Professor Jarman. First impressions.

This is a preliminary and perhaps impressionistic account of Professor Jarman’s  evidence. There will be much more in the way of important evidence this week, so I wanted to make an attempt to capture first impressions.  I hope that other people with a much more detailed grasp of the statistical systems involved will also choose to analyse the case that he has made.

Professor Jarman has played a very prominent role in the course of the Midstaffs Inquiry. It is the use – or possibly abuse of the statistical systems that he created that led to the highly contested “excess death figures”. These figures, which were set to be included in the health care commission report at the very last moment and then were withdrawn after a major row, have completely dominated the press and media coverage of the Midstaffs story, and are the reason why I am now involved in a campaign for press reform.

With me there are key witnesses that I needed to see in person. Professor Jarman was one of these. I needed to see the person in order to see what his system means to him. This may sound like a strange approach to a matter of Statistics, but been discovering from the Inquiry is that it is the statisticians who are most passionately involved with what has happened here, and that the different systems for monitoring and regulating are always built on a very individual approach. People and personalities matter!

Like everything else in the Midstaffs Inquiry this is not as simple as it might seem!

First – what did we learn about Professor Jarman’s personal history.

It is clear that Professor Jarman’s career is both long and distinguished. One of the things that he is most committed to now is his involvement with the Institute for Health improvement in Cambridge and Boston Massachusetts USA. Since 2001 This is a body of people who are deeply committed to improving the quality of health care. His work with them is a reflection of his own deep commitment.

Professor Jarman’s early background is interesting – He did not begin medical training until the age of 31 after early training as a geologist. His first PHD was in seismic wave propagation.  He then went on to develop an interest in Socio economic indicators and has developed computer systems for CAB and Social services.

He became a GP in 1970. He was a member of the Community health council for Bloomsbury in the 1970s, and thinks they managed things very well.  When visiting a hospital he witnessed a serious untoward incident, which he believed could have led to a death. He does not think this was reported. This may have led to his wish to look for ways of improving quality of health care through better training.

He talked about the unintended Impact of the Griffiths report in 1983, which he believed divorced the health service from control by the clinicians and put it into the control of Health service managers. He clearly feels that this was a mistake.

He was involved in the Bristol Inquiry, where his statement gives us an interesting insight into his relationship with the government – He believes he would not have been the Government’s first choice for this task!  He set up the Dr Foster Unit as a response to what he saw at Bristol.

 He has been working on Mortality rates since 1990 so this forms a very significant part of his life’s work.

It became clear as he gave his evidence that this is something about which he feels very very deeply, and that he sincerely believes that he has developed the tools that have the potential to save many lives.

A little of the detail.

Because I am rushing to get to today’s inquiry I am now going to focus on the points that stood out from the evidence – all of which I will try to come back to later. I would of course advise people to read the transcripts for themselves. Do not take it from me! I am not objective, and neither is anyone else who is reporting this matter!

There was discussion about the Doctor Foster Unit and Dr Foster Intelligence. The Inquiry tried its best to clarify this difficult distinction. Dr Jarman is keen to emphasise that there are points of real difference between them, and that he is often at pains to point out where he thinks they are going wrong.

There was a long discussion about HSMR and the basics of coding. What struck me from this is Professor Jarmans emphasis on the importance of Primary coding. The system depends on people getting this right. It was made clear that this was a matter of clinical judgement – often by junior Doctors working under stress. Professor Jarman sees this as a simple matter- the question which is still unanswered from my point of view, and I think from the point of view of Robert Francis is how simple is this in practice.

The discussion got bogged down in “primary coding” actually meant. It was clear from board minutes in Midstaffs that the hospital did not have the same understanding of this as Professor Jarman. He seemed genuinely surprised by their degree of incomprehension.

Robert Francis asked a hypothetical question about how you could code a case where a person was admitted with a broken Hip and then developed CDiff. Professor Jarman’s answer was that it was a matter of clinical judgement how this would in fact be coded.

