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To ask the Secretary of State for Health if he will make a statement | :00:08. | :00:13. | |
on the report of the investigation into deaths at Southern health NHS | :00:14. | :00:26. | |
foundation trust. The whole house will be profoundly shocked by this | :00:27. | :00:29. | |
morning's allegations of a failure to investigate over 1000 unexpected | :00:30. | :00:37. | |
deaths by Southern Health Nhs Foundation Trust. Following the | :00:38. | :00:49. | |
death of a young man in July 2013, a report was commissioned into | :00:50. | :00:53. | |
unexpected deaths between April 2011 and March 20 15. The draft report, | :00:54. | :01:00. | |
submitted to NHS England in September, found a lack of | :01:01. | :01:03. | |
leadership, focus and sufficient time spent in the trust on carefully | :01:04. | :01:10. | |
reporting and investigating unexpected deaths of mental health | :01:11. | :01:15. | |
and learning disability service users. Of 1454 deaths reported, only | :01:16. | :01:24. | |
272 were investigated as critical incidents and only 195 of those were | :01:25. | :01:31. | |
reported as serious incidents, requiring investigation. The report | :01:32. | :01:36. | |
found there had been no effective, systematic management and oversight | :01:37. | :01:40. | |
of the reporting of deaths and investigations that follow. Prior to | :01:41. | :01:46. | |
publication or indeed showing the report to me, NHS England) asked the | :01:47. | :01:51. | |
trust for their comments. They accepted failures in their reporting | :01:52. | :01:56. | |
and investigations into unexpected deaths, but challenged the | :01:57. | :01:59. | |
methodology, in particular pointing out that a number of the deaths were | :02:00. | :02:04. | |
outpatients for whom they were not the primary care provider. However, | :02:05. | :02:08. | |
NHS England have assured me this morning the report will be published | :02:09. | :02:12. | |
before Christmas, and it is our intention to accept the vast | :02:13. | :02:18. | |
majority of the recommendations it makes. Our hearts go out to the | :02:19. | :02:22. | |
families of those affected. More than anything, they want to know the | :02:23. | :02:28. | |
NHS loans from tragedies and that is something we pay to Mayfield to do | :02:29. | :02:33. | |
on too many occasions at the moment. Nor should we pretend this is as the | :02:34. | :02:40. | |
result of the wrong culture at just one NHS trust. There is an urgent | :02:41. | :02:44. | |
need to improve the investigation and learning from the estimated 200 | :02:45. | :02:50. | |
double deaths we have every week across the system. I will give the | :02:51. | :02:54. | |
house more details about the report and recommendations when I have had | :02:55. | :02:58. | |
the chance to read the final version and understand the recommendations, | :02:59. | :03:02. | |
but I can tell you the important steps that will help create a | :03:03. | :03:08. | |
changing culture. Firstly, it is totally and utterly unacceptable | :03:09. | :03:13. | |
that according to the leaked report, on the 1% of the unexpected deaths | :03:14. | :03:20. | |
of patients with learning disabilities where investigated. | :03:21. | :03:24. | |
From next June, we will publish independently a steward Ofsted style | :03:25. | :03:27. | |
ratings of the quality of care offered to people with learning | :03:28. | :03:33. | |
disabilities, for all 209 areas. This will make sure we shine a | :03:34. | :03:38. | |
spotlight on variations in care, and knowing rapid action to be taken | :03:39. | :03:45. | |
when standards fall short. Secondly, NHS England have commissioned the | :03:46. | :03:48. | |
University of Bristol to do an independent study into mortality | :03:49. | :03:52. | |
rates of people with learning disabilities in NHS care. This will | :03:53. | :03:55. | |
be a very important moment to step back and look at the way we look | :03:56. | :04:00. | |
after that particular, highly formal ball group. Thirdly, I have | :04:01. | :04:05. | |
committed previously that next year, we will publish the number of | :04:06. | :04:12. | |
avoidable deaths by NHS trusts. They have worked hard to provide a | :04:13. | :04:17. | |
methodology to do this and will write to all trusts next week, | :04:18. | :04:22. | |
