“Ensure the toilet door in the section 136 suite at Antelope house is replaced quickly”

Earlier this week, Rich was out and I was home alone. The growing condiment pile felt right and a deep late Autumn sunset beckoned. I grabbed my camera and headed to South Park. I bumped into a few people I knew walking down there. Brief, warm and casual catch ups. Heading off between each with an eye on the sun. Despite knowing from a newly discovered nerdy site sunset was at 6.52pm.

Across the park there were smatterings of students/freshers, young people and others. Being or pounding across the park in serious running strides, sitting, walking, talking, laughing and playing games. Loosely shared eye and phone action on the slowly setting sun.

I dipped down to dandelion level while waiting.

It was quiet and spectacularly beautiful.

Walking home [after the reported 6.52 sunset and 30 minute twilight window] I felt peaceful.

The next day my phone rang. The latest Care Quality Commission inspection of Southern Health (Sloven) was embargoed until Friday. Ah. Ok… Sloven. A Trust with an astonishingly grim back drawer full of failing CQC inspections. A Health Services Journal award winning CEO (2011 from memory) who doshed a mate millions before disappearing with a £250k pay off back in 2016.

Yep.

All that still trips off my ‘you effectively killed my beautiful, beyond loved son’ tongue. And it will continue to do so until I really understand why.

Back in March we naively thought the outcome of the Health and Safety Executive criminal prosecution and £2m fine was a seminal moment in NHS history. A shot across the bow of all Trusts. A judge pulling no punches in his ruling. Generating critical scrutiny across the health and social care provision of this crapshite trust and wider. Good care, ligature points, care plans, medication storage, staff supervision and so much more sorted. These are basics after all.

Reading this latest report generated yet more tears and distress. How low can you continue to go in providing ‘health’ and ‘social care’.

The inspection in June 18 generated a warning notice around the safety of young people in a Southampton based unit. A warning notice around safety.

Five years after our son drowned. [He drowned]

And so many others have died.

The Sloven exec board are still stretching out their entitled legs. Apparently kicking any whiff of a negative inspection report into the long grass. No determination, commitment or even interest in trying to own these continued failings.

Reminding me of those early, baking hot July days. Almost five years to the day swatting away the CQC inspection like they did with LB’s death. [He died]

There were 20 breaches of legal requirements that the trust must put right. We found 74 things that the trust should improve to comply with a minor breach that did not justify regulatory action, to prevent breaching a legal requirement, or to improve service quality

We issued seven requirement notices to the trust. Our action related to breaches of 21 regulations in seven core services.

I dunno. Reading it I jotted so many notes. Bashing on the keyboard. Scratching furious fucking pen to paper. So much so wrong. Still. Beyond wrong.

The trust had not completed the anti-ligature work at Leigh House (identified as needed in previous CQC inspections) which posed a significant risk to young people and was not being adequately mitigated against.

Governance systems did not always provide robust assurance to the trust board about issues within services. For example, we found the board were not cited on staffing issues in some services, low levels of staff supervision, poor compliance with care planning and an inability to provide accurate restraint data. 

And more:

Poorly written and stored care plans; no patient involvement in or knowledge of care plans; poor note keeping; not following the MHA; lack of staff supervision; inappropriate medication management and storage; risks to young people in MH services; lack of hygiene and broken equipment; issues around privacy and gender; safeguarding issues; ward temperature issues; lack of competence in syringe driver training.

The same old and more. Five years on.

Lives tossed out like rubbish. With no consideration. Reputation ruling the roost still..

This sentence strangely leapt out, from the 54 page report.

Ensure the toilet door in the section 136 suite at Antelope house is replaced quickly.

Sort the toilet door. It only takes a few fucking hours.

Hancock’s half hour and condiments

Been kind of distracted by a focus on condiments this week in our newly, unexpectedly empty home. A tweet about condiment gathering earlier generated a cracking list of missing flavours and textures. Thank you.

Meanwhile, Matt Hancock, Secretary of State for summat and summat gave his first patient safety talk earlier today. It took months for the Department of Health/NHS England to comment on the findings of the #leder review. They were, however, able to publish the text of this talk immediately. Kind of extraordinary really.
Without wanting to give any spoilers, it’s seriously shite. (Comments in bold.)

Thanks for having me today.

Anyone who has had family members needing care knows what it feels like to sit and wonder whether or not someone you love is going to be OK. You take it for granted that the care you receive will be safe, but sadly we know that’s not always the case.