What was I felt notable by its absence was any prolonged discussion on Secondary coding. We know clearly from the Health care commission report that this was something that was being done entirely wrong in Stafford. The coding manager had been off sick for a long time, the stand-ins found difficulty getting information about co-morbidities. They therefore had to rely on Primary coding (which may or may not have been accurate).

To my mind, and I am of course no expert on this, any system which sets out to tell us if a death is “expected” or “not expected” has to reflect the total medical condition of a patient. Let’s take a case study from my own family. My mother in law was admitted to hospital (in Scotland) because she had had a massive stroke, brought on by the medication for the rheumatoid Arthritis which she had suffered from for 15 years. The Stroke left her immobile, and she was in acute pain whenever staff had to move her because of the arthritis and eventually needed morphine to enable her to cope with being moved. Her breathing patterns became very irregular, and she needed heavy medication to cope with this. She had kidney infections and needed antibiotics. Her condition stabilised.  She at one point was told that she would be fitted with a peg feeding tube and discharged to the only nursing home that could cope with her complex conditions. She did not want this and went down hill rapidly at this point. She then got C Diff. She eventually died from heart failure.  I do not think she died of “a primary cause” I think she died of all these reasons combined.  I have no idea how her case was coded.

To form any judgement of how well the HSMR system works, I think we need to look at a large number of case studies and understand the variation of coding that occurs in practice.

There was a lot of discussion about a factor that came as complete news to me after three years of looking at the Stafford Case.  Professor Jarman makes it clear that he is always open to suggestions about how to improve his system, and as a result of concerns from some of the users he changed the statistical model in 2007.

The “customers” for the system had pointed out the need for a palliative care code, which would make it easier to show cases where a patient was essentially just being kept comfortable, and was unexpected to survive. The introduction of this code came in 2007 and this along with the failure of Stafford to “rebase” their coding explains why there was a huge jump in their HSMR. The Hospital had been expecting to see HSMR at 114, High but not alarmingly high, It in effect came in as a result of their failure to use the new palliative care code at 127. The figure that sparked all the fuss.  

It is clear that West Mids hospitals as a whole had missed the introduction of the Palliative care code, and that therefore those hospitals which had a high case load of elderly patients – with complex health problems, who were not expected to survive, were being wrongly coded. This may – and I repeat may – be the explanation for the higher than usual HSMRs on the 6 hospitals in the West mids region.

A slide which drew a lot of attention from the Inquiry, and very much pleased the press, related to the work that the SHA did with its hospitals at this point to sort out their coding problems. The three hospitals that Professor Jarman pointed out began using the palliative care code extensively and their HSMR consequently fell rapidly. 

What Professor Jarman clearly felt, and the press picked up on was that this was “gaming” the system.  I think it is perfectly possible that there was some overcorrection going on, but I think it is also very important to view this in the light of the genuine undercoding that had been going on previously.  This was not discussed and I think it should have been.

There was quite a lot of discussion of the way in which the SHA had commissioned the Birmingham university group to carry out research into HSMR. Dr Jarman clearly interprets this as a personal slight. His anger about this was tangible.

He also feels immensely strongly that the DoH have not valued his work in the way that they should and that if they had done so thousands of lives would have been saved.  He puts out the HSMR data to all hospitals now, not because he is paid to do so, but because he feels it is his moral duty.

One thing which did impress me is that he described work which he had done with a hospital to help them study their processes and help them bring down mortality.  I think this may be in contrast with the work of DFI where the emphasis is on offering training and consultancy to hospitals to help them use the system better.

Dr Jarman is a physician. He wants people to do things better, and what his system can do at its best is to help people identify areas of concern. It is only at that point that the work begins. People have to analyse what is happening, and work out how to do things better.

Dr Jarman’s system can help people begin this intellectual journey. So can all the statistical systems that have been shown to us by the Trust, The SHA and the CQC.  It is also clear from the work highlighted by Ben Goldacre, that systems that this government has wished to scrap – involving the Targets, can also help people begin this journey very effectively.

Getting beyond the politics.

