Liverpool Care Pathway - Who Monitors The Monitors And The Monitors Of Monitors...?

What does it take to catch a fool? It matters not, only that he is an honest man...




The Kirkup Morecambe Bay Investigation reported finally on 3rd of March -

Clinical zealots come under fire. There are reported failures to communicate and to respond to opportunities. The regulatory bodies fall under repeated criticism for missed opportunities to intervene.

A specific watchdog has been accused of cover-ups and cover-ups of cover-ups in the press...

- The Independent

and  this is discussed -

1.67 Ms Abraham was clear that in raising the matter she had conveyed the nature of her concerns that there were systemic problems...

1.68 Ms Bower’s recollection was less clear, but she was definite that the matter of systemic problems was not raised with her... 

1.69 Within the context of everything else that we heard from both PHSO and CQC interviewees, we believe that Ms Abraham’s account is distinctly more convincing; we were also disconcerted by the proviso in Ms Bower’s account (“… unless somebody can show me a memo…”75). It is clear that there was no shared understanding of the conversation.

1.71 We also considered carefully an email from Mr Halsall, the Chief Executive of the Trust, to his Chair, Mr Kane, around this time, which included the following odd phrase in relation to Mr Titcombe’s complaint: “… if I am right then the CQC can cover off the Ombudsman”. We received no satisfactory explanation of what this meant.

The remedial response of the Report findings is to propose yet another regulatory body; another monitor to monitor the monitors.

The Report discusses the confusion of responsibilities at this time…

1.53 Not only is this complex and changing picture difficult to follow on occasions, we believe as a result of what we heard from a range of interviewees that the organisational changes led to confusion of roles and responsibilities, loss of organisational memory as personnel changed and, in some cases, staff of new organisations struggling with responsibilities for which their previous experience had not equipped them.

Such was our experience in pursuing our complaint...

1.51 …From 1 April 2009, the Healthcare Commission was replaced by a new body, the Care Quality Commission (also responsible for the quality and regulation of social care providers), which had operated in shadow form from the preceding autumn....

Political interference only bedevilled what was already an arduous and soul-destroying process. There is an unmistakable culture to make little and less of what is seen as no more than just a much of a muchness with lessons to draw on to improve the service. And 'justice', in Ombudsman's language, is not justice at all.

The State should always step back. When the State steps in, it leads only to cronyship, cover-up and corruption.

Is it more monitors we need or just good, honest, decent folk like Will Powell. Mr. Powell’s campaigning spirit has been steadfast and unfailing in the face of all odds, at every twist and turn the establishment have ambushed him with.

‘Duty of Candour’: what does that mean? It means your doctor should be open and honest with you. Should you not expect that? Does there really have to be a law to enforce that?

- The Independent

You take your car in for a service and all the Lords and Ladies in the land would not disagree that the mechanic should not rip you off with shoddy workmanship or charge for work done that has not been done. Is a car worth more than a human life that it demands such greater terms of service?

Speaking to The Independent on Sunday, Mr Powell of Ystradgynlais, Powys, said that a statutory duty of candour would represent "one of the biggest changes in patient safety since the inception of the NHS", but called for it to be extended to all individual health professionals, rather than to organisations.

Catch 22

That sounds strangely familiar...

Can that be the Catch 22 of all Catch 22s...?

When we responded to the Healthcare Commission Decision which had admitted failings – serious failings - but concluded that these had been addressed through ‘learnings’ undertaken by the Trust, Mr. Peter Pinto de Sa responded to us thus:

We are not empowered to undertake a general investigation into the performance or conduct of unnamed individuals at a particular institution or organisation where it is said that there have been general failings on the part of that institution or organisation or its staff in general.

We had assumed that meant we had to pursue a case against “that institution or organisation or its staff in general” and not against the individuals themselves. Re-reading it again, I'm not at all sure what it means.

Is it just gobbledegook or Newspeak for saying that, were you even able to pursue a duty of candour against individual health professionals, there could be no case to pursue in any case because their actions would constitute “general failings on the part of that institution or organisation or its staff in general”?

The Report discusses the confusion of responsibilities at this time...

Clearly, to all those concerned, those whom they would directly affect, the coming changes being steam-pressed by parliament were as clear as proverbial mud.

The Commission itself was doing a doggy-paddle in the mud and sent out this leaflet in the January of that year -

The information leaflet says:

From 1 April 2009 there will be a new regulator that will check on the quality of healthcare and adult social care services in England. The Care Quality Commission will take over the work currently done by the Commission for Social Care Inspection, the Healthcare Commission and the Mental Health Act Commission, “the three existing commissions”. 

We have sent you this leaflet because we are in correspondence with you about a process or matter that is not likely to be concluded before the Care Quality Commission takes over. This leaflet answers some of the questions you may have about the change.

The leaflet then demonstrates the level of misunderstanding in place. At Item 4, the leaflet asks: Will I have to start the process all over again on April 1st 2009? The leaflet responds with an answer:

No you won’t. The Care Quality Commission will continue the work of the three existing commissions after 31 March 2009. The Care Quality Commission will continue with the process as though no change had taken place. You won’t need to start again and you won’t need to contact them to tell them who you are or what process you are involved with. From April 1st 2009 you will simply begin to receive letters or information from the Care Quality Commission.

