:00:08. > :00:13.To ask the Secretary of State for Health if he will make a statement
:00:14. > :00:26.on the report of the investigation into deaths at Southern health NHS
:00:27. > :00:29.foundation trust. The whole house will be profoundly shocked by this
:00:30. > :00:37.morning's allegations of a failure to investigate over 1000 unexpected
:00:38. > :00:49.deaths by Southern Health Nhs Foundation Trust. Following the
:00:50. > :00:53.death of a young man in July 2013, a report was commissioned into
:00:54. > :01:00.unexpected deaths between April 2011 and March 20 15. The draft report,
:01:01. > :01:03.submitted to NHS England in September, found a lack of
:01:04. > :01:10.leadership, focus and sufficient time spent in the trust on carefully
:01:11. > :01:15.reporting and investigating unexpected deaths of mental health
:01:16. > :01:24.and learning disability service users. Of 1454 deaths reported, only
:01:25. > :01:31.272 were investigated as critical incidents and only 195 of those were
:01:32. > :01:36.reported as serious incidents, requiring investigation. The report
:01:37. > :01:40.found there had been no effective, systematic management and oversight
:01:41. > :01:46.of the reporting of deaths and investigations that follow. Prior to
:01:47. > :01:51.publication or indeed showing the report to me, NHS England) asked the
:01:52. > :01:56.trust for their comments. They accepted failures in their reporting
:01:57. > :01:59.and investigations into unexpected deaths, but challenged the
:02:00. > :02:04.methodology, in particular pointing out that a number of the deaths were
:02:05. > :02:08.outpatients for whom they were not the primary care provider. However,
:02:09. > :02:12.NHS England have assured me this morning the report will be published
:02:13. > :02:18.before Christmas, and it is our intention to accept the vast
:02:19. > :02:22.majority of the recommendations it makes. Our hearts go out to the
:02:23. > :02:28.families of those affected. More than anything, they want to know the
:02:29. > :02:33.NHS loans from tragedies and that is something we pay to Mayfield to do
:02:34. > :02:40.on too many occasions at the moment. Nor should we pretend this is as the
:02:41. > :02:44.result of the wrong culture at just one NHS trust. There is an urgent
:02:45. > :02:50.need to improve the investigation and learning from the estimated 200
:02:51. > :02:54.double deaths we have every week across the system. I will give the
:02:55. > :02:58.house more details about the report and recommendations when I have had
:02:59. > :03:02.the chance to read the final version and understand the recommendations,
:03:03. > :03:08.but I can tell you the important steps that will help create a
:03:09. > :03:13.changing culture. Firstly, it is totally and utterly unacceptable
:03:14. > :03:20.that according to the leaked report, on the 1% of the unexpected deaths
:03:21. > :03:24.of patients with learning disabilities where investigated.
:03:25. > :03:27.From next June, we will publish independently a steward Ofsted style
:03:28. > :03:33.ratings of the quality of care offered to people with learning
:03:34. > :03:38.disabilities, for all 209 areas. This will make sure we shine a
:03:39. > :03:45.spotlight on variations in care, and knowing rapid action to be taken
:03:46. > :03:48.when standards fall short. Secondly, NHS England have commissioned the
:03:49. > :03:52.University of Bristol to do an independent study into mortality
:03:53. > :03:55.rates of people with learning disabilities in NHS care. This will
:03:56. > :04:00.be a very important moment to step back and look at the way we look
:04:01. > :04:05.after that particular, highly formal ball group. Thirdly, I have
:04:06. > :04:12.committed previously that next year, we will publish the number of
:04:13. > :04:17.avoidable deaths by NHS trusts. They have worked hard to provide a
:04:18. > :04:22.methodology to do this and will write to all trusts next week,
:04:23. > :04:27.explaining how that works and asking them to supply estimated figures
:04:28. > :04:32.that can be published in the spring. Central to this will be establishing
:04:33. > :04:36.80- blame reporting culture across the NHS, where people are rewarded
:04:37. > :04:43.and not penalised for speaking openly and transparently about
:04:44. > :04:47.mistakes. Finally, I would like to pay tribute to corner's mother Sarah
:04:48. > :04:52.Bryant, who has campaigned tirelessly to get to the bottom of
:04:53. > :05:00.these issues. Her determination to make sure that her son's unexpected
:05:01. > :05:05.and preventable early death is an inspiration to us all. Today, I will
:05:06. > :05:17.write to her and other families affected by this and apology. These
:05:18. > :05:24.are truly shocking revelations, that if proven, revealed deep failures at
:05:25. > :05:29.Southern Health Foundation Trust. The BBC has reported that the
:05:30. > :05:37.investigation has found over 10,000 people died between April 2011 and
:05:38. > :05:44.March 2015, and of those 10,000, 1454 were not expected. All a 195 of
:05:45. > :05:48.those unexpected deaths, just 13%, were treated by the trust as a
:05:49. > :05:54.series incident, requiring investigation. Perhaps most
:05:55. > :05:57.worryingly, it appears the likelihood of an unexpected death
:05:58. > :06:05.being investigated depended hugely on the patient. For those with a
:06:06. > :06:11.learning disability, just 1% of unexpected deaths were investigated.
