Serious questions raised over the investigation of NHS incidents
The number of Serious Untoward Incidents classified by the Norfolk, Suffolk and Cambridgeshire Strategic Health Authority and latterly the NHS East of England, are shocking.
Since 1st April 2004 there have been 491 Serious Untoward Incidents, 454 of these effecting adults in mental health care, according to figures made available under the Freedom of Information Act. The 454 adults in mental health care effected breaks down to 64 deaths, 362 absconsions, 6 assaults and 22 incidents classified as “others”. People with learning disabilities are classified separately and these make up 23 of the remaining incidents of the period.
That’s an average of over two a week. This wouldn’t be quite so alarming if the figures were improving. In the April 2004 – April 2005 period there was a total of 96 incidents but this rose to 160 in the following 12 months. The figure improves in 2006-2007 to 116 but the number of unexpected deaths remains at 22. The figures for 2007-2998 are not complete but the number will be higher as the bench mark of the previous 12 months has already been exceeded by the 10 months for which figures are available to date.
Alarmingly, the number of assaults are there highest in the most recent (and incomplete) period. This includes figures for assaults on staff and patients, but the ratio on the total figure from 2004 to date is 7:4, with seven patients assaulted. It has been argued that CCTV should be installed for the protection of staff but if these figures are anything to go by then the patients are at a significantly higher risk.
Perhaps most alarming to the general public is the number of absconsions – cases of people, the vulnerable and often mentally ill, going “missing” for want of a better expression. In 2005-2006 a total of 128 people, all but one of them being in adult mental health care, absconded from care – that equates to more than two a week. The figures for 2006-2007 and 2007-2008 are better but still work out to an average of more than seven per month.
This situation is not however a new one. Back in March of 2002 the Local Health Partnerships (LHP) NHS Trust reported that a shocking 179 complaints, that’s one every two days, made about care in Suffolk. Over the period 80 of these complaints related to mental health care.
But, it is not just the number of incidents each year that are worrying but the standards of investigation into those incidents, which frequently take months on end and don’t reach any conclusions. It has to be asked – if incidents were investigated properly could they be prevented in future? Could and more importantly shouldn’t we be working to get these figures reduced? Well, of course, although they could never be eliminated they could certainly be reduced and this is the most worrying aspect of my research. All investigations, when dealing with the NHS, are slow, frequently ineffective and lessons are not learnt, otherwise why would we still be recording these unacceptably high levels of incidents. Where recommendations are made following incidents, such as in the case of cot-sides in the Wedgewood unit, those recommendations are often ignored.
The figures alone prove that more needs to be done. But is it just the NHS that’s the route of this problem? I would argue that no, it isn’t. While we cannot expect the police to investigate every incident it could probably be argued that, in certain circumstances, where there is reason to suspect an individual’s actions or that the Trust may be criminally negligent, the police have a duty to investigate on the grounds of public safety and public interest. Most importantly, they have a duty to do so in a timely manner while memories are fresh and evidence is to hand, in order to prevent the situation from re-occurring.
What do you think is a timely manner? When we see crimes reported in both the news and even more so in TV police fiction, we see the police questioning witnesses and suspects in a matter of hours. Being realistic, especially when dealing with a body the size of the NHS we would perhaps concede that interviews might take a matter of days. Would it alarm you to find out that sometimes this can take many months?
How is anyone supposed to remember a single incident from what could, according to NHS figures actually be a twice weekly occurrence?
In the case of Mr Graham Barrett, formally of Bury St Edmunds, whose incident occurred in the East of England NHS figures worst year, months are exactly what it did take. Were the police at fault? Well, it’s hard to say. There are procedures in place to protect the staff and while this is quite reasonable it does provide an excellent delaying mechanism to thwart investigations by the police and by the Trust itself.
In this case DI Simon Curtis of Suffolk Police admitted in an email sent to a relative on the 27th April 2006, some three months after the incident took place; ‘….we should be starting to interview the staff next week.’
On the 18th May 2006, some three weeks later he added; ‘I am as frustrated as you ………….. undoubtedly is about the time – but I assure you I have not been able to deal any quicker.’
Were the police being ‘frustrated’ by the Trust, its procedures, or perhaps a lack of manpower within their own division?
From DI Curtis’ comments it would appear that the procedures put in place by the Trust are certainly a factor when he remarks; ‘….there are protocols to follow and this has slowed the investigation down somewhat.’
When the daughter complained to the police she was told in an email from DCI Martin Wright that ‘Hospital staff had to be interviewed when at work and when relevant union reps were available….those factors together with the necessary strategy meetings taking place with the local health authority first would have accounted for the lapse of a significant period of time.’
I raise the question of how this investigation would have differed if the NHS were not involved.