explaining how that works and asking them to supply estimated figures | :04:23. | :04:27. | |
that can be published in the spring. Central to this will be establishing | :04:28. | :04:32. | |
80- blame reporting culture across the NHS, where people are rewarded | :04:33. | :04:36. | |
and not penalised for speaking openly and transparently about | :04:37. | :04:43. | |
mistakes. Finally, I would like to pay tribute to corner's mother Sarah | :04:44. | :04:47. | |
Bryant, who has campaigned tirelessly to get to the bottom of | :04:48. | :04:52. | |
these issues. Her determination to make sure that her son's unexpected | :04:53. | :05:00. | |
and preventable early death is an inspiration to us all. Today, I will | :05:01. | :05:05. | |
write to her and other families affected by this and apology. These | :05:06. | :05:17. | |
are truly shocking revelations, that if proven, revealed deep failures at | :05:18. | :05:24. | |
Southern Health Foundation Trust. The BBC has reported that the | :05:25. | :05:29. | |
investigation has found over 10,000 people died between April 2011 and | :05:30. | :05:37. | |
March 2015, and of those 10,000, 1454 were not expected. All a 195 of | :05:38. | :05:44. | |
those unexpected deaths, just 13%, were treated by the trust as a | :05:45. | :05:48. | |
series incident, requiring investigation. Perhaps most | :05:49. | :05:54. | |
worryingly, it appears the likelihood of an unexpected death | :05:55. | :05:57. | |
being investigated depended hugely on the patient. For those with a | :05:58. | :06:05. | |
learning disability, just 1% of unexpected deaths were investigated. | :06:06. | :06:11. | |
And for all the people, with a mental health problem, just 0.3%. We | :06:12. | :06:16. | |
will obviously await a full response from the government, when the report | :06:17. | :06:21. | |
on the investigation is published. But there are a number of immediate | :06:22. | :06:27. | |
questions that need answers today. Firstly, does the Health Secretary | :06:28. | :06:32. | |
Judge services at the trust to be safe? A recent report found, | :06:33. | :06:40. | |
inadequate staffing levels in community health services was | :06:41. | :06:44. | |
impacting on the delivery of safe care. What advice can he give | :06:45. | :06:48. | |
patients and their families of patients currently in the care of | :06:49. | :06:56. | |
Southern Health? Secondly, can the confirm, he did confirm that NHS | :06:57. | :07:01. | |
England received this report in September. Can he explain why it | :07:02. | :07:06. | |
still hasn't been published and can he provide a specific date on which | :07:07. | :07:11. | |
the final report will be made publicly available? Thirdly, when | :07:12. | :07:18. | |
was the Health Secretary first made aware of concerns about Southern | :07:19. | :07:22. | |
Health, and what action did he personally take at that time? What | :07:23. | :07:29. | |
does he have to say to the relatives and friends of people who have | :07:30. | :07:31. | |
unexpectedly died in the care of the trust and who, today, will be | :07:32. | :07:36. | |
reliving their grief with a new anxiety. The issue raises broader | :07:37. | :07:43. | |
questions about the care of people with learning disabilities or mental | :07:44. | :07:48. | |
health problems. Just because some individuals have less ability to | :07:49. | :07:52. | |
communicate concerns about their care, must never mean that any less | :07:53. | :07:59. | |
attention is paid to their treatment or their death. This would be the | :08:00. | :08:05. | |
ultimate abnegation of responsibility and one which should | :08:06. | :08:09. | |
shame us all. The priority now must be to understand how this was | :08:10. | :08:13. | |
allowed to happen and make sure it is put right, so it can never, ever | :08:14. | :08:23. | |
happen again. I agree with what the Shadow Health Secretary says and I | :08:24. | :08:26. | |
think she's absolutely right, in both the tone of what she says and | :08:27. | :08:30. | |
the serious nurse with which she points to what has happened. It is | :08:31. | :08:33. | |
important to say that this is only a draft report. Just to put her mind | :08:34. | :08:43. | |
at rest, NHS England received, and by the way, I am completely | :08:44. | :08:46. | |
satisfied that NHS England took this seriously from the moment we | :08:47. | :08:51. | |