To my mind the big problem that all of us are struggling with is how statistical systems, which need to be carefully evaluated, and carefully used, have found themselves at the heart of what is essentially now a political battle.

The Conservatives took a political position on this. Targets were out, Outcomes were in, and Professor Jarman’s system, alongside his belief in the importance of a GP led Health care system would do the job.  This annexation of professor Jarmans work may have been damaging to him. He clearly expected that his work would finally now be recognised, but yesterday he expressed his disappointment with the contents of the Health bill.

Could the press act as regulators for the health service?

I have been thinking about this article from Health Policy Insight

Editor’s blog Thursday 2 June 2011: NHS quality regulation doesn’t work; try this instead

I was alerted to it by a twitter exchange between the outgoing chief executive for Midstaffs and one of the journalists who has spent what must seem like a high proportion of his life covering the Midstaffs story.

The Health Policy Insight blog makes the point that regulation does not always do what it says on the tin, and given that in a series of recent NHS scandals the press have got to the problem before the regulator, he wonders if we should just forget about regulation and give the money to the press to do it for us.

Here is his solution.

Having read many of the witty and incisive pieces written by this writer, it is quite likely that this is a piece of kite flying, but it is interesting that both the CEO and the journalist were very taken by the idea.

Abolish poorly-functioning national quality regulation, and give the money as a subsidy with a range of conditions to local newspapers. A small sum needs to be paid to some independent regionally-based staff, to monitor and follow up on the output.

Regulation and the Stafford Inquiry

Like the Journalist and the CEO I have also devoted a lot of my time to days at the inquiry, or reading transcripts. I do so because I am interested in the challenge of regulation, and also because I have become fascinated by the many important issues that this case has raised about the press, and the real difficulties the press may sometimes face in painting a fully rounded picture. I have learnt a lot about the many sided and often un-graspable nature of “truth” in this process.

In my opinion the impetus for the public inquiry at Stafford came from four different directions.

·         Obviously there is the hurt of the individual campaigners and their need to make sense of their experience. This need quickly became enmeshed with the needs of politicians.

·         There is the press and their sense of duty and financial commitment to a  powerful public interest story

·         Then there is the political impetus. The story was an apparent opportunity to prove the “failure of the NHS“ and to prove the need for the Government’s now teetering health reform package.

·         And then there is the question of how to regulate the health service. It became abundantly clear that regulation, as it was at 2006-2007 was not doing its job. Regulation should either have been able to flag up problems, or give the health service a clear defence against disproportionate criticism. It could do neither. We are not looking back to a golden age of regulation in the past. Regulation has been developing for decades, partly as a response to political need, but this slowly evolving art has not yet reached a stage where we know it can do the job.

How Regulation is developing

What is clear to me is that the health service has learnt a huge amount about regulation as a result of the complex but demonstrable regulatory failure at Stafford. The service has responded with quiet reforms so that the regulatory systems and tools that we now have are unrecognisable from the systems as they were in 2007.  I am not sure that these major changes are yet widely understood. I would advise reading the evidence and statement of Richard Hamblin who served in both the Healthcare commission and the Care Quality commission as a good starting point on this.

The new tools are promising, but a crucial element of this new approach to regulation, is the recognition of the limitations of the statistical systems. The systems matter, and matter a lot, because they are the way in which we can build a framework to keep NHS standards national. It is clear from David Cameron’s recent speech that the government is depending upon them for this purpose. The practitioners, those who understand the systems best, know that what we have is at the very most a warning system. The data is subjective, quality of coding matters, there are few people with the skills to do this well, and human error occurs. As investment in “non essentials” is squeezed then this is an area of the health service performance that may well suffer.  What the statisticians tell us plainly is that simple statistics cannot be used to demonstrate that a hospital is “failing”. The League tables so loved by the press for their simplicity and dramatic effect should now be a thing of the past.

The CQC new philosophy of regulation combines use of the indicators that may flag up potential problems with skilled people on the ground to delve into areas of concern and to help hospitals begin to be able to identify clearly where they can do better. The weakness that the CQC has now, and I think this is demonstrated by the Winterborne case, is that there are simply not enough skilled inspectors to do the job. There is a serious recruitment problem.

