And the end shall be the beginning…
OK, let’s start with the conclusion. Why? Because I suspect this is what the entire 263 page (including 14 appendices) Verita report of their “independent review into issues that may have contributed to the preventable death of Connor Sparrowhawk” is really about (see here for links to the full report and an easy read summary http://www.england.nhs.uk/publications/invest-reports/#connsparr ). The longer and more ‘thorough’ the report, the more likely most people will be to turn straight to the conclusions and not read the rest. The conclusions, of course, will no doubt shortly be cited in a Southern Health press release, alongside some passive-aggressive statements about how this has been a very distressing and distracting experience for the staff involved, how they will study the report carefully and learn the lessons for when they ‘absorb’ their next shockingly bad Trust to inculcate in the modern way, and how everyone can now Vanguard along, nothing to see here.
The three conclusions in the full report, which I predict will be front and centre of the Southern Health press release, are as follows:
6.70. There is no evidence that acts or omissions of commissioners contributed to the inadequate care received by Connor that led to his preventable death. We set out our rationale for this in our overall conclusion.
6.71. Quality reviews carried out before the acquisition or at the point of acquisition did not find that STATT had acute clinical, managerial or systems failures. In contrast, concerns were focused on the non-Oxfordshire part of the former Ridgeway services where patient safety risks had been identified.
6.72. An over reliance on a ‘business as usual’ approach to this acquisition was not appropriate. Southern Health should have ensured that any deterioration in the quality of services could be identified quickly and through processes that Southern Health could place their confidence in.
So, what evidence is contained within the Verita report that leads the authors to these conclusions?
The authors are at great pains to point out the rigour of their investigation (57 interviews! Including an interview with Sir Stephen Bubb! [why???] Stakeholder and focus groups! Over 250 documents, 8,000 pages plus!) and it has clearly been a major undertaking. It’s a bit of a shame that the rigour this is intended to convey is undermined by widespread typos and errors throughout. We also know that in Southern Health crucial documents tend to go missing or are ‘incomplete’, until mysteriously ‘found’ at the last minute. It’s also extraordinary that in this “independent” investigation, interviews with many Southern Health personnel (apparently at their request) were conducted with the Trust’s lawyer present on the following (to me, chilling) terms:
“The solicitor is instructed by the trust and will be attending the interviews (where requested by staff) in her role as legal adviser to the trust. In this role, she will be supporting and advising the interviewees through the interview. If the interviewees so wish, she will be reviewing and commenting upon any transcripts produced and she will be taking notes of the interviews. Any notes that she makes may be shared with the trust. If she is sent any interview transcripts, by Verita or the interviewees, she will share these and any other comments upon them with the trust. The interviewees who have asked to be supported in this way are fully aware of the above points and are in agreement with them.”
This might be one reason why this report has no redactions – a welcome improvement in transparency or a sign that everything has been squared off to Southern Health’s satisfaction?
What was this Verita review supposed to be investigating? Here’s the terms of reference in the executive summary:
6.1. The scope of the investigation as laid out in the terms of reference was to:
“Identify whether there were any wider system aspects [commissioning, leadership, management arrangements] that contributed to the preventable death of Connor [our emphasis].”
“Review whether, prior to Connor’s death, the local authority, Clinical Commissioning Group and/or Southern Health NHS Foundation Trust were aware of:
· any quality, safety or delivery concerns in respect of the Short Term Assessment and Treatment Unit
· the broader learning disability provision and
· to consider whether appropriate action was taken to address any concerns.”
The report tends to ask questions in roughly chronological order, starting with: What did Southern Health and their commissioners know about the quality and safety of services in STATT before the acquisition?
My reading of the evidence from commissioners at the time is pretty damning. They knew that Ridgeway wasn’t great and that it was going downhill. The chaos of the Health and Social Care Act meant wholesale changes to health commissioning, and a determination to offload Ridgeway (too small to become a ‘Foundation’ NHS Trust on its own) on to an ‘absorbing’ Foundation Trust (see http://dataforlb.blogspot.co.uk/2015/03/shrink-wrapped-absorption-of-ridgeway.html ).