understood there was an issue around the tragic death of that young man. | :08:52. | :09:01. | |
CU members of South met the family and ordered the investigation. It is | :09:02. | :09:05. | |
a very thorough investigation. As she will understand, when you have | :09:06. | :09:13. | |
an investigation about as serious as avoidable mortality, you have to | :09:14. | :09:18. | |
give the staff the chance to correct it factual inaccuracies and | :09:19. | :09:23. | |
methodology. It has taken from September till now to get to the | :09:24. | :09:27. | |
point where the report is ready to be published. I have been assured | :09:28. | :09:30. | |
this morning that it will be published before Christmas, so we're | :09:31. | :09:33. | |
not going to allow any further arguing about methodology to stand | :09:34. | :09:38. | |
in a way of that report being published, as it was always planned | :09:39. | :09:45. | |
to be before Christmas. In terms of her very important question about | :09:46. | :09:52. | |
whether or not services are safe at Southern Health, we have an expert | :09:53. | :09:56. | |
view on this. That is a new inspector of hospitals and they have | :09:57. | :10:01. | |
done an inspection of Southern Health. They're not saying services | :10:02. | :10:05. | |
are as safe as they should be, they are saying that along with many | :10:06. | :10:08. | |
other trusts, services need to become safer. She was right to draw | :10:09. | :10:14. | |
attention to some of the feelings alluded to in that report. | :10:15. | :10:40. | |
The fundamental question that we will all need to reflect on is, why | :10:41. | :10:48. | |
is it that we do not currently have the right reporting culture in the | :10:49. | :10:52. | |
NHS, when it comes to unexpected deaths? I think we have to be honest | :10:53. | :11:00. | |
and depth back, there are reasons good and bad why these happens, | :11:01. | :11:05. | |
people are extremely busy, there is a huge amount of pressure on the | :11:06. | :11:08. | |
front line, there is a desire to spend clinical time with patients in | :11:09. | :11:12. | |
front of you rather than going over medical notes and trying to | :11:13. | :11:14. | |
understand something that went wrong, sometimes there will be | :11:15. | :11:19. | |
prejudiced and dissemination and the whole house will reunite in St | :11:20. | :11:28. | |
should stamp that out. Sometimes people are worried they will be | :11:29. | :11:31. | |
penalised if they speak out and we need to move away from the blame | :11:32. | :11:38. | |
culture in the NHS to a culture where doctors and nurses are | :11:39. | :11:41. | |
supported if they speak out which too often not the case. The whole | :11:42. | :11:45. | |
house will want to unite in making sure we support the leaders of the | :11:46. | :11:51. | |
NHS who want to change that culture. It is unfinished business from | :11:52. | :11:54. | |
mid-Staffs, inedible important to get it right and I know the NHS is | :11:55. | :12:00. | |
determined to do just that. The allegations in the draft report | :12:01. | :12:03. | |
about Southern health are deeply disturbing and I welcome the steps | :12:04. | :12:08. | |
that the Secretary of State has announced, and particularly that he | :12:09. | :12:15. | |
will not treat this as an isolated incident. Looking at the key | :12:16. | :12:17. | |
findings from the draft report, can I ask him, for nearly two thirds of | :12:18. | :12:23. | |
the investigation, there was no family involvement, and he sent a | :12:24. | :12:28. | |
message to all trusts that particularly for those who cannot | :12:29. | :12:32. | |
speak for themselves, it is vitally important to involve family members? | :12:33. | :12:35. | |
Will he sent up a message for a clearly today? I well and I will be | :12:36. | :12:44. | |
grateful to her for giving me the opportunity. All too often, we had a | :12:45. | :12:49. | |
story in the Sunday newspapers, another example where a family were | :12:50. | :12:57. | |
shut out of a decision involving an unexpected baby death. People with | :12:58. | :13:04. | |
mental health problems and people with learning disabilities must have | :13:05. | :13:08. | |
this support because the family might be their best advocate. We | :13:09. | :13:11. | |
need to change the assumption that things will become more difficult if | :13:12. | :13:15. | |
