pointing finger

The truth

The furore over the despicable treatment of Martha and her mother, Guardian journalist, Merope Mills continues to rumble on.

Martha died at Kings College Hospital in London. Ostensibly… sepsis but as far as I can see, actually… institutional insouciance and very poor medical management.

If there’s any justice in this world King’s would be obliged to erect a hundred foot banner, outside its entrance proclaiming; we killed Martha and we are humbled and deeply sorry.

It looks to me… key players in this tragedy are still working at King’s and should have to walk past it every day. You might ask why they are still working in the NHS, at all?

The Coroner’s ‘prevention of future deaths report’ is brief but disguises a rat’s nest… this is a very good up-sum of the bigger picture.

I’ve always been a proponent of transparency, encouraging people to come forward, if they’ve made an honest mistake. 

Tell us…’ I’ve said, ‘… we’ll learn… make sure it doesn’t happen again.

The catastrophe at King’s is not in that league. It’s in a class of its own. These are not ‘honest mistakes’. Everything done was deliberate.

The on-call Consultant stayed at home, can’t be right, can it? Delayed transfers of care, why? Disregarding parents, unforgivable…

… it’s a horrible catalogue. Structural faults; I’d guess personality clashes, lack of supervision, poor record alignment, inadequate escalation procedures, key training opportunities missed, a Board asleep at the wheel. 

A young girl is dead. The way things worked at King’s, killed her.

It’s rare a company or Trust is charged with corporate manslaughter. In order to be found guilty, all of the following must be proved:

  • the defendant is a qualifying organisation;
  • the organisation owed a relevant duty of care to the deceased;
  • there was a gross breach of that duty by the organisation;
  • the way in which its activities were managed or organised by its senior management was a substantial element in the breach; 
  • the gross breach of the organisation’s duty caused or contributed to the death.

For a sympathetic lawyer, it has to be worth a try.

Martha’s mum wants a new law, entitling patients to a second opinion. Something which she was denied. The useless GMC states all doctors must;

… respect the patient’s right to seek a second opinion’

Fat lot …

Yesterday, the excellent HSJ published an interview with Rosie Bennyworth. 

She’s been the Health Service Investigation Branch’ interim-boss. She’ll now lead the organisation into becoming an independent body. 

HSIB had a difficult birth. Internal argy-bargy, bullying, sexism and racism. I would have closed it down… but we are where we are.

Ms Bennyworth says; 

I think it’s fundamental that ICSs put safety at the core of everything they do… I don’t think operational… or financial decisions … should be made without considering the implications for safety.”

This is naive claptrap and one of the reasons none of the regulatory mechanisms work.

Regulator-tunnel-vision can’t or won’t acknowledge the bigger picture because they know system failure is the root-cause and it is beyond their purview.

They are powerless and redundant.

As the HSJ points out; 

… 14 out of 42 [ICS] … are forecasting deficits [and] subject to NHSE’s ‘financial control regimes’ … rules that limit their spending on staffing.’

See that Rosie… ‘rules that limit their staffing‘… mean anything to you?

And Rosie… how about four-in-10 ICBs have no formal patient involvementever wonder why?

The NHS is systemically unsafe because it is ‘overtrading’; doing more work than it is resourced for. 

Nothing will change. How do I know? 

  • Because after years of the CQC stomping around, inspecting and destroying morale… the NHS is obviously no safer.
  • Because governance, patient safety and quality are a preoccupation of NHSE, but makes no difference.
  • Because there are over 126 organisations who exert some regulatory influence on NHS providers, plus the forty-odd ICBs. Makes no difference. They all overlap.
  • Because Royal Colleges, Regulators, the GMC and NMC huff-n-puff-n-preen but in reality, make us no safer.

I’ve had an overwhelming response to this sad story and thank you all. If I haven’t replied yet, I will.

This, from a reader;

I investigated serious incidents… often accompanied by a complaint…the reports were scrutinised [and changed] by managers… sent to the [then] CCG… and became a light touch of what truly happened. 

No one was reprimanded, no one… ever managed to prevent [it happening again] … it is still happening up and down the country… now. 

No one wants to tell the truth…

Years and layers of regulation, laws, guidance, organisations, people, managers…

…none of it will make a difference because from top to bottom the NHS is mesmerised with its relationship with reputation and won’t change anything… 

…until it dumps the regulatory junk-yard and makes a solemn and sincere commitment, from the bottom up…

…to establishing a reputation for its relationship with the truth.

News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.