Urgent Question on Southern Health NHS Trust House of Commons


Urgent Question on Southern Health NHS Trust

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To ask the Secretary of State for Health if he will make a statement

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on the report of the investigation into deaths at Southern health NHS

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foundation trust. The whole house will be profoundly shocked by this

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morning's allegations of a failure to investigate over 1000 unexpected

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deaths by Southern Health Nhs Foundation Trust. Following the

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death of a young man in July 2013, a report was commissioned into

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unexpected deaths between April 2011 and March 20 15. The draft report,

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submitted to NHS England in September, found a lack of

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leadership, focus and sufficient time spent in the trust on carefully

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reporting and investigating unexpected deaths of mental health

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and learning disability service users. Of 1454 deaths reported, only

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272 were investigated as critical incidents and only 195 of those were

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reported as serious incidents, requiring investigation. The report

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found there had been no effective, systematic management and oversight

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of the reporting of deaths and investigations that follow. Prior to

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publication or indeed showing the report to me, NHS England) asked the

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trust for their comments. They accepted failures in their reporting

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and investigations into unexpected deaths, but challenged the

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methodology, in particular pointing out that a number of the deaths were

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outpatients for whom they were not the primary care provider. However,

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NHS England have assured me this morning the report will be published

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before Christmas, and it is our intention to accept the vast

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majority of the recommendations it makes. Our hearts go out to the

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families of those affected. More than anything, they want to know the

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NHS loans from tragedies and that is something we pay to Mayfield to do

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on too many occasions at the moment. Nor should we pretend this is as the

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result of the wrong culture at just one NHS trust. There is an urgent

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need to improve the investigation and learning from the estimated 200

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double deaths we have every week across the system. I will give the

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house more details about the report and recommendations when I have had

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the chance to read the final version and understand the recommendations,

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but I can tell you the important steps that will help create a

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changing culture. Firstly, it is totally and utterly unacceptable

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that according to the leaked report, on the 1% of the unexpected deaths

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of patients with learning disabilities where investigated.

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From next June, we will publish independently a steward Ofsted style

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ratings of the quality of care offered to people with learning

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disabilities, for all 209 areas. This will make sure we shine a

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spotlight on variations in care, and knowing rapid action to be taken

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when standards fall short. Secondly, NHS England have commissioned the

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University of Bristol to do an independent study into mortality

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rates of people with learning disabilities in NHS care. This will

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be a very important moment to step back and look at the way we look

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after that particular, highly formal ball group. Thirdly, I have

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committed previously that next year, we will publish the number of

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avoidable deaths by NHS trusts. They have worked hard to provide a

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methodology to do this and will write to all trusts next week,

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explaining how that works and asking them to supply estimated figures

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that can be published in the spring. Central to this will be establishing

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80- blame reporting culture across the NHS, where people are rewarded

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and not penalised for speaking openly and transparently about

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mistakes. Finally, I would like to pay tribute to corner's mother Sarah

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Bryant, who has campaigned tirelessly to get to the bottom of

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these issues. Her determination to make sure that her son's unexpected

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and preventable early death is an inspiration to us all. Today, I will

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write to her and other families affected by this and apology. These

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are truly shocking revelations, that if proven, revealed deep failures at

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Southern Health Foundation Trust. The BBC has reported that the

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investigation has found over 10,000 people died between April 2011 and

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March 2015, and of those 10,000, 1454 were not expected. All a 195 of

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those unexpected deaths, just 13%, were treated by the trust as a

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series incident, requiring investigation. Perhaps most

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worryingly, it appears the likelihood of an unexpected death

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being investigated depended hugely on the patient. For those with a

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learning disability, just 1% of unexpected deaths were investigated.

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And for all the people, with a mental health problem, just 0.3%. We

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will obviously await a full response from the government, when the report

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on the investigation is published. But there are a number of immediate

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questions that need answers today. Firstly, does the Health Secretary

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Judge services at the trust to be safe? A recent report found,

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inadequate staffing levels in community health services was

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impacting on the delivery of safe care. What advice can he give

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patients and their families of patients currently in the care of

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Southern Health? Secondly, can the confirm, he did confirm that NHS

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England received this report in September. Can he explain why it

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still hasn't been published and can he provide a specific date on which

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the final report will be made publicly available? Thirdly, when

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was the Health Secretary first made aware of concerns about Southern

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Health, and what action did he personally take at that time? What

