In October an inquest jury found neglect contributed to the death of 18-year-old Connor Sparrowhawk at a Southern Health NHS Trust learning disabilities unit.
Standing outside the coroner’s court, Connor’s mother, Sara Ryan, and stepfather, Richard Huggins, were told Southern Health had issued an apology.
“Have they?” came the reply. “To who? They’ve not said anything to us.”
The trust had made sure to tell journalists they were sorry. They just hadn’t told those that needed to hear it most.
Southern Health got its priorities wrong then and it did so again last week in the way it responded to a leaked report ordered by NHS England after Connor’s death.
The report, by audit firm Mazars, accused Southern Health of investigating just 1% of deaths of people with learning disabilities and 0.3% of deaths among over 65s with mental health conditions.
A lack of leadership
Southern Health contests those figures and has spent much time and effort making sure people know it. Yet the trust has said far less about a series of failings in leadership, governance and family involvement flagged up by the Mazars review.
These include concerns the trust’s senior management placed too little focus on making sure deaths among these patient groups were properly looked into. That the trust failed to act properly on warnings from coroners over the quality of investigations. That the board was too quick to accept reassurance from senior management that everything was in order. And that the trust’s culture meant there was a lack of openness when things went wrong.
Families
And families? Families were apparently left out of almost two-thirds of investigations which were carried out. When people with a learning disability died, involvement of their families was “negligible”. Some of the trust’s written reports also used the wrong names for the deceased, something Mazars said would have caused “further distress” to those who lost loved ones if they’d known about it.
Last week, after the report leaked, Southern Health’s chief executive, Katrina Percy, was asked if the trust had let down patients and families. She apologised to anyone “who feels let down” – a very different apology to acknowledging people were let down. She has refused to resign.
It is right that Southern Health can challenge the Mazars findings. It is also the case that they’ve had the opportunity to do so for months. In whose interests is it that the report, due to be published in the autumn, is still not in the public domain?
Staff and service user wellbeing
The trust say they are contesting the findings primarily out of concern for patients. A briefing Southern produced for NHS England, prior to the leak, said inaccurate findings could impact the wellbeing of patients and staff.
The wellbeing of patients and staff at Southern Health has come up before. Back in February, the Care Quality Commission’s inspection report found some of Southern’s staff and service users were concerned at a lack of openness and honesty in the trust’s response to Connor Sparrowhawk’s death.
The report said: “This was clearly causing distress and affecting staff morale and unrest with people using services and their families. They felt the trust had failed to communicate effectively and was acting outside of its own values”.
NHS England will publish the Mazars review before Christmas, possibly this week. When it does, Southern Health will again have to respond and consider what matters most here.
The trust could take a cue from the way some of its own frontline staff handled Connor’s inquest. Over the two weeks of evidence sessions, some of the staff involved in Connor’s care took the opportunity to apologise to his family. Not through a statement issued to media, but by looking them in the eye and saying sorry.
Connor’s family later said how grateful they were for those “heartfelt apologies” from staff. It meant a lot that people had taken responsibility. In contrast, the trust’s response left them feeling that the organisation’s leaders were “focusing more on their reputation” than the distress caused to families.
With its responses to the Mazars review so far, Southern is making the same mistake.
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Thank goodness that the CQC are now doing their job, where would we be without them?
Might we also see the BBC, Safeguarding, LAs, Unison etc also getting involved in protecting the Public or have they only time to concentrate on pillorring vulnerable Care Homes.
It seems that whenever there are failings in an institution of this sort, even if they get caught bang to rights, they preface any apology with a statement which is patently untrue, such as, ‘the health and wellbeing of our patients is our highest priority.’ Well, no it isn’t – if it were, the situation would not have arisen in the first place. And then the actual apology is mealy-mouthed in the extreme – ‘we’re sorry if people are distressed,’ and spends much time explaining all the extenuating circumstances. It is time these organisations took responsibility for these failings which often affect the management culture and structure as much as individual staff. Another example is where nurses were sent to prison for falsifying records and the Chief Exec of that health trust merely said complacently that it appeared that no patients came to significant harm. Blow the affront to their human rights and the need to treat people honestly and with respect and dignity. All staff at all levels in health and social care should be asked, would you like your mother/sister/brother/partner/child to be treated in your hospital or care home and be expected to be able honestly to say yes.
Spot on.
Well said. All of us who have next of kin with a learning disability living in a care home can live in fear and I have had enough of hearing an over paid NHS director offer insincere apologies after a life has been prematurely extinguished because of appalling care under their watch. There are no excuses. Ever.
