A Failure of Care?

CONSTRUCTING ACCOUNTABILITY

I want to make an enormous generalisation, if you can stand it? It’s about how I came to see the police and the NHS constructing accountability after adverse events, especially contact deaths.  I have various experiences of my own as well as anecdotes from other professionals in addition to the obvious conclusions we can draw from reading material in the public domain.  Most usually, it’s reports, Preventing Future Death notices and inspection materials but letter’s like this add to that as does social media commentary.  All of that lead me to this generalised conclusion and if you want it further explained, I can do another post.  Here goes –

• The police and its accountability structures tend to look for individual blame and don’t look sufficiently at systemic factors which have obvious bearing on outcomes.
• The NHS and its accountability structures (such as they are) tend to look for systemic issues to explain deaths and don’t look sufficiently at individual issues which had obvious bearing.

Now once more: this is a crude generalisation because there are examples of NHS staff or Approved Mental Health Professionals facing prosecution for lapses in professional standards and this being highlighted in things like Preventing Future Death reports.  We also see examples of Coroners and police forces flagging systemic factors which were relevant in incidents leading to a tragic, adverse outcome.

But I still think there’s something in this: time and time again we see justice campaigns after police contact deaths where it’s already known we had undertrained, under-led police officers, operating in environments where there was an absence of multi-agency protocols and agreements which Chief Constables should have had in place and yet the focus after a death is upon officers doing what most officers would have done and have always done, albeit having had the luck their actions went unconnected to any tragic outcome.  Equally, we see Coroners PFDs where we really should be wondering why on EARTH some psychiatrist granted s17 leave roughly half-an-hour after a suicide attempt with the patient making it plain they would kill themselves if allowed out of hospital.  Yet when the patient then did exactly what they warned the psychiatrist they would do, it’s somehow a systemic issue that isn’t the “fault” of the individual doctor.

MID-STAFFS

Do you remember the Francis Review in to the hospital scandal in Mid-Staffordshire? – not a mental health inquiry, but something which looked closely at a serious of appalling neglects by NHS staff which became known because of the incredible Helene Donnelly OBE, the whistleblower who brought the whole thing to public attention.  Amongst many other things in the review, it was recommended the Government legislate to create new criminal offences of wilful neglect of patients who have capacity.

When considering the appalling incidents disclosed, there were various examples of outrageous neglect of patients who were left in soiled beds or without sufficient food / water, etc. But the criminal investigation which looked at the cases found there was no criminal offence with which they could prosecute neglectful staff.  It was already a criminal offence to wilfully neglect a patient detained under the Mental Health Act 1983, or to do so in respect of someone who lacked capacity (under the Mental Capacity Act).  But it was not a criminal offence to wilfully neglect patients who had capacity if they were not also detained under the MHA – so the Francis Review suggested changing the law and you can now see two offences created in sections 20 and 21 of the Criminal Justice and Courts Act 2015.

Something which reinforced my reservations about how the culture of the NHS views accountability was reaction to these proposals. We saw doctors and nurses writing in about “creating a dangerous precedent” and all the stuff we see above about failures to consider systemic and organisational issues and how they have bearing on the individual decisions nurses or doctors might take. Once all the chat was over, however, opposition to the offences meant someone was arguing that if a nurse has deliberately left an elderly patient in a soiled bed for hours and either done nothing about it or nothing to alert others including managers to help the person if they personally couldn’t, it should not be an offence – to leave someone rotting a way in their own faeces or whilst so deliberately leaving them so thirsty, dehydration has become dangerous.

MEANWHILE IN EAST LONDON

So back to the original case:  Dr Gibbons asserts in her letter –

“It is important to note that this was not a manslaughter conviction, but a health and safety one. Even so, the message it sends—that suicide is a failure of care—is a difficult one for frontline clinicians.”

I really don’t think this conviction does suggest “that suicide is a failure or care” at all – to think that is a failure to understand what a criminal trial is attempting to do.  They turn on their individual merits and speak only to the specific facts of the trial itself.  It may well be telling us that THIS suicide was a “failure of care” but it doesn’t tell us anything about anyone else’s care, even if there was a suicide and even if someone thinks there were failures.

All things turn on their own merits.