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does he have to say to the relatives and friends of people who have

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unexpectedly died in the care of the trust and who, today, will be

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reliving their grief with a new anxiety. The issue raises broader

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questions about the care of people with learning disabilities or mental

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health problems. Just because some individuals have less ability to

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communicate concerns about their care, must never mean that any less

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attention is paid to their treatment or their death. This would be the

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ultimate abnegation of responsibility and one which should

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shame us all. The priority now must be to understand how this was

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allowed to happen and make sure it is put right, so it can never, ever

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happen again. I agree with what the Shadow Health Secretary says and I

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think she's absolutely right, in both the tone of what she says and

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the serious nurse with which she points to what has happened. It is

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important to say that this is only a draft report. Just to put her mind

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at rest, NHS England received, and by the way, I am completely

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satisfied that NHS England took this seriously from the moment we

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understood there was an issue around the tragic death of that young man.

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CU members of South met the family and ordered the investigation. It is

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a very thorough investigation. As she will understand, when you have

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an investigation about as serious as avoidable mortality, you have to

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give the staff the chance to correct it factual inaccuracies and

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methodology. It has taken from September till now to get to the

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point where the report is ready to be published. I have been assured

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this morning that it will be published before Christmas, so we're

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not going to allow any further arguing about methodology to stand

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in a way of that report being published, as it was always planned

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to be before Christmas. In terms of her very important question about

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whether or not services are safe at Southern Health, we have an expert

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view on this. That is a new inspector of hospitals and they have

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done an inspection of Southern Health. They're not saying services

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are as safe as they should be, they are saying that along with many

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other trusts, services need to become safer. She was right to draw

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attention to some of the feelings alluded to in that report.

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The fundamental question that we will all need to reflect on is, why

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is it that we do not currently have the right reporting culture in the

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NHS, when it comes to unexpected deaths? I think we have to be honest

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and depth back, there are reasons good and bad why these happens,

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people are extremely busy, there is a huge amount of pressure on the

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front line, there is a desire to spend clinical time with patients in

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front of you rather than going over medical notes and trying to

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understand something that went wrong, sometimes there will be

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prejudiced and dissemination and the whole house will reunite in St

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should stamp that out. Sometimes people are worried they will be

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penalised if they speak out and we need to move away from the blame

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culture in the NHS to a culture where doctors and nurses are

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supported if they speak out which too often not the case. The whole

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house will want to unite in making sure we support the leaders of the

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NHS who want to change that culture. It is unfinished business from

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mid-Staffs, inedible important to get it right and I know the NHS is

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determined to do just that. The allegations in the draft report

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about Southern health are deeply disturbing and I welcome the steps

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that the Secretary of State has announced, and particularly that he

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will not treat this as an isolated incident. Looking at the key

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findings from the draft report, can I ask him, for nearly two thirds of

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the investigation, there was no family involvement, and he sent a

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message to all trusts that particularly for those who cannot

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speak for themselves, it is vitally important to involve family members?

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Will he sent up a message for a clearly today? I well and I will be

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grateful to her for giving me the opportunity. All too often, we had a

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story in the Sunday newspapers, another example where a family were

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shut out of a decision involving an unexpected baby death. People with

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mental health problems and people with learning disabilities must have

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this support because the family might be their best advocate. We

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need to change the assumption that things will become more difficult if

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you involve families. More often than not, things like litigation

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melt away if families are involved properly from the outset of a

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problem. It is when families feel that the door is being slammed in

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their face that they feel they have to resort to the courts which is in

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no 1's interest. I would echo what the Secretary of State said about

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family involvement which should be routine in investigating an advert

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event and it definitely takes the heat out of the situation. --

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adverse event. There is a shocking difference in 30% of adult deaths

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being investigated and 1% of people with learning disabilities, and

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Connor represents the human face of that and that is frightening. The

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second issue is, it is being left to death to individual trusts to

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describe but they are investigating and what they produce. I think it is

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required that there is a much more systematic looking at the hotel. NHS

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England publish the annual mortality figures and what is very striking is

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that there are trusts, 16 trust identified with higher than expected

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mortality that had higher than expected mortality the year before.

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And there does not appear to be any action taken. The problem is, the

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benchmark appears to be average. If you are having poor performance,

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average is set lower, we should be aspiring higher than that. She is

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absolutely right and I would argue that 30%, the 30% figure was people

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with mental health conditions, it was not all adults. I would question

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why we are only investigating 30%, which is the highest, of unexpected

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deaths. These are not just deaths, they were unexpected deaths. I dig

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it is the duty of every medical director in every trust to satisfy

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themselves that they have thought about every single unexpected death.