In a weird variant of the “You shouldn’t blog because transparency makes us panic” logic used against @sarasiobhan, the Verita report argues that the Winterbourne View expose made commissioners narrow their focus to parts of the Ridgeway service where they were worried about potential abuse happening, so forgetting about more mundane bad practice in Oxford:
6.24. The Winterbourne View exposé focused attention on the abuse that had happened there and on restraint in particular. From Oxfordshire’s point of view, commissioners had concerns about services in Wiltshire and Buckinghamshire, some of which related to restraint. Their attention was naturally focused there. By contrast, Oxfordshire services had experienced fewer incidents so they received less attention.
6.26. Concerns about the quality of Ridgeway services tended to relate to those outside Oxfordshire. Commissioners thought that services in Oxfordshire needed less attention, although they were acknowledged as being old-fashioned and reliant on a bed-based model of assessment and treatment.
[Aside: note the rhetorical work being done by ‘naturally’ in 6.24]. So, before the ‘acquisition’ Oxfordshire County Council and health commissioners knew that the Oxfordshire service was less than great and had an arrogant, defensive culture, but it wasn’t actively abusive enough for them to do anything about it. An inspid review in late 2012 (with no health professionals in the team) and an ‘informal’ 45-minute visit in 2013 (the result of which was Oxfordshire County Council commenting on the state of the décor in STATT) was the extent of quality monitoring and action. Er – what are commissioners for?
The executive summary of the Verita report then goes on to state:
6.27. As will be seen in the main body of the report Southern Health had a well thought out strategy for preparing for the acquisition which from our review of the available evidence was carried out effectively. This included a wide range of communication processes and as seen below quality and safety reviews.
To my mind, the ‘evidence’ to underpin this seems mainly to be Katrina Percy impressing the acquisition panel with general shininess and corporate bullshit to tell the acquisition panel what they wanted to hear [another aside – what does the fact that the Calderstones bid was rejected say about that service?]. Some of the evidence cited in the report (the NHS Confederation ‘case study’ of the acquisition) has been taken off the NHS Confederation website, and an internal review of Southern Health’s due diligence process noted how it wasn’t conducted properly (see http://dataforlb.blogspot.co.uk/2015/08/diligence-negligence.html ). And again, there is strong evidence of commissioners abrogating their responsibility in their expressed ‘relief’ that Southern Health were going to come in and ‘sort it all out’.
What did Southern Health know about the quality of Ridgeway services before the acquisition?
Well, it turns out they should have known quite a lot. There were multiple reports on the Ridgeway service related to the due diligence process Southern Health was doing – most of them financial, but some of them, given what we now know from the inquest, heartbreaking.
For example, in May 2012 (almost a year before Connor entered STATT), Ridgeway staff conducted a review of their electronic records using the RiO system. The Verita report summarises:
11.26. The review found inadequate completion of electronic risk assessment entries and said staff needed to be trained on how to move from paper records to putting data into the RiO system. It also recommended developing risk assessments on RiO and other record keeping issues.
So Southern Health knew about this, and it is clear from the inquest that they did absolutely nothing about it.
Contract Consulting reported in September 2012 on a review done for the then Strategic Health Authority (dissolved in March 2013) on quality and governance in Ridgeway. Some lowlights from this review included:
“There appears to have been culture within OLDT that could best be characterised as a combination of defensiveness and complacency in respect of quality, safety and risk.”
“Some we spoke to indicated that there is a disconnect between senior leaders within OLDT and the staff delivering or managing the services in terms of the understanding of quality issues and the assurance that actions needed have been taken and are fully implemented.”
Big, honking, warning klaxons for Southern Health.
Good job they’ve got their much-trumpeted mock CQC inspection system then. One of these was conducted by Southern Health on STATT in August 2012 (I’m sure the diagnostic radiographer was particularly helpful), which concluded that everything was basically tickety-boo, with the exception that:
“Care plans, risk assessments and treatment plans did not match up; not all plans were reviewed on the agreed four weekly basis.”