The role for the press and the public.

The thing which I think appealed to the CEO and the journalist about the idea of the press as quasi regulators, is that the CEO has said there is a need for thousands of pairs of eyes. It is everyone’s responsibility to take care of the health and care services. We all need to raise concerns. The question that remains is what is the best way to be able to do this effectively?

One thing that was abundantly clear from the Midstaffs case is that the complaints system within the hospital was dysfunctional. It was quickly reformed and is or course being reformed again now.

Complaints directed outside the hospital were effectively useless, as many different people ended up with one or two pieces of paper on their desk. -Never enough to form a pattern.- None of this connected.

The need for an effective patient participation vehicle was of course completely recognised and the LINks system was in the process of forming as a replacement to earlier vehicles for participation when the Midstaffs problems kicked off. This small group of willing and well meaning volunteers was not in any way equipped to deal with the huge problems the Stafford Campaign group brought with them. Having witnessed some LINks meetings at this period the volunteers who might well have done a good job in other circumstances were paralysed by the truly astonishing level of animosity that these meetings generated. It is perhaps useful to mention that the LINKs system, which was crying out for more public involvement received virtually no support at all from the local press, and did not become visible until the press were in a position to criticise them.

So the channels which should have led to constructive engagement between the public and the hospital over the problems that existed failed, and we were left with a situation where the press perhaps rightly saw it as their job to side with the pressure group against the hospital. The hospital found itself on the receiving end of literally thousands of negative articles, ( I have boxes of them) which may arguably have contributed to the loss of staff morale, patient confidence and to the financial problems of the hospital. Energy that could have gone into resolving the problems that existed was diverted into simply surviving the barrage.

Changing the game

The public voice needs to be heard –but how?

I think there are a number of ways in which this has already been tackled:

·         The Hospital pioneered comfort checks, which means that potential “complaints” are tackled before they ever reach that point.

·         The hospital brought in simple boards for patients and families to raise suggestions.

·         The board meetings are all held in public, and actively encourage public engagement.

·         Training for staff brings the patient experience to the forefront.

·         The Trust holds meetings on a range of issues which are all designed to help the public make their voice heard.

·         NHS Choices was set up by the DOH and SHA and already functions as a way of channelling complaints and concerns  through to CQC and presumably to the hospitals.

·         LINks  in Stafford got adopted by County Council, Not sure what impact this has had, but it removed the temptation to use it as a political football.

·         Healthwatch will have a clearer integration path to CQC which will assist to ensure all problems channelled into a place where they can be collated.

·         One element of the CQC system which is still very new, but potentially game changing is the QRPs. Hard data, particularly hard data that tells you what you think it does, is hard to find. For it to be of any value it requires skilled people spending time collecting data, Some of this is essential, but it is at least for the time being politically unpopular. The QRPs will make it possible for many sources of “soft data“ such as patient complaints and press stories to be logged in a way that would give some idea of patterns or clusters of complaints.  If this takes off then the press will find that there is potentially more of a response to their efforts than was ever possible in the past.  This would help everyone. If low level complaints can be heard there should no longer be the necessity for vocal and potentially divisive and delaying campaigns. So with or without a “quasi regulatory” role the press should be able to play through the QRPs  a more effective role in helping to express people’s concerns. Richard Hamblins evidence is again helpful on this matter.

Could the press do more?

To go further, to actually direct public money at the press to help regulate the NHS and other services is a genuinely interesting proposal, but I think this raises some rather serious questions about what the press is actually for and how far the press is willing to modify their role.

If you had asked me this question 20 years ago I would have said that the local press was there to serve the good of its community, but 20 years of observing the press in practice has made me question this.  

What the press perhaps has to offer is the skills of individual journalists in assisting individuals to make their points. Many journalists would be able to do this job very well, and the community would be better for it. But does this sit comfortably with the role of the press?

A regulator – and anyone who would want to perform a regulatory role has to be accountable. Their first priority is to see clearly the truth of a situation from all sides. This will generally mean slow, careful research, the checking of facts, and making it possible for different people to give their side of a story.

