Change that leads to better lives

On the Mazars Report

Our response to the Mazars report investigating deaths of people under the care of Southern Health NHS Trust.

Essentially, it seems that the leaks of a few days earlier were accurate. So many things could be written, and indeed have been written by others – see for example Chris Hatton’s blog that I will confine myself to three main issues.

1. It’s basically about equality and rights.

Amongst the most telling statistics were that whilst 30% of deaths in adult mental health services were investigated, only 1% of those of people with learning disabilities and 0.3% of older people in mental health services were investigated. The only plausible explanation for this is a belief that the lives of people with learning disabilities and of older people are less important than those of others. This may have been driven by a belief that non-investigation of those deaths was less likely to be challenged, or possibly by a cruder lack of value given to the people themselves. Either way, we are talking about equal rights and discrimination. In my role as a member of the Equality and Human Rights Commission’s Disability Committee, I have asked whether the EHRC has the powers and remit to take matters further.

In Southern Health’s press statement in response to the report, their Chief Executive, Katrina Percy, stated;

“We believe that Southern Health’s rate of investigations into deaths is in line with that of similar NHS organisations.”

To be clear, this is an NHS Chief Executive stating that other NHS Trusts also fail to equally investigate the deaths of people with learning disabilities and older people. The evidence to support this claim needs to be provided, and NHS England, the NHS Confederation, the DH and indeed the Minister need to be aware that this claim has been made and take action accordingly – either to investigate all NHS Trusts because of similar failure, or to disprove this claim in the interests of the reputation of other NHS Trusts.

2. It’s about leadership.

The Mazars report is heavily critical of the leadership of Southern. Leadership sets the tone and tenor of the culture of an organisation. Organisational culture is a prime determinant of things like equality of attitude and treatment.

There is a story I have told privately for some years about my time as National Director of Learning Disabilities. It is time to tell it publicly. I was sent by the then Minister, Stephen Ladyman, to meet Regional Health Authority Chief Executives whose regions were failing to close the long stay hospitals. In one region, I met with the Chief Executive, along with the relevant PCT Chief Executives and Directors of Social Services. It was clear they were not going to speed things up. When I said I would have to report this back to the Minister, who would not be happy, the RHA Chief Executive said to me, “Rob, you know and I know that I will not lose my job if I don’t deliver on the learning disability agenda”. He was right – then, in 2003. It is about time that changed. If accountability and responsibility is not accepted by senior people for these failures, the NHS will not be taken seriously by people with learning disabilities and their families.

3. It is time for action.

Why has Jeremy Hunt announced there will be a CQC investigation? How many investigations and reports do we need (Mazars is not the first one) before something is done to change how people with learning disabilities and their families are experiencing some parts of the NHS (and older people, and people with mental health problems). If the mental health anti-discrimination campaign will forgive me for stealing their name – it’s Time to Change.

Rob Greig
December 17, 2015

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