Laughing Boy: a preventable death

18 months ago, an 18 year old lad called Connor Sparrowhawk aka Laughing Boy drowned in the bath while he was in the 'care' of Southern Health NHS Foundation Trust at a residential mental health unit in Oxford called Slade House STATT (which stands for Short Term Assessment Team Something-or-other). Connor had a learning disability, autism and epilepsy and at the time of his death he had been in the unit for about three and a half months for 'assessment and treatment'. At first Southern Health attempted a cover up, claiming that Connor had died from 'natural causes', but when this didn't wash they commissioned an external investigation which found that Connor's death was preventable and that he died from drowning, most probably because he had an epileptic seizure while he was unsupervised in the bath. The investigators said that the unit had 'failed significantly' in the care and treatment it provided for Connor, not just in relation to his epilepsy care but also in relation to the overall care he received.

Failings, failings and more failings, but no accountability

Having allowed one of its patients to drown on its watch, or more accurately while it was not watching, you would think that Southern Health would have tried really hard to get things right in future, especially perhaps at this particular cluster of services. You would be wrong. A Care Quality Commission (CQC) inspection carried out a few months after Connor's death found a catalogue of serious failings including the building being 'not suitably clean (i.e. dirty), 'not suitably safe' (i.e. unsafe) for patients and visitors, unsafe medication administration and inadequate storage, emergency equipment out of order, inaccurate recording and ineffective monitoring of health and safety. In the STATT unit where Connor died, it was reported that "up to four staff mainly worked on administrative tasks within their office, with one member of staff out on the unit. Over the course of two days, we saw few social or therapeutic nursing interactions with people who stayed there. There appeared to be an impoverished environment with little therapeutic intervention or meaningful activities to do."

The STATT unit was closed by Southern Health in December 2013 but one of its sister units on the Slade site, John Sharich House (JSH), was still open when the inspectors came back in March 2014. They found that in response to Connor's death a senior professional at the unit had decided, knee-jerk, to ban all patients from having baths. A blanket bath ban (I mean a blanket bath ban you understand, which is only marginally less ludicrous than a blanket bath ban) was bang out of order. No relevant risk factors for bathing had even been identified for those patients, not that it would have been any better if they had. So much for individual, person-centred care planning, patient involvement in decision making and finding appropriate ways to manage risk. Once again, the inspectors criticised the unit for "little obvious therapeutic activity throughout the day" and noted that "staff stayed in the staff room for considerable lengths of time, working on administrative tasks." No improvement there then either.

Eventually JSH was also closed, so the next inspection in September 2014 was of the one remaining unit on the Slade site, known as House 2 or Step Down for reasons that are unclear but which I'm choosing to interpret as an advice note to Southern Health NHS Trust Chief Executive Katrina Percy. Just do it. Like now. The unit is described by Southern Health as part of the forensic care pathway. Having witnessed at close quarters the operation of the notorious Liverpool Care Pathway, phrases like that set alarm bells ringing for me. The government report into the Liverpool Care Pathway death scandal is entitled More Care, Less Pathway, which I suspect is as appropriate here as there. The inspection report on Step Down was published earlier this month, although the publication date on the document itself is noted as November 2014, for which there is no doubt a perfectly defensible reason. Its findings show that, 14 months since leaving a patient to drown in a bathroom, Southern Health has failed to put its houses in order and is still seriously failing in two main areas: firstly staffing and secondly quality and suitability of management. I say houses because it's more than one. Take a look at the inspection reports on Antelope House, Evenlode and Parklands for instance.

Employment highs and lows

As a zero hours worker with zero hours work and a zero pounds payslip each month to match, the area of staffing is of special interest to me, so I took some time to read the whole CQC report on House 2 at Slade to see what it revealed about this specific aspect of Southern Health and Katrina Percy's failure, described thus in the inspectors' summary: "We found the service was not always safe. There was not always enough qualified, skilled and experienced nursing staff to meet people’s needs or to cover sickness and absence. These meant nurses were regularly working very long hours and doing multiple on call duties. The safety of the service was heavily dependent on an unsustainable workload on individuals." In the next paragraph, the inspectors deem the service 'effective'. I maintain that no service that is unsafe can possibly be effective; that particular illusion can only be maintained until another patient drowns in the bath or meets a similar preventable fate by which time it will be, then as now, much too late.

The staff team at Step Down told the inspectors they were"very short staffed, very tired," hardly surprising when just three qualified nurses were trying to cover 24/7 between them. The inspectors report that "[t]his led to nursing staff 'feeling pressured' to work long hours to sustain continuity for the people they supported. This pressure increased at time of sickness and/or holiday," and they go on to say: "We reviewed the rotas for the last 10 weeks and saw that when one of these nurses took leave and/or were off ill so it was covered by the other two nurses. This meant nurses were regularly working very long hours and doing multiple on call duties. On one occasion we saw that the nurse who was also in interim management of the home worked 83 hours and was on call four times." This one little snapshot of a failing service exemplifies a much wider problem prevalent in many parts of the health and social care sector, but often hidden or ignored at the peril of both service users and staff. Unfortunately, those with overall responsibility for such services, the Katrina Percys of this world, seem largely to escape accountability for being in charge of these disasters waiting to happen.

