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Filtering by Category: Post

When a Review is not a Review

Nic Hart

Dr. Christine Vize has been asked by North Norfolk Clinical Commissioning Group (NNCCG) to undertake a "review" into Averil's care.

Sadly this so called "review" is typical of the NNCCG' underhand way of working as they continue to cover up the true facts behind Averil's death.

"When a review is not a review ...."

  1. When the remit is set by NNCCG's legal team behind closed doors.
  2. When the questions are set by the NNCCG's legal team behind closed doors.
  3. When the patient's (Averil's) family are excluded from the review process in case they expose the truth.
  4. When the person undertaking the review may not be truly independent of those that were involved in Averil's death.
  5. When the type of review is against the Royal College of Psychiatrists own guidelines.

(More on the closed shop that is the Royal College of Psychiatrists to follow, and how they protect their own).

As we were told shortly after Averil died " may never get to know the truth unless you can get an independent inquiry or someone to blow the whistle within the NHS organisations involved".

We know that in the end the truth will come out.

Sam Morrish: Another NHS Tragedy Similar to Averil's

Nic Hart

The Parliamentary and Health Service Ombudsman recently released its report into the death of Samuel Morrish. The report finds strong evidence of NHS failures:

"We have found that each of these organisations have failed in some way... Had Sam received appropriate care and treatment, he would have survived, and that a lack of appropriate and timely bereavement support compounded the distress caused... We have also found failures in the way that the NHS investigated the events that took place."

The parents of Samuel Morrish, a three-year-old, took him to a local GP, worried about his "flu-like symptoms", and were given antibiotics in case an infection developed. The next day, a second GP gave him cough syrup and sent him home. As his condition worsened, Sam's mother phoned NHS Direct's "111" service, and was referred to Devon Doctors. However, the call centre failed to notice the severity of Sam's case, and Mrs Morrish was told to take him to a GP. That GP immediately arranged for him to be admitted to Torbay Hospital.

While the doctors at Torbay realised that he had pneumonia, and suspected Sepsis, they prescribed antibiotics that were not administered for three hours, after which time they were too late to have any effect. Sam died of Sepsis, an avoidable condition, due to the failures of the NHS organisations that were charged with his care.

Following Sam's death, there was insufficient bereavement support. The local surgery did not contact the family, while there was confusion between the surgery and the NHS Trust at Torbay Hospital as to who was to assist the family. 

The NHS Complaints Procedure

When NHS care results in the death of a patient, clarity, openness and timely responses to communications are essential. The experience of the Morrish family is characteristic of the NHS complaints system, which fails to uphold these values.

The Surgery itself conducted a "root cause analysis" of Sam's death, but the meetings held simply consisted of the relevant GPs denying that Sam had seemed seriously ill when they saw him. They failed to respond to the family's specific questions, giving inadequate responses. Having discovered Sam's death three months later, NHS Direct conducted its own review. They did not, however, contact them or attend the root cause analysis meeting, nor did they release their recordings to the PCT. The report found that "the actions of NHS Direct fell so far below the applicable standards that they amount to maladministration."

The PCT's report failed to give evidence-based responses to the concerns of the family, and the second report's improvements still failed to reach this point. The Morrish family was left without any confidence in the NHS.

Our Experience

The report credits the Morrish family for its contributions of information and responses to draft reports. This underestimates their role. They pushed at every stage to ensure that the PHSO understood their complaints and had the evidence it needed to reach a conclusion. To date, we have found that in Averil's case the NHS Trusts involved work from a premise of denial.

Over a year after Averil's death, responses to our inquiries become slower and slower. Many of our most important questions remain unanswered, and some have been dodged on technicalities. While Norwich and Norfolk University Hospitals Foundation Trust have promised an independent review, neither Cambridgeshire and Peterborough Foundation Trust nor the North Norfolk Clinical Commissioning Group have been able to make the same promise. Instead, they have attempted to duck questions wherever possible, and, in so doing, are preventing us seeking the clear explanation we need.

Meeting with Anna Dugdale at NNUH, 7th July 2014

Nic Hart

It had been a long wait, but at last Miranda and I were at the Norwich and Norfolk Hospital to meet with Anna and Paul Robinson. 

The aim of our meeting was to see Dr. Paul Robinson (head of MARSIPAN) to try and ensure that his inquiry into Averil's care would look carefully at the failings of the hospital and the care that Averil received. 

We hope(d)  that his report and recomendations when implemented by the NNUH will help Anorexic patients brought to the hospital for emergency treatment n the future.

Comment: For more information on MARSIPAN see Downloads.