The press – at least the press as we know it does not do this. The role of the press is to tell interesting stories and to sell papers and advertising space. We are dealing with businesses trying to make a profit in a market that is under some fairly extreme pressure.

Journalists do not have the luxury of time to research carefully. They must tell their story in the required number of words, in time to get the paper to press.

Papers belong to wealthy men, who have friends and have political allegiances. Running papers means attracting advertising revenue, and people who pay well are obviously important to any proprietor. Public services, and especially the NHS is deeply political. Journalists are hired and fired for a variety of reasons, and unless journalists acting as “regulators” can be protected from the subtle pressures to say “the right thing” they could not carry out this role objectively.

Beyond that there is the whole way in which the press sees the world. The press likes stories where people are shocked or disgusted or angry. They like stories of distress and human suffering. They like blame and retribution. These are the stories that set the tills ringing. Other stories, less dramatic but equally important do not have the same weight.

Just as an example, I spent 5 years trying to interest the press in the complex issues that were addressed in the Labour party White paper on social care, and are now going to be addressed by the Dilnot report.  These are issues that cause very real hardship and distress to thousands of families, but because I was interested in seeking solutions to the problem, and was working with people to do so, this was not really a very interesting story to the press. I was not prepared to blame anyone for the problems that I had personally encountered, and therefore there was no conflict to make this important story entertaining.

If we were to direct public money at the press it would need to carry the requirement for them to deal with stories, sometimes, complex stories, in which they might not actually be very interested.

So is the whole thing impossible?

Perhaps not.

Papers as we know them are at the end of their life. All journalists accept this. When papers go the influence of the powerful men who run them will go too. This influence is already waning as the internet continues to bring together clusters of individuals who work together to make their voice heard. Papers are already losing their monopoly of “the truth”.

But this is not enough. In five to ten years the press and the internet will have changed beyond recognition, but the skills that good journalists have to offer will still matter.

If we do go down the road of GP commissioning and shadowy new providers then it could be that the press really will have a vitally important role to play   When providers are not open, then real investigative journalism will be needed.

“The advantages for local papers are that a subsidy to deliver adequate health coverage would reinforce their curiosity about local provider (and indeed commissioner) performance. There are many good stories to be had.”

The internet is bringing a quiet revolution, the democratisation of information. NHS Choices is a part of this. But more need to be done to make this quieter more collaborative approach work for people. This kind of development is a tool for a healthier democracy.

Journalists have a role to play here. If everyone is helped to use their voice, if we get beyond the paternalism of the press in its current form, then there will be thousands of stories that at present we simply never hear.  Good journalists could help with the task of making these visible. If they really help to give people a voice they can play a part in transforming our communities.

The Problem of “Truth”

The writer makes the assumption that the libel laws we currently have are enough to ensure that the truth will generally be told by the press. My perceptions of the Stafford Story show why in this particular case – which may well be unique I would have deep reservations about this. Truth is not always a simple matter. That is why many millions of tax payers money are now being spent to find out what really did happen at Stafford, and even when we have with of hundreds of hours of clear evidence and witness statements to go on then we find that there is still some surprisingly radical differences in the interpretation of the “truth”. 

For the press to be able to play the part that I would like it to play in our communities, either as a “quasi- regulator” or simply as good newspapers I think there are some simple changes which need to happen.

This is perhaps most easily illustrated by looking at a single element of the Stafford Story.

The single biggest problem with the reporting of the Stafford Hospital story comes from the fact that the excess death figures were presented as authoritative fact, when in my favourite euphemism of the moment, they are “not an entirely uncontested version of events.” They were something which came from a document that has been deleted, under circumstances we now clearly know, leaked by a person who has not been identified, based on data acknowledged by virtually all informed opinion to be seriously flawed, and using a calculation which the creator of the data system has clearly stated to be inappropriate. If this is fact it is certainly not fact as I recognise it. – but due to the extreme complexity I am not yet satisfied that the PCC would see it as a clear infringement of the editors code.