you involve families. More often than not, things like litigation | :13:16. | :13:21. | |
melt away if families are involved properly from the outset of a | :13:22. | :13:24. | |
problem. It is when families feel that the door is being slammed in | :13:25. | :13:27. | |
their face that they feel they have to resort to the courts which is in | :13:28. | :13:35. | |
no 1's interest. I would echo what the Secretary of State said about | :13:36. | :13:42. | |
family involvement which should be routine in investigating an advert | :13:43. | :13:46. | |
event and it definitely takes the heat out of the situation. -- | :13:47. | :13:51. | |
adverse event. There is a shocking difference in 30% of adult deaths | :13:52. | :13:58. | |
being investigated and 1% of people with learning disabilities, and | :13:59. | :14:01. | |
Connor represents the human face of that and that is frightening. The | :14:02. | :14:06. | |
second issue is, it is being left to death to individual trusts to | :14:07. | :14:10. | |
describe but they are investigating and what they produce. I think it is | :14:11. | :14:13. | |
required that there is a much more systematic looking at the hotel. NHS | :14:14. | :14:18. | |
England publish the annual mortality figures and what is very striking is | :14:19. | :14:25. | |
that there are trusts, 16 trust identified with higher than expected | :14:26. | :14:28. | |
mortality that had higher than expected mortality the year before. | :14:29. | :14:33. | |
And there does not appear to be any action taken. The problem is, the | :14:34. | :14:37. | |
benchmark appears to be average. If you are having poor performance, | :14:38. | :14:42. | |
average is set lower, we should be aspiring higher than that. She is | :14:43. | :14:49. | |
absolutely right and I would argue that 30%, the 30% figure was people | :14:50. | :14:54. | |
with mental health conditions, it was not all adults. I would question | :14:55. | :15:01. | |
why we are only investigating 30%, which is the highest, of unexpected | :15:02. | :15:06. | |
deaths. These are not just deaths, they were unexpected deaths. I dig | :15:07. | :15:10. | |
it is the duty of every medical director in every trust to satisfy | :15:11. | :15:13. | |
themselves that they have thought about every single unexpected death. | :15:14. | :15:18. | |
There are some very serious things that we need to reflect on. She is | :15:19. | :15:25. | |
right about the need to get a system of process when there is an | :15:26. | :15:30. | |
unexpected death so that we do not have variation between trusts. The | :15:31. | :15:37. | |
exercise that we are doing at the moment is about trying to establish | :15:38. | :15:41. | |
standardised way of understanding when death is preventable and when | :15:42. | :15:45. | |
it is not. At the heart of this, as I am sure she is able to understand | :15:46. | :15:55. | |
as a practising physician, is getting it right so the trusts will | :15:56. | :15:59. | |
not take the easy route and blame the clinician rather than trying to | :16:00. | :16:04. | |
understand the systemwide problems which might have caused the | :16:05. | :16:06. | |
clinician to make a mistake in each individual instant. Behind each | :16:07. | :16:13. | |
statistic is a person and the Secretary of State is absolutely | :16:14. | :16:16. | |
right to say that finger-pointing should not be at clinicians alone. | :16:17. | :16:22. | |
It is much more importance to look at the whole system and the culture | :16:23. | :16:26. | |
within a trust. Would he please encourage all trusts, and, indeed, | :16:27. | :16:32. | |
all medical schools and nursing schools to make the reading of the | :16:33. | :16:36. | |
Francis Report into mid Staffordshire compulsory? There is | :16:37. | :16:39. | |
so much in there that could prevent future occurrences like this. No one | :16:40. | :16:45. | |
knows more about the Francis Report than he does because of the direct | :16:46. | :16:49. | |
impact he had on his own local hospital. He is right to talk about | :16:50. | :16:54. | |
that culture change. There is an interesting comparison to the | :16:55. | :16:56. | |
airline industry, when they investigate accidents. The vast | :16:57. | :17:01. | |
majority of times, those investigations point to systemic | :17:02. | :17:07. | |