:06:12. > :06:16.And for all the people, with a mental health problem, just 0.3%. We
:06:17. > :06:21.will obviously await a full response from the government, when the report
:06:22. > :06:27.on the investigation is published. But there are a number of immediate
:06:28. > :06:32.questions that need answers today. Firstly, does the Health Secretary
:06:33. > :06:40.Judge services at the trust to be safe? A recent report found,
:06:41. > :06:44.inadequate staffing levels in community health services was
:06:45. > :06:48.impacting on the delivery of safe care. What advice can he give
:06:49. > :06:56.patients and their families of patients currently in the care of
:06:57. > :07:01.Southern Health? Secondly, can the confirm, he did confirm that NHS
:07:02. > :07:06.England received this report in September. Can he explain why it
:07:07. > :07:11.still hasn't been published and can he provide a specific date on which
:07:12. > :07:18.the final report will be made publicly available? Thirdly, when
:07:19. > :07:22.was the Health Secretary first made aware of concerns about Southern
:07:23. > :07:29.Health, and what action did he personally take at that time? What
:07:30. > :07:31.does he have to say to the relatives and friends of people who have
:07:32. > :07:36.unexpectedly died in the care of the trust and who, today, will be
:07:37. > :07:43.reliving their grief with a new anxiety. The issue raises broader
:07:44. > :07:48.questions about the care of people with learning disabilities or mental
:07:49. > :07:52.health problems. Just because some individuals have less ability to
:07:53. > :07:59.communicate concerns about their care, must never mean that any less
:08:00. > :08:05.attention is paid to their treatment or their death. This would be the
:08:06. > :08:09.ultimate abnegation of responsibility and one which should
:08:10. > :08:13.shame us all. The priority now must be to understand how this was
:08:14. > :08:23.allowed to happen and make sure it is put right, so it can never, ever
:08:24. > :08:26.happen again. I agree with what the Shadow Health Secretary says and I
:08:27. > :08:30.think she's absolutely right, in both the tone of what she says and
:08:31. > :08:33.the serious nurse with which she points to what has happened. It is
:08:34. > :08:43.important to say that this is only a draft report. Just to put her mind
:08:44. > :08:46.at rest, NHS England received, and by the way, I am completely
:08:47. > :08:51.satisfied that NHS England took this seriously from the moment we
:08:52. > :09:01.understood there was an issue around the tragic death of that young man.
:09:02. > :09:05.CU members of South met the family and ordered the investigation. It is
:09:06. > :09:13.a very thorough investigation. As she will understand, when you have
:09:14. > :09:18.an investigation about as serious as avoidable mortality, you have to
:09:19. > :09:23.give the staff the chance to correct it factual inaccuracies and
:09:24. > :09:27.methodology. It has taken from September till now to get to the
:09:28. > :09:30.point where the report is ready to be published. I have been assured
:09:31. > :09:33.this morning that it will be published before Christmas, so we're
:09:34. > :09:38.not going to allow any further arguing about methodology to stand
:09:39. > :09:45.in a way of that report being published, as it was always planned
:09:46. > :09:52.to be before Christmas. In terms of her very important question about
:09:53. > :09:56.whether or not services are safe at Southern Health, we have an expert
:09:57. > :10:01.view on this. That is a new inspector of hospitals and they have
:10:02. > :10:05.done an inspection of Southern Health. They're not saying services
:10:06. > :10:08.are as safe as they should be, they are saying that along with many
:10:09. > :10:14.other trusts, services need to become safer. She was right to draw
:10:15. > :10:40.attention to some of the feelings alluded to in that report.
