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.