And goes further to compound the misinformation by asking: Will I still be dealing with the same person I was before? And answers:

This is very likely. Many of the staff working for the three existing commissions will be working for the Care Quality Commission and the person you are dealing with will carry on supporting you after 1 April 2009. If this isn’t possible a new person will take over and will be told about your case. They will  know how far you have got in the process we are currently writing to you about.

How many of those staff on that fateful April Fool’s Day 2009 just cleared  out their desks and found themselves without a job?

We had been in ongoing correspondence with the Healthcare Commission (HC) which had been shut down and so approached this regulatory body which had, so we had been informed, been set up in its place. Not so. They had made April Fools of us all.

This whole tier of appeal had been shut down. After the Primary Care Trust (PCT), the next port of call to take your complaint became the Parliamentary and Health Service Ombudsman (PHSO).

The PHSO replied that our papers had been archived. We had to supply duplicate copy of all correspondence or wait months to retrieve the archived content – if it could be retrieved. But what of the HC’s own record notes? What gems of information did they contain which was not made available to us and would not now be available to the PHSO? Such was our predicament.

The report explains correctly...

From 1 April 2009, the Healthcare Commission was replaced by a new body, the Care Quality Commission (also responsible for the quality and regulation of social care providers), which had operated in shadow form from the preceding autumn. Responsibility for the second stage of the NHS complaints procedure did not pass to the CQC, however, but to the Parliamentary and Health Service Ombudsman (PHSO), who had previously become involved only when the Healthcare Commission did not resolve a complaint. The regulator for Foundation Trusts, other than for the CQC’s responsibilities, was Monitor, which also ran the application process by which NHS Trusts were judged suitable or not to become Foundation Trusts.

Another monitor, by designation as well as by definition...

Looking at the record of reported subsequent failings by Foundation Trusts/University Hospitals, is Monitor really fit for purpose as a suitable arbiter to adjudge suitability?

Who shall monitor these monitors and these monitors of monitors?

This is from the Press Release –

The investigation report details 20 instances of significant failures of care in the FGH maternity unit which may have contributed to the deaths of 3 mothers and 16 babies. Different clinical care in these cases would have been expected to prevent the death of 1 mother and 11 babies. This is almost 4 times the frequency of such occurrences at the Trust’s other main maternity unit, at the Royal Lancaster Infirmary.

The report says the maternity department at FGH was dysfunctional with serious problems in 5 main areas:

• Clinical competence of a proportion of staff fell significantly below the standard for a safe, effective service. Essential knowledge was lacking, guidelines not followed and warning signs in pregnancy were sometimes not recognised or acted on appropriately.

• Poor working relationships between midwives, obstetricians and paediatricians. There was a ‘them and us’ culture and poor communication hampered clinical care.

• Midwifery care became strongly influenced by a small number of dominant midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care.

• Failures of risk assessment and care planning resulted in inappropriate and unsafe care.

• There was a grossly deficient response from unit clinicians to serious incidents with repeated failure to investigate properly and learn lessons.

The report says proper investigations into serious incidents as far back as 2004 would have raised the alarm. It was not until 5 serious incidents occurred in 2008 that the reality began to emerge.

Clinical zealots come under fire.

There are many such zealots out there whose dedication to their cause borders on the obsessional and the irrational and binds them to it unswervingly, as were it holy writ. One such holy writ has perpetrated a medical holocaust but, with disdain, the ardent host has damned the evidence as anecdote.

There are many dedicated to their cause who pursue it faithfully but for whom duty also calls and know that you have to do the right thing.

Lawrence D Hills, a father-figure of modern organic gardening, became devoted to the cause of promoting the abundant uses of the comfrey plant, founding the Henry Doubleday Research Association (HDRA) in 1954. When Brussels started banning historic British vegetable varieties, he set up the HDRA seed library to ensure they would not be lost.

Devoted though he was, zealot he was not. When reports emerged in 1978 in Australia of links between comfrey, cancer and liver damage, Hills knew it was his duty to alert users and did so, going public with this in the national press. This caused him to become the subject of consternation, comment and criticism by fellow travellers.

Hills was one of those good, honest, decent folk and duty overrode dedication. He knew he had to do the right thing. 

Is it more monitors we need or just good, honest, decent folk at every level, doing their very level best to always do the right thing?

How many are they in public life who know that honesty is always the best policy and to always do the right thing?

In the Metro, following a 'grubby plot':

Charles Walker, the Tory MP who chairs the procedure committee, told the Commons he had been 'played the fool' after Mr Hague and Mr Gove failed to mention the motion when he met them this week.

'I will look in the mirror and see an honourable fool looking back at me, and I would much rather be an honourable fool in this and any other matter than a clever man,' Mr Walker said.

Perhaps so...

Footnote

Dr Bill Kirkup will be joining the Gosport Independent Panel alongside geriatric medicine specialist Dr Colin Currie, investigative journalist David Hencke and former Scotland Yard Commander Duncan Jarrett.

At last, will some light be shone along those dark corridors of The War Memorial...

Additional reading –

Liverpool Care Pathway – The Audacity Of Hindsight

Liverpool Care Pathway - Ten Years In The Waiting

Liverpool Care Pathway - Blowing The Whistle On The Half Century

Liverpool Care Pathway – Corruption, Corruption, Corruption

 Liverpool Care Pathway - Have You Read the Olds Lately?