failure but when the NHS investigates clinical accident, the | :17:08. | :17:10. | |
vast majority of times, we pointed individual failure. It is not | :17:11. | :17:15. | |
surprising that clinicians feel about intimidated about speaking | :17:16. | :17:23. | |
out. They want to do the right thing for patients and we need to support | :17:24. | :17:29. | |
them. The Coalition Government rightly established a public enquiry | :17:30. | :17:35. | |
to look into the appalling care at mid Staffordshire Hospital and the | :17:36. | :17:37. | |
Secretary of State has rightly pointed to the challenge to culture | :17:38. | :17:42. | |
that that was port, the Francis Report, in gendered followed -- that | :17:43. | :17:47. | |
report, in gendered following a scandal. We need to do something | :17:48. | :17:55. | |
similar for people with learning disabilities and mental health | :17:56. | :17:59. | |
issues who too often I treated as second-class citizens in the NHS? It | :18:00. | :18:07. | |
seems the time is right to shine a light on what is going on. | :18:08. | :18:11. | |
I am happy to consider it. First of all, let me say that he and I are on | :18:12. | :18:19. | |
the same page on these issues. My only hesitation is that public | :18:20. | :18:24. | |
enquiries take two or three or four years, and I want to make sure we | :18:25. | :18:30. | |
take action now. I hope that I can reassure him and the House that, for | :18:31. | :18:36. | |
example, by publishing Ofsted style ratings of the quality of care for | :18:37. | :18:40. | |
people with learning disabilities across all areas, we will shine a | :18:41. | :18:43. | |
spotlight on poor care in a way that the Francis Report tells us we must | :18:44. | :18:51. | |
do. I do not see the treatment of people with learning disabilities | :18:52. | :18:54. | |
distinct from the broader lessons of the Francis Report. If I fail to | :18:55. | :18:57. | |
make progress and know he will come back to me and rightly so. Many of | :18:58. | :19:04. | |
my constituents will be service users of Southern Health and the | :19:05. | :19:07. | |
families of service users. What they are looking for from the Secretary | :19:08. | :19:11. | |
of State is reassurance that this is not simply going to be an immediate | :19:12. | :19:16. | |
intense Scott light but an ongoing one, -- spotlight, and they will | :19:17. | :19:20. | |
have confidence going forward that the scrutiny and oversight, | :19:21. | :19:23. | |
particularly in the case of young people with learning difficulties, | :19:24. | :19:27. | |
will be ongoing. I can absolutely give that assurance to her | :19:28. | :19:31. | |
constituents. I would say this, I hope that they will look at the tone | :19:32. | :19:36. | |
of what I said in my earlier statement and realise that we are | :19:37. | :19:40. | |
not looking at this simply as an issue in Southern Health. There are | :19:41. | :19:43. | |
clearly important changes that must happen there and happen quickly, and | :19:44. | :19:47. | |
we will do everything we can to make sure they happen. There is a | :19:48. | :19:54. | |
systemic issue over the low reporting of avoidable and | :19:55. | :19:58. | |
preventable deaths and avoidable and preventable harm. And the failure to | :19:59. | :20:01. | |
develop a true learning culture in the NHS which in the end is what | :20:02. | :20:05. | |
doctors, nurses and patients all want and need. Can I thank him for | :20:06. | :20:11. | |
his payment and congratulate NHS ins and for what sounds like a very | :20:12. | :20:19. | |
thorough support. -- report. Challenging the methodology is the | :20:20. | :20:22. | |
first offence used by the now disgraced management at mid Staffs | :20:23. | :20:28. | |
hospital. -- first defence. Will he answer the question as to where | :20:29. | :20:31. | |
ministers first knew about problems in this trust which went back to | :20:32. | :20:35. | |
2011, and what actions need to be taken as a result? I thank him for | :20:36. | :20:40. | |
his comment and I hope I did just that by saying that the first time | :20:41. | :20:43. | |
that we realised there was an issue was when we realised that there were | :20:44. | :20:50. | |
issues around the tragic death of Conor sparrowhawk. That is what | :20:51. | :20:53. | |
started the process going which led to the independent investigation and | :20:54. | :20:58. | |
