First, if you can bear to read this section from our local Clinical Commissioning Group’s Quality and Performance Report, dated 25.7.13 (available online/names removed – although not sure why I’ve removed them). It refers to the unit LB was in.
In the non-acute sector
i. Trust A
There are concerns about the safety culture and quality of patient care in specialist inpatient ‘Assessment and Treatment’ services for people with a learning disability and mental health issues.
Since 2011 there have been concerns about the way in which serious incidents requiring investigation (SIRIs) have been investigated by the [Old] Trust. The concerns were around the organisational response to incidents and specifically that they appeared to suggest the lack of a robust safety culture within the organisation.
It was hoped that when the [Old] Trust was acquired by Trust A that concerns would be addressed. However [X]CCG and [X]CC have not been sufficiently assured that the required change has taken place. Currently [X] county are not placing patients in one Trust A Assessment and Treatment Service and there are conditions in place around placing patients in a second service of this type.
Many of the SIRIs [Serious incident reviews] involve the use of physical restraint. This is a high risk area which requires a clear organisational approach, strong leadership and close supervision. At CCG’s request [X]CC has issued a performance notice to Trust A around the management of physical restraint. The notice requires that the trust develops and implements a code of practice for restriction and restraint.
XCCG and XCC have been working with Trust A and continue to do so. XCCG continues to monitor Trust X SIRIs in services used by X county patients closely.
A few thoughts. I’ll keep them brief.
- How could significant concerns around a specialist service for vulnerable people drag on since 2011?
- Why are these concerns not common knowledge? We would never have let LB be admitted to the unit if they were.
- He was restrained at length in the unit even though this unnecessary practice was known to be an issue within this service, by the CCG/CC. An 18 year old pup. Heartbreaking.
- By the time this meeting was held in July, the CCG must have known about LB’s death and yet they drivel on about ‘continuing to work with the Trust’ and monitor services. Boredom, disinterest and non-action palpable.
- The CCG raise concerns about the ability of the Trust to respond effectively to ‘incidences’ and yet the Trust are still able to ‘mark their own homework’ through conducting the internal review into LBs death.
How could any of this happen? Be happening?
So. For the record.
- We have no confidence that the Trust will carry out an effective internal review.
- And we have no confidence in the County Council or CCG to do anything to improve the lot of learning disabled people.
Our son lost his life through what are obviously longstanding and ongoing, shabby, careless and stagnant practices within a state-run organisation. In “specialist” services that are supposed to provide ‘care’ to one of the most vulnerable (and my brain screams to have to keep stating this, because I despise the term so much) groups in our society.
Once again. Is anyone in health or social care with any power going to do anything about this?
Oh, and if anyone knows Ann Clwyd, MP, could you bounce this to her?