:10:41. > :10:48.The fundamental question that we will all need to reflect on is, why
:10:49. > :10:52.is it that we do not currently have the right reporting culture in the
:10:53. > :11:00.NHS, when it comes to unexpected deaths? I think we have to be honest
:11:01. > :11:05.and depth back, there are reasons good and bad why these happens,
:11:06. > :11:08.people are extremely busy, there is a huge amount of pressure on the
:11:09. > :11:12.front line, there is a desire to spend clinical time with patients in
:11:13. > :11:14.front of you rather than going over medical notes and trying to
:11:15. > :11:19.understand something that went wrong, sometimes there will be
:11:20. > :11:28.prejudiced and dissemination and the whole house will reunite in St
:11:29. > :11:31.should stamp that out. Sometimes people are worried they will be
:11:32. > :11:38.penalised if they speak out and we need to move away from the blame
:11:39. > :11:41.culture in the NHS to a culture where doctors and nurses are
:11:42. > :11:45.supported if they speak out which too often not the case. The whole
:11:46. > :11:51.house will want to unite in making sure we support the leaders of the
:11:52. > :11:54.NHS who want to change that culture. It is unfinished business from
:11:55. > :12:00.mid-Staffs, inedible important to get it right and I know the NHS is
:12:01. > :12:03.determined to do just that. The allegations in the draft report
:12:04. > :12:08.about Southern health are deeply disturbing and I welcome the steps
:12:09. > :12:15.that the Secretary of State has announced, and particularly that he
:12:16. > :12:17.will not treat this as an isolated incident. Looking at the key
:12:18. > :12:23.findings from the draft report, can I ask him, for nearly two thirds of
:12:24. > :12:28.the investigation, there was no family involvement, and he sent a
:12:29. > :12:32.message to all trusts that particularly for those who cannot
:12:33. > :12:35.speak for themselves, it is vitally important to involve family members?
:12:36. > :12:44.Will he sent up a message for a clearly today? I well and I will be
:12:45. > :12:49.grateful to her for giving me the opportunity. All too often, we had a
:12:50. > :12:57.story in the Sunday newspapers, another example where a family were
:12:58. > :13:04.shut out of a decision involving an unexpected baby death. People with
:13:05. > :13:08.mental health problems and people with learning disabilities must have
:13:09. > :13:11.this support because the family might be their best advocate. We
:13:12. > :13:15.need to change the assumption that things will become more difficult if
:13:16. > :13:21.you involve families. More often than not, things like litigation
:13:22. > :13:24.melt away if families are involved properly from the outset of a
:13:25. > :13:27.problem. It is when families feel that the door is being slammed in
:13:28. > :13:35.their face that they feel they have to resort to the courts which is in
:13:36. > :13:42.no 1's interest. I would echo what the Secretary of State said about
:13:43. > :13:46.family involvement which should be routine in investigating an advert
:13:47. > :13:51.event and it definitely takes the heat out of the situation. --
:13:52. > :13:58.adverse event. There is a shocking difference in 30% of adult deaths
:13:59. > :14:01.being investigated and 1% of people with learning disabilities, and
:14:02. > :14:06.Connor represents the human face of that and that is frightening. The
:14:07. > :14:10.second issue is, it is being left to death to individual trusts to
:14:11. > :14:13.describe but they are investigating and what they produce. I think it is
:14:14. > :14:18.required that there is a much more systematic looking at the hotel. NHS
:14:19. > :14:25.England publish the annual mortality figures and what is very striking is
:14:26. > :14:28.that there are trusts, 16 trust identified with higher than expected
:14:29. > :14:33.mortality that had higher than expected mortality the year before.
:14:34. > :14:37.And there does not appear to be any action taken. The problem is, the
:14:38. > :14:42.benchmark appears to be average. If you are having poor performance,
:14:43. > :14:49.average is set lower, we should be aspiring higher than that. She is
:14:50. > :14:54.absolutely right and I would argue that 30%, the 30% figure was people
:14:55. > :15:01.with mental health conditions, it was not all adults. I would question
:15:02. > :15:06.why we are only investigating 30%, which is the highest, of unexpected
:15:07. > :15:10.deaths. These are not just deaths, they were unexpected deaths. I dig
:15:11. > :15:13.it is the duty of every medical director in every trust to satisfy
:15:14. > :15:18.themselves that they have thought about every single unexpected death.
:15:19. > :15:25.There are some very serious things that we need to reflect on. She is
:15:26. > :15:30.right about the need to get a system of process when there is an
:15:31. > :15:37.unexpected death so that we do not have variation between trusts. The
:15:38. > :15:41.exercise that we are doing at the moment is about trying to establish
:15:42. > :15:45.standardised way of understanding when death is preventable and when
:15:46. > :15:55.it is not. At the heart of this, as I am sure she is able to understand
:15:56. > :15:59.as a practising physician, is getting it right so the trusts will
:16:00. > :16:04.not take the easy route and blame the clinician rather than trying to
:16:05. > :16:06.understand the systemwide problems which might have caused the
:16:07. > :16:13.clinician to make a mistake in each individual instant. Behind each
:16:14. > :16:16.statistic is a person and the Secretary of State is absolutely
:16:17. > :16:22.right to say that finger-pointing should not be at clinicians alone.
:16:23. > :16:26.It is much more importance to look at the whole system and the culture
:16:27. > :16:32.within a trust. Would he please encourage all trusts, and, indeed,
:16:33. > :16:36.all medical schools and nursing schools to make the reading of the
:16:37. > :16:39.Francis Report into mid Staffordshire compulsory? There is
:16:40. > :16:45.so much in there that could prevent future occurrences like this. No one
:16:46. > :16:49.knows more about the Francis Report than he does because of the direct
:16:50. > :16:54.impact he had on his own local hospital. He is right to talk about
:16:55. > :16:56.that culture change. There is an interesting comparison to the
:16:57. > :17:01.airline industry, when they investigate accidents. The vast
:17:02. > :17:07.majority of times, those investigations point to systemic
:17:08. > :17:10.failure but when the NHS investigates clinical accident, the
:17:11. > :17:15.vast majority of times, we pointed individual failure. It is not
:17:16. > :17:23.surprising that clinicians feel about intimidated about speaking
:17:24. > :17:29.out. They want to do the right thing for patients and we need to support
:17:30. > :17:35.them. The Coalition Government rightly established a public enquiry
:17:36. > :17:37.to look into the appalling care at mid Staffordshire Hospital and the
:17:38. > :17:42.Secretary of State has rightly pointed to the challenge to culture
:17:43. > :17:47.that that was port, the Francis Report, in gendered followed -- that
:17:48. > :17:55.report, in gendered following a scandal. We need to do something
:17:56. > :17:59.similar for people with learning disabilities and mental health
:18:00. > :18:07.issues who too often I treated as second-class citizens in the NHS? It
:18:08. > :18:11.seems the time is right to shine a light on what is going on.
