Meetings with NNCCG have always been difficult and this was to be no exception. The organisation is geared towards deflecting criticism and hiding the truth behind its failures. When you meet with NHS representatives you feel as if you are meeting a firm of lawyers who know how to tell you black is white, grind you down, and essentially get all but the most persistent patient or relative to go away and shut up.
NNCCG don't appreciate that this is not going to happen with Averil's family and friends - we will get to the truth, however long it takes and we will make the truth of Averil's tragedy known to all so that lessons can be learned.
The meeting at Thetford Healthy Living Centre was held to provide an update on NNCCG progress into the various inquiries being undertaken into the death of Averil Hart, who died whilst being "cared for" by NCEDS and the UEA medical centre.
Summary points of the meeting:
- It was agreed by MT that there was no quality control by the commissioners of the NCEDS service.
- It was agreed by MT that the NCEDS service was understaffed and that this lead to a sub standard service being provided to the patients in the care of NCEDS with added potential risk.
- NH asked MT to agree that the death of any young individual only ten weeks after starting university should be of great cause for concern and by its very nature illustrated a failure of the medical services involved in caring for a young person in the community. MT was not able to agree to this premiss, and this added to an underlying feeling of mistrust in the meeting.
- NH expressed concerns that NNCCG who were supposed to be coordinating the investigation into Averil's death had not answered a considerable number of the emails points raised by the Hart family and that NNCCG had avoided answering emails that were critical to the investigation.
The Hart family also felt that NNCCG had deliberately tried to stall responses by claiming that CPFT were to provide responses to some of the questions originally raised of NNCCG, thus prolonging the response time. An example question such as the straight forward structure and personnel chart of NCEDS was cited by NH.
NH requested that NNCCG run through the correspondence from the Hart Family and state whether NNCCG had indeed answered each of the questions raised. MT flatly refused to provide a listing of the questions answered and those still outstanding.
- MT stated that NNCCG had enlisted the help of a Psychiatrist from the Wiltshire area to look at the paperwork, case notes and answers provided by NCEDS and the other service providers involved. NNCCG were also looking for an external physician to look at the same records.
NH pointed out that the answers so far provided by NCEDS and the UEA medical centre were superficial NHS policy statements in many cases and provided little clue as to the real course of events in Averil's tragedy. NH felt that In the majority of cases the answers had been phrased to mislead the reader and divert from the fundamental causes of Averil's death.
NH strongly felt that the process was therefore fundamentally flawed. Any inquiry should be external and be able to look at exactly what went wrong, raise new questions about the course of events, interview those concerned in Averil's care and provide a detailed timeline of what went wrong, when it went wrong and what should be done to ensure no repetition of this tragedy.
- NH suggested that the Hart family should have an opportunity to meet and discuss the facts of Averil's case with anyone taking part in an investigation into Averil's death prior to their work. This was agreed by MT.
- MT indicated that NNCCG would hold a stakeholder meeting at the end of their paper exercise and that the Hart family would be asked to attend.
NH pointed out that as the process was fundamentally flawed then there would be little point in an NHS meeting and that the family would not be willing to partake in a meeting designed to rubber stamp the answers provided by NCEDS and UEA medical centre.
- NH indicated that the Hart family were concerned that there had been a "cover up" of the facts leading to Averil's death.
NH asked what questions NNCCG had raised of a clinical nature of the service providers NCEDS as a result of the SI report.
MT said that there had been two clinical concerns from the SI raised by NNCCG. The first was about the care provided by Addenbrooke's and the second concerned the supervision of staff at NCEDS.
NH wanted confirmation in writing that there was only one clinical question that had been raised by NNCCG about the death of his daughter. MT flatly refused to provide this in writing, stating that it was a matter of "trust". NH indicated that there was little or no trust in NNCCG given the prior issues.
- NH cited an example of the problem of trust in NNCCG handling of the aftermath of Averil's death. NH had previously raised a question about the role of the care coordinator and the assessment of risk by NCEDS in Averil's care.
The response to the question had stated that NCEDS had changed Averil's risk assessment (as stated in her discharge notes) from "High Risk" to "Low Risk". At the time NH had stated his concern about this apparent lack of judgement and had asked for this to be investigated (who made the change in risk assessment, when and with what basis and authority ?).
- MT indicated that no questions had been raised about this by NNCCG and that was not NNCCG's concern.
- NH stated that this showed NNCCG lack of care and integrity and that this was specifically why the Hart family felt that there had been a "cover up of the facts".
The meeting ended after one hour with no agreement as to the way forward.