I am very easily satisfied. All that I ever required from the press is clear attribution. If they had begun with the premise all “facts” must be traceable back to their source, I do not believe they would have been tempted down the road they travelled. Repeated quotes of “hundreds of deaths” would be so much less appealing if it was immediately followed by the details of what was known and not known about this “information”.

Health policy insights says

There are also the pitfalls of bias, grudge-settling and other such drivers – but the press are used to dealing with these motives, and to presenting both sides of a story. More to the point, the British press knows that it is subject to some of the world’s most stringent libel laws, in which absolute truth and the public interest are key defences.

This Is something that I would really like to be able to rely on, but at the moment I do not genuinely believe that I can do so.

The press is in the dock now, over a growing range of different abuses. All institutions must now come under scrutiny and it is the turn of the press. Maybe now is the time to set the ground rules for giving us the press reform that I believe both most good journalists and the public want and need. The Stafford Hospital story gives us valuable pointers to the reforms we should be looking for.

 I could be reassured if

·         journalists would always produce their source material if requested for it,

·         in the event of serious disagreements over the interpretation of “truth” that one could call upon an impartial expert tribunal to act as an “appeal court”,

·         in the case of science based stories these tribunals would be expected to call in people who understand the material in question,

If this were done then I would genuinely welcome the major improvements that this would bring to journalistic practice, and would welcome an appropriate role for the press in helping people hold public services to account.  

Questions for Andrew Lansley.

The Guardian is holding a live NHS question time for Andrew Lansley. Here are some questions I would love him to answer.  

My questions for Andrew Lansley come from the fact that I live in Stafford, have been a very close observer of the Stafford Hospital story for the last three years, and am aware of the way in which Andrew Lansley has frequently used the Midstaffs Hospital scandal as a way to “demonstrate” the need for radical NHS reform. This is exemplified by the way in which the Stafford Pressure group appeared on his conference platform as an illustration of the “failings” of the NHS.

This falls into a pattern where this government tends to use “exceptional cases” or “headline facts” to illustrate the need for change. Often, as in the case of the yacht story quoted by David Cameron in his “I love the NHS” speech these assertions do not bear close examination

I have put together a brief video which explains some of the misconceptions which lay behind the Stafford hospital story, and indicate the role that Andrew Lansley himself played in giving the story the massive prominence that it received.  It is also clear from a detailed study of the press coverage in 2009-2010 that most people would have accepted the findings of the Robert Francis Independent inquiry of 2010 and the recommendations that came from this.  The demand for the lengthy and expensive full public inquiry would not have been carried through without the very active support of Andrew Lansley. (I have yet to publish the information on this).

The government is now committed to taking on board the recommendations of the Midstaffs Public Inquiry, which we understand will now continue taking some evidence up to November, and may then spend many months writing its report. The evidence which we are hearing from many different sources has so far completely failed to endorse Andrew Lansley’s vision for the future of the health service. It has also raised many questions about the precise level of “failure” that is represented by Stafford Hospital. Whilst the Inquiry in its months of evidence taking has uncovered some errors, failed opportunities, failures of communication, and deficiencies in training, it has also shown a hospital were many good people were trying very hard to do a good job, often without sufficient resources to do it. It has presented a much more rounded picture of a hospital with its share of problems rather than a uniquely bad hospital.

The Statistical basis for “the case against the hospital” which has been used by Andrew Lansley has been examined in minute detail – though this is never covered by the press – and has been shown to be seriously flawed.

Here are my questions:

The Statistical evidence against Stafford has the characteristic that those who see the statistics at a “granular level” (granular has become a buzz word at the Inquiry) know that they are simply seeing a “signal” which can be confused for a variety of reasons. Those who are operate above the “granular level” have been in this case misled into believing the statistics told them more than they did, often relying on “information” gleaned from the press.  Andrew Lansley (and David Cameron) have both referred on a number of occasions to hundreds of unnecessary deaths at Stafford Hospital. How “granular” is his understanding of the Stafford Hospital statistics?