:18:12. > :18:19.I am happy to consider it. First of all, let me say that he and I are on
:18:20. > :18:24.the same page on these issues. My only hesitation is that public
:18:25. > :18:30.enquiries take two or three or four years, and I want to make sure we
:18:31. > :18:36.take action now. I hope that I can reassure him and the House that, for
:18:37. > :18:40.example, by publishing Ofsted style ratings of the quality of care for
:18:41. > :18:43.people with learning disabilities across all areas, we will shine a
:18:44. > :18:51.spotlight on poor care in a way that the Francis Report tells us we must
:18:52. > :18:54.do. I do not see the treatment of people with learning disabilities
:18:55. > :18:57.distinct from the broader lessons of the Francis Report. If I fail to
:18:58. > :19:04.make progress and know he will come back to me and rightly so. Many of
:19:05. > :19:07.my constituents will be service users of Southern Health and the
:19:08. > :19:11.families of service users. What they are looking for from the Secretary
:19:12. > :19:16.of State is reassurance that this is not simply going to be an immediate
:19:17. > :19:20.intense Scott light but an ongoing one, -- spotlight, and they will
:19:21. > :19:23.have confidence going forward that the scrutiny and oversight,
:19:24. > :19:27.particularly in the case of young people with learning difficulties,
:19:28. > :19:31.will be ongoing. I can absolutely give that assurance to her
:19:32. > :19:36.constituents. I would say this, I hope that they will look at the tone
:19:37. > :19:40.of what I said in my earlier statement and realise that we are
:19:41. > :19:43.not looking at this simply as an issue in Southern Health. There are
:19:44. > :19:47.clearly important changes that must happen there and happen quickly, and
:19:48. > :19:54.we will do everything we can to make sure they happen. There is a
:19:55. > :19:58.systemic issue over the low reporting of avoidable and
:19:59. > :20:01.preventable deaths and avoidable and preventable harm. And the failure to
:20:02. > :20:05.develop a true learning culture in the NHS which in the end is what
:20:06. > :20:11.doctors, nurses and patients all want and need. Can I thank him for
:20:12. > :20:19.his payment and congratulate NHS ins and for what sounds like a very
:20:20. > :20:22.thorough support. -- report. Challenging the methodology is the
:20:23. > :20:28.first offence used by the now disgraced management at mid Staffs
:20:29. > :20:31.hospital. -- first defence. Will he answer the question as to where
:20:32. > :20:35.ministers first knew about problems in this trust which went back to
:20:36. > :20:40.2011, and what actions need to be taken as a result? I thank him for
:20:41. > :20:43.his comment and I hope I did just that by saying that the first time
:20:44. > :20:50.that we realised there was an issue was when we realised that there were
:20:51. > :20:53.issues around the tragic death of Conor sparrowhawk. That is what
:20:54. > :20:58.started the process going which led to the independent investigation and
:20:59. > :21:01.that investigation, because NHS England wanted it to be very
:21:02. > :21:06.thorough, went right there when it back to 2011 and carried on right
:21:07. > :21:10.the way until 2015, looked at all unexpected deaths in that period.
:21:11. > :21:14.But at the reporting culture and the lessons that had not been learned as
:21:15. > :21:20.a result. This is something where a lot of action has been taken. I
:21:21. > :21:23.cannot reassure him that during that period, we have been implementing
:21:24. > :21:27.the recommendations of the Francis Report which have meant that
:21:28. > :21:32.throughout the NHS, there is a much greater focus on patient safety,
:21:33. > :21:37.much more transparency about safety, and indeed, it is important to give
:21:38. > :21:42.the NHS credit. During a three-year period, we have seen 25% increase in
:21:43. > :21:47.the number of reported incidents so I think people are treating this
:21:48. > :21:51.much more seriously than the past but there is much more to do. Can I
:21:52. > :21:57.also welcomed the statement from my right honourable friend, and the
:21:58. > :22:02.news that he is planning to accent the recommendations from this very
:22:03. > :22:06.sobering report. -- accept. Can he also reassure the House that anyone
:22:07. > :22:10.found to be deliberately contributing to patient neglect or
:22:11. > :22:13.failing to investigate avoidable deaths will be held to account both
:22:14. > :22:21.by the professional regulators and by the full weight of the law? I can
:22:22. > :22:29.of course give her that assurance. But there is a note of hesitation in
:22:30. > :22:38.my response to that. Partly because professional standards, as she will
:22:39. > :22:43.know, not a matter for politicians and have to be done by the GMC and
:22:44. > :22:46.MMC. If we are going to improve the reporting culture, which is what
:22:47. > :22:50.this report is about, we had to change the fear that many doctors
:22:51. > :22:54.and nurses have that if they are open and transparent about mistakes
:22:55. > :22:57.that they have made or they have seen, that they are going to get
:22:58. > :23:02.dumped on. And that is something that is a real worry for many
:23:03. > :23:06.people. I think part of this is creating supportive culture where,
:23:07. > :23:11.when people take the brave decision to be open about that has gone
:23:12. > :23:18.wrong, they get the support that they deserve. As well as asking the
:23:19. > :23:22.Secretary of State about how the learning on this very important
:23:23. > :23:27.issue will be shared with the devolved administrations, can I ask
:23:28. > :23:31.him, whether or not all of the trusts are being advised that they
:23:32. > :23:36.will now probably received approaches from families who have
:23:37. > :23:39.questions about their own experiences, and no doubt honourable
:23:40. > :23:45.members maybe counteracted in that regard? Is he -- contacted in that
:23:46. > :23:52.regard? Is he made whether they will be sensitive about historic cases?
:23:53. > :23:59.I can give him that reassurance. I think trusts are already doing that
:24:00. > :24:05.and families will have had people in touch with them about concerns about
:24:06. > :24:08.potentially avoidable and preventable deaths. I hope this will
:24:09. > :24:13.be a reminder to all trusts that they need to take those concerns
:24:14. > :24:19.very seriously indeed. The disparity in excess deaths between honourable
:24:20. > :24:23.groups at Southern Health is truly shocking, but of course,
:24:24. > :24:29.responsibility for looking after the people in question does span health
:24:30. > :24:32.and social care. If the content that we have the Informatik someplace
:24:33. > :24:38.that will allow outliers to be identified and therefore read to
:24:39. > :24:44.occasion to be under way. One assumes that could easily be done by
:24:45. > :24:50.NHS England, but at the moment, it seems in format X is problematic.
:24:51. > :24:53.He's absolutely right and that is why the professor is developing a
:24:54. > :25:04.methodology to help us understand number of avoidable deaths. I think
:25:05. > :25:11.we have good methodology for understanding the number of
:25:12. > :25:16.avoidable deaths. It is not until we localise it that we will get real
:25:17. > :25:20.local action and that is the next step. I wondered if the Secretary of
:25:21. > :25:26.State is satisfied that for families to seek truth and justice for their
:25:27. > :25:34.loved ones, they are having to rely on parole board all lawyers for
:25:35. > :25:45.information and for crowd sourcing to get legal help. I'm afraid that
:25:46. > :25:48.probably does happen, but what I would say is we all passionately
:25:49. > :25:54.believe in the NHS and support it. It should never come down to
:25:55. > :25:57.lawyers. If that is a problem, we needs a culture where the NHS is
:25:58. > :26:01.totally open and skin the families are themselves to understand what
:26:02. > :26:09.happened and what lessons can be learned. If nothing else, that is
:26:10. > :26:17.the thing we need to learn from this report. It is clear there is a
:26:18. > :26:24.cultural problem, both in Southern Health and across the NHS. Does he
:26:25. > :26:27.agree with me that far too often, NHS management and clinicians are
:26:28. > :26:31.far too defensive, end up arguing about the data rather than
:26:32. > :26:36.addressing the underlying causes, which of the address them, would fix
:26:37. > :26:40.the problem in the first place. He is right, and I think it is quite
:26:41. > :26:44.heartbreaking that when these things happen, we seem to have an argument
:26:45. > :26:49.about methodology and statistics, and is it that many thousands,
:26:50. > :26:53.rather than looking at the underlying causes. But we also have
:26:54. > :26:59.to ask yourselves why it is people feel they need to be defensive in
:27:00. > :27:04.these situations. We have to recognise that everyone is human,
:27:05. > :27:08.but uniquely, doctors are in a profession where, when they make
:27:09. > :27:14.mistakes, as we all doing our own worlds, sometimes died. The result
:27:15. > :27:18.of that shouldn't automatically be to say that the doctor was
:27:19. > :27:22.clinically negligent. 99 times out of a hundred, what we should you
:27:23. > :27:26.juice is what can be learned to avoid that mistake in the future. Of
:27:27. > :27:30.course, when that is gross negligence, due process should take
:27:31. > :27:34.its course, but that's only a minority of cases. And I think
:27:35. > :27:38.that's where things have gone wrong. Not many people are as grateful to