Again, a crucial issue in the inquest, which Southern Health’s own quality processes had flagged, specifically for STATT, 7 months before Connor arrived.
There was also one of the famed matron walk-arounds, done by Southern Health staffer John Stagg as part of a broader quality and safety review of Ridgeway written in November 2012. Again, pretty much tickety-boo as far as specific mentions of STATT are concerned. However, the quality and safety report, which summarised across Ridgeway services as a whole (and therefore should be taken to apply to all Ridgeway services, including STATT) are prophetic in identifying crucial issues relating to Connor’s death. Narrative conclusions and recommendations are in the Verita report as Appendix I and Appendix J. I quote these conclusions extensively because they exactly predict the findings of the inquest – they also predict the findings of the CQC inspection of STATT 2 months after Connor died. Southern Health knew – they knew, and they did nothing:
· 1. Record Keeping: Both electronic and secondary paper file records require to be up to date and matched against risk assessment and care plans. It was difficult to ascertain other professional assessments and intervention and there was a lack of joined up MDT working evident within risk assessments and care plans. The transfer from paper to electronic records is reported by staff to be difficult and in some areas lacks appropriate support.
· 2. Multidisciplinary Working: There was a lack of evidence to support adequately integrated MDT/ multi-professional or multi agency care plans, particularly within community settings.
· 3. Risk Assessment & Risk Management: The overall MDT approach to clinical risk assessment and risk management was poorly evidenced in some areas. In in-patients this seemed to be led by nursing staff and in the community risk assessment and management was very limited indicating a potential lack of adequate risk management of high risk patients within the community. This was due to poor evidence within electronic records and a lack of access to secondary files and other professional/ clinical records. Within in-patients there was evidence of good risk assessment in some areas, but for some patients there was a lack of consistent record keeping. There was a common failure to match the electronic record to the secondary paper file so that the electronic record at times lacked the detail contained within paper records. The risk assessments did not always evidence the clinical assessments which would inform risk and risk management.
· 5. Physical Health Monitoring: There was evidence of good practice in some areas where the Health Action Plan (HAP) had been extended to include more complex health needs…The lack of physical health care plans could lead to potential risk and where this occurred.
· 7. Clinical Pathways/ Evidence Base: There was limited evidence of joined up MDT working which reflected a clinical pathway or clinical map which identified clinical outcomes to measure assessment and treatment particularly within community settings. Although in-patient services followed the ‘in-patient pathway’, it was difficult to ascertain the ‘tool box’ of assessment and treatment processes available to patients according to their needs and the approach taken by professionals and the team. For example, a patient with epilepsy did not have a care plan which stemmed from a comprehensive epilepsy profile which detailed seizures, risks, affect and effect of medication, the aims for the nurses and the patient in providing care. Expected outcomes for the patient were unclear so could not be measured/ evaluated.
· 9. Clinical Supervision & Management Supervision: There was evidence that identifies that both types of supervision are limited due to frequency, regularity, recording and staff training. There were no other methods of clinical supervision identified other than where a psychologist would be made available for group supervision following an incident. Staff reported a lack of reflective supervisory methods and there seemed to be a reliance on management supervision alone.
· 10. Mental Health Act/ Mental Health Care: There was evidence that the MHA is not implemented consistently across all services in relation to policy for locked doors, policy for observation, policy for Section 17 leave arrangements (monitoring, recording and signing patients out for leave and on return from leave).
· 11. Environment: Maintenance in relation to a safe environment was an issue in some areas but also in relation to ligature assessment and management. Ligature assessment and management policy has not been consistently applied across services.
· 12. Medical Devices: There was inconsistent management of medical devices in terms of on-site inventory, monitoring, calibration and maintenance.
· 14. Learning Out of Concerns: This is an area reported by staff, some of whom felt that they were not informed of outcomes from investigations including the learning from disciplinary investigations. Changes in practice were not felt to always impact at the staff/ ward level. There was also commentary that staff felt changes in practice e.g. changes to shift patterns to accommodate breaks (a positive change) was not evaluated in terms of overall impact e.g. the time period for hand over and staff meetings.
An update of this report by John Stagg in 31 May 2013 was based on information from local managers – yes, these would be the local managers that Southern Health had already been warned about in terms of a culture of arrogance and defensiveness – concluded:
“Overall this report provides assurance and information that the quality factors identified within the Ridgeway Partnership (Oxfordshire Learning Disability NHS Trust) have been or are being addressed effectively.”
That must be because Southern Health swept in with their modern ways, viral leadership and finely wrought action plans to sort it all out, yes?
What did Southern Health do?
There’s a short answer and a long answer (no surprise there, then). Short answer: fuck all – Southern Health took the money and left Ridgeway to rot (see my take on this here http://dataforlb.blogspot.co.uk/2015/03/shrink-wrapped-part-2-shrinking-estate.html ).
The long answer goes something like this...
The two main people in Southern Health responsible for the management of the acquisition, and who were expected to lead the former Ridgeway services after acquisition, scarpered in early 2013 (indeed, they told senior people in Southern Health in 2012 that they didn’t want the jobs). The fact that one of them couldn’t drive didn’t help visibility in the former Ridgeway service.
Southern Health dispensed with the services of their ‘interim transition director’.
The new post-acquisition director of the merged learning disability services didn’t have any experience of services for people with learning disabilities.
According to commissioners, after the point of acquisition, Southern Health stopped talking to them “It felt as if, they won the bid, they got their contracts, they started in November and then they sort of disappeared.” An email to Katrina Percy from a commissioner in February 2013 (a month before Connor entered STATT) stated:
“We heard over a week ago that Amy Hobson has left her post as director for learning disability at Southern Health, but as yet have received no communication from Southern Health to us as commissioners, nor to Lucy Butler as joint manager of the Community Teams service manager.”
“Since the acquisition of Ridgeway Partnership by Southern Health we have had no contact from senior managers at Southern Health, have had difficulty arranging meetings with Amy, and when we succeeded she was unable to attend on the day. My last 2 emails to Amy remain unanswered. As you are aware from the acquisition process, it is very important to us to establish a productive relationship and dialogue with our providers in order to maximise the benefits for our service users from the contracts we manage. Our impression of Southern Health throughout the acquisition process was that we could expect to establish a productive partnership and our experience so far has been very disappointing.”
“Please could you let us know formally who is now managing the learning disability services that we commission so that we can arrange to meet with them as soon as possible to discuss our concerns?”
According to Katrina Percy, Southern Health were held up in doing anything because the commissioners didn’t tell Southern Health what they wanted. Katrina Percy also “doesn’t actually do my own emails”.
Up to April 2013, the ever-changing Southern Health staff were busy working on a ‘business plan’ which included ‘saving’ at least £1.7 million from Ridgeway’s costs [why this planning wasn’t done before acquisition is beyond me, but anyway…]. While they were doing this (and not bothering to talk to the former Ridgeway staff, according to them) Southern Health adopted a ‘business as usual’ approach – as far as I can tell, this seemed to involve Southern Health treating the former Ridgeway service as if it had always been a branch of Southern Health and leaving the staff to magically acquire all Southern Health’s ‘modern ways’ without any assessment of what staff needed, any training, or any plan to help them.
“As has been explained in a number of interviews, upon the date of acquisition, Southern Health took the decision to operate the entirety of the learning disability division services (including the former Ridgeway services) on a ‘business as usual’ basis; i.e. to encourage integration, the acquired services were treated the same as all of the other services in Southern Health’s existing learning disability division.”
“This means that those services formed part of the learning disability division’s ordinary assurance processes to monitor quality, safety and performance – i.e. there were no extraordinary measures put in place to monitor the quality and safety of the former-Ridgeway services.”
As Sue Harriman, the acting CEO for Southern Health at the time (Katrina Percy was on maternity leave) says below, Southern Health apparently forgot that former Ridgeway staff were people:
“I think some of it was around the people part, the softer part, the bit that makes a registered practitioner fill in a form and to say ‘Is everything is okay?’, ‘Okay,’ when it is not okay. That bit we had really missed somewhere in the mix, that this was a group of people who, clearly, felt or were behaving as if they were totally disenfranchised.”
The business plan was launched at Newbury Racecourse (obviously) in April 2013, when Connor was already on the STATT unit, and it looks (and looked to the Ridgeway staff) like a wholesale cost-cutting exercise, with swathes of posts disappearing. Apparently staff weren’t consulted in advance. The post-acquisition management of Southern Health services was a complete mess.
On July 4th, 2013, Connor Sparrowhawk died.
After a damning CQC report of STATT in September, an internal review identified problems with the STATT unit that had been obvious to Southern Health before acquisition and that they had done nothing about:
o The practice of moving senior staff when problems arose did not assist in maintaining safe, quality services in the former Ridgeway Partnership. A number of the issues were significantly stressful and demanding to deal with. SHFT may not have realised the degree of strain amongst its new senior management team.
o Senior managers worked hard however their increasing range of responsibilities led to a reduced level of support and leadership notably on STATT and JSH.
· Transaction and post transaction
o The lack of robust local management support for STATT and JSH appears to have continued since transaction occurred, despite various quality initiatives led by others not in a direct line management relationship with the ward manager…
o The governance arrangements which prevailed post transaction did not readily enable communication and a change in culture due to the top down approach, and apparent lack of empowerment for front line staff. A good example of where the disconnect became apparent during the investigation was with regards the post transaction process of review and amalgamation of policies.
Yet another internal investigation of management can perhaps best be summarised in this one line:
· The evidence gives the impression of complete chaos leaving staff feeling uncertain and distressed.
There is much more in the Verita report, but for the purposes of this blog I want to stop there. This has been a bit of a trawl through (part of) the evidence, but I thought it was important to do this for me to see what conclusions I would come to, based on the evidence presented.
The Verita report has this brief discussion that, for me, gets to the heart of the matter in terms of responsibility for Connor’s death:
4.8. A quote from the executive summary of Sir Robert Francis’ report on Mid Stafford Hospital (which looked at the causes of the failings in care at the hospital between 2005-2009) gives guidance on one aspect of evaluating evidence relevant to this test:
“There is … a difference between a judgement which is hindered by understandable ignorance of particular information and a judgement clouded or hindered by a failure to accord an appropriate weight to facts which were known.” (Paragraph 70)
4.9. This insight leads us to consider:
· whether commissioners and Southern Health failed to seek out information that they should have known or needed to know to provide a safe service; and
· whether commissioners and Southern Health had information that they failed to act on.
To me, the evidence is overwhelming that:
· Commissioners knew throughout there were serious problems with the Ridgeway Trust, and fobbed off their responsibilities on to Southern Health as quickly as they could.
· Well before they ‘acquired’ Ridgeway, Southern Health knew exactly what the problems were, to the extent that they virtually predicted the issues contributing to Connor’s death set out by the inquest jury.
· After acquisition, Southern Health left former Ridgeway staff to fend for themselves, while threatening their jobs and not ‘leading’ (hey, there’s a word) or managing any part of the former Ridgeway service effectively.
To my naïve brain, it is clear that, using the Francis test, the actions (and inactions) of both commissioners and Southern Health were contributory causes of Connor’s death.
Throughout the Verita 1 investigation and the inquest, it has been painfully clear that Southern Health’s strategy has been to pin all the responsibility for Connor’s death on to the staff working on the STATT unit. In this context (and bearing in mind that Verita have ‘form’ when it comes to conducting independent investigations for Southern Health’s precursor which pin the responsibility for shocking failures squarely on staff, as in this report on Fordingbridge Hospital in 2008 http://www.dailyecho.co.uk/resources/files/7412 ), it’s hard for me to see this Verita 2 report as anything other than a continuation of the same strategy. I cannot reconcile in my head the evidence contained in this report and the conclusions it reaches – short of finding video evidence of Katrina Percy stalking the corridors of STATT with a piece of lead piping I doubt that any evidence would have been sufficient to make Verita reach a different conclusion.