Andrew Lansley’s role in Stafford has helped to create the widespread public anxiety that still exists today. Would he like to take the opportunity to reinforce the point made by all the statistical experts that the excess death figures should not be taken at face value?

Andrew Lansley was very strongly in favour of the publication of Hospital Standardised Mortality Rate league table statistics in 2007, and appeared to believe that the use of this kind of statistical information could lead to driving up standards in the health service. The recommendations of the Robert Francis Independent inquiry 2010 led to groups of statisticians working together to devise new and hopefully more reliable systems to monitor hospital performance. We now know that HSMR figures will not be used again in the way that there were in 2007, and that a new “richer” system Summary Hospital-level Mortality Indicator (SHMI). will take its place. The SHMIs will have the virtue that it will be much harder for the press to “over interpret” the figures to mean something that it does not mean. The announcement of these changes has been made very quietly indeed, would Andrew Lansley like to take the opportunity to tell people that the health service has moved away from over simplistic comparisons of death rates at different hospitals?

Andrew Lansley’s reforms lean heavily on local decision making, with a prominent role for the GPs and the Local Health Scrutiny Committees. In the case of Stafford these failed to see any problems at Stafford Hospital, and it is clear that problems did exist, though not on the scale misleadingly indicated by the Dr Foster Figures. Does this give Andrew Lansley confidence that the shift of emphasis to Local decision making will be a sufficient protection for uniformly high quality in the health service?

Andrew Lansley’s reforms of the health service are a major structural re-organisation. It is clear from listening to the evidence of the Stafford Inquiry that the major organisation of 2006-2007, coupled with the financial constraints, and the commercial pressures of moving to Foundation Trust status created the conditions for the problems that did occur. It is also clear form listening to the evidence that the health service has from 2007 onwards been reforming itself organically from within. The PCTs and SHAs did reach the point of having a clearly defined role and having the right people in the right places, though this is already being severely disrupted by the current “reforms”. The SHAs and the CQC have worked quietly and purposefully to devise new better systems for monitoring the NHS, and this has all been done without structural change. The problems that Andrew Lansley saw in 2006-2007 no doubt were real, and were real consequences of the re-organisation, but there are good indications that the Health service has reformed itself very substantially from within.  Many people at the Stafford Inquiry have shared their fears  that another major top down organisation can only serve to disrupt the delicately balanced working relationships within the NHS. Is Andrew Lansley willing to consider the possibility that major structural reform may not be the best answer for the NHS?

A major part of Andrew Lansleys reforms involves using competition to drive up standards. The evidence of the Inquiry is that competition carries with it a number of negative side effects. A lot of information becomes commercially sensitive, and this militates against transparency. In a situation where hospitals are competing for customers this give disproportionate power to the press, who can make or break a hospital’s reputation. In the case of Stafford Hospital it could be argued that the press have behaved in a way which is irresponsible. How does Andrew Lansley intend to ensure that the future press reporting of Health service matters at a local level is carried out in a fair and accurate manner?

Andrew Lansley has committed the Government to listen to the lessons from Stafford. Listening to the evidence it is clear that we are hearing a lot of strong pointers for the reforms that are actually required within the health service. Calling upon the people who have survived the Stafford experience and thought very deeply about what it has to teach us could be a good starting point for reforming the NHS in a well founded way. I would strongly advocate a listening event for those members of the health service who have been involved in the Stafford Story, before any further progress is made on NHS reforms. Is Andrew Lansley willing to consider this?

The Healthcare Commission Story Part 1

For anyone who has been close to the Stafford Hospital Story over the last three years one of the most significant and contentious events was the decision by the Healthcare Commission to launch an investigation into the hospital in early 2008.

The Midstaffs Public Inquiry has been taking evidence from a number of people who were involved in the HCC at the period that this decision was being made.

This is a brief summary of some of the things that have seemed most important to me. I am aware that I will need to come back and flesh this out much more fully, but I am also aware that the messages I am picking up through the Inquiry raise really serious questions about the assumptions of “a failing NHS” which lie behind the Governments proposed Health reforms. I want to alert more people to this possibility now, at a crucial time for decisions about the health reforms.

