By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, 15 December 2016
The NHS powers that be have once more tried to deny an obvious culture of cover up.
The phrase “cover ups” appears once in CQC’s latest report on how the NHS investigates deaths:
“If trusts spent more time on dealing with recommendations rather than on cover ups, we would not be here. They should put more effort in saving people’s lives. It is always people at the bottom, nurses, agency staff etc., people at the bottom get all the blame, it is never the people at the top, the managers, the decision makers.” CQC Family Listening Day 1
The Department of Health and its allegedly “arms length” bodies, have led the public a merry but exhausting dance for years. NHS scandals have been “handled” rather than properly addressed. As Sir Ian Kennedy the former chair of the Healthcare Commission told the Midstaffs Inquiry:
“My experience of the Department of Health is that they have a tendency to shoot the messenger rather than embrace changes that need to be made. This is not particular to healthcare. Their first priority is to ‘handle’ the situation, rather than consider and implement change, and those were the realities we had to work with. The politicians were most interested in how any story would be received, and this was also true for Mid Staffs.” 2
Ineffective systems of oversight have been installed to control political embarrassment. In the Care Quality Commission (CQC), we have the absurdity of a quality regulator that refuses to investigate. 3
The latest government charade is the CQC’s report of its so-called Deaths Review of the NHS’ handling of deaths. 1 This was ordered by Jeremy Hunt, after hundreds of uninvestigated deaths at Southern Health NHS Foundation Trust were unexpectedly revealed by an off-message auditor, Mazars. 4 CQC’s review is an exercise in damage limitation, not genuine reflection.
In the pattern to which we have become accustomed, CQC’s report provides much anecdote but limited hard evidence on NHS incident handling. It does not fully account for how data was gathered, or for how a sample of twelve trusts were chosen and how they were examined. It also basically tells us what we already know.
CQC’s report launches yet another tokenistic makeover of the NHS serious incident framework. CQC essentially pretends that NHS deaths investigations have been flawed primarily because people don’t know how to investigate, guidance isn’t good enough and the system isn’t coordinated enough. According to the CQC, it’s more “confusion” than cover up. 5
This is misleading, because there has been sufficient guidance in place for years for a reasonable investigatory job to be done, if the NHS’ masters had actually wanted this. 6 Politicians have told the public many times that they did. Indeed, in 2002 the DH solemnly promised after the Bristol Heart Inquiry to ensure that sentinel events would be safely managed and lead to learning. 7
The reality is that superficial, incompetently conducted and sometimes frankly corrupt investigations have been tolerated, because they are politically expedient and spare ministers and senior officials embarrassment. 8 9 Repeated scandals have revealed a failure to improve the quality of NHS investigations since the MidStaffs Public Inquiry highlighted this as an issue. 10 4 11
Existing NHS guidance on involving bereaved families and candour – “Being Open” 12 – has been flouted. The DH, CQC and others have repeatedly allowed this. Extraordinarily, CQC’s report does not even refer to the Being Open guidance. To do so would be to highlight the wilful departures from these accepted principles for over ten years. CQC instead re-invents the wheel and pretends it is progress:
“Recommendation 3: Define what families and carers can expect from healthcare providers when they are involved in the investigation process following a death of a family member or somebody they care for.” 1
In short, as CQC’s latest report has refused to properly acknowledge that there are intentional cover ups, it naturally contains no real remedies for this. CQC should never have been tasked with the Deaths Review in the first place, given its wilful blindness to concerns about cover ups 13 and track record of deliberately pulling its punches about NHS failure. 14
Nevertheless, CQC now states that not a single NHS trust is investigating and learning properly from deaths.
“Across our review we were unable to identify any trust that was able to demonstrate good practice across all aspects of identifying, reviewing and investigating deaths and ensuring that learning is implemented – although we did identify trusts that demonstrated good practice at individual steps in the investigation pathway.” 3
CQC’s Chief Inspector says he didn’t know how bad things were. 15
“The extent of the problems is more than I expected.”
This is pretty astonishing given countless disclosures to CQC about fiddling and cover up, and all the hundreds of millions that have been spent on purportedly making the CQC intelligence driven.
CQC’s report quotes one family who referred to cover ups. 16 Yet in its summing up CQC refers only to how families “experience” a lack of openness by the NHS. The CQC knows from patients, families, whistleblowers, coroners and repeated inquiries that there is falsification by the NHS. 17 It is truly remarkable that CQC has largely avoided this mountain of data in its report.