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There are some very serious things that we need to reflect on. She is

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right about the need to get a system of process when there is an

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unexpected death so that we do not have variation between trusts. The

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exercise that we are doing at the moment is about trying to establish

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standardised way of understanding when death is preventable and when

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it is not. At the heart of this, as I am sure she is able to understand

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as a practising physician, is getting it right so the trusts will

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not take the easy route and blame the clinician rather than trying to

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understand the systemwide problems which might have caused the

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clinician to make a mistake in each individual instant. Behind each

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statistic is a person and the Secretary of State is absolutely

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right to say that finger-pointing should not be at clinicians alone.

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It is much more importance to look at the whole system and the culture

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within a trust. Would he please encourage all trusts, and, indeed,

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all medical schools and nursing schools to make the reading of the

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Francis Report into mid Staffordshire compulsory? There is

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so much in there that could prevent future occurrences like this. No one

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knows more about the Francis Report than he does because of the direct

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impact he had on his own local hospital. He is right to talk about

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that culture change. There is an interesting comparison to the

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airline industry, when they investigate accidents. The vast

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majority of times, those investigations point to systemic

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failure but when the NHS investigates clinical accident, the

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vast majority of times, we pointed individual failure. It is not

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surprising that clinicians feel about intimidated about speaking

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out. They want to do the right thing for patients and we need to support

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them. The Coalition Government rightly established a public enquiry

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to look into the appalling care at mid Staffordshire Hospital and the

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Secretary of State has rightly pointed to the challenge to culture

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that that was port, the Francis Report, in gendered followed -- that

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report, in gendered following a scandal. We need to do something

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similar for people with learning disabilities and mental health

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issues who too often I treated as second-class citizens in the NHS? It

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seems the time is right to shine a light on what is going on.

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I am happy to consider it. First of all, let me say that he and I are on

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the same page on these issues. My only hesitation is that public

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enquiries take two or three or four years, and I want to make sure we

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take action now. I hope that I can reassure him and the House that, for

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example, by publishing Ofsted style ratings of the quality of care for

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people with learning disabilities across all areas, we will shine a

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spotlight on poor care in a way that the Francis Report tells us we must

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do. I do not see the treatment of people with learning disabilities

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distinct from the broader lessons of the Francis Report. If I fail to

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make progress and know he will come back to me and rightly so. Many of

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my constituents will be service users of Southern Health and the

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families of service users. What they are looking for from the Secretary

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of State is reassurance that this is not simply going to be an immediate

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intense Scott light but an ongoing one, -- spotlight, and they will

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have confidence going forward that the scrutiny and oversight,

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particularly in the case of young people with learning difficulties,

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will be ongoing. I can absolutely give that assurance to her

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constituents. I would say this, I hope that they will look at the tone

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of what I said in my earlier statement and realise that we are

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not looking at this simply as an issue in Southern Health. There are

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clearly important changes that must happen there and happen quickly, and

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we will do everything we can to make sure they happen. There is a

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systemic issue over the low reporting of avoidable and

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preventable deaths and avoidable and preventable harm. And the failure to

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develop a true learning culture in the NHS which in the end is what

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doctors, nurses and patients all want and need. Can I thank him for

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his payment and congratulate NHS ins and for what sounds like a very

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thorough support. -- report. Challenging the methodology is the

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first offence used by the now disgraced management at mid Staffs

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hospital. -- first defence. Will he answer the question as to where

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ministers first knew about problems in this trust which went back to

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2011, and what actions need to be taken as a result? I thank him for

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his comment and I hope I did just that by saying that the first time

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that we realised there was an issue was when we realised that there were

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issues around the tragic death of Conor sparrowhawk. That is what

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started the process going which led to the independent investigation and

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that investigation, because NHS England wanted it to be very

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thorough, went right there when it back to 2011 and carried on right

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the way until 2015, looked at all unexpected deaths in that period.

