Persecution: SUI-Cide is Painless in Betsi
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.
SUI Cide
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”.
Draft minutes
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.
Selection bias
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.
Higgo to Makin
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
The light of day illuminates:
I have worked for many years with large public companies and was heartened by one aspect of their approach to ethics and a key statement made that stuck in my mind was that one should act in a way that you would be happy to be read in the light of day eg in a newspaper. I am heartened to see what I have read here. Keep it up.
And the saga goes on regarding psychiatry and its treatment of vulnerable people.
You certainly have my best wishes and support for a positive outcome. thanks for caring and sharing.
From TRM
This is a very familiar story. A small number of gifted academic and clinical professionals spend a lifetime building up a centre of outstanding service and novel research. They motivate teams who look forward to “every tomorrow at work.” The brightest and best trainees are fired with enthusiasm and further raise standards of patient care and valuable, patient centered clinical research. The highest achievable quality of patient care prevails, is maintained and progresses.
Then come the guidelines and clinical protocols, perched on the clipboards of managers from the “greasy pole society.” They cavort in their wickedness to reduce the remarkable to the mediocre. The teams are demoralized and their achievements are mocked. Guidelines of committee derivation cannot by definition and experience be scientific. They are rigidly imposed by the new “Vichey government” – The price paid by wounded, maimed and dying patients is only too clearly understood.
Those who have lead this malicious descent into mediocrity are knighted and promoted to spread their wisdom in the ways of the wicked elsewhere.
The descent into dangerous and shambolic care continues – whilst knowledge, understanding,empathy and wisdom despair.
“And a man’s enemies shall be found within his own house.”
(Gospel according to Matthew perhaps?)
I do not think self seeking congregations of pseudo-scientific guideline writers, protocol extremists nor the managers who maliciously pedal their wares will be keen to guide and manage the new ebola centers.
T
Your experience with the minutes mirrors the experience of every single “MH” patient I have ever spoken to.
I hope the point regarding the “profitability” of any inpatient psychiatric unit is not missed. The profits are in the drugs…
The highest achievable quality of patient care is not profitable – worse it will drive the *wicked ones* into bankruptcy !!
“There’s no money in the cure”– ?
BUT– Gaining mastery over the “ONE ring”holds the promise of incalculable fortune– saving the “wounded, maimed and dying patients”; demonstrating the
power, dignity and of value inherent in every single human life–
One who knows her capacity to *create value* , cannot be corrupted by power or money.
It would seem the Irish way has come to roost amongst the Welsh Hills…”Shut up, cover up and don’t ever tell”. Name and blame but cover your “Assets” and here’s a brown envelope to confirm our Pact…
Best wishes to you Dr Healy and your colleagues as you all remain steadfast on the Road of Truth…Your opening words at the front of your book Pharmageddon tells it all –
“For over Fifteen Years I have been involved in cases linked to injuries on drug
treatment. This book is for those who have survived to pass their stories on,
for the families who have been left behind, and especially for those who have
struggled to put things right”.
Thank you for caring…
Dear David,
I read with dismay the last few posts on your blog today.
As you know, but for your readers I shall mention – I am an Australian based child and adolescent psychiatrist but also worked as a locum child psychiatrist in Bangor in 2003-2004 and every August from 2005 to 2008. The child psychiatry clinic is downtown in Bangor and not with the hospital, but I had enough visits for older adolescents admitted to the Hergest Unit and for the invigorating journal club and teaching medical students to get a strong impression of a well functioning Hergest Unit at Ysbyty Gwynedd (Gwynedd Hospital). I also heard from the psychiatry trainees when I supervised them about how generally happy and keen they were in the training program.
Here in Australia I caught up with Dr Andy Hughes recently at the ANZ child psychiatry conference. He was a stalwart at the Hergest Unit in Bangor but is now in Australia. We talked about what a brilliant unit the Hergest was up until the late 2000’s, with a vibrant group of consultants and trainee psychiatrists, psychologists and good morale amongst the nursing staff. Also the community services were good. There was a humane approach and atmosphere conducive to recovery for patients.
Attending the journal/professional development meeting on a Friday afternoon was always interesting, and if presenting one had to be on the ball to field the questions and participate in the robust but very collegial discussion.
Thus it is with utter dismay that I heard about the problems and the departure of so many good staff. It is tragic for the staff and of course for the patients and people of North West Wales – of Gwynedd a Ynys Mon as many of them would prefer to say in Welsh.
There needs to be a truly independent inquiry above the level of the Betsi board. Gaining information from staff who recall the halcyon days but sadly have left would be vital to a full understanding of the issues.
My forebears are from Caernarfon and Ffestiniog – the area has a rough history of repression but the locals love the place dearly, it doesn’t need to be deprived of good resources in the present. Given the drain of such good services for the people, perhaps the local member of the Cynulliad Cenedlaethol Cymru (Welsh National Assembly) should take an interest?
With best wishes,
Peter
Hello to you Dr Parry. Thank you for your very fine and positive perspectives on this toxic situation. The very fact that Dr Healy has for years been required to defend what is in fact a brilliant career is a scandal. Briefly, I am an author and editor who first contacted Dr Healy following the death by suicide of my healthy undepressed teenage daughter Caitlin who had sought prozac, having seen ads in the USA on tv. Friends told her that you lose weight and feel great. 63 days later Caitlin was gone having hanged herself in the guest bedroom of her home. Dr Healy understood, supported me in what seemed at the time a futile attempt to carry on. He is part of a rare, unofficial and diamond-like group of people around the world who have managed to balance expertise and ambition with the need to remember the reason we are all in this business in the first place…healing, recovery, love of life and one another. Looks like you are another diamond. Thanks.
All someone needs to do is view the disciplinary cases heard by the Health and Care Professional Council to confirm this. 80% of the cases against registrants are instigated by the employer, usually a public body. Any dissenter to management can be easily subject to a trawling exercise which can raise extremely petty discrepancies in documentation, attendance etc, etc to question their competence and consequently their registration and career. I feel this is a major failure in the system which deters anyone challenging their employers systematic failures or colleague’s poor practice.