Speech to the legal/healthcare conference on 20/04/12

Good afternoon and thank you for this invitation to speak, Cure the NHS was formed four years ago following the death of my Mother. The group is made up of mostly relatives who have lost loved ones at Mid Staffs. Because of the time limitations I will take it that most people here know about Mid Staffs.

Many people say that the HCC was the worst report in the history of the NHS, it reported that hundreds of people lost their lives unnecessary. To date no one has been held to account for those deaths and failings.

An accurate figure has never been put on those deaths, when it suits the NHS they refer to the Dr Foster statistics but when the figures say what they don’t want to hear, they dismiss them.

The day the HCC report came out Alan Johnson the SOS for health at the time, stood in up in Parliament and said Stafford was an isolated case and that each family would be entitled to a case note review of their loved ones death.

It proved a wasted exercise because of the poor recording of information by the professionals, or the altering of information and missing documentation. The majority of deaths were older people or those who had other illnesses. Dr Laker who carried out the reviews claimed only a few could be certain of losing their lives through the lack of care.

My own case note review concluded that my Mother would have died anyway, although she was being discharged the next day. The evening before she was dropped by a member of staff and an ECG found her heart had been damaged, all previous ECG had found nothing. But my Mother was 86 and from experience over the last 4 years, proving an unnecessary death for the elderly within the NHS, is practically impossible.

Following the publication of the HCC, the group campaigned for a PI, the HCC had told us what had happened but not why and why so many people had been allowed to suffer for so long.

We began our legal challenge for a PI, we wanted evidence to be given in Public and witnesses compelled to give evidence. One reason for this was the refusal by the coroner to give evidence to the HCC to assist them with their investigation.  I still find that totally unacceptable.

Hundreds of people had contacted me and told me about their loved ones dreadful death. Our banners during our campaign even asked how many more unnecessary deaths? I question to this day how I could spot there was a problem and yet others couldn’t.

As you know we got our PI but it was only because it suited the political climate, at the time. Our Judicial review was unsuccessful as the Labour Gov had worded the Independent inquiry that they offered us in such a way that would make our challenge fail, if we proceeded.

During the PI we heard lots of evidence that would convince us that the law doesn’t help those within the NHS system, being harmed or who have been harmed. Each body we encountered and each body we heard from during the PI confirmed that.

There was no clear evidence that came out of the PI as to who was responsible for patient safety. We are even unsure if there is a definition of harm, error or medical negligence. Perhaps there are some formal legal definitions I can take away from this afternoon.

Through a Freedom Of Information request from a member of the public, evidence was produced over the death of Gillian Astbury. A woman who had gone into hospital insulin dependent and over 2 days had been starved of her insulin. The case exposed a catalogue of blunders and negligence throughout the whole system.

The request exposed a series of emails from the Health and Safety Executive, saying that if they took this case on the floodgates would open, as they didn’t have the resources to proceed with such cases within the NHS. They argued it was the Care Quality Commissions’s responsibility.

The HSE were also involved in the case of John Moore Robinson, a young man who had been sent home from A&E with a ruptured spleen, he died a few hours after discharge. Like Mrs Astbury, John’s case wasn’t taken up by the HSE. They did get involved with a case of a man who had fallen off a trolley but even that didn’t lead to a prosecution, this surprised us as it happened again within a matter of weeks, leading to another death.

Each case we heard about where the HSE were involved the families seemed to be led down the garden path. Long, long delays before a decision was taken, torturing the family. Eventually telling them they wouldn’t be proceeding with a case. The Crown Prosecution service did the same, they like the HSE kept these grieving families dangling for years until they decided they wouldn’t be proceeding with the case. Leaving both families further traumatised.

The police should have been there to protect us but they didn’t.

I heard of several cases where people had wandered off the ward, one man wandered off the ward during my Mums stay. Confused, he had asked and asked all afternoon to go for a cigarette, a nurse had chastised him for pestering her. He was found dead a few days later in undergrowth. This I later found out wasn’t even recorded as a Serious Untoward Incident.

The police were involved for looking for this man, in fact the night he went missing they frightened the life out of me by shining a torch under my Mums bed as I slept in a chair trying to protect her.

