A few weeks ago, we found out someone sent an anonymous letter to the Sloven CEO in 2011 flagging up health and safety concerns. Katrina Percy was, of course, totally oblivious. An independent Health and Safety consultant, Mike Holder, was appointed to troubleshoot. Two months later, he handed in his notice. Sloven were not prepared to listen or act.
Holder has shared the relevant documents and his leaving report with the Care Quality Commission (CQC), the Health and Safety Executive and Hampshire MPs, Suella Fernandes and Kit Malthouse. I caught up with some of this paperwork this evening. A couple of things leap out (outside of Holder’s meticulous detailing of the myriad ways Sloven were breaking Health and Safety legislation). These relate to ligature risks.
Holder shared this diagram showing the increase in ligature incidents over four years with the Interim Director of Nursing and AHP (dunno what AHP stands for) in Feb 2012.
Her reply is enough to make hair follicles seal up:
Holder’s reply. Challenging the nonsensical with sense and clarity:
Rich and I chatted about this earlier. He was reminded of this quote from Clifford Geertz, a classic anthropologist:
I have never been impressed by the argument that as complete objectivity is impossible… one might as well let one’s sentiments run loose. As Robert Solow has remarked, that is like saying as a perfectly aseptic environment is impossible, one might as well conduct surgery in a sewer.
Sloven clearly and consistently embrace the sewer approach with an abandon and a carelessness that is sickening. [There was another report today about the death of another patient/Sloven failings. Lesley Stevens, who seems to have a full time job attending inquests, was again bleating about ‘changes’.]
Changes my arse.
Dipping back to Feb 2012, the second, related point, is around action plans and (non) actions. Someone working with Holder emailed him with serious concerns around ligature risks. The assessor was concerned that either the risk scoring was inaccurate or signalled a general lack of understanding about how to complete ligature risk assessments. Both were deeply worrying. He concludes:
Finally there are action plans in each of the assessments which list all the points where actions are required; there appears to be no record of any actions being completed. This raises the question as to whether the actions have been completed at all, and the assessments not updated to reflect that, or whether the actions are still outstanding.
The same old, same old shite. Across four years now. Documented and shared with the senior management team. Who ignore it.
Given that Holder’s appointment came about because of an anonymous letter raising safety issues, you’d think his resignation and the various health and safety breaches he identified in a couple of months, would be taken seriously. But no. It was business as usual. Six months later, in August 2012, a quality review, detailing shocking failings at the unit where LB died, was similarly ignored. [Howl]
Fast forward to April 2016, whipping past numerous failed CQC inspections, numerous deaths, inquests and Prevention of Future Deaths reports. Past the publication of the Mazars review… to which Sloven, four years after the above discussion about ligature risk, applied the same baseline stats (non) defence. The latest CQC inspection report will be published later this week. The Sloven senior team are, by all accounts, mounting their schmooze counter-attack. There isn’t a reflexive bone in their collective body that allows them to think, hang on a minute… We’ve really ballsed up here. Repeatedly. Patients have died. Repeatedly. And we clearly can’t do what is needed to improve the services we provide…
Nah. Nothing like it.
This CQC inspection was part of Jezza Hunt’s response to the Mazars review. It was the necessary first step before the CQC and NHS Improvement decide on any regulatory action. [I know]. Given the inspection identified failures generating warning notices a week or so ago. Given everything that has gone before. Given everything. There cannot be any more propping up of this toxic senior management shower. Surely.