NHS trusts trot out the same tired statements and move on, until it happens again. I’ve always thought an apology is pointless and it’s better not said at all. If any director of an NHS trust is forced into apologizing then it’s a sign they are accountable.
Highly paid NHS directors are there to slash budgets and produce reports rather than having any understanding that care means treating a member of someone else’s family like you would your own. If they don’t get it they need to be outed and fired.
I would like to see harsh punishments and prison sentences for all those held accountable. You get the sense they get away with what is in reality unlawful killing because society views people with a learning disability and autism and communication problems as less valuable and less important.
I find it so very sad, reading articles like this – proof of how little things have changed since Mid Staffs, or the scandalous deaths of children like V. Climbie, and “Baby P”.
These issues ought to be revealing to us that there is a consistent theme – that of the carers NOT caring. Whenever things go wrong within a healthcare organization, what we are seeing is anything but an appropriate, empathic and caring response. What we see, time and time again, is lies, obfuscation, side-stepping of accountability, lack of responsibility, cover-ups, fake apologies…
The above is evidence (in my opinion, for whatever that matters) of serious, and possibly entrenched, problems within the healthcare professions. I am not saying that these problems are shared by ALL staff; far from it. SOME staff are genuinely well-meaning and very supportive. However, it only takes a small number of “rotten apples” to poison the whole “barrel”!. THIS is what we are seeing – a small(ish) number of people who have somehow been able to sneak into the healthcare professions (usually, and very disturbingly, at management level), but who do not truly care at all.
We really do need to start asking some serious questions about what is going on. Beginning with asking why, oh why, such scandals seem to keep occurring. Surely, once there has been just one scandalous death, or evidence of neglect or poor treatment, within the healthcare sector we should be seeking to know just how this came about, and doing everything possible to learn lessons that make sure it will NEVER happen again.
Instead, what we are seeing is evidence that some people working within health and social care are NOT caring in the least. We see evidence that mistakes are made, and then attempts are made to cover them up and lie about them. We see evidence of poor treatment and malpractice, again with attempts made to hide it. The impression that I am getting is that some people working in the healthcare sector are more interested in IMAGE than in actual patient care. Put simply, they want to present the impression that all is well, when actually it isn’t – any evidence to show that there may be problems is routinely overlooked, ignored, destroyed, hidden, or otherwise made unavailable. Any staff (whistleblowers) who try to point out failings, flaws or potential problems are subjected to bullying and harassment, or forced resignation, and possibly even dismissal.
This is NOT how it should be. How can anyone learn from mistakes, improve, and prevent future flaws if they are routinely covered-up? If there is a culture of secrecy encouraged, in which people are not permitted to speak out? If a false image of perfection is maintained at the expense of the truth? If dishonest, manipulative, uncaring staff are promoted over and above caring, empathic ones?
Last night (15/12), I watched a TV programme about PSYCHOPATHS and the problems that they cause within the workforce. Ironically, this programme strikes a chord with what I am reading here. It appears that our employment culture (including that within the healthcare professions) is becoming more “hard nosed”; we are becoming excessively focussed on statistics, image, profits, cost cutting… We promote people who have a bombastic, self-aggrandizing attitude towards work; the sort of people who rarely see the human side of a job, they merely see profits and loss. This does NOT work in healthcare. Here, we need people (from those at the very bottom right up to senior management) who have experience of working hands on with patients, who are truly caring, sympathetic, supportive, empathic. People who see the very HUMAN aspect of working in healthcare – people who treat patients as humans, not as statistics. People who genuinely view the health and wellbeing of patients as their highest priority, rather than merely paying lipservice to this.
We have got it so badly wrong. HOW did this come about? Maybe we should be asking those uncomfortable questions… questions that may reveal the true nature of the problems that the healthcare professions face… questions such as…
WHY are all the scandals and cover-ups occurring?
WHO is covering them up, and WHY?
HOW did the staff that caused the problems come to be working there in the first place?
ARE we employing the right people, and encouraging the right values?
WHY are the general public not told the truth?
SHOULD we view these scandals as evidence that patients and their rights are being devalued?
IS the failure to investigate the deaths or maltreatment of patients who are elderly, mentally ill, or learning disabled evidence of prejudice against these groups of people?
ARE some workers within the NHS and Social Services prejudiced (a.g. against elderly people, or people with learning disabilities and mental illnesses)?
DO we need to screen all potential staff for prejudicial ideation?
IS there a need for improved training of all staff to stop problems happening?
SHOULD all healthcare managers be made to join a registration body that can police their behaviour?
HOW do we weed out bad managers, because in these scandals, the rot often starts at the top?
Southern Health will be an ideal case study in Crisis Management – how not to do it!
See latest blog post at https://999crash.wordpress.com/blog/