Been a bit quiet on here as I concentrate on bashing out my book evenings and weekends. I’m trying not to get too angry as I’m determined to produce a good read (the intense rage is in temporary abeyance). Sadly, the 5.30ish-9pm space I plotted tonight, as I lit the fire and made sure there were some cans of Heineken in the fridge, was blown out of the water by the latest in the (almost farcical but sadly not funny) shit stream blown out of the backside of a Jeremy Hunt, NHS Improvement and CQC combo.
Yesterday, the Expert Reference Group (ERG) for the CQC Deaths Review (published in December) met to look at how the recommendations of the report are being implemented. Rich and I had concerns about this review (reinforced by the final report) but there’s always space for action. Except for when there ain’t, as it transpired. For some reason, a new set of Department of Health bods (clearly in Jeremy Hunt’s human factor crusader back pocket) are now taking the lead and acting on recommendations. Family involvement? You might as well whistle down the wind.
Today, we were sent a cheeky copy of a letter sent to trusts from the CQC and NHS Improvement, detailing changes to be implemented as an outcome of the death review. A letter not shared with the ERG yesterday or any of the families who wasted valuable time and emotion contributing to the review.
The full letter can be read here: 17022204-learning-from-deaths.
There is so much wrong with it, I can’t be arsed to identify the Eddie Stobart lorry size holes throughout. There are patches of ‘if only…’ or ‘almost hitting the mark’ but the unnecessarily tentative, non-mandatory, half arsed and convoluted statements obliterate them. The letter is almost unreadable in ‘sense’ terms because of the contortions the authors have gone through to remove any hint of wrong doing, failure, negligence, from it.
Just one early paragraph:
Erasing the humanity of patients and presenting their deaths as teaching tools is about as offensive as you can get in my book, particularly when it’s dressed up in such benign terms as ‘the care provided’. Sloven, ironically, excelled at the teaching tool shite three years ago with a training powerpoint that, as far as we know, is still available on their intranet. Our request for confirmation that it has been removed, ignored.
When I think about Sloven’s attempts to not disclose records or publish reports which they dressed up as protecting LB’s ‘confidentiality’ after his death, and look at this powerpoint, another part of me dies. That no one, who should, has done anything about this, makes that rage bounce right back from the abeyance pen… Could you please do something about this?
Someone must be responsible???
Meanwhile, the national Learning from Deaths conference mentioned a couple of times in the letter is arranged for March 21. Leaving ‘open, transparent and collaborative’ at the invite only door:
Nearly four years on, we’re left with:
- Dead patients treated as teaching fodder in a human/Hunt factor health world.
- Families ignored, other than in particular, staged and performative (that is, fake) spaces.
- No change in the lives (or premature deaths) of learning disabled people.
It was my dad’s 80th birthday this week and we had a big old lunch on Sunday with family and my parents’ friends of 60 or so years. The swearing and the anger I often express on this blog cropped up chatting with one of his mates. I’m sorry Sid, it wasn’t clear whether (or how much) you disapprove of the swearing (and I completely appreciate and love this ambiguity) but this bunch of fuckingcuntstainwankdrops are clearly incapable of implementing effective change. It couldn’t be clearer.
Wow. The long word you used really is descriptive.
It’s a shameless society right now – I think we’re going through a dip in morality. That’s why no one’s answering or being responsible.
Your anger’s a natural reaction.
Good luck with your book.
Instead of the distancing phrase ‘learning from deaths’ they should be saying ‘preventing future deaths’ or ‘making sure the same thing doesn’t happen to another patient’.
And for families ‘appropriate engagement processes ‘ could mean anything. No action needed there then.
Where are the words ‘preventable’ and ‘ avoidable’ in this letter? I feel it has been written from a point far away from the patients and families affected, who have been reduced to statistics in quality control. It’s all too comfortable and soothing for trusts.
“Fuckingcuntstainwankdrops”: finally we have a collective noun for NHS managers.
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