There had been many failings at the Norfolk and Norwich Hospital hospital; They failed to protect Averil from a bad fall and head injury after leaving her to wander around the ward (completely against MARSIPAN guidelines), they had expected Averil to feed herself from the trolly and essentially  this lack of experience and their incorrect treatment of Anorexia was instrumental in her rapid decline. As a result she was later transferred to Addenbrookes hospital in order to try and save her life.

In the event the meeting was very mixed.

Anna Dougdale seemed to be behind a proper inquiry and implementation of the recommendations, however, her office had not even given Paul Robinson a copy of our Official Complaint (see the downloads section for a copy) and all Paul had in the way of background information from us was a file of notes that I had sent the SI inquiry more than a year ago.

One can't help but wonder why an expert would be asked to come from London for a two day inquiry without having all the information for prior consideration ?

We discussed the Hospital's lack of appropriate care and hope that this will be a focus for the next two days inquiry. 

We also discussed the difficult issue of parental access in an acute ward where one's child is dangerously ill. I was made to wait for hours before seeing Averil and the hospital suggested that this was until they had Averil's permission. However …. when mental capacity is poor for a young person who has been unconscious, this is a terrifying and terrible situation for the parent and young person. It seems as if bureaucracy got in the way of common sense on that fateful Friday and that access was finally given only once I had broken down.

We still have serious concerns that the NNUH have been poor in communicating with us and that they may water down the recommendations of the report, but we hope that the outcome will be:

  • Highlighting the failings of Averil's care.
  • Implementing change and improved care at the NNUH and other hospitals.
  • Communicating the report and changes to other Acute and A&E units.
  • A public apology to Averil, her family and friends.
  • Creating a model of how to deal with complaints in a non confrontational way that has the patient and relatives at the very centre.

Rabone: NHS Negligence in the Community

Nic Hart

Art. 2 of the European Convention on Human Rights gives every individual the right to life. In all functions, the state and its organs are subject to four duties. First, they must not kill, save in limited circumstances; secondly, they must properly investigate deaths; thirdly, they must maintain a legal framework that protects life. The fourth duty is most important for the vulnerable in the care of the state. Where there is a real and immediate risk to life, in certain contexts, there is a duty on the part of state actors to take preventative measures. Rabone v Pennine Care NHS Foundation Trust.

Melanie Rabone was a voluntary mental health patient with a long history of self-harm and suicide attempts, admitted to hospital following one such attempt. She was a “voluntary” patient, not detained under the Mental Health Acts. She requested a weekend’s “leave” from her hospital place, about which her parents were worried, and hung herself from a tree on her first day home.

The heart of the case is this: while the “operational” duty was set out in Osman v UK (1998), it has not yet been possible to develop a single test to determine when it applies. It has been recognised in several individual scenarios, but these remain the only guide available. Lady Hale and Lord Dyson both recanted the case law, but two cases proved influential.  

In Savage v South Essex Partnership NHS Foundation Trust [2009], a schizophrenia patient detained under the Mental Health Acts absconded and killed herself, but this was found to be as a result of the failure to put in place systems to prevent patients absconding. When she escaped, there was a real and immediate risk to her life, and, as a result, those aware of that risk were under a duty to prevent the risk eventuating. Conversely, in Powell v United Kingdom [2000], the applicants’ son died as a result of an illness suspected by doctors a year earlier, but not tested for. At this point, there was not a real and immediate threat to life, so the operational duty did not arise.

The justices rightly found that there was a duty to preserve the life of a voluntary mental health patient, even when they could have discharged themselves and rejected care. While this expands the liability faced by the NHS, it is important that doctors adequately monitor those in their care who may be outside of the hospital. Had she insisted upon leaving, they could, and would have detained her under the Mental Health Acts.

The idea of “care within the community” is particularly important as the NHS has restructured. What Rabone demonstrates is that the NHS’ duty of care does not end at the hospital doors. When doctors assume responsibility to a patient, and when they are aware of a real and immediate threat to their life, they must act, and their failure to do so is inexcusable, both morally and in the eyes of the law.

Meeting with NNCCG, 10th March 2014

Nic Hart

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:

  1. It was agreed by MT that there was no quality control by the commissioners of the NCEDS service.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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 ?).
  10. MT indicated that no questions had been raised about this by NNCCG and that was not NNCCG's concern.
  11. 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.

When the Minutes Don't Reflect Reality

Nic Hart

Following a meeting with Diane Collier and Mark Taylor (NNCCG) earlier in October 2013, the set of minutes that returned were not as I had expected, displaying an important element of the complaints process. Unless independent minutes are taken, those returned are unlikely to match the reality experienced by those attending.

Having discussed in detail several key points, the minutes recorded only the general topics discussed, accompanied by textbook responses, which bore little resemblance to the responses given in the meetings. Even comments made by key clinical members of the CCG team were totally absent from the recorded minutes. I e-mailed to ask for another opportunity to record the meeting, but this was flatly refused.

At all further stages in the complaints process, these minutes will be the only official reflection of the meeting, and may have a significant impact on future proceedings. Given the vagueness of the minutes provided, many of the points made at the meeting have been lost. So much for a duty to be clear, open and transparent - the NCCG have an apparent ability to lie about proceedings and not be accountable to anyone.

Just another example of discgraceful conduct after someone has died and total disrespect for the Averil and her family. 


NNCCG Progress Update: 10th November 2013

Nic Hart

Following a meeting yesterday with NNCCG, it's time to reflect on progress. While some gains have been made, there is still a lot to do. The NNCCG had received a response from NCEDS following my questions on the “care co-ordination role.” As expected the answers were evasive and vague and, in some cases, showed how incompetent the service was.

The meeting highlighted that things need to progress with more haste from herein, partly because there may be some areas which are time-limited. While progress in some areas has been reasonable, slow responses from NCEDS and the UEA Medical Service suggest that we now need to accelerate our involvement in the complaints process. The NHS procedure is not likely to be successful, and will make little difference. Our efforts need to be more diverse.

Regarding Primary Care, our progress is as follows:

  1. Approximately 10 letters to the UEA medical services requesting information (less than half of which have received satisfactory replies).
  2. Work with NNCCG to complete two tables of information from UEAMS, firstly on medical care and examinations and secondly on communications. These highlighted a complete lack of care for Averil and lack of communication with NCEDS.

With regards to Secondary Care:

  1. Questions to NCEDS via NNCCG regarding care co-ordination which have been partly responded to as above
  2. Agreement with NNCCG to submit a timetable in the next few days with outline areas for questions to be submitted to NCEDS / CPFT. This timetable will be agreed between Mark Taylor chief exec’ of NNCCG and Damyn x , chief exec of CPFT prior to our submissions. The questions will be derived from the existing submissions gap analysis of the SI report as well as new questions arising from their answers.

Other Agencies and NHS complaints procedures

  1. I had a meeting with BEAT chief exec, Susan Ringwood in Norwich, she said she would help contact Charlotte Robinson’s family to see if they could be of assistance.
  2. MARSIPAN meeting and discussions with the chair, Paul Robinson with a case study produced of Averil’s care in the next MARSIPAN report to be released in late 2013.
  3. Calls and emails to “The Patients Association”, with a case study of Averil’s care in the annual report to be released in November (This to go to the national press including various medical editors).
  4. Discussion with Norfolk Coroner’s office and emails, which although sympathetic outlined that any case would have to go to the Cambridge Coroner.
  5. Cambridge Coroner’s office. Diane Collier of NNCCG has contacted the Cambridge office on my behalf, they have a record for Averil and we may be in a position to get a inquest, although certain factors could make this difficult.
  6. Legal. Cleo has sent through a case which may be relevant to us. It is Rabone v Pennine Care NHS trust. This details the lack of care afforded to a young person and the judgement resulting from the court case. We may wish to consider this route given the outcome and also the 12 month time constraints on legal proceedings.
  7. Contact with AvMA. They are a medical negligence charity who I contacted with details of Averils case. They replied in general terms and may be of further assistance to us if we are unable to get further resolution elsewhere.
  8. NHS England. This is complaints body for primary care. We can approach them with a complaint for Primary care, only if we have not complained directly to the primary care UEAMS (which we haven’t yet). I have contacted them and informed them that we will be filing a complaint about UEAMS in the next few days.

Saturday, 15th December 2012

Nic Hart

Today the 15th December 2012 our wonderful daughter, sister and friend Averil died in our arms.

Its late in the evening and we have been by Averil's bedside for several days now and although Averil has been unconscious, we have been holding her, talking gently to her, playing her favourite music and as it is nearly Christmas and Averil's birthday .... we have been singing carols.

Averil has been surrounded by love on her journey throughout her life.

Today there is an aura of love around her, as in the near darkness, she gently takes her last breath and she lets the pain of her illness slip away and she leaves us forever.

We sit and hold Averil and weep, but the room is empty and we feel bereft and exhausted.

We cannot imagine life without our wonderful Averil.

The hospital is quiet, the lights are still on, but a wonderful light has gone out in our lives.