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But at the reporting culture and the lessons that had not been learned as

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a result. This is something where a lot of action has been taken. I

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cannot reassure him that during that period, we have been implementing

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the recommendations of the Francis Report which have meant that

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throughout the NHS, there is a much greater focus on patient safety,

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much more transparency about safety, and indeed, it is important to give

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the NHS credit. During a three-year period, we have seen 25% increase in

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the number of reported incidents so I think people are treating this

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much more seriously than the past but there is much more to do. Can I

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also welcomed the statement from my right honourable friend, and the

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news that he is planning to accent the recommendations from this very

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sobering report. -- accept. Can he also reassure the House that anyone

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found to be deliberately contributing to patient neglect or

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failing to investigate avoidable deaths will be held to account both

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by the professional regulators and by the full weight of the law? I can

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of course give her that assurance. But there is a note of hesitation in

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my response to that. Partly because professional standards, as she will

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know, not a matter for politicians and have to be done by the GMC and

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MMC. If we are going to improve the reporting culture, which is what

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this report is about, we had to change the fear that many doctors

:22:47.:22:50.

and nurses have that if they are open and transparent about mistakes

:22:51.:22:54.

that they have made or they have seen, that they are going to get

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dumped on. And that is something that is a real worry for many

:22:58.:23:02.

people. I think part of this is creating supportive culture where,

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when people take the brave decision to be open about that has gone

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wrong, they get the support that they deserve. As well as asking the

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Secretary of State about how the learning on this very important

:23:19.:23:22.

issue will be shared with the devolved administrations, can I ask

:23:23.:23:27.

him, whether or not all of the trusts are being advised that they

:23:28.:23:31.

will now probably received approaches from families who have

:23:32.:23:36.

questions about their own experiences, and no doubt honourable

:23:37.:23:39.

members maybe counteracted in that regard? Is he -- contacted in that

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regard? Is he made whether they will be sensitive about historic cases?

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I can give him that reassurance. I think trusts are already doing that

:23:53.:23:59.

and families will have had people in touch with them about concerns about

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potentially avoidable and preventable deaths. I hope this will

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be a reminder to all trusts that they need to take those concerns

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very seriously indeed. The disparity in excess deaths between honourable

:24:14.:24:19.

groups at Southern Health is truly shocking, but of course,

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responsibility for looking after the people in question does span health

:24:24.:24:29.

and social care. If the content that we have the Informatik someplace

:24:30.:24:32.

that will allow outliers to be identified and therefore read to

:24:33.:24:38.

occasion to be under way. One assumes that could easily be done by

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NHS England, but at the moment, it seems in format X is problematic.

:24:45.:24:50.

He's absolutely right and that is why the professor is developing a

:24:51.:24:53.

methodology to help us understand number of avoidable deaths. I think

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we have good methodology for understanding the number of

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avoidable deaths. It is not until we localise it that we will get real

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local action and that is the next step. I wondered if the Secretary of

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State is satisfied that for families to seek truth and justice for their

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loved ones, they are having to rely on parole board all lawyers for

:25:27.:25:34.

information and for crowd sourcing to get legal help. I'm afraid that

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probably does happen, but what I would say is we all passionately

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believe in the NHS and support it. It should never come down to

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lawyers. If that is a problem, we needs a culture where the NHS is

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totally open and skin the families are themselves to understand what

:25:58.:26:01.

happened and what lessons can be learned. If nothing else, that is

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the thing we need to learn from this report. It is clear there is a

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cultural problem, both in Southern Health and across the NHS. Does he

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agree with me that far too often, NHS management and clinicians are

:26:25.:26:27.

far too defensive, end up arguing about the data rather than

:26:28.:26:31.

addressing the underlying causes, which of the address them, would fix

:26:32.:26:36.

the problem in the first place. He is right, and I think it is quite

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heartbreaking that when these things happen, we seem to have an argument

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about methodology and statistics, and is it that many thousands,

:26:45.:26:49.

rather than looking at the underlying causes. But we also have

:26:50.:26:53.

to ask yourselves why it is people feel they need to be defensive in

:26:54.:26:59.

these situations. We have to recognise that everyone is human,

:27:00.:27:04.

but uniquely, doctors are in a profession where, when they make

:27:05.:27:08.

mistakes, as we all doing our own worlds, sometimes died. The result

:27:09.:27:14.

of that shouldn't automatically be to say that the doctor was

:27:15.:27:18.

clinically negligent. 99 times out of a hundred, what we should you

:27:19.:27:22.

juice is what can be learned to avoid that mistake in the future. Of

:27:23.:27:26.

course, when that is gross negligence, due process should take

:27:27.:27:30.

its course, but that's only a minority of cases. And I think

:27:31.:27:34.

that's where things have gone wrong. Not many people are as grateful to

:27:35.:27:38.

the NHS as I am, who has just returned to full health, thankfully,

:27:39.:27:45.

due to the intervention of the wonderful team at the Guy 's

:27:46.:27:52.

