The last blog post I wrote here was hastily tapped out on my phone from Heathrow Airport. Waiting to board a flight to Sri Lanka, a holiday long since planned for relaxing and recuperating after a busy year of campaigning. The (not in anyway unreasonable) expectation was that the #Mazars review would be long published before I went on holiday. Yet for some unknown reason the main point of contact in NHS England insisted on ignoring my emails:
The intentional and wilful ignoring of my question causes further harm and damages brittle relationships; as ever with the NHS system it drives people to their breaking point.
I was told when I came back from holiday that they’d got a new phone and they’d been out the office a lot – both of which apparently led to them not receiving/choosing to respond to my emails. I could not believe that the report still had not been published, and actually more disturbingly that no date for publication had been set. This is then a timeline of what happened:
2 Dec: I chased NHS England for an update and in the response I received confirmation that there was still no date for the publication of the final report but ‘we have been working towards the week commencing the 7 December‘. I was told that Sara was aware of the plans.
3 Dec: Out of nowhere the next night a new email came through which contained this statement ‘We have been working towards a date of publication w/c 7 December. However, this is now not possible’. A meeting was now planned for 11 Dec to confirm the date for publication. No explanation or reason for the further delay was offered.
4 Dec: I checked back through the minutes of the Expert Reference Group and the emails to members and discovered a number of incomplete actions on behalf of NHS England and discrepancies between the information shared with members. Drawing this to the attention of NHS England I requested an explanation. Sara blogged about how these never ending delays felt here.
5 Dec: I received two direct messages on twitter from a senior member of staff at NHS England on Saturday evening trying to persuade me to have a phonecall (at this stage I had lost any energy for phonecalls, I was not prepared to gift any more of my time to this process).
6 Dec: A response was sent to my email with partial explanation and the reiteration that the meeting on 11 Dec would agree the publication date.
9 Dec: A comment was posted on Sara’s blog just after 4:30pm that alerted us to the fact that the report had been leaked.
However, it has come to our attention the report has been leaked to the media, despite it not being finalised. We would not usually comment on a leaked draft report, but…
I’m not going to give Southern Health any more airtime for their propaganda. The discussion in the comments of Sara’s blog revealed that the member of staff who had shared this update was doing so because they believed it their responsibility under the Duty of Candour. Somewhat refreshing, and completely isolated occurrence in what followed. There’s been no such offering of candour from anyone else.
Sara brought this to NHS England’s attention and their response was equally surprising they ‘were made aware’ that the draft report had been leaked to the BBC and they would be running a story that evening (this email was sent early evening). Why if NHS England were aware they didn’t proactively let Sara or the ERG know is beyond me.
That evening a further email was sent informing us the meeting scheduled for 11 Dec had been cancelled and a phonecall had taken its place that afternoon. Despite this no publication date was offered.
The BBC ran a headline story on the leaked report on the 6pm and 10pm news. This included pre-recorded material that had been prepared some weeks in advance, alongside live coverage from Michael Buchanan.
10 Dec: Early morning we heard that Heidi Alexander (Shadow Health Secretary) had tabled an emergency question on the report. At 10:35 that morning #JusticeforLB’ers across the country sat glued to their screens as the debate took place. Half an hour of emergency debate, promises from Jeremy Hunt that he’d tolerate no further arguments about methodology and several MPs pushing for a speedy publication, Sara has blogged about what that 24hrs felt like here.
Rather naively we actually believed that the report would be published soon. We were receiving a lot of online pressure from people challenging us to publish the latest version of the report (that we have been told was final). We contacted NHS England again asking for information and confirmation of a publication date and asking them to publicise it.
11 Dec: 24 hours later we received a reply from NHS England that stated ‘we plan to publish the report and the NHS England response early next week‘. I responded and tried to get an actual date, this email was completely ignored.
Despite this we foolishly thought that we could relax and exhale, early next week, we could handle the pressure for a little longer. We wouldn’t give in to the online pressure and the journalists requests, we would wait for NHS England to publish the report early this week.
14 Dec: Yesterday, Monday, ‘early’ this week. We hadn’t heard anything by late afternoon so I emailed requesting an update. This email was completely ignored.
15 Dec: Today, Tuesday, surely the last possible day that could be ‘early this week’. Beverley (another member of the ERG) contacts NHS England about support for families. Her email is responded to by return. This response includes the term ‘when the report is published later this week‘.
Now, I don’t know about you, but Wednesday is midweek. Whether you consider the week to start on Sunday or Monday, there can be little argument that Wednesday is in the middle. A report due out ‘early’ in the week should have been out Monday or Tuesday. The conspiracy theorists have been having a field day about the political reasons for delay, what on earth NHS England are trying to finalise, when Parliament breaks for the holidays. I went back to the evidence, ISO 8601 is the standard relating to timekeeping and it is clear that the week starts on Monday, so early this week ends today.
We still have no date for publication of the Mazars report. A man has made it into space today, but NHS England can’t even make a decision about a publication date.
The continual delay and deliberate ignoring of Sara and myself shows the very real gap between the theory and practice of candour, transparency and honesty.
A month after my last post, and we’re still no further forward. Which assuming the same rate as reported from the report, that probably means another 4 unexpected deaths of learning disabled people or people with mental health problems at Southern Health, for this latest delay period alone. At the very least I hope that the scrutiny of the last week might mean that their deaths are investigated. Small consolation really.
Given the Duty of Candour is obviously an irrelevance to NHS England, I’ll just leave this here, the Nolan Principles from 1995, only twenty years to embed them: