AvAM meeting supported by Verita 5th March 2015.
Investigations Fit for a Modern Health Service.
Report written by Brenda Prentice:
The first speaker was (to my shame) unknown to me, Dr Umesh Prabhu. After making a mistake where a baby died he felt like giving up paediatrics, but was persuaded not to and instead devoted the rest of his career to improving patient safety. I don’t think I have ever heard a more passionate speaker. He was a breath of fresh air and what a way to start the day. For those who want to know more about him please see http://lifeinthefastlane.com/umesh-prabhu-changemaker/
After rising through the NHS he was in a position where if he found clinicians not able to do their job, even if simply because they thought themselves ‘untouchable’ he got rid of them. I wanted to ask, how, given the employment laws, but he managed!
He talked of the importance of having ‘value based leaders’ and that he had 220 Patient Safety Champions now operating within his organisation. This man has put words into actions and really should meet with Jeremy Hunt and Bernard Jenkin as soon as possible as they are still trying to answer the ‘how’ questions regarding reform of patient safety. He was a difficult act to follow and I didn’t envy the next speaker.
The next speaker was Chris Brougham the Director of Investigations and Training at Verita. She also advises Trusts on patient safety and wants to see a clear model for carrying out investigations and better training for the lonely job of investigating. She was an interesting speaker and one who should be listened to by Trusts.
She spoke about being ‘open and transparent’ and said simply, ‘this is about telling the truth’. Chris also talked of the front-line staff just going through the motions filling out ‘fish-bone’ charts to provide root cause analysis without any real idea of how to analyse the data. Clearly training for front-line staff carrying out the initial investigation is badly needed and something that PHSO could tackle. Chris also said that the Terms of Reference must be relevant to each incident, not generated from some central source and that it was vital that Trusts investigated those aspects most important to the complaint. Obvious really.
Peter Walsh spoke next and talked particularly about the new duty of candour and Will Powell’s long fight to achieve ‘Robbies Law’ in the name of his son who died due to NHS negligence more than 20 years ago. Quite a campaign! Peter said that previously the system frowned upon cover ups, but tolerated them, forcing complaints to devote their lives to finding out the truth about their loved one. Peter complained that there were different standards of duty of candour between the NHS and the Private sector which left loopholes. He was also concerned that the clinical investigation board presently under discussion at PASC would provide ‘legal privilege’ to all participants which he felt went directly against the new duty of candour.
I was lucky enough to be sitting next to a lady who said she was a trustee at AvMA, Suzanne Shale. She stood in for James Titcombe who was listed to speak but after the Kirkup report, he was emotionally exhausted. We watched a film James had made of his complaint journey. Coming from the nuclear fuel industry he could not believe that less time would be spent investigating the death of a baby than would be spent investigating a single rusty bolt. With great composure he spoke of the dawning realisation that there was a cover up and the anger this generated when he had lost his baby son to negligence. You can see this film here on Patientstories.org.uk and may wish to contact this organisation to put your own story forward. http://www.patientstories.org.uk/films/joshua-story/ Suzanne then spoke passionately and with authority about his case and it was insightful.
The speaker Della and I were waiting to hear was Mick Martin the Managing Director of PHSO. I thought he looked strained and he was contrite. He didn’t try to defend the record of PHSO and readily admitted it was more difficult to effect change than he might have wished. He suggested that ‘defensiveness’ is a natural reaction to a complaint and it should be expected.
He talked about the ‘journey to travel’ in relation to PHSO and the modernisation programme. One of the aspects which will have to change according to Mr. Martin will be the way PHSO investigate in private as he said this was impossible in the modern world. That will be a relief to many, but I wonder if anyone has told the front line staff.
He spoke of new operational changes which meant that PHSO could be held to account. One of these was PHSO’s decision to use external, independent reviewers to audit PHSO decision making. He stated this as though the management of PHSO decided this was a good idea when in fact it was recommended by the Health Select Committee in their recent report. In reality PHSO have been minimising their use of external reviewers with only three currently employed. Another fact which may be of interest to some of you is that the work of PHSO is no longer unduly affected by the 12 month time limit, as they are using their discretion to allow more complaints to be investigated which would previously have been ‘out of time’.
We were able to ask questions of Mr. Martin at the end of the meeting and
Della asked where PHSO would find the new ‘indpendent’ external investigators for the audit process. Mr. Martin replied that PHSO would recruit and employ them, so I think we can all see the obvious conflict of interests here. He who pays the piper …..
A theme of the day was that human beings make mistakes and complainants need to forgive human frailty. I added that I would be very happy to forgive but as ‘they’ were in arrogant denial that anything was wrong, there was nothing to forgive them for! Point was taken.
I also flagged up that conferences such as this should encourage more service users to attend by giving some free places. All the other attendees had their costs covered but these events are expensive for complainants even with a reduced rate.
The day seemed to support us, the PHSO Pressure Group, we have many people agreeing that change must take place. We must keep pushing at the opening door.
A modern health service is one that values complaints
and really does listen to them.