The assumption that has been made in the press, and by many of the politicians who rely on the press for their information is that the sequence of events which led to the HCC Stafford Hospital investigation is as follows:

·         The Dr Foster Intelligence produced in mid 2007 a league table of hospital mortality rates which it published in the Daily Telegraph, raising widespread public concern (and also widespread outrage within the NHS about the appropriateness of using the data in his way)

·         Julie Bailey’s mother died in November 2007, sparking a low key local campaign which led to the formation of “Cure the NHS” in Early 2008.

·         Cure the NHS began systematically contacting anyone concerned with the Health service, and build up their contacts with the local press to raise the profile of the concerns about basic nursing care that they felt about Stafford Hospital.

·         Cure the NHS contacted the Healthcare Commission in early 2008 and it was the combination of the Dr Foster mortality rates and the Cure the NHS concerns that triggered the Healthcare Commission investigation of the hospital.

This assumption – according to the testimony given by different members of the HCC is wrong. What actually happened is this:

·         The HCC were aware of the Dr Foster league table, but shared the opinion of other statisticians and regulators within the NHS that the HSMR rates were useful as a management tool, but that the mortality rates produced by this method are insufficiently robust to be used as a league table, and cannot be used as an indicator of quality of care.

·         The HCC did not monitor the local press and so had not picked up on the campaign by Cure the NHS.

·         The HCC received a flood of complaints brought together by the newly formed Cure the NHS in early 2008. They had received no complaints from Stafford before this. They noted the complaints, but would have been unlikely to have triggered an investigation as a response to this.

·         What did trigger the investigation was a new statistical system that the HCC was working on in conjunction with the Dr Foster Unit. (It is important to note that the Dr Foster Unit, which is an academic body attached to imperial college, is entirely separate from Dr Foster Intelligence, which is a commercial company which sells mortality information and consultancy to the health service).

·         This new statistical system was to look at outliers. It was being developed by the Dr Foster Unit as a means of measuring outcomes in the NHS. It is broader that mortality, taking in matters like the development of bedsores, or delays in discharge, or readmissions. Whereas the HSMR system gives a composite figure for a hospital which may for a number of reasons give a very misleading impression, the Outliers system is intended to allow people to focus on the fine detail of performance on a particular ward, or kind of surgery.

·         The reason why this system was being developed is that the Dr Foster Unit and HCC both recognised the limitations of HSMR and needed something that would give managers a much more detailed window into their own performance. This system is, as the evidence of Martin Bardsley makes clear, primarily designed as a tool to assist managers and clinicians drive up quality. It was not conceived as a means of measuring quality of performance.

·         The work on these new outliers was being carried on in a rather clandestine way. The HCC make it clear that they were nervous of word of this new system getting out as they believed that they would be criticised by many people within the health service for this groundbreaking new approach. The Dr Foster unit may also have been aware of the commercial possibilities of the system, and wanted to “keep it under wraps”. The wider Health service was not told about this work which the HCC witnesses have all been at pains to say was a “pilot scheme”. They have said this in reply to questions of why they were not sharing the information they were getting through the alerts generated by the system with the SHA, PCT and Monitor.

·         The very first alert produced by this brand new pilot system came in July 2007 and related to operations on the jejunum carried out at Stafford Hospital. The very cautious approach taken by the HCC statisticians to this new information was that this was not necessarily telling them anything, but it raised questions which they wished to follow up with the Hospital. They expected that the outlier was probably caused by coding problems. The process that they followed was to write a letter to the Hospital asking for further information.

·         Robert Francis speculates on how this would have been received by the hospital. They were being asked to respond to a system that they knew nothing at all about, and they may not have understood what was expected from them. (It is clear that this would have been happening at the time when the hospital was undergoing significant problems as a result of cut backs caused by the financial problems. There were real problems occurring within the hospital and dealing with this extra paperwork exercise may not have seemed like a high priority task.)

·         Between July and November more outlier alