In any complex system it’s inevitable that mistakes will be made that have tragic consequences. Supporting, caring for and enabling people with learning disabilities or mental health problems is precisely a complex system; the goal of such a system has to be to maximise good quality care and support for as many people as possible, so that they can lead equal lives, and minimise tragic and very poor quality situations as much as possible.
The reasons why I am so angry with Southern Health are multiple, but especially include the way in which they have abrogated their responsibilities at every single juncture, before and after, when it comes to Connor Sparrowhawk –a brilliant 18-year-old, son, brother, friend who died a preventable death in the “care” of an institution run by Southern Health. The latest in a very, very long line of examples is them protecting their account on Twitter, following a distinct lack of any leadership from their, erm, leadership award-winning Chief Executive.
What I was personally aiming/hoping for through #justiceforLB was 3 things:
- Justice for Connor (or “Laughing Boy” (LB), as his mum called him)
- A line of influence that directly connects what happened to Connor with work being done with the approximately 3,500 people with learning disabilities who still “live” in and are “cared for” in (post-)Winterbourne View-type institutions
- A wider call to action about how to achieve equality of opportunity for people with learning disabilities, mental health conditions and, indeed, all disabled people.
If Southern Health had simply done what Connor’s mum outlined in her post “Imagine” after his preventable death, then #justiceforLB would have a very different tone and aim.
In considering Southern Health’s actions since Connor died and looking through Southern Health’s Board papers for 2013, however, I have come to add a fourth aim:
- To prompt relevant organisations – statutory, regulatory, legal or otherwise – to fundamentally question and consider Southern Health’s ability to provide care services to people in the future.
I question their fundamental future fitness for purpose. This post explains (in some detail) why.
The characteristics of Southern Health’s apology
The key characteristics of Southern Health’s apology for Connor’s preventable death are as follows:
- Deep sorrow
- A recognition that they failed to take the necessary actions to keep Connor safe
- A commitment to learning from the tragedy to prevent it from happening again
- Concern that the unit Connor died a preventable death in was found to be non-compliant with a number of CQC standards
- Working with commissioners to bring service delivery in line with the model that has delivered good results in Southampton and Hampshire
- A number of resulting actions, including:
- Reviewing staff training
- An audit of all existing care plans, including ensuring the social history of a patient is included along with advice and details provided by family members and carers
- Committing to listening to our patients and acting on their feedback
- Looking closely at the relationship between our various learning disability teams and services to make sure they are working together to best effect.
There are some of us who are skeptical about Southern Health’s ability to appropriately follow through on these actions, and who doubt whether they will make any meaningful difference to the “care” and services “provided” by Southern Health.
Our skepticism was based on how we knew Southern Health to have dealt with everything regarding Connor’s preventable death so far. However, we have found a similar case in which Southern Health’s actions led to the death of a patient and in which their response then followed a very similar pattern to now.
Southern Health has prior
Hannah Groves was 20-years-old, had made two suicide attempts in three as well as attacked her mother and brother, and had been noted as suicidal by a trainee doctor. Treatment had been requested in October 2012 at Antelope House, a specialist mental health unit in Southampton run by Southern Health. No assessment or treatment was forthcoming, and on 22 October 2012 a member of the mental health team at Antelope House described Hannah as a “fucking waste of time” and “an attention seeker”.
Hannah committed suicide, and was found dead later that day.
The Coroner, in September 2013, delivered what was described as a “damning assessment” of Southern Health’s actions in the days leading up to Hannah’s death. It was noted that the increasing risk to Hannah’s safety was “not adequately identified” and there was “at all stages a failure to appreciate the extent of the risk that Hannah was at” and to realise “a wholly impossible stage had been reached and that for however a modest period of time Hannah required hospital admission and care”.
The key characteristics of Southern Health’s public apology for Hannah’s death were as follows:
- Sincere apologies
- Admitting liability for Hannah’s death
- A commitment to learn from the experience and ensure that similar incidents are avoided in the future
- A number of resulting actions, including:
- Ensuring staff have further training
- Working more closely with relatives and carers to ensure their concerns are actively considered as part of care-planning and risk assessment
- Improving the way care is coordinated between individuals and teams.
Looking at the minutes of the Board meeting of 10 September 2013 (paragraph 7.2 , pp.7-8) we also see that Southern Health:
- Provided assurance that immediate actions identified in a dedicated action plan for Antelope House had been undertaken, and confirmed that the actions required would be completed by the Trust by the end of October 2013
- Noted that in Hannah’s case the Trust had “missed the opportunity to take adequate account of the views of the family”
- Noted “it was critical for a single lead for an individual’s care”
- Sought assurance of what had changed as a result of the learning from this event, which included “new senior clinical leadership within the Southampton area, and that work was underway to improve capabilities within teams for effective risk assessment”.
Now, it only takes a casual glimpse to see that the things Southern Health said they would put in place following Hannah Groves’s (preventable) suicide are almost identical to the things Southern Health have said they are putting in place following Connor’s preventable death.
The question we should ask, then, is what difference did these things make after Hannah died?
Taste the difference?
Whilst Southern Health were publically confident that “the transformations made during the last nine months” at Antelope House meant they were better able to support people there, the Board minutes note that:
Work had commenced [on the resulting action plan] from October 2012; [the Acting CEO] expressed concern that the Board had not received adequate assurance of these actions, and suggested that further information and assurance be provided via Quality & Safety Committee in order to monitor this, and provide upwards assurance to the Board. [The] Non-Executive Director and Chair of the Quality & Safety Committee, endorsed this approach, and requested a full discussion at the next Committee meeting [14 October 2013], with the appropriate information available. [The] Chairman concurred, and requested that the Committee provide assurance to the Board that the action plan was robust and implemented appropriately.
