Dear Moon,

Out of people to write to so thought I’d try the moon. Or a moon. Any moon really. Full or otherwise.

Jezza Hunt, the Secretary of State today made a speech about patient safety.  He starts with ‘intelligent transparency’. Word rubbish. ‘Intelligence’ doesn’t mean anything other than fake measures of fake, plumped up fakery. LB scored below zero on ‘intelligence tests’ but beat the pants of most of us for getting stuff. For just being. But ‘intelligence’ carries weight. It’s a sought after marker of summat. 

‘Intelligent transparency’ leads to action he tells us. And then goes on to explain how it doesn’t. [I know, just try to hang in there if you can…]  Each NHS trust in England has been asked to self report their annual number of avoidable deaths. Yes. Self report. Mark your own homework. I think we can anticipate a chunky zero from at least one trust not 100 miles from here. And, even more absurd… the way in which each trust does this marking varies so there is no ‘national standard’. Across the, er, National Health Service.

Some may use an abacus. Some may use a mix of patient and local roadkill intelligence. Some may use quantitative or qualitative methods. Some may just count how many toenails they can ping into the bin in the corner of their office from their swivel chair. It simply doesn’t matter. It’s action. That comes from intelligent transparency.

What matters is that trusts are, at last, estimating avoidable deaths and being open about it. 

There are a few Mikes involved in this new process. Richards and Durkin. A coming together of the Care Quality Commission and NHS England. Richdurk. An integral part of  making the NHS the world’s largest learning organisation. [You gotta read some of this stuff for yourself, Moon. Sorry. There are sections that are so full of bullshit I can’t precis them…]

Picking up the speech from ‘A true learning culture must come from the heart … ‘ [not the tagline for a new Sunday night BBC drama but the actual words of the Secretary of State]. He talks about the suffering band of rellies who have cried out to him in frustration about the lack of accountability. Blimey. What a patronising and demeaning load of guff.

And he includes us in this shite with mention of Sloven. That painfully, awkward, 30 minute ‘meeting’ in the same (not safe) space as him allows him to nail us to his suffering family mast. We were forced to listen to him indignantly spout his human factor speak while he completely ignored our concerns that learning disabled people are being effectively erased. 

[Families should be given a public health warning after experiencing the catastrophic death of a family member in an NHS setting. Alerting them to this parasitic leeching by public representatives who should actually be doing stuff. Instead of feathering their nests. And furthering their cult like causes.]

Turns out our attempts to get some sort of accountability for LB’s death is misguided. Bad mistakes can be made by good people and a ‘proper study of environment and systems in which mistakes happen’ is needed.  And when patients are given an honest account of what happened alongside an apology, the impact is less litigation, lawyers and more rapid closure ‘even when there have been the most terrible tragedies’. 

My arse.

The JezzRichDurkBromTit* version of human factors feeding into the new HSIB (Health Safety Investigation Branch) is simply absurd:

Affected patients or their families will need to be involved as part of the safe space protection. And while the findings of investigations will be made public, the details will not be disclosable without a court order or an overriding public interest, with courts being required to take note of the impact on safety of any disclosures they order. This legal change will help start a new era of openness in the NHS’s response to tragic mistakes: families will get the full truth faster; doctors will get support and protection to speak out; and the NHS as a whole will become much better at learning when things go wrong. What patients and families who suffer want more than anything is a guarantee that no-one else will have to re-live their agony. This new legal protection will help us promise them ‘never again’.

Er, sorry Jez, you made a bit of a leap there. Families want accountability. In the same way they want accountability when someone dies outside of the ‘safe space’ of the NHS. And how can you talk about a new era of openness in the same paragraph as court orders? Just barmy. Oh, and HSIB will only look at 30 deaths a year. And Jezza has decreed these will be in maternity services.

Intelligent transparency anyone?

Just boys and their toys.

*Hunt, Richards, Durkin, Bromily, Titcombe