Monday, 30 June 2008

BLPT Trust Board

There was an "analysis" of the 8 (I think) SUIs (Serious Untoward Incidents) at BLPT during April on their website. The link is still here but it no longer works. *edit - thanks to Calum for pointing out that the link is now operational again.*

I was intending to post on the document, because the analysis was sadly lacking. Basically it featured 5 sudden deaths, 2 incidents concerning POVA (protection of Vulnerable Adults) and one theft from Trust property (the disappearance of a prescription pad). The analysis seemed to say that there was no problem, there were no themes, nothing to see, move along please. I fail to understand how it is an analysis. However, the document is no longer available for you to look at and see if my interpretation matches yours.

It also appears, from the most recent Trust Performance Report, that examination of SUIs is well behind schedule:

There are currently 34 open SUI cases requiring further action:
7 of the 34 cases are within SUI reporting timescales (i.e. 45 working days).
22 of the 34 are outside SUI reporting timescales one of which is subject to ongoing legal proceedings and the delay is therefore unavoidable.
5 of the 34 have been subject to, or are currently following, the Safeguarding of Vulnerable Adults (SOVA) procedure. In such cases, the risk management team would await the conclusion of the SOVA investigation before being in a position to update the SHA and PCT.
A robust management plan is in place to complete at least the 16 ‘simple’ outstanding cases by 7 July 2008.

The Trust declares that it is "keen to learn from SUIs to improve mental health services. " to that end, "a comprehensive database of learning has been set up by the Risk Management Team" and "The current Policy and Procedure for Reporting Adverse Incidents will be revised in consultation with commissioners with an emphasis on learning and preventative action. All open SUIs are now in a database which is reported weekly to the Chief Operating Officer for review in the Performance Management meetings and to the Risk Management and Assurance Framework Group each and thence to the Audit and Assurance Committee. "

My problem with this is that I don't see any major change here from what has supposedly been happening for some time. Surely SUIs should always have been looked at by the Trust Board? In fact, they have, because they regularly feature on the Closed Trust Board meeting agendas. I think it is the attitude which needs to change - an attitude which currently seems to boil down to stating that those involved were mentally unwell and therefore there was nothing the Trust could do. In some cases there may be an argument that the Trust has done all it can to help, but in others I know personally that support was asked for and not made available. The sudden untoward death of anyone is a situation which merits thorough, unbiased, independent investigation which looks at the deepest causes and examines whether anything could have been done to prevent it. Perhaps all investigators should start with the question, "If this was your relativie, what would you have expected?"


mandy lifeboats appeal said...

Hi C

This has hit a spot cause Tommy killed himself in April, so he has become one of the 'serious untoward incidents'.

All I can see going on with these kinds of reports is backside covering and masses of paperwork leading to comments of "We will use this as a learning curve". What price a human life...or human lives eh?

Rainbow dreams said...

In my opinion all healthcare workers and anyone involved with caring for anyone should start with that question - what would we expect or hope for if it was us / our family in the same situation...
and then do everything in their power not to let those people down
nothing makes me more sick that people not valuing another person's life and being

Disillusioned said...

Yes, Mandy,, I can appreciate that this would be a difficult one for you. I felt it was important to post though. I agree about the self protection involved for the trust too.

Katie, it seems an obvious point, doesn't it? And for some of those I have encountered, it does seem to be their starting point. Unfortunately, not for all. Which is very sad, because that attitude doesn't require qualifications or special skills - just compassion and humanity.

mandy lifeboats appeal said...

Hi again D

I think it was important that you posted it too.

I see the indications are that the national survey result will be on the poor side. Good to see BLPT improving on previous years!!!!!!

mandy lifeboats appeal said...

P.S. As in there is sarcasm in there somewhere.

Someone asked me to play nicely and I said let me have a sandpit and I will. Ha!

Disillusioned said...

Hi Mandy

Indeed, I too am pleased to see such clear improvements in BLPT performance in service user surveys. (Sarcasm intentional).

Perhaps if they acted on service user concerns instead of ignoring and minimising them, their survey results would improve? Just a thought.

Calum said...

You prob know now that the SUI document is still available.

There is a compacency to the document which is mind-blowing. Is the equivalent document on SUIs for the previous meeting done in similar style? Does it give any more detail or does it hide behind not received" and "not signed off"?