' We particularly welcome the section dealing with involving families and carers which requires contact to be initiated by the Clinical Director, and ensure " appropriate mechanisms will be established to enable the families and carers to contribute to the internal review where appropriate and take into account their needs and wishes ... and meet with the review chair " .. subsequently. The Inquiry had examined the local procedure for serious and untoward incident ( SUI ) Review
Frequently long delays ;
Conduct at the meetings inadequate at a number of levels ;
Reports frequently late or not at all; they were not appropriately distributed.
The constitution of the review meetings was not best designed to achieve a critical evaluation of the care given.
Apart from the Trust chair no one present was independent of responsibility for care delivery in the instant case
.... in particular no-one present was qualified to give a qualitative judgement of the standards of care given or of the clinical management with any degree of independence.
The process could have been considerably improved by involving senior nurses and clinicians - who had not been involved in the case - to evaluate the actions of their colleagues. Records were used to provide a factual basis for a chronology, and were not used to test or verify the assertions contained in statements. There was no evidence of discussion of good practice guidance standards or protocols or consideration of service delivery against any external or format internal standards.
These deficits could have arisen from a misperception of the purpose of internal review. Some reports are little more than a summary report of involvement. In others there is also some recorded discussion and recommendations.
In most of these cases the question posed seems to have been "How do we feel about what happened, are we likely to be criticised?" - rather than: "What happened, was there anything we could have done better?"
In many of the reports there is a tone of exoneration in recording the discussion that took place.
In very few of the reports, is the reaction of the family or any contact with them to inform or counsel them about the incident mentioned. It is appropriate to discuss such things as the need for staff support, or how staff feel about the process of review, within the review process. However in some of these reports this type of discussion, and recommendations concerning it, is disproportionate to the discussion of care issues. As demonstrated in the appended spreadsheet, in the reports as a whole - eleven recommendations were made relating to process, against twenty-four for services
In some cases only process recommendations were made and this was inappropriate given the seriousness of some of the care issues in those cases.The process falls short of the standard set out...in not
moving from iformed investigation, through the receipt and testing of evidence against received standards to conclusions of fact, and so to recommendations derived fromthose conclusions.
......
Is it coincidental that in these (two) cases, where this external panel found much to crticise in the care given to the patients the review reports are some of the weakest ?
... in both cases it could be argued that trepidation over external scrutiny appears to have led the Trust to avoid conducting a robust internal review.
Here from the External Inquiry Report are some comments on pre-discharge practice
- on the local delivery of the Care Programme Approach.
... about integrating care management (LASS) with Care Programe Approach (Health)
... Both this External Inquiry and that of the Social Inspectorate in 2001 found that social work files usually contained little or no social history, even where the files went back many years - unless there was specific requirement e.g. a Tribunal appeal
Indeed, the Inqiry found ....that the reports for serious incident reviews often contained more background information than had been available prior to the pateint/client death.
This deficiency compounded the repeated failures of the in-patient staff to obtain or collate historical information.
Family Involvement
.... We did share ( with family members who attended the Inquiry ) real concerns in the following areas:-
.... the extent to which families were asked to contribute history and circumstances to care planning
the involvement of families in planning for leave and discharge of vulnerable patients
... families were not involved in reviews and discussions of the care of their deceased relative.
A general comment could be made here about the role of those responsible for defending the actions of a public body. Public bodies are given their duties under statute. Their first duty is to discharge the statute, defending themselves for any perceived shortcomings in performance is wholly subsidiary to that end. Health Trusts accordingly should first strive to give care to the best of their ability, and where problems arise their duty is to investigate, acknowledge and improve in order to fulfil their statutory duty to attend to other patients. Defensive conduct that minimises or evades the full examination of such incidents in whatever forum through a desire to protect the Trust is likely to be in open conflict with that primary duty of continuing care.
This is the distinguishing factor between the public and private sector, which justifies the continuation of public trust. It is the foundation of public accountability.
An Organisation with a Memory identified fear of retribution as a potential barrier to local reporting by staff of adverse events, and spoke of the need to develop a btame-free culture to promote non-punitive local reporting of adverse events.
Building a safer NHS for patients described the barrier that needs to be overcome as
.... fear of point-scoring by colleagues, retribution by line management, disciplinary action or litigation. These are cultural factors.
That report identified a need to provide NHS staff with the skills required to identify, gather information on, record and report events and near misses, undertake formal root analysis.
( p97 )
.... The Health response ..... ' assures the Coroner that action is in hand to respond to his concerns but
gives no detail' .
This level of expression of concern is in itself unusual, and we would have expected to be shown, and did not see at the Trust, files of correspondence, further reviews and action plans responding to the Coroner's concerns in each of those cases.
The comparison of internal review reports and Inquest material led to the following further conclusions:-
Factual findings reached at internal reviews were sometimes inaccurate
Hard facts facilitate hard conclusions.
In particular material available to the Inquest to evidence state of mind was not considered at review, so comforting but inaccurate interpretations were perpetuate.
The public interest in establishing the circumstances of death of a person in receipt of mental health services, as expressed through the work of the Coroner's office and the review process of a health provider, proceeds from different directions and has different emphases in each forum.
The facts of each case though are common, much of the evidence used in each process is or should be common, the aim of each agency in broad terms should overtap- an open attempt to expose the facts.
Each agency should make every effort by sharing information actively and openly, and by incorporating each other's findings into their processes, to ensure that accurate conclusions are arrived at and messages are not lost.
There is no evidence that the Trust recognised the Coroner's office as such a source of information to inform its own review, or considered how it could actively assist as opposed to respond ( and then sometimes in a limited and defensive fashion ) to the enquiries of the Coroner.
In some cases the Coroner exercised his power to bring to the Trust's attention matters that had caused him concern. We did not see evidence that the board discussed these formally. It would seem essential that such important, matters should be dealt with within the serious incident review policy for possible inclusion in action plans.
The public interest in establishing the circumstances of death of a person in receipt of mental health services, as expressed through the work of the Coroner's office and the review process of a health provider, proceeds from different directions and has different emphases in each forum. The facts of each case though are common, much of the evidence used in each process is or should be common, the aim of each agency in broad terms should overtap- an open attempt to expose the facts. Each agency should make every effort by sharing information actively and openly, and by incorporating each other's findings into their processes, to ensure that accurate conclusions are arrived at and messages are not lost.
There is no evidence that the Trust recognised the Coroner's office as such a source of information to inform its own review, or considered how it could actively assist as opposed to respond (and then sometimes in a limited and defensive fashion) to the enquiries of the Coroner.
In some cases the Coroner exercised his power to bring to the Trust's attention matters that had caused him concern. We did not see evidence that the Trust Board discussed these formally. It would seem essential that such important, matters should be dealt with within the serious incident review policy for possible inclusion in action plans.
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