I have heard from several people during the campaign whose relatives tried to escape from the hospital. Sadly the police just returned them back to the suffering. The only involvement the group had with the police was when they would watch over us while a group of elderly grieving relatives would stand in silence, always in silence, never any trouble. But the police thought they needed to watch us, instead of protecting the vulnerable.

I could spend all day discussing the coronial system but I will keep this brief and urge if you haven’t to read the South Staff’s coroner’s evidence, to the inquiry.  How can one have confidence in a department which includes serving solicitors and doctors from the hospital in its own area, is this unusual? I don’t know.

We know from the PI that although there was so many unnecessary deaths, the coroner didn’t spot a trend. There was no consistency with Rule 43 letters, very few were written. We saw internal emails, though, that said that letters the coroner had sent in the past to the hospital, would they now consider them as rule 43 letters, although they weren’t marked as rule 43 letters. There didn’t seem any point to them, as there was no follow up as to what actions had been taken or what actions should be taken. Although this coincided with the beginning of the HCC.

The first thing a family have to do is to fight for the inquest even when there is concern over a death. Families then often face years, before an inquest takes place. We had never heard of a jury inquest inStafforduntil after the HCC report and then there have only been a few. Once at inquest the families feel that the coroners department isn’t impartial and they are faced with a group of professionals. Very often they are a lone voice as getting representation is too expensive and not covered by legal aid.

Getting any legal representation is difficult, solicitors are reluctant to take on negligence cases. Despite all the evidence at Mid Staffs families were advised to settle out of court and relied on round table discussions for small settlements, as they were mostly older people anyway. Some were given advice before the failings were exposed and are now unable to challenge the decision without private finance. One member of the group who gave evidence to the PI now tries to live with the harm that was caused, her name is Nicola Monte and I urge you to read her evidence. A young woman who’s life is ruined, unable to challenge because she doesn’t qualify for legal aid but doesn’t have the resources for other legal support.

This is the battle we did and still face, once there is a death, the family believe is avoidable.

The first hurdle is getting the case notes. That’s always a battle and it is whilst you are grieving. Then you have to pay £50 and take a risk that they are complete, which they are usually not. Very often they arrive without the information we need. CTNHS believe, these should be given as a right if there are concerns over a death of a loved one.

During the PI we heard evidence about the role of a medical examiner and this CTNHS believe is the way forward. Although we heard that this role is still being tested. It was something that we believe would help.

What the public want is honesty, fairness, justice, transparency, impartiality, consistency!

For this there needs to be a whole culture change, we don’t need the HSE, medical defence unions, and the police in our hospitals, we need zero harm and right first time adopted throughout the whole of the NHS.

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1 Comment on "Speech to the legal/healthcare conference on 20/04/12"

  • eileen kirk says

    Dear Julie,
    Re your question, “How can one have confidence in a department which includes serving solicitors and doctors from the hospital in its own area, is this unusal? I would have to say, NO.
    Seven weeks after the maternal death of our daughter and first grandchild, in 2005, (whilst still in shock), the Nottingham Inquest Coroner, after some sixty minutes, returned a verdict of accidental death. Some weeks later, I rang the coroner’s office, to ask if accidental death was cause for compensation. He gave me the name of a Nottingham solicitor, telling me to do everything this man said, but asking I tell no-one, he’d put the name forward.
    The Notts, solicitor, who after a first independent obstetric report, asked if we wanted tea, coffee or champagne, did a U-turn on receiving an independent anaesthetic report. “Our daughter had been unfortunate.” (In spite of the fact, continued attempts at Central Venous Placement, by both the Anaesthetic Registrar and the Consultant Anaesthetist, had caused the heamothorax that killed our daughter).
    When I turned to AVMA for help, the same solicitor was one of their most experienced referral panel members, and AVMA felt his legal advice was correct.
    We would recommend, anyone, with a comlaint about the NHS to go well out of their area for help.
    The complete trust we’d once placed with legal and medical professionals, is totally destroyed.
    Against all the odds, you got the truth out there Julie!
    Warmest Wishes
    Eileen Kirk.