Report finalisation and the National Death Service

While writing about Devon days, life, loss and inhumanity yesterday evening, I received this email from NHS England:

Report finalisation:

Following a series of comments regarding the accuracy of methods of reporting to national NHS incident reporting systems, as set out in the Mazars report, Mazars have made some further amendments to their report.
We have been working towards a date of publication w/c 7th December. However, this is now not possible. There is a meeting being scheduled for the 11th December, with Mazars and NHS England national team to agree publication date and process.
This will include the planning for support for families, who may seek information post publication.
ERG will be sent final report ahead of publication, together with the communication handling plan.
Kind regards


ERG stands for Expert Reference Group.
WTAF stands for What the Actual Fuck?

Er, why has the publication date, process and planning support for families not been organised before now? How can further delay possibly be necessary? The report content was known in the summer. The full version circulated at the beginning of September. Why is a meeting with Mazars necessary to arrange publication date? They were commissioned to write a report. They’ve written it. It’s up to NHS England to decide on a publication date.

NHS England who fell over themselves to publish the (crap) Verita 2 report they also commissioned six weeks ago now. With no scrutiny.  They have pored over the Mazars review with microscopic intensity. Prevaricating, posturing, ignoring the significance of what this report represents and the right of the public to know. To know that our national health service has acted as a national death service for a group of people. In full view.

Scandalous, harrowing. Unforgivable. Sloven may have rushed to buff up their dire practice with a shedful of new processes but the delay in publication allows similar practice in other Trusts to go unchecked. For the deaths to continue. Extraordinary.

The problem is, I think, that these lives (and deaths) are not considered worthy enough for the magnitude of the scandal the Mazars review reveals. Does that make sense? Learning disabled people can’t be allowed to disrupt the complacency of NHS England, Sloven or the CQC. It’s almost an embarrassment. Particularly after the Winterbourne View faux activity. And talk of transforming care. All that handwringing, those national programmes, endless meetings, croissants, and fuck knows how much time, money and the like. While an NHS Trust quietly went about its business burying all the bodies.

I wrote yesterday about not knowing how I would ever get out of bed on Sunday after remembering what life used to be like. Today I’m supposed to go to a meeting in London. But I can’t get out of bed.

I feel ill.

26 thoughts on “Report finalisation and the National Death Service

  1. Nothing adequate I can say really but I’m trying to thought transfer you some strength to keep going. And remember how proud LB would be of your pursuit of justice. I think your other kids are pretty proud of you too.xx

  2. deeply moved first and incredibly angry second. My anger is all consuming at the moment and I want to scream in their faces.

  3. Angry for you/with you – really wonder how this behaviour in a healthcare system can be allowed..why does nobody (and it really sounds like nobody) in this whole panorama not think about the people who are affected by this outrageous bureaucracy let alone the constant pushing/shoving/itching/poking/trampling over your grieving…x

  4. Very sad if unsurprising but this is the Trust that supplied misleading information to MIND in a freedom of information request. The Trust appears to understate figures for complaints about restraint by the simple expedience of not reading the complaints file! They just rely on someone putting individual complaints (which often include multiple heads of complaint) into a specific category. This was only exposed three days ago: see the letter to MIND and revised figures at:

    In practice (and this is an actual example), a complaint of detention without lawful justification involving inter alia forcible restraint and bodily harm of a patient who has had a epileptic-type seizure and a suspected stroke – all without a risk assessment – is not categorised as a complaint about restraint. And this happened well before Connor’s preventable death.

    NHS England does not surprise me either: its Chief Executive’s Office is known to have lost a letter from a patient of the same Trust (how’s that for security of sensitive personal medical data) and its Chief Executive failed to respond at all on receipt of a copy – or perhaps he lost the copy too!

  5. Has anyone checked for any conflicts of interest that might be delaying publication of the Mazars review?

    Dr Martyn Diaper, NHS England’s Head of Patient Safety (Primary Care) and the chairman of the Primary Care Patient Safety Expert Group at NHS England was, until the end of 2014, Medical Director (Quality) for Southern Health NHS Foundation Trust, working for NHS Improving Quality as clinical lead for patient safety. This is in the public domain at:

    Dr Diaper’s efficacy in his other role at Southern Health NHS Foundation Trust (Caldicott Guardian) has been questioned too.

    I wonder if the Mazars report makes any criticism of his work at the Trust, especially as he was, “Clinical lead for patient safety”?

  6. Sadly, a family who I’ve known all my life, will probably find out via mazzars report that their daughter died as a result of neglect to her physical health, by the inpatient unit that had become her home.
    The family think that she was just unlucky to get a bad chest infection that developed in to pneumonia, complicated by other health issues, including COPD, schizophrenia and possible LD
    I was pretty sure that the general attitude of staff, and ‘persons rights’ not to take care of themselves [!] was a significant factor in her death in her 40s.
    The family loved her, but were unable to keep contact with her due to her illness and staff protecting her right to no contact.
    I’m not sure if she really wanted no family contact, or if she was just saying that, because of the way staff asked her.
    She did not remember me, so when our paths crossed over the years as a fellow patient, I did not disclose the fact that I did know her.
    As this family are about to have a second Christmas without her, this report (if disclosed to them) will be devastating beyond anything I can imagine.

    • Happened yesterday so definitely not included, also hopefully the person will make a recovery as they are currently in Southampton General hospital.

  7. I don’t have anything adequate to say either, other than that I’m so sorry.n:(

    There doesn’t seem to be any way to stop this inhuman behaviour. 😦

  8. TQ is absolutely right: apologies. It looks like similar serious incidents have occurred twice in one year at Melbury Lodge – the first is at:
    – only the first patient died. One incident like this is slovenly – two may be negligent. I assumed from the posting that it must be the same case – even the photo’ looks similar.
    Mazars knew about Carl Lewis; they will know shortly of the second case.

  9. Oh Sara, I felt like crying for you when I read this. It must by now be plain and obvious to all (including Sloven) that the report is so damning, Sloven are attempting to polish a turd before the report is (finally) released. Sending you digital hugs my darling X X

  10. Sara the image of you not wanting to get out of bed and not wanting to face a another day without Connor is pitiful. The thought that even as you live the nightmare there is still the added dread of waiting for the Mazars report and the possibility that Sloven are still willing to hurt you. Still want to drag out the agony. What utter bastards they are.

    I know the feeling of not wanting to get out of bed in the morning. The not wantiing to go to bed until exhausted because of the fear that your thoughts will not let you sleep. My son is still alive but living a life with no quality. Living in crisis respite because he has become so unwell that we cannot manage him at home. The staff are kind but he has lost so much of his independence that he is just sitting in his wheelchair most of his days. Drugged on SSRI’s which has caused him to have three major seizures. I feel like I have abandoned him and these feelings are so intense that I am crying while I write this. I long like you to have the days back when he was walking talking and happy.

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  12. The lead director at Mazars is on holiday until 11 December but we cannot blame her for taking leave – she probably booked it in full expectation that the report would be published well before now anyway. However, I am sure NHS England and the Trust would not have hesitated to take advantage of her absence to cause further delay.

    May I may a prediction? The Mazars review will be published on the very day that senior officials at NHS England and the Trust go on leave for the festive season so that they are not available to take the flak from the families and the media. They will be lining up respectively ‘Counsellors’ and spin doctors for this purpose.

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