Whistleblowers are not mentioned in CQC’s report. Their submitted evidence has been ignored. One might be forgiven for thinking that this is an attempt to draw attention away from deliberate cover ups. CQC’s report largely glosses over the fact that NHS investigations often fail to involve staff properly or at all. No apparent attempt is made to measure this core failure, which in some cases is a deliberate act of suppression.
And what about the 46 trusts that CQC has rated ‘Good’ on safety? And the 90 trusts that CQC has rated ‘Good’ and 13 trusts rated ‘Outstanding’ on the Well led domain?
How is it possible that such accolades were valid if none were investigating sentinel events properly?
Moreover, what of all the past CQC claims in inspection reports that it had evidence of good incident handling in the NHS? Some high profile examples are collated here:
So, were CQC’s rosy claims about its favourites warranted?
CQC’s assertions that trusts have met their statutory duty of candour are tarnished (see a recent analysis by AvMA 18 ), not least as without effective investigation and identification of all harm and failure, there can be no complete candour.
Which version of CQC’s ‘truth’ should we believe, if any? Jeremy Hunt has spun a narrative of tough quality regulation to smooth over unsafe destruction of the NHS. He insisted that the CQC had been transformed and would serve as the single version of NHS truth. 19 But what we see are wobbly, serial revisions of the ‘truth’ by CQC.
Importantly, CQC has kicked the institutional mistreatment of and discrimination against mental health and learning disability patients into the long grass. Its report does not acknowledge the full depth of health inequality or the strategic cover up about deaths in the most under-funded services. 20 CQC’s recommendations for protecting the rights of learning disabled and mental health patients are shamefully vague and are not enforceable standards. 21 There is nothing in CQC’s report that will stop the NHS nodding by the loss of lives considered less worthy. See a blog by Connor Sparrowhawk’s mum on this central failure:
CQC’s report refers briefly to the statutory requirement for deaths of people detained under the Mental Health Act to be subject to inquest. It conveniently omits to mention that 742 of such deaths were NOT referred to coroners. 22 Neither does CQC account for its part in this serious failure, although it is the body with lead responsibility for policing the use of the Mental Health Act and safeguarding the rights of detained patients.
As part of his response to CQC’s Deaths Review, Jeremy Hunt has claimed he will force trusts to publish data on preventable deaths by March 2017. 23 That might sound like a good idea but it is beset by technical difficulties and the high cost of doing it properly. The risk is that the DH will dumb it down and use it as a PR exercise to parade low quality data that underestimates the real number of preventable deaths.
In fact, Hunt first promised in February 2015 to publish avoidable deaths data. This was part of pre-emptive counter-spin to the embarrassment of the about to be published Freedom to Speak Up Review, on the suppression of NHS whistleblowers. 24 He renewed the promise as part of managing the embarrassment caused by the Mazars report. But no such data has yet been published. 25
In response to the Mazars revelations, NHS England asked trusts a year ago to submit self-assessment data on avoidable deaths:
We have not seen hide nor hair of this data.
In other words, the NHS that does not investigate itself properly and is thus unable to give a true figure, was asked to provide the – as yet unseen – statistics. Worse than pinning the tail on the donkey.
As Professor Nick Black has observed of Mr Hunt’s Project Publish:
“We’re sort of into a chicken and egg [situation] then; if we had an accurate indicator of the safety of a hospital we wouldn’t need to do all this, so I’m intrigued by how that would work and to be honest, I cannot see that it would.” 24
A CQC NED said at yesterday’s Board meeting that the Deaths Review report is “very good”.
But for whom?
The denial machine speeds on, as does governance by sound bite.
Update 19 December 2016:
Today, Jeremy Hunt admitted to the Health Service Journal that his plans to publish avoidable deaths last year were shelved:
“Mr Hunt said plans to publish trust data on avoidable deaths last year were shelved because the response was “essentially meaningless”.
He said: “We asked every trust what they thought their numbers of avoidable deaths were. The vast majority of trusts just took the average 3.6 per cent from the Helen Hogan and Nick Black work. What that basically told us was that people don’t have a local methodology.”
- Whistleblowers unheard by CQC, 5 December 2016
A report with supporting FOI data which shows that the CQC continues to ignore many whistleblower disclosures.
2. Tall Stories by the CQC 9 December 2016
A response to CQC’s claims to Health Committee about its performance, and its attempt to dismiss concerns set out in a letter to the Times by campaigners.
1 Learning, candour and accountability. Report of CQC Deaths Review. 13 December 2016
2 Ian Kennedy oral evidence to the Mid Staffs Public Inquiry 4 may 2011
3 CQC FOI responses to questions about whether it investigates
4 Report by Mazars on Independent review of deaths of people with a learning disability or mental health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015, December 2015
5 Learning, candour and accountability. Report of CQC Deaths Review. 13 December 2016
“There is confusion and inconsistency in the methods and definitions used across the NHS to identify and report deaths leading to decisions being taken differently across NHS trusts.”
6 National Patient Safety Agency, National Framework for Reporting and Learning from Serious Incidents Requiring investigation 2010
There have been several subsequent updates of this guidance.
7 Learning from Bristol. The DH response to the Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995
“Bristol Heart Inquiry Recommendation 112: “All sentinel events should be subject to a form of structured analysis in the trust where they occur, which takes into account not only the conduct of individuals, but also the wider contributing factors within the organisation which may have given rise to the event.
DH response: We agree. This is already a requirement of the Department’s Risk Management System. It will be reinforced by root cause analysis of serious incidents to understand the underlying cause(s). Guidance will be issued by the NPSA in 2002.”
Bristol Heart Inquiry Recommendation 118: “The process of reporting of sentinel events should be integrated into every trust’s internal communications, induction training and other staff training. Staff must know what is expected of them, to whom to report and what systems are in place to enable them to report.
DH response: We agree. This will be included in the revised guidance on the Department’s Risk Management System, to be issued in January 2002 and guidance from the NPSA”
8 Bill Moyes oral evidence to the Mid Staffs Public Inquiry, 1 June 2011:
“I mean, the culture of the NHS is a danger to this approach, let me be quite clear about that. The culture of the NHS, particularly the hospital sector, I would say, is not to embarrass the minister.”
9 Report of the Morecambe Bay investigation by Dr Bill Kirkup March 2015
“Although we were unable to find definitive evidence, we believe that, on the balance of probability based on all that we did hear, Trust officers decided to give the report limited circulation amongst Trust staff and to delay sharing it with external bodies.”
10 PHSO. The People’s Ombudsm and and how it failed us. Patients Association November 2014
11 PHSO Review into the quality of NHS complaints investigations, December 2015
12 Being Open. Communicating patient safety incidents with patients and their carers. National Patient Safety Agency 2005
13 Whistleblowers unheard by CQC. Minh Alexander, Pam Linton, Clare Sardari and a fourth NHS whistleblower, December 2016
14 Labour’s cover up on failing hospitals: ministers tried to silence watchdog on eve of general election
15 Mike Richards: Deaths investigations poor and ‘need an overhaul’. Sharon Brennan, Health Service Journal, 13 December 2015
16 Learning, candour and accountability. Report of CQC Deaths Review. 13 December 2016
“If trusts spent more time on dealing with recommendations rather than on cover ups, we would not be here. They should put more effort in saving people’s lives. It is always people at the bottom, nurses, agency staff etc., people at the bottom get all the blame, it is never the people at the top, the managers, the decision makers.”
17 The examples of NHS falsification are legion and too numerous to cite exhaustively.
A famous example of manipulation of evidence given to coroners relates to a MidStaffs case: A Law Unto Themselves. Dr Phil Hamond Private Eye, June 2013
A recent example of evidence of alleged NHS cover up, exposed by inquest, can be found here:
18 Regulating the duty of candour. Hannah Blythe for AvMA, August 2016
19 Patients First and Foremost, Government’s initial response to the Mid Staffs Public Inquiry, March 2013
20 Who cares about the rising number of suicides by mental health patients? Minh Alexander August 2016
21 Learning, candour and accountability. Report of CQC Deaths Review. 13 December 2016
“Recommendation 4: Provide solutions to the range of issues we set out for people with mental health conditions or a learning disability across national bodies, including the Royal Colleges. This should aim to improve consistency, definitions and practices that support the reduction of the increased risk of premature death”
22 Trusts fail to report hundreds of mental health deaths to coroners.
Shaun Lintern, Health Service Journal, 9 August 2016
24 Hunt’s plan for local avoidable deaths estimates ‘meaningless’ Will Hazel Health Service Journal 10 February 2015
25 Hunt’s ‘avoidable deaths’ data subject to major delays. Sharon Brennan, Health Service Journal 9 September 2016