Accidents at Emergency

We've heard a lot recently about Accident and Emergency departments that don't have sufficient staff to operate safely. One nurse in Wales described her work last year, before the current 'crisis', as more stressful than a war zone and we hear reports of nurses who've been working 90 hour weeks this winter. This article suggests some of the reasons for the pressure over and above 'increased demand', including cuts in social care funding that make discharge of patients into the community more difficult, insufficient doctors and nurses to maintain a safe and sustainable service as well as money wasted on expensive locums and agency workers instead of appointing permanent staff.

Disability and employment

As I mentioned earlier, I have a job that doesn't generate any working hours or income. I used to work supporting unpaid carers until the service was put out to tender and I was transferred under TUPE arrangements to an employer whose Chief Officer thought it was unreasonable of me to object to working in a windowless office lit by fluorescent strip lights when those lights triggered migraines for me, rendering me unable to function. That dispute led to me spending the best part of three years floundering in the murky waters of grievance then employment tribunal processes, ultimately representing myself in a week-long disability discrimination and constructive dismissal hearing. While all that was going on, I was searching for other work and found a post as a worker at a project run by a national charity supporting three women with learning disabilities to live independently in the community. My own disability meant I was only offered a zero hours 'relief staff' contract but for various reasons this suited me at the time: I wasn't committed to any regular hours but was offered enough - later topped up by the Tribunal award - to keep the wolf from the door and could generally make myself available at short notice if needed.

How overwork happens...

The full time staff at this project frequently worked over their contracted hours to cover for sickness and holidays, sometimes 50, 60 or even more hours a week plus sleeping in shifts and there is no doubt that staff became tired and irritable and less able to provide a quality service under these circumstances, which is hardly surprising. At that time, there was no overt pressure on staff to cover shifts, although with limited relief workers available and what I understood to be an absolute ban on bringing in agency staff, finding other cover wouldn't always have been easy. Then the service was put out to tender again and the contract won by a new service provider to whom I was transferred under TUPE. Based on my previous experience of TUPE transfer, I wasn't optimistic about the likely outcome of this for my employment prospects and I wasn't disappointed. The new provider glibly told the full time staff they would now learn what time off looked like, that they'd get one weekend in three off and would have a set rota that wouldn't be chopped and changed "because we know you've got lives outside work." It all sounded too good to be true and it was. The new company had not previously used bank staff and it definitely didn't like using me. It failed to make reasonable adjustments so I could attend training sessions, and after four months I was no longer offered any shifts at all.

...And how overwork is ensured

As my shifts were drying up, the company strategy in relation to its contracted staff was becoming clearer. Instead of appointing sufficient additional staff, the permanent staff were given a lose-both-ways choice of covering for sickness and holiday amongst themselves, usually without recourse to bank staff, or having their rotas recalled and completely rewritten at as short as 24 hours notice. So much for lives outside work. Of course, staff paid not much above the minimum wage are likely to be struggling to make ends meet and may be glad of the extra money overtime brings, but we're not talking just a few hours here. Service providers and, more importantly, contracting authorities appear to have little or no concern about the detrimental impact of such practices on the lives of service users and staff. They should do. This would be easy to fix: there are plenty of people out of work who would make excellent support workers, not to mention those of us who are already on the payroll twiddling our thumbs as we wait for another blank payslip to drop through the letterbox.

Now what?

Going back to the very beginning, Laughing Boy's life ended in an unsupervised bath and Southern Health Trust has shown us it's still not fit to be providing in-patient services to vulnerable people. If we want to prevent such avoidable tragedies in future, we need to make service providers properly accountable for all acts and omissions that compromise safety, and that includes staff working under extreme pressure. Those guilty of serious failures should resign or be removed. And we need to find ways of sharing work out so a few people - generally the frontline workers - don't end up with an unmanageable load until they crack. Public and private service providers don't seem to be able to do it. I think that means we have to demand it, to insist on it, or somehow find ways to reclaim control so that services are provided in co-operative and properly person-centred ways for the benefit of patients and service users, rather than in the interests of Chief Executives and shareholders. The NHS is potentially facing irreversible privatisation if TTIP goes ahead, while much of our social care has already been privatised with companies seeking to undercut their competitors and maximise profits for their shareholders. This drives down wages, working conditions and safety, and it is the vulnerable, the people for whom those services are supposed to exist, who suffer most.

Blowing the Whistle

Unsafe working practices thrive when almost everyone pretends they don't exist and those few who do speak out can safely be persecuted and victimised by the perpetrators. We need to tip the balance so that whistleblowers are properly protected, so that blowing the whistle is safe and becomes the norm, rather than the highly risky exception. If you see something, say something, before it's too late. More information about whistleblowing at The Whistler, The Speak Out Safely Campaign and Compassion in Care.

Justice for Laughing Boy

Connor's family and others are working together to try and get a new law passed that will protect vulnerable people, make sure they get better services and that their views and those of their families are properly taken into account. See Justice for Laughing Boy and LB Bill for more information.