For example: If an incident resulting in a person sustaining a serious injury took place in, say a shopping centre, would the police wait until the witnesses were frequenting the place again before talking to them? Would they only be able to interview the staff when they were next on duty or would they be able to talk to them outside of working hours? Suspects are of course allowed legal representation and this is provided for them if they cannot provide their own. But a duty solicitor does this – a person on call, on a rota 24/7, we don’t have to wait for him or her to come back their holidays either. I would have thought the NHS, and the unions, given their sizes would have enough people in place to ensure that delays are kept to a minimum.
But why should the NHS be treated differently, and why should staff be treated differently by a police investigation than normal members of the public? Why should they be treated differently than you or I? Are they really telling us that if we work in the NHS we could, in theory, commit an assault and not even be questioned until it’s convenient for us? This is what appears to be happening.
If it does take months then by the time the witnesses are interviewed their statements are likely to be at best vague and at worst they could end up being very similar. Of course, I am not suggesting that the statements are anything other than accurate but maybe the similarity between them is a result of the time has elapsed and their ability of “compare notes” with each other or perhaps to have been briefed by a third party?
Where questions are raised, such in the case of Mr Barrett who wife was told he was “found in bed” but then somehow also managed to have been dressed, these questions cannot be addressed if too much time has elapsed.
Another question that perplexes the family of Mr Barrett is – why did the most senior member of staff on the morning of the incident leave the scene without making a report? Surely this is a standard procedure and may have shed some light on the incident, especially if that person was then going to be off duty for some time afterwards.
Why, when the NHS later claims it could have been a fall, were there no bruises even though everyone was really interested to look for them? And why were the staff that cared for Mr Barrett after his “incident” not questioned about his injuries? They had more involvement and more experience of the injury that the people who were there at the time.
The only person to treat Mr Barrett after the incident and subsequently be called to the inquest was one brave doctor who no longer worked in A&E and so was prepared to stick his head above the parapet and say that he was sick of patching up people from incidents like this. He elaborated on several incidents taking place in that week but there was no investigation to see if there was a link between these. The family were immensely grateful that someone had the courage to speak up for the patients in what otherwise appeared a closed shop.
Are we really expected to believe that he got out of bed, fell with the severity to push his leg bone through this hip socket displacing his leg by several inches, then got up with this leg now much shorter than the other, and got back into bed? That he then covered himself up, went back to sleep, woke up, either partly dressed himself and got back into bed or was being dressed when he first felt any pain and put back into bed where he then was described to the wife as being “found in bed in pain” by staff?
Given that they accepted at the inquest that no persons questioned had know him to fall or that there was any record he had ever fallen before this becomes even more far-fetched. With someone of that age and build a fall should have caused bruising, there was none. He subsequently, through lack of co-ordination hit himself with a spoon and the bruising was obvious.
What is more plausible, although only a theory of course, is that he had a really good nights sleep after a meal fed to him by his wife the previous afternoon. He was then woken to be dressed, and as he was known to be bad tempered in the morning he wasn’t very co-operative. With an Alzheimer’s patient the secret then is to leave them for ten minutes and come back. Even Mrs Barrett, unqualified but who had cared for him for six years, knew this.
Undoubtedly the staff did there best to calm him down but he wasn’t going to co-operate. Perhaps, when they went to put on his socks (which, along with his trousers, they did successfully it should be noted) he kicked out.
If he kicked out then perhaps he struck something, or someone. This, combined with his previously undetected osteoporosis, meant that the leg had no where to go but to puncture through the weakened hip joint.
It was an accident, albeit unrecorded in the incident book, but perfectly plausible.
It’s a lot more plausible than the explanation presented to the family and the coroner and perhaps one that would have come out if the staff had been questioned while they could still recollect the matter. But, we will never know. It’s certainly an explanation that would have saved the taxpayer a lot of money and the police a lot of time and effort.
The internal investigation by the NHS didn’t find an answer. At the inquest the investigating officer for the Trust admitted that in his years of experience this was the only one he hadn’t been able to find an explanation for.
Owing to the time lapse and non-direct causation between the hip injury and his death, the coroner determined that the incident was largely out of the jurisdiction of the inquest, and so this part of the inquest was concluded without the family or their barrister being able to address the questions raised here.
The family have no more answers now than they did two years ago, in fact, they probably have even more questions.
Should the police have done more or is the system within the NHS to blame? Could the subsequent retirement of Suffolk Police Chief Constable Alastair McWhirter from the force to become the non-executive chairman of the Suffolk Primary Care NHS Trust in April of 2007 have any bearing on the investigation? What really happened to Mr Barrett of the morning of the 28th January 2006? It is unlikely we will ever know.
But, most importantly, is there anything that could be done to prevent this sort of incident taking place again?