:27:39. > :27:45.the NHS as I am, who has just returned to full health, thankfully,
:27:46. > :27:52.due to the intervention of the wonderful team at the Guy 's
:27:53. > :27:56.Hospital. Many of us have known for a long time that access to full
:27:57. > :28:05.national health treatment for people with learning difficulties and
:28:06. > :28:09.particularly people on the autism spectrum, there are very many of
:28:10. > :28:15.them with poor communication skills, who finish up with inadequate access
:28:16. > :28:22.to the health service. I don't particularly want a public enquiry,
:28:23. > :28:28.I want fast action to change. I am delighted he was looked after by Guy
:28:29. > :28:32.'s Hospital, where my mother was a nurse and I was born, so I have
:28:33. > :28:37.connections to that trust as well. He is right in what he says, in
:28:38. > :28:41.making sure we get this culture right. It is something about
:28:42. > :28:45.creating a more supportive environment for the people who do a
:28:46. > :28:51.very, very tough job every day of the week. I think, when you have a
:28:52. > :28:54.conversation with patients, with their constituents, they understand
:28:55. > :29:01.as well. What they need to know is that lessons will be learned and
:29:02. > :29:08.acted upon. Was it necessary to delay the publication of the report
:29:09. > :29:12.for 23 months, a week or two I could understand, but not to three months,
:29:13. > :29:17.and here it will now not be published in a fortnight's time
:29:18. > :29:21.before Christmas, but next week, when we will be here. I hope it will
:29:22. > :29:26.be published next week. The commitment I have had from NHS
:29:27. > :29:31.England is it will be published before Christmas. I'm confident that
:29:32. > :29:36.it will get a huge amount of media interest, rightly so, and partly
:29:37. > :29:39.thanks to the Shadow Health Secretary's question today. When the
:29:40. > :29:44.draft report was sent to the trust, they did come back with 300
:29:45. > :29:50.individual items of concern about the draft report. And they think it
:29:51. > :29:56.was right for NHS England, just in the interests of accuracy and
:29:57. > :30:03.justice, to consider those issues raised by the trust. They have given
:30:04. > :30:06.me assurance that the report will now be published before Christmas,
:30:07. > :30:12.whether they have reached agreement with the trust or not. What is the
:30:13. > :30:20.Secretary of State during about whistle-blowing, because I'm sure
:30:21. > :30:23.that most of us have had problems in the past. Some people have been
:30:24. > :30:29.victims of the National Health Service because of their concerns.
:30:30. > :30:36.What will he do about that? We had a full report done by Sir Robert
:30:37. > :30:39.Francis, the Freedom To Speak Up report, which I presented just
:30:40. > :30:44.before the election, which looked specifically at this issue. The
:30:45. > :30:49.problem people have when they speak out about a problem in their trusts,
:30:50. > :30:52.they are not only on occasions, hounded out of that trust, but
:30:53. > :30:59.sometimes they find it difficult to get a job anywhere else in the NHS,
:31:00. > :31:03.because word gets around on the old boys network. If we have to have
:31:04. > :31:07.whistle-blowing at all, we have failed, because what we need is a
:31:08. > :31:11.culture where, when people raise concerns, they are confident they
:31:12. > :31:16.will be listened to. There are other industries who have managed to do
:31:17. > :31:20.that. The airline industry, the nuclear industry, the oil industry.
