In a class of their own…


I sometimes wonder if the NHS is left handed or right handed.

Left handed people are supposed to be ‘arty’. Just ten percent of the population and been persecuted over the years for being ‘sinister’.

Right handed people are like the rest of us!

One thing I am sure of, the NHS’ left hand doesn’t know what its right hand is doing. In fact it is cack-handed.

What better example than the CQC… yes, it’s them again.

Somehow, somebody there has decided that Trusts are not doing enough to learn from the deaths of their patients.

They cite a number of reasons. Lack of staff, training and concerns about repercussions for professional careers.

In English I think that means, there is no time to do it, no people to do it and no one wants to get involved with the blame game.

Curiously, the organisation paid to represent Trusts, NHS Providers, jumped on the bandwagon and said, in terms, Trusts should be doing this. Nothing about the practicalities of achieving it.

Apparently, guidance is being ignored. Why?

I’ve given you the answer… no time, not enough people and the blame game.

Until you fix that, you can send out all the guidance you want but it will take its place in the queue behind financial balance, gaps in rota and rehearsing for the next CQC palaver.

As well as the CQC being blind to the fact that the HEE failed to get a workforce plan that actually works, up and running and there’s scarcely enough staff to wipe a backside never mind delve into deaths which is a huge undertaking… nearly half of all deaths occur in hospital and one in 3 patients in hospital are in the last year of their lives.

There is priceless learning from these events. Not just in the possibility that the death might need not have happened in the first place but was the death a soft landing for the patient, the relatives and the staff and what can we do better.

The CQC, ever willing to point the finger, as usual, have it all wrong. They have forgotten about, or never knew about, the Medical Examiner Programme. They need to point their blame-finger towards Whitehall.

The government have been saying, since god was a lad in short trousers, that the roll-out of a national system for medical examiners, to scrutinise every death in hospital, is due in April 2019. I make that about five working days.

Guess what… nothing’s happening.

The plan was, for every death, not referred to the coroner, to be independently examined. Pilot examiner systems have been running since 2008… yes, that’s right, eleven years ago.

Guess what… nothing’s happened.

There’s been the no little imperatives of austerity funding, staffing, Brexit and the foibles of three Secretaries of State who have each had their own priorities plus, of course, the CQC stomping around, parking their charabanc on Trusts lawns… all occupying Trust board’s attention, more than a little.

For years, there’s been draft legislation on the books, to give medical examiners a statutory role and the funding was to come from cremation fees, plus central funding.

Guess what… nothing’s happened…

… it’s been parked. There have been pilots and they have been hugely successful.

I wrote about my visit to Buckinghamshire Healthcare Trust, were they have their version of the programme and it has improved care, helped relatives through the darkest days and supported staff in learning to get better at what they do.

Diffusing complaints, questions answered. All in a nonthreatening environment of learning and caring.

Of course we should have every death examined, but it can take over two hours to review each case… and takes the clinicians, involved in the care, out of the front line, to contribute to the discussions, which means backfill.

The learning has to be cascaded through the organisation and the wider NHS… for which there is no mechanism.

The CQC always was a bad idea. Done badly it is an even worse idea. To point their finger in the wrong direction undermines them as an authority and to ignore failed government policy puts them in a class of their own.

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Reproduced at by kind permission of Roy Lilley.