However, if the Panel assesses Southern Health’s leadership and service users’ evidence against Dr Kirkup’s observations, its report will be damming.
Clearly, the current leadership at Southern Health NHS Foundation Trust has shown no wish to engage with its most unhappy customers – the bereaved families.
It refuses to use them as any source of learning.
Indeed, it has done exactly the opposite!
Dr Kirkup was followed by Dr Josephine Ocloo (Senior Researcher and Health Foundation Improvement Science Fellow at King’s College, London) and Keith Conradi (Chief Investigator at Healthcare Safety Investigations Branch).
Their evidence is so important that it warrants a separate report. For now, we must credit Jospehine for her description of historical cases as, “The dark side of the NHS.”
¹ “When you have a lot of unhappy customers demanding limited time and limited resources, the financial cost can be big—from hundreds to hundreds of thousands of dollars. The faster you can reduce the number of unhappy customers you have, the better it is for your business.” [Anita Toth, ‘Bill Gates Says Unhappy Customers Are Good for Your Business. Here’s why’, first published 22 October 2020 in ‘Entrepreneur Europe‘.]