Liverpool Care Pathway - Dignity In Living

Such is the mettle of those who, lacking that courage themselves, deny and question that courage in others.



It is two years ago.

Jason Pitt spoke exclusively to Heart -

“Walsall Hospital have replaced humanity with procedure and compassion for compliance.”

Jason’s Mum, Lynda, had her life taken on Mother’s Day, 2013.

“Despite the fact my mum was completely paralysed with limited ability to communicate we asked her the question did she want to go and she indicated strongly that she wanted to fight she wanted to be here and we also asked her if she felt let down by Walsall Hospital and she pressed her thumb to indicate 'yes she did'.”

Not everyone is just prepared to roll over and die. As inevitable as death may be, they don't plan on checking out just yet and certainly not without a fight.

The Quislings have taken over. When Death comes knocking, they will not fight for us but happily hand us over.

It is modern medical practice to always see the glass half-empty...

This is Heart West Midlands reporting on the Walsall Manor Hospital Review in 2013 -

Off the back of scandal-hit Stafford Hospital a 12 week independent review of death rates at Walsall Manor hospital is due out next month - with a brief update on the 12th March.

The Walsall Healthcare Trust was investigated over it's mortality rates which were almost 20% higher than expected between April 2011 and March 2012.

According to the Doctor Foster Hospital Guide into mortality rates at Hospital's across the country which came out in December 2012, Walsall Manor Hospital had 117 deaths between April 2011 and March 2012. The expected is 100.

Life is such a very precious gift and not to be readily surrendered.

Doctors gave Lady Campbell a year to live when she was born. Nine years ago, they put a DNR notice on her medical records, as if her life was not worth living.

Baroness Campbell of Surbiton, founder of Not Dead Yet, was once told by doctors that they “presumed” she would not want resuscitation if she experienced complications during treatment.

It is part of the human spirit to struggle to survive, to appreciate and understand life for the precious gift it is and not to be readily surrendered.

Further reading -

Liverpool Care Pathway - When Doctors Lack Capacity

- The Mott MacDonald Review

The following is taken from the Walsall Manor Hospital Review -

“All models are wrong but some are useful” –George Box

Hospital Standardised Mortality Ratio (HSMR) is an internationally recognised and used indicator to analyse the rate of inpatient mortality by comparing it to the national mortality rate, adjusting for various factors such as whether the patient was admitted for palliative care, how sick they were (number of comorbidities they had), and standardising for age, sex, deprivation and other population factors. It is shown as a ratio with a number higher than 100 representing higher than expected mortality and a number lower than 100 being lower than expected. 

Issues such as coding, variation in palliative care activity and reporting of comorbidities can all lead to high HSMRs. 

These issues are explored further in the contents of this report, with a particular focus on determining the sensitivity of key variables used within HSMR, and testing to see how Manor Hospital’s HSMR has been historically affected, and can be influenced in the future, when changes in practice, care provision and coding occur. 

In 2008 the Trust was identified, along with many other Trusts in England, as having a high rate of palliative care coding which can have the effect of lowering HSMR. In response to this the Trust brought its rate of palliative care coding back down to below the national average. 

The use of Palliative Care coding can have a significant effect on a hospital’s HSMR, as the addition of the ICD10 code Z515 “Other medical care –Palliative Care” significantly increases the risk, or probability of death for a patient, within the HSMR calculation.If enough patients are coded with a palliative care code, this has the effect of lowering the overall HSMR for a hospital by increasing the expected chance of death for these patients in the calculation. The sensitivity of HSMR to palliative care coding is a well-documented issue and is often a source of controversy as it can provide a mechanism for hospitals to artificially lower their HSMR by over using these codes. Over-coding of Z515 widely occurred throughout the NHS from 2006/07 to 2008/09, with the proportion of deaths coded with a Z515 code increasing by over 300% nationally over this time span. This relates to initial and then revised CFH coding clinic guidelines on the use of the palliative care (Z515), which is a known national issue. This was also a focus in the recent Mid Staffordshire mortality review. 

There is a clear inverse relationship between palliative care coding and HSMR. 

This could be interpreted as an attempt by Walsall to reduce itsHSMR artificially simply by increasing the level of palliative care coding in the hospital, however we do not believe this to be the case. 

We believe the current rate of palliative coding, despite being approximately 1.5 times that of the national average, is appropriate for Walsall NHS Trust as a high proportion of the population die in hospital as opposed to in the community in hospices or care homes. It would be expected that many of these ‘excess’ patient deaths in the Trust would be appropriately receiving palliative care and then coded as such. The addition of 2 new palliative care consultants in the Trust and wider local health economy seeing all end-of-life in patients as part of a palliative care team will also have direct causal effect on the increase in palliative care coding in the Trust. The Trust and CCG have also spent considerable effort assessing the issue of palliative care coding as evidenced by private board level reporting on the issue and a report by the CCG looking at coding from January to April 2012. Both concluded the level of coding was appropriate based on national coding guidelines and clinical best practice.

The Review says, unequivocally, that ‘excess’ patient deaths in the Trust would be appropriately receiving palliative care and then coded as such.

Patients receiving palliative care are on End of Life Care (EoLC) Pathways.

They are 'diagnosed' for palliative care.

Excess deaths...

The ACD, EoLC and the 1% Death Lists are all in place to wind down care; the glass is perceived to be half-empty,not half-full.

Just because the odds are that there is a less than best chance of a successful outcome, do you then give up?

But what is the alternative?

Walsall Council's response to the excess deaths at the Manor Hospital was to send them home to die. That is what the Review recommends.

This is the Walsall Council Health Scrutiny Panel –

Members were given a chance to  raise queries about the latest measures being put in place to ensure good quality care for those in the final stages of life at the latest health scrutiny panel meeting. 

At their meeting earlier this month members received the third in a series of updates on progress from Walsall NHS Healthcare Trust staff on their End of Life Care action plan. 

Plans to develop a local approach for end of life care, following national best practice guidance are progressing well. 

Key actions reported to the panel include arrangements to share information safely and appropriately with partners on patients' wishes for their end of life care, a roll out of a new training programme on palliative care for all relevant hospital staff and improvements to support for families dealing with bereavement. 

Further progress is also being made on working individually with each patient and their family to tailor support to their needs and wishes, such as help with equipment or care should they wish to spend their final days at home. 

Councillor Doug James, Vice Chair of the panel, said: "This is a good opportunity for the panel to reflect on the journey we've been on together with the hospital, social care and other partners. 

"The panel has been criticised in the past, for example on the Mott McDonald report into mortality rates at the Manor, but this highlighted the need for greater integration between agencies. 

"Since the report's publication the panel has seen a significant improvement and an ongoing commitment by all agencies that when people go through tough decisions they are responded to jointly by the whole health economy. 

"We have moved forward and we now have a much improved service to patients, but we will not become complacent, we will continue to improve. 

"This is an opportunity to move forward together and offer an improved service. 

"Thank you to all who have been involved." 

Question: How do you reduce the hospital (diagnosed) palliative excess death rate?

Answer: ‘Head ‘em up; move ‘em out’!

Further reading -

Liverpool Care Pathway - The State Rules, Okay?

Liverpool Care Pathway - Lamb's Move And Mate...

Liverpool Care Pathway - The Many Pathways To The Perdition That Awaits Us

Liverpool Care Pathway - The Micawber Principle

Liverpool Care Pathway - Back To A Way Forward

Post Note:

Even after the fallout from the LCP Review;

- Sunday Post 

even after all the publicity...

Professor Julian Savulescu is pictured here posing on a window seat against the backdrop of the campus grounds on the pages of QUT Queensland University of Technology).

Professor Savulescu proposes Palliated Starvation as a legal and ethical form of assisted dying.

This is QUT -

People with terminal illness have the right to refuse to eat and drink and receive palliative care if they wish to die, argues world renowned ethicist Oxford University Professor Julian Savulescu.

Professor Savulescu will speak about the place of refusal of food and hydration as a legal and ethical form of assisted dying at QUT School of Law's 2014 Health Law Research Centre annual public lecture on March 31.

QUT Health Law Research Centre director Professor Ben White said euthanasia, and proposed legislation surrounding euthanasia and assisted dying had been a long-standing staple of debate in the health law and bioethics fields, and in the broader community.

So, was the LCP always just euthanasia by the back door?

Additional reading -

Liverpool Care Pathway – "So This Is Christmas..."

Liverpool Care Pathway - A Blind Faith

Liverpool Care Pathway - It Is MURDER!