Hospital. Many of us have known for a long time that access to full

:27:53.:27:56.

national health treatment for people with learning difficulties and

:27:57.:28:05.

particularly people on the autism spectrum, there are very many of

:28:06.:28:09.

them with poor communication skills, who finish up with inadequate access

:28:10.:28:15.

to the health service. I don't particularly want a public enquiry,

:28:16.:28:22.

I want fast action to change. I am delighted he was looked after by Guy

:28:23.:28:28.

's Hospital, where my mother was a nurse and I was born, so I have

:28:29.:28:32.

connections to that trust as well. He is right in what he says, in

:28:33.:28:37.

making sure we get this culture right. It is something about

:28:38.:28:41.

creating a more supportive environment for the people who do a

:28:42.:28:45.

very, very tough job every day of the week. I think, when you have a

:28:46.:28:51.

conversation with patients, with their constituents, they understand

:28:52.:28:54.

as well. What they need to know is that lessons will be learned and

:28:55.:29:01.

acted upon. Was it necessary to delay the publication of the report

:29:02.:29:08.

for 23 months, a week or two I could understand, but not to three months,

:29:09.:29:12.

and here it will now not be published in a fortnight's time

:29:13.:29:17.

before Christmas, but next week, when we will be here. I hope it will

:29:18.:29:21.

be published next week. The commitment I have had from NHS

:29:22.:29:26.

England is it will be published before Christmas. I'm confident that

:29:27.:29:31.

it will get a huge amount of media interest, rightly so, and partly

:29:32.:29:36.

thanks to the Shadow Health Secretary's question today. When the

:29:37.:29:39.

draft report was sent to the trust, they did come back with 300

:29:40.:29:44.

individual items of concern about the draft report. And they think it

:29:45.:29:50.

was right for NHS England, just in the interests of accuracy and

:29:51.:29:56.

justice, to consider those issues raised by the trust. They have given

:29:57.:30:03.

me assurance that the report will now be published before Christmas,

:30:04.:30:06.

whether they have reached agreement with the trust or not. What is the

:30:07.:30:12.

Secretary of State during about whistle-blowing, because I'm sure

:30:13.:30:20.

that most of us have had problems in the past. Some people have been

:30:21.:30:23.

victims of the National Health Service because of their concerns.

:30:24.:30:29.

What will he do about that? We had a full report done by Sir Robert

:30:30.:30:36.

Francis, the Freedom To Speak Up report, which I presented just

:30:37.:30:39.

before the election, which looked specifically at this issue. The

:30:40.:30:44.

problem people have when they speak out about a problem in their trusts,

:30:45.:30:49.

they are not only on occasions, hounded out of that trust, but

:30:50.:30:52.

sometimes they find it difficult to get a job anywhere else in the NHS,

:30:53.:30:59.

because word gets around on the old boys network. If we have to have

:31:00.:31:03.

whistle-blowing at all, we have failed, because what we need is a

:31:04.:31:07.

culture where, when people raise concerns, they are confident they

:31:08.:31:11.

will be listened to. There are other industries who have managed to do

:31:12.:31:16.

that. The airline industry, the nuclear industry, the oil industry.

:31:17.:31:20.

I don't think any other country has managed to get this right. You get

:31:21.:31:29.

individual hospitals who have fantastic learning cultures, like

:31:30.:31:33.

the Salford Royal. I want to get that culturally to across the

:31:34.:31:39.

country. I very much welcome the statement. Does the Minister agree

:31:40.:31:51.

with me that to address this, one needs tough care quality commission

:31:52.:31:59.

inspections, good leadership locally and the right support from the

:32:00.:32:00.

government for moving forward. We can draw some comfort from the

:32:01.:32:18.

fact that the NHS itself is commissioning reports that a very

:32:19.:32:23.

hard-hitting, don't pull any punches, and the new CQC inspection

:32:24.:32:28.

regime does exactly that. Can I commend all the staff at the Medway

:32:29.:32:32.

