Shiny new policies, ducks and ‘learning lessons’

The ‘learning lessons’ tripe regularly spouted by NHS Trust representatives in the wake of a negative report, inquest or otherwise (typically not in response to the harm caused to a person and their families) really naffs me off. We learn all the time. LB’s death wasn’t a ‘lesson’ to be learned from. He shouldn’t have died. Simple as. A point brilliantly made by AnneMarie Cunningham yesterday in a talk to a group of psychiatrists. To use ‘lessons learned’ in this context trivialises and further dehumanises LB (and everyone else who has died or experienced serious harm). Particularly when crap all is actually learned.

After the first review into LB’s death (Verita 1) was published, back in the day it made several recommendations around epilepsy care. 18 months later, during LB’s inquest, it was clear that Sloven staff members giving evidence had learned little about epilepsy. This didn’t stop Sloven’s Medical Director talking the talk about shiny new epilepsy policies and toolkits at the end of two weeks of harrowing evidence.

Similarly, when Sloven (eventually) realised that they were in a teensy bit of trouble around their response to deaths in their learning disability/mental health provision (a good 16 months after they knew an independent investigation was commissioned by NHS England), they started talking the talk about their mortality policies and processes. The Sept and Oct 2015 board papers include 65 and 70 mentions of SIRIs (Serious Investigations Requiring Investigation) and mortality respectively. There were 8 mentions in the June and July papers.

Wow. That’s good. They are taking the Mazars review seriously,’ you may be thinking.

Mmm. They are clearly taking it seriously. But I suspect the it is an unprecedented threat to their reputation. Evidenced by remarkable challenges to the content/publication of this review which remains under wraps somewhere in NHS England. If Sloven can’t bury or somehow influence the review, they will want to line their ducks up to try to distract attention from the brutality of their practice up to now.

Various changes – a central investigation team will now oversee investigation and learning, training and implementation of a new electronic investigation system continues, 50 investigators attended a 2 day investigation training course in November, so on and so on – must be in place and operational by the time the shit hits the fan. [On my more cynical days I can’t help thinking this delay is enabling these ducks to be better placed for buffing and final shiny distraction attempts. Easing the inevitable discomfort felt by pretty much every organisation involved in this scandalous and inhumane tale].

But hey ho. Sloven remain all talk and little real action. The December Board papers record that an inquest into a patient who used their mental health services was adjourned on Nov 11th until January 26th 2016. The quality of the SIRI reports provided by Sloven and Hampshire County Council were [still] not good enough. Another family facing the torture of further delay – across Christmas – caused by Sloven (and local authority) disregard and carelessness.

Their shiny new focus on SIRIs, candour and involving families can be tossed in the nearest skip. It doesn’t translate into action and they don’t give a shit about what really matters.


7 thoughts on “Shiny new policies, ducks and ‘learning lessons’

  1. I don’t know how you carry on Sara. Rather than ‘lessons learned’ by adult institutions, it seems like some young children’s responses to what they have done -it wasn’t me – it was him- I didn’t mean it-I won’t do it again. But who are the ‘parents’ Of these trusts who can set them back on track?

  2. It is physically painful to read this stuff. I cringe so hard, my muscles burn, looking at descriptions of yet more shite gushing out of Sloven’s seemingly endless fount of sewage.

    I see the Sloves’ new chairman is joining in with KP’s game of sending second-hand apologies via PR channels and pushing for a face-to-face meeting with you before he’ll issue a direct apology. Kudos to My Life My Choice for slapping him with the bleedin’ obvious and asking “Why don’t you write?”; and for spotting the evasions and asking the follow-up questions.

    But the thought of yet another family suffering right now because of their crass ineptitude… just sickening.

  3. The Trust’s current Medical Director has known of ‘learning opportunities’ relating to epileptic-type seizures and risk assessment since 2012 – the patient survived. She knew of risk assessment failings again in the case of Nico Reed in 2013 and again when the Verita 1 was published. Yet at the Inquest, still it is claimed that Trust members giving evidence had learned little about epilepsy.

    Most disturbingly, the Medical Director allegedly told LB’s inquest that she did not know where the buck stops!!! That says it all – when will she resign?

    I would not give up on the new Chairman yet. Why not try meeting him off-site (on his own) to give him a chance? There appears to be nothing to lose and, who knows, you may be surprised – though no guarantees.


    ‘Learning opportunity’ – means we have made a mistake but do not want to admit just how serious it was.

    ‘Lessons learned’ – an oxymoron – lessons have not been learned until there is evidence that they have been learned: until then they remain a learning obligation (not an opportunity).

    Keep up the good fight!

  4. I had a conversation with a GP last week. He said ‘do you know it is rare for me to see an adult with a learning disability in the surgery these days, unless brought by their parent.
    I explained that lack of support to get to surgery for minor illnesses and health checks may mean his surgery is by passed when individual is admitted to hospital as an emergency. He agreed. But what can he do he said, he is in danger of drowning from the demand for his care.

    People who have lived safely in the community with support that with their support removed or reduced to below dangerous levels, are being threatened with residential – ‘institutional ‘ care, such has been their deterioration, suffering from ‘self’ inflicted neglect and or having become seriously ill; they failed to try hard enough to re-able themselves.
    But ‘Loads a’ new business for all the Sloven’s etc?

  5. the terrible terrible learning, the awful graphs learning up, harm down. The lame assurance of an action plan by the trust ( they must promise to evidence it to the ombudsman because someone is going to check that the tens of thousands of pounds of taxpayer’s money for the investigation helped point that arrow north ) in the certain knowledge there is/was relevant guidance and protocol a plenty just no one adhered to it.

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