Crumbs. Bit all over the place here. This is the guy who called health professionals ‘carers’ the other day mind.

Ensuring patients are safe underpins everything we do. I’ve set out my early priorities – workforce, technology and prevention.

What does prevention mean?

Patient safety is the golden thread that runs through all of them.

Eh? Golden thread? Why? How? What do you mean? Did you initially forget patient safety?

I’m fresh off the night shift with the fantastic staff at Derriford Hospital in Plymouth so forgive me if I look a bit tired!

White noise.

The compassionate and good-humoured nurses, doctors, managers and paramedics I met all told me the same thing: they focus relentlessly on patient safety.

White noise.

They said they need safe systems around them. Opportunities to learn from mistakes are crucial. And a culture where staff are empowered to speak out when things go wrong.

In my first few days in the job, I agreed with Dr Aidan Fowler, the new NHS Director of Patient Safety, that the new national patient safety strategy will mean safety is cemented into our long-term plan for the NHS.

NHS Director of what? [Just googled, he’s NHS Director of Patient Safety of NHS Improvement.]

What does ‘safety is cemented into our long term plan mean’? What do these words mean Matt? None of these words mean anything.

I want to pay heartfelt tribute to Jeremy Hunt, who led this agenda and drove it for so many years. Be in no doubt: we will drive it for years and years to come.

How much longer do you anticipate driving an agenda for patient safety? Do you not work to clear, measurable outcomes? Surely you should be looking to removing the need to ‘drive’ stuff not boast about driving it for years.

We’ve made huge progress over the last few years. The CQC is internationally recognised for its inspection regime – driving up standards across the NHS and improving care for patients.

Is it? Where’s the evidence?

Patient Safety Learning have put forward a very positive set of proposals. Dr Fowler will soon set out an exciting and powerful vision for patient safety over the next decade. Every patient – whether in hospital, at home, in a GP surgery – expects compassionate, effective and safe care.

Who or what are Patient Safety Learning? Why are you talking at an event organised by this group? What is exciting and powerful about expecting ‘compassionate, effective and safe care’? There’s nothing new here.

To achieve that, we need to improve learning, we need to better shout about the work that the best trusts are doing, and the NHS must be as open and transparent as we can.

Christ. Who wrote this? You are saying nothing new incredibly badly.

Commitment to learning

There are many figures I could quote – numbers of errors, adverse events. But in some ways they hide the real issue – which is the impact on people and families.

A bit of actual evidence would probably be useful here. So far you’ve demonstrated no evidence. Just words.

I won’t ever forget, James, the hot summer day you came into my office in the department overlooking Parliament and told me the sad, sad story of Joshua. We cried together, because nothing can bring Joshua back. And in so many ways the huge progress on patient safety is his legacy. James, I pay tribute to your work, to this series of conferences, and to your publication today which is a blueprint for the change we need to see.

Eh? James? James who? The same James who organised this gig? Can we have a bit of transparency around your involvement in this event? Chumminess is deeply unprofessional and concerning.

We’ve heard today of the things we can all learn from those tragic events at Morecambe Bay. We’ve also heard of the emerging lessons from the first few HSIB investigations.

These lessons are vital. We must learn from them in our quest to make the NHS the safest healthcare system in the world. And we must apply those lessons to the whole health and care system.

‘Those tragic events at Morecambe Bay…‘…emerging lessons from the first few HSIB investigations’. An exemplar in a light touch Hancock talk and more words. Just words.

Safety is not just about telling people to do better. Patient safety is about accountability, not blame. It’s an irony that to build a safer system we need less of a blame culture.

When is safety ever about telling people to ‘do better’. We saw a tot riding one of those wooden bikes without peddles across the road earlier. He got a bit of speed on and his mum, some way behind, started shouting ‘stop!’ to him. She didn’t shout ‘do better!’ The poverty of understanding, knowledge and engagement here is woeful.

Instead, we need transparency and accountability in a positive culture, where people can have the confidence to be self-critical, because only then will we get the continuous improvement. And we need to improve the systems and processes that support staff. All with the goal of minimising human error.

Words.

The Learning from Deaths programme has been a major step. It means trusts better understand where care needs to improve. And it says trusts must have proper arrangements for learning from deaths of patients including, crucially, supporting and engaging with families.

Words. Meaningless words.