:31:21. > :31:29.I don't think any other country has managed to get this right. You get
:31:30. > :31:33.individual hospitals who have fantastic learning cultures, like
:31:34. > :31:39.the Salford Royal. I want to get that culturally to across the
:31:40. > :31:51.country. I very much welcome the statement. Does the Minister agree
:31:52. > :31:59.with me that to address this, one needs tough care quality commission
:32:00. > :32:00.inspections, good leadership locally and the right support from the
:32:01. > :32:18.government for moving forward. We can draw some comfort from the
:32:19. > :32:23.fact that the NHS itself is commissioning reports that a very
:32:24. > :32:28.hard-hitting, don't pull any punches, and the new CQC inspection
:32:29. > :32:32.regime does exactly that. Can I commend all the staff at the Medway
:32:33. > :32:36.Hospital who have worked so hard to raise the standard of care over the
:32:37. > :32:41.past three years, which has not been easy for them. He has not yet
:32:42. > :32:46.mentioned the role of the medical examiner. Doesn't this latest
:32:47. > :32:52.tragedy of a street that the introduction of a national system of
:32:53. > :33:00.medical examiners, as recommended by public enquiries and supported by
:33:01. > :33:05.medical bodies, is now long overdue. I agree with her. It was a
:33:06. > :33:09.recommendation of the Francis Report and the Coalition Government
:33:10. > :33:15.committed to implement this, and we will be telling the house shortly
:33:16. > :33:20.what our plans are on this front. People will be both saddened and
:33:21. > :33:27.dismayed at what has happened to mid Staffordshire and the new CQC
:33:28. > :33:32.inspection regime. If problems like this can still arise. Does he agree
:33:33. > :33:37.with me that, while there is no simple solution, the solution does
:33:38. > :33:44.not lie in trusts adopting and relying on a tick box approach to
:33:45. > :33:47.safety? He is absolutely right. It is worth saying that this tragedy
:33:48. > :33:54.that sparked this report actually happened before the new CQC
:33:55. > :34:01.inspection regime had got under way. But I think the old CQC regime was a
:34:02. > :34:05.tick box approach. Partly because the people doing the inspections
:34:06. > :34:09.were often themselves not doctors, who were able to make peer review
:34:10. > :34:14.judgments about the quality of services. If you're not a doctor,
:34:15. > :34:17.you tend to want to look at things where you can tick yes or no in
:34:18. > :34:24.response to a question and not the underlying issue. Having judgment in
:34:25. > :34:28.inspections is a very important step forward. This investigation would
:34:29. > :34:34.not have happened, had it not been for their tenacity and work of Sarah
:34:35. > :34:37.Ryan, Connor Sparrowhawk's mother. Is it right that the legal
:34:38. > :34:43.representation for the family was funded by crowd sourcing? I think
:34:44. > :34:49.it's tragic that anyone has to resort to the courts to get justice,
:34:50. > :34:55.and Sarah Ryan is one of many, many people who have had to go to huge
:34:56. > :34:59.expense to get justice and the truth, with respect to their loved
:35:00. > :35:08.ones. Last week, I went to the launch of a book by a campaigner,
:35:09. > :35:13.who has campaigned for years to get justice over the death of his son
:35:14. > :35:18.Joshua. And that is what we have to change. Pity confirm whether the
:35:19. > :35:28.draft report also covers the Southern Health mental health
:35:29. > :35:35.services for adults? Is he satisfied that the temp three report was
:35:36. > :35:45.rigorous enough, since they judged there are services good. It is
:35:46. > :35:47.important to say that when the CQC does its reports, they inspect
:35:48. > :35:52.individual elements and give different ratings to different parts
:35:53. > :35:55.of the trust. Within one trust, you can have big variations in the
:35:56. > :36:03.quality of care, but I will look into that. He rightly mentions the
:36:04. > :36:08.fact that the culture needs to change that people are more
:36:09. > :36:12.uninhibited, talking about problems within trusts and hospitals. Can I
:36:13. > :36:20.remind him that the culture starts at the top? Can he come back to the
:36:21. > :36:24.dispatch box and tell us and the families of those who have lost a
:36:25. > :36:29.loved ones when he first knew there were problems? As I have said
:36:30. > :36:37.already and I think this is the third time, BN set is that Connor
:36:38. > :36:43.Sparrowhawk's tragic death happened in July 20 13. Sarah Ryan campaigned
:36:44. > :36:46.bravely, and as always happens in these situations, it starts with a
:36:47. > :36:53.local process, where you raise the issue with your trust. That was
:36:54. > :36:59.escalated to NHS England in early 2014, when the chief executive of
:37:00. > :37:03.NHS England and the chief nurse got involved. Ministers were kept
:37:04. > :37:14.informed throughout on what was going on. That was the point in time
:37:15. > :37:18.at which the report was commissioned. It is a very thorough
:37:19. > :37:27.report, and we will now see that report when it is published before
:37:28. > :37:35.Christmas. Would the leader of the house give us the business for next
:37:36. > :37:40.week, please? The business for next week will be on Monday the 14th of
:37:41. > :37:46.December, consideration in committee and remaining stages of the European
:37:47. > :37:50.Union approval Bill, followed by a debate on a European document
:37:51. > :37:51.relating to the communication of migrants in need of international
:37:52. > :37:53.protection,