This is the Sixth in the Persecution Series, after The Persecution of Heretics, The Persecution of Vulnerable Adults, Harassment from the BBC to GMC, Harassment from Rolf Harris to James Coyne to Doctor Who, Persecution: Black Riders in the Shire & Persecution: Rumbles from Mordor.
When something serious goes wrong in healthcare it is standard to have a Serious Untoward Incident (SUI) review.
If conducted in good faith, in areas like surgery where the issues are clear cut, having a critical incident review like this has some chance of working.
But in mental health, the issues are rarely clear cut. And as one of one of the managers within BCUHB put it – SUIs are an opportunity to
“get your own back on others”.
If the services truly wished to find out how they might learn from what has gone wrong and how to improve in future, they would include families in the process. But families are excluded even after the Ombudsman has raised this issue with Betsi.
Finally a cardinal rule of all critical incident reviews is that those being interviewed are not themselves being reviewed.
A death in 2013 of a patient being treated within Betsi mental health care ticked a number of boxes that called for a SUI.
As one of the many clinicians involved, I was invited to a meeting with Dr Robert Higgo and Gordon Kennedy, initially on March 12 but deferred to April 10, as Dr Higgo had a headache. I had not met either Dr Higgo or Mr Kennedy before. Notes of the meeting were taken by GP.
The original email inviting participation mentioned that I could bring along anyone I wished and could make use of the support services of occupational health. I brought no-one.
It also said:
“I am writing to advise you that you have been identified as an individual who was involved in delivering this care and we shall therefore need to interview you in relation to this. I should point out that this meeting is not to investigate any allegations made against you personally and therefore you are not the subject of this investigation”.
The email did not clarify the auspices under which the process was taking place, who had commissioned it, whose desk any report was likely to land on, or what exactly was being investigated. At the time of the interview, Dr Higgo didn’t know if an inquest had been held and if so what the verdict had been.
It simply said:
“as you may be aware an ongoing investigation is being conducted into the death of CASE A who was a patient within the mental health CPG. Please find attached an invitation letter requesting your attendance for interview in relation to this matter”.
I accepted the invitation immediately but also asked about the auspices of the process and was told:
“All deaths of this type receiving mental health services are externally reported to the Welsh government. These incidents have then to be fully investigated and the reports with agreed action plans forwarded onto the patient safety team at Welsh Government.
This patient was subject to an ongoing POVA investigation at the time of death and in line with the Adult Protection Policies and Procedures BCUHB has been requested to undertake an investigation and submit a written report to the Designated Lead Manager of the POVA strategy group”.
When I turned up for the interview I registered surprise that it was not being recorded. GP didn’t even take short-hand. It would have been a difficult task for anyone to represent from memory the amount of material being covered and it would have been particularly difficult given the complexity of some of the issues for someone with no background in mental health.
On May 7, GP sent a 9 page draft set of notes with an invitation to amend if indicated and sign as a fair representation of the meeting.
The meeting went on for close to 2 hours and was rapid-fire the whole way. Such a meeting would generate close 40 pages of denser transcript so these notes represent less than a quarter of the content of the meeting.
All the important points to do with the very many complex issues this case threw up were omitted. All points that reflected poorly on Betsi services were omitted. All the points the family would have wished to see addressed were omitted. The entire emphasis was on my role.
Anyone reading these draft notes would get a seriously misleading impression of the conversation that had taken place. I indicated by return of email that these minutes were seriously deficient and that I would be preparing an addendum.
After an interview like this, where there is disagreement on content it would be standard practice to offer an addendum to the minutes to take into account missing points. I wrote one.
But long before seeing the addendum, almost instantly after I had indicated that the minutes seemed to me to be deficient, Dr Higgo replied saying that he was going to approve the original minutes.
In this SUI roughly 20 people were interviewed.
Of the four medical staff with contact with CASE A while in Hergest, I was the only one interviewed. Of the many other medical staff involved at one point or another, none appear to have been interviewed.
Of the twenty-four nursing staff from the ward CASE A was based on in Hergest only one was interviewed. This nurse was harassed into an interview – contacted at home on several occasions while on sick leave. She was “spooked” to find she was the only member of ward staff interviewed. When she asked why, she was told that it was because she had been the major contributor to the nursing documentation.
Given this, she took another member of staff with her and both commented after that the interview process had many of the hallmarks of a witch-hunt.
She made corrections to the transcript and returned it – but commented to colleagues that the transcript had left out many things that were covered.
Of the 38 members of the community mental health team, two appear to have been interviewed, of whom one has had no contact with either the patient or me.
In May after receiving the deficient draft of the minutes I enquired further about the auspices of the report and whose desk it might land on. There was no reply for weeks.
Long before there was any reply, within days of receiving the minutes, by another route, I became aware that Dr Makin, the Medical Director, was expecting to see a report imminently, had likely already been briefed about it, and was expecting hostile comments about me.
From comments made, it was clear that there had been communication with the Medical Director and the issue of my clinical practice had been flagged up before my response to the interview process was even lodged.
To be continued…
Betsi – BCUHB – Betsi Cadwaladr University Health Board
Formed in 2010 from an amalgamation of 3 Trusts across N Wales
Dr Matt Makin, Medical Director BCUHB
Dr Paul Birch, Assistant Medical Director West
Dr Giles Harborne, Chief of Staff, Mental Health Clinical Programme Group (CPG)
Mary Burrows, Former CEO BCUHB
Geoff Lang, Former Acting CEO BCUHB
Dr Robert Poole – Consultant Psychiatrist Wrexham
Dr Robert Higgo – Consultant Psychiatrist Wrexham