And from April, medical examiners will significantly overhaul the way we learn from the care given to patients who die. They will confirm the cause of all deaths that don’t need to be investigated by a coroner. Bereaved families will be better involved and offered more opportunities to raise concerns so we can ensure that we learn from mistakes and more families don’t have to go through the agony of unnecessarily losing a loved one.

Christ Matt. Do you not think about any of this stuff before saying it? And those listening, do you not critically engage with what he’s saying? It’s not happened so far and it certainly won’t happen magically from April. Do you have any understanding of concerns around the coronial process? Around Prevention of Future Deaths reports disappearing into the never never? Introducing medical examiners (and the myriad questions around this role) won’t lead to better involved families.

At a national level, the Healthcare Safety Investigation Branch is a world first. It uses independent professional investigators to get to the root cause of some of the most serious patient safety incidents.

HSIB CEO Conradi earlier today spoke about the lack of knowledge about and engagement with this body (because it’s also shite and doesn’t have a clue about communication). And it ain’t independent.

But I still want to go further. We will set up a new independent body to conduct investigations.

We have published our Health Services Safety Investigation Bill in draft, and I want to hear your views on how it should work.

And I want to ensure Professor Tim Briggs’s excellent work on ‘Getting It Right First Time’ helps us spread best practice on patient safety across the NHS.

The National Clinical Improvement Programme is emulating this approach at a consultant level. I was really impressed to see there’s a way for doctors to be totally upfront, sharing their individual clinical outcomes so they can learn from each other.

Eh, new Bill? Briggs? National Clinical Improvement Programme? You’re skittering around stuff quicker than a skittering squirrel. Slow down. What do you actually mean? What are you talking about?

I also know that there’s often a case of information overload. Multiple patient safety alerts about a huge range of issues, meaning it’s hard to prioritise which matters the most.

The irony. The fucking irony…

So Aidan Fowler will head up a group of experts who will help you understand the clear actions that need to be taken, protecting patients from the most serious risks.

Who? What group of experts? What ‘you’ do you mean? Health professionals? The public?

Opportunities of technology in health

Hancock suddenly switches on here and begins to talk with a bit more confidence.

Finally, we must harness the power of data and technology. IT issues can lead to patients being given poor care because systems don’t communicate. Ultimately lives can be lost.

Such blatant disconnect/hobby horsing here. We know lives can be lost. You’ve touched on this above remember.

We need to use cutting-edge technology to deliver safe, high quality and patient-centred care. And we need to use transparent open data to be able to spot anomalies that might indicate systemic failures. We’re moving towards full roll-out of electronic prescribing and medicines administration in secondary care to extend inter-operability and reduce medication-related error.

On a roll Matty boy, on a roll. Safer ground (ironically) from the above fudge stuff.

Our new Patient Safety Incident Management System will improve how we capture and spread the insight that we can gain from incident reporting in the NHS, harnessing the new opportunities for analysis that machine learning can offer, to ensure our safety intelligence remains cutting edge.

This ain’t the answer.

And we must – we must – improve the way we spot sepsis and save lives starting with our new ‘suspicion of sepsis dashboard’. Sepsis is such a devastating condition and I’ve been so incredibly moved listening to stories from families who have lost loved ones. We must do all we can to stop it.

The new dashboard will measure the number of patients who come to hospital with serious infections, and give quick information so doctors can see which of those infections cause patients to deteriorate very quickly and help them understand which treatments are most effective, and how to intervene quickly.

In the future, all this data will be used to help analyse which infections most often lead to sepsis. It is yet another example of how technology has the potential to improve patient care in the NHS when we can get the systems to talk to each other. And I’d like to thank the clinicians and experts at Imperial who have helped develop it. It is the next step in the NHS’s fight against sepsis. But we need to go further.

No comment.

No complacency

Improving patient safety is a determined and unwavering commitment for us all. We must constantly strive to listen to patients and their families and listen to staff so that we can learn from mistakes, be innovative and continually improve.

We need a culture of humility, openness and learning. There is no room for complacency.

I want every one of those staff who care for patients to be able to work safely and deliver safe care. I want patients and their families to have total confidence in the care they receive. I want the NHS to rise to the challenge of being the safest health system in the world.

That is our goal. We can achieve it. And I look forward to working with all of you to get there.

The end. Zero confidence in this man achieving anything meaningful. A jumble of poorly written, ill informed and empty words.