Note that this is fully 12 months after Hannah Groves died.
In the summary note of the Quality & Safety Committee meeting of 14 October 2013 (paragraph 2.1.2) it is noted that
Significant work had been undertaken to implement the agreed actions, including a review of the clinical leadership within the team.
Similarly, in the full meeting minutes of the 14 October Quality & Safety Committee meeting the following is included:
[It was] noted that in addition, attempts were always made to involve the family and carers [in Critical Incident Reviews] (para 6.3)
[Committee member] asked for assurance as to whether the identified actions would prevent reoccurrence of a similar issue. [Executive Manager] confirmed that there were a number of elements within the action plan, which would help to prevent a similar issue occurring (para 6.5)
[Committee Member] questioned the strengths of staff at appropriate risk management. [Executive Manager] noted that a programme of work was underway to improve the processes for the management of complex clinical risk, including tailored training for clinical staff (para 6.6).
What this tells us, then, is that Non-Executives sought, and were given, reassurance that the things they expected to be in place were indeed in place.
For a moment, then, let’s take all of this information at face value: there had been a serious incident arising from inaction at Antelope House in October 2012, but a comprehensive action plan was put in place to address the issues highlighted.
What, then, did the CQC have to say about Antelope House when they inspected it on 1 August 2013 (pdf)? Of the 8 areas inspected, 6 met the required standard, but 2 – care and welfare of people who use services; and medicine management – needed action. So, two areas were not compliant with the CQC nine months after Hannah Groves had died.
What happened when the CQC did a follow-up inspection on 2 December 2013 (pdf)? Three areas were not compliant with the CQC; one of which required enforcement action. Which one? The care and welfare of people who use services – one that had already been identified as “needing action” 4 months before.
That is, the state of the service at Antelope House had demonstrably got worse, despite the assurances of the Executive Team that suitable actions were in place.
When considering the characteristics of Southern Health’s apology in the case of Hannah Groves, then, we can see the actions they took made no difference.
What does this mean for Connor’s care?
For each of the commitments Southern Health made as a result of Hannah Groves’s (preventable) suicide, what can we say had an impact on the “care” Connor received? I’ve grouped together all of the relevant statements made after Hannah Groves died, and now look at each of them in turn.
A commitment to learn from the experience and ensure that similar incidents are avoided in the future
The fact #justiceforLB exists shows that a similar incident wasn’t avoided.
We will put in place new senior clinical leadership
As Verita’s report finds (F19) over Connor’s death: “The unit lacked clinical leadership, in particular from S1 and S3.” The new leadership at Antelope House has made things worse, not better.
Ensuring staff have further training (especially regarding appropriate risk assessment)
Verita noted that epilepsy was not part of Connor’s risk assessment and that, despite it being known Connor enjoyed taking long baths, no specific risk assessment was undertaken on this topic. Furthermore, according to the CQC, Southern Health did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service, some two months after Connor died. In no way could it be said there was appropriate and relevant training in place at the STATT unit.
Working more closely with relatives and carers to ensure their concerns are actively considered as part of care-planning and risk assessment, and so not “miss opportunities to take adequate account of the views of the family”
Southern Health’s staff didn’t just not engage with Connor’s family; the report indicates they actively chose not to engage with them. For example, “Trust staff had little or no prior knowledge of [Connor], so they should have found out more about his family’s understanding of his needs” (comment after paragraph 7.11). Furthermore, there was “no evidence that the experience and knowledge of [Connor’s] parents were captured at the beginning of his admission or included as part of his risk assessment and care plan” (F13). There is no evidence at all that Southern Health staff tried to work more closely with Connor’s relatives or not “miss opportunities” to take account of their views.
Improving the way care is coordinated between individuals and teams, including it being “critical for a single lead for an individual’s care”
Verita found that the unit “caring” for Connor “operated a team-based approach in which no individual/s held the responsibility for ensuring that the care and management of [Connor] was appropriate and coordinated effectively.” Something Southern Health’s own board noted as “critical” wasn’t in place.
Provided assurance that immediate actions had been undertaken, and confirmed the actions required would be completed by the Trust by a certain date
As we’ve noted, the service that failed to prevent Hannah Groves’s suicide got demonstrably worse, despite the assurances of the Executive Team that suitable actions were in place.
There is a saying which suggests: “Once is an accident, twice is a coincidence, and three times is a pattern.”
Following the (preventable) suicide of Hannah Groves, Southern Health’s Cheif Executive and Executive Managers made a series of public and internal commitments about what they would do to (a) improve the relevant service; and (b) ensure it wouldn’t happen again.
CQC inspections have shown that the relevant service got worse. And not only did it happen again, but each of the elements of learning and action arising from Hannah Groves’s case were contributing factors to Connor’s death.
I don’t think any assurances provided by Southern Health about what they will learn and do in the future can be trusted.
It is for this reason, built on all of the details presented above, that I call to prompt relevant organisations – statutory, regulatory, legal or otherwise – to fundamentally question and consider Southern Health’s ability to provide care services to people in the future.
(For more information about #justiceforLB, the summary is here and all information and reaction on Twitter is channeled through @JusticeforLB.)