Hospital who have worked so hard to raise the standard of care over the

:32:33.:32:36.

past three years, which has not been easy for them. He has not yet

:32:37.:32:41.

mentioned the role of the medical examiner. Doesn't this latest

:32:42.:32:46.

tragedy of a street that the introduction of a national system of

:32:47.:32:52.

medical examiners, as recommended by public enquiries and supported by

:32:53.:33:00.

medical bodies, is now long overdue. I agree with her. It was a

:33:01.:33:05.

recommendation of the Francis Report and the Coalition Government

:33:06.:33:09.

committed to implement this, and we will be telling the house shortly

:33:10.:33:15.

what our plans are on this front. People will be both saddened and

:33:16.:33:20.

dismayed at what has happened to mid Staffordshire and the new CQC

:33:21.:33:27.

inspection regime. If problems like this can still arise. Does he agree

:33:28.:33:32.

with me that, while there is no simple solution, the solution does

:33:33.:33:37.

not lie in trusts adopting and relying on a tick box approach to

:33:38.:33:44.

safety? He is absolutely right. It is worth saying that this tragedy

:33:45.:33:47.

that sparked this report actually happened before the new CQC

:33:48.:33:54.

inspection regime had got under way. But I think the old CQC regime was a

:33:55.:34:01.

tick box approach. Partly because the people doing the inspections

:34:02.:34:05.

were often themselves not doctors, who were able to make peer review

:34:06.:34:09.

judgments about the quality of services. If you're not a doctor,

:34:10.:34:14.

you tend to want to look at things where you can tick yes or no in

:34:15.:34:17.

response to a question and not the underlying issue. Having judgment in

:34:18.:34:24.

inspections is a very important step forward. This investigation would

:34:25.:34:28.

not have happened, had it not been for their tenacity and work of Sarah

:34:29.:34:34.

Ryan, Connor Sparrowhawk's mother. Is it right that the legal

:34:35.:34:37.

representation for the family was funded by crowd sourcing? I think

:34:38.:34:43.

it's tragic that anyone has to resort to the courts to get justice,

:34:44.:34:49.

and Sarah Ryan is one of many, many people who have had to go to huge

:34:50.:34:55.

expense to get justice and the truth, with respect to their loved

:34:56.:34:59.

ones. Last week, I went to the launch of a book by a campaigner,

:35:00.:35:08.

who has campaigned for years to get justice over the death of his son

:35:09.:35:13.

Joshua. And that is what we have to change. Pity confirm whether the

:35:14.:35:18.

draft report also covers the Southern Health mental health

:35:19.:35:28.

services for adults? Is he satisfied that the temp three report was

:35:29.:35:35.

rigorous enough, since they judged there are services good. It is

:35:36.:35:45.

important to say that when the CQC does its reports, they inspect

:35:46.:35:47.

individual elements and give different ratings to different parts

:35:48.:35:52.

of the trust. Within one trust, you can have big variations in the

:35:53.:35:55.

quality of care, but I will look into that. He rightly mentions the

:35:56.:36:03.

fact that the culture needs to change that people are more

:36:04.:36:08.

uninhibited, talking about problems within trusts and hospitals. Can I

:36:09.:36:12.

remind him that the culture starts at the top? Can he come back to the

:36:13.:36:20.

dispatch box and tell us and the families of those who have lost a

:36:21.:36:24.

loved ones when he first knew there were problems? As I have said

:36:25.:36:29.

already and I think this is the third time, BN set is that Connor

:36:30.:36:37.

Sparrowhawk's tragic death happened in July 20 13. Sarah Ryan campaigned

:36:38.:36:43.

bravely, and as always happens in these situations, it starts with a

:36:44.:36:46.

local process, where you raise the issue with your trust. That was

:36:47.:36:53.

escalated to NHS England in early 2014, when the chief executive of

:36:54.:36:59.

NHS England and the chief nurse got involved. Ministers were kept

:37:00.:37:03.

informed throughout on what was going on. That was the point in time

:37:04.:37:14.

at which the report was commissioned. It is a very thorough

:37:15.:37:18.

report, and we will now see that report when it is published before

:37:19.:37:27.

Christmas. Would the leader of the house give us the business for next

:37:28.:37:35.

week, please? The business for next week will be on Monday the 14th of

:37:36.:37:40.

December, consideration in committee and remaining stages of the European

:37:41.:37:46.

Union approval Bill, followed by a debate on a European document

:37:47.:37:50.

relating to the communication of migrants in need of international

:37:51.:37:51.

protection,

:37:52.:37:53.

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