that investigation, because NHS England wanted it to be very | :20:59. | :21:01. | |
thorough, went right there when it back to 2011 and carried on right | :21:02. | :21:06. | |
the way until 2015, looked at all unexpected deaths in that period. | :21:07. | :21:10. | |
But at the reporting culture and the lessons that had not been learned as | :21:11. | :21:14. | |
a result. This is something where a lot of action has been taken. I | :21:15. | :21:20. | |
cannot reassure him that during that period, we have been implementing | :21:21. | :21:23. | |
the recommendations of the Francis Report which have meant that | :21:24. | :21:27. | |
throughout the NHS, there is a much greater focus on patient safety, | :21:28. | :21:32. | |
much more transparency about safety, and indeed, it is important to give | :21:33. | :21:37. | |
the NHS credit. During a three-year period, we have seen 25% increase in | :21:38. | :21:42. | |
the number of reported incidents so I think people are treating this | :21:43. | :21:47. | |
much more seriously than the past but there is much more to do. Can I | :21:48. | :21:51. | |
also welcomed the statement from my right honourable friend, and the | :21:52. | :21:57. | |
news that he is planning to accent the recommendations from this very | :21:58. | :22:02. | |
sobering report. -- accept. Can he also reassure the House that anyone | :22:03. | :22:06. | |
found to be deliberately contributing to patient neglect or | :22:07. | :22:10. | |
failing to investigate avoidable deaths will be held to account both | :22:11. | :22:13. | |
by the professional regulators and by the full weight of the law? I can | :22:14. | :22:21. | |
of course give her that assurance. But there is a note of hesitation in | :22:22. | :22:29. | |
my response to that. Partly because professional standards, as she will | :22:30. | :22:38. | |
know, not a matter for politicians and have to be done by the GMC and | :22:39. | :22:43. | |
MMC. If we are going to improve the reporting culture, which is what | :22:44. | :22:46. | |
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 | :22:55. | :22:57. | |
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, | :23:03. | :23:06. | |
when people take the brave decision to be open about that has gone | :23:07. | :23:11. | |
wrong, they get the support that they deserve. As well as asking the | :23:12. | :23:18. | |
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 | :23:40. | :23:45. | |
regard? Is he made whether they will be sensitive about historic cases? | :23:46. | :23:52. | |
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 | :24:00. | :24:05. | |
potentially avoidable and preventable deaths. I hope this will | :24:06. | :24:08. | |
be a reminder to all trusts that they need to take those concerns | :24:09. | :24:13. | |
very seriously indeed. The disparity in excess deaths between honourable | :24:14. | :24:19. | |
groups at Southern Health is truly shocking, but of course, | :24:20. | :24:23. | |
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 | :24:39. | :24:44. | |
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 | :24:54. | :25:04. | |
we have good methodology for understanding the number of | :25:05. | :25:11. | |
avoidable deaths. It is not until we localise it that we will get real | :25:12. | :25:16. | |
local action and that is the next step. I wondered if the Secretary of | :25:17. | :25:20. | |
State is satisfied that for families to seek truth and justice for their | :25:21. | :25:26. | |
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 | :25:35. | :25:45. | |
probably does happen, but what I would say is we all passionately | :25:46. | :25:48. | |
believe in the NHS and support it. It should never come down to | :25:49. | :25:54. | |
lawyers. If that is a problem, we needs a culture where the NHS is | :25:55. | :25:57. | |
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 | :26:02. | :26:09. | |
the thing we need to learn from this report. It is clear there is a | :26:10. | :26:17. | |
cultural problem, both in Southern Health and across the NHS. Does he | :26:18. | :26:24. | |
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 | :26:37. | :26:40. | |
heartbreaking that when these things happen, we seem to have an argument | :26:41. | :26:44. | |
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. |