messages from inquiries and reviews · 2019. 2. 25. · • barbara robb (1967) sans everything: a...
TRANSCRIPT
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Messages from inquiries and reviews
Jill Manthorpe
Essex Safeguarding Adults Board
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Different types of inquiry & review
• Personal accounts
• Inspections
• Complaints
• Serious Case Reviews + coroners’ inquests
• Government inquiries
• Commonalities and differences in messages
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This presentation focuses on older people’s inquiries
Contextual factors include: • Ageism & ambivalence
(especially in LTC; in semi-professional practice);
• Never a golden age - systemic and historical under-resourcing of support to older people;
• Public & professional tolerance of poor practice & standards for older people.
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Previous Inquiries – present themes?
• David Roxan (1967) “I saw patients being treated like dogs” News of the World, 27 Sept. p.7.
• DHSS (1969)Report of the Committee of Inquiry into Allegations of Ill-treatment of Patients and other Irregularities at the Ely Hospital, Cardiff.
• Barbara Robb (1967) Sans Everything: a case to answer ,London, Nelson.
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Personal reports in media
• Ash Court – BBC Panorama
• Daughter – Jane Worrall - camera surveillance
• Support of advocacy/ campaigning group Residents & Relatives Association
• Highly critical of CQC • Week after Winterbourne
View screening on BBC TV
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Care Quality Commission
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A lack of inquiry by the CQC?
The case for more not less work by CQC by R&R
1. More inspections – risk based approach not adequate
2. More detail on reports 3. More analysis, eg of
death rates 4. Re-launch relatives’
survey
Picture of circle dancing from Cynthia Heymanson
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Complaints – the Clwyd-Hart review
Response to Mid-Staffs report & general concerns ‘Putting Patients Back in the Future’
One year implementation with 12 stakeholders
Duty of candour – remains to be decided – Trust or professionals? Extent of this and how it would work?
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Clwyd-Hart Recommendations • Chief Executives to take
responsibility for signing off complaints. Trust Board to scrutinise all complaints & action. Board member to be responsible for whistle-blowing.
• Trusts to publish an annual complaints report in plain English
• More information on wards. • Patients and communities should
be involved in designing and monitoring the complaints system in hospitals.
• Easier ways to communicate. • Rebrand, Resource and Review
Patient Advice and Liaison Service and Independent Advocacy Services.
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Local Inquiries (SCRs)
New names emerging • Safeguarding Adult
Reviews - SABs Other developments • Children’s SCRs - publish • Domestic Homicide
Reviews • Overviews eg
Hampshire on chocking incidents
‘Corporate Accountability and Adult Safeguarding’ Edited by Rt Hon Paul Burstow MP 2013
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Coroner inquiries
There was institutionalised abuse throughout the home and it started, in my view, at a very early stage, and nobody did anything about it. Penelope Schofield, Coroner, re Orchard View (closed late 2011)
http://www.channel4.com/news/orchard-
view-care-home-coroner-inquest, picture ITV
To be followed by SCR...
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Government Inquiries: Francis/Mid Staffs legacy
• Not just long-stay hospitals... (Ely)
• Testing of professional, governance, regulatory and criminal justice systems
• Clinical and compassionate imperatives
• Weakened trust? • Power of relatives and the
costs to them http://www.dailymail.co.uk/news/article-
2274296/Mid-Staffs-report-Families-head-NHS-resign-damning-scandal.html
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Messages 1: Why is organisational abuse being missed?
Ash (2013) asked:
• Why aren’t care reviews & regulatory systems picked up earlier on residents’ poor quality of life?
• Why isn’t the known ‘whole-place-is-an-abuse’ home questioned, challenged or confronted by visiting social workers & other professionals?
Cognitive mask (theory)
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Message 2: why is abuse tolerated?
Nomalised Deviance theory
Eg people find ways to work round apparently daft hurdles and get things done... All a matter of perceptions
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Messages 3: Minimising harm to relatives and whistleblowers
Julie Bayley Margaret Haywood
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Message 3: minimising inquiry overload
• Role for Safeguarding Adult Board (some have sub-committees or panels)
• Roles for Safeguarding Managers to co-ordinate
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Message 4: sector and inter-sectoral peer review and audit
• Value of peer review
• New developments on outcome measures
• Making the most of data
• Huge need to include other providers
• Need to assess value of ‘provision at risk’ etc
• Share sector led initiatives
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Message 5: communicate & consider findings and recommendations
• Everybody’s business = nobody’s business !
• Decide how to do it – no set formula
• Communication is not the same as reflection
• Potential to go wider than staff to user/carer groups, politicians & public
• But addressing dissonance and mask
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Acknowledgements & Disclaimer
• We acknowledge the contribution of the Policy Research Programme at the Department of Health for its support for the Unit
• The views expressed in this presentation are those of the author and not necessarily those of Department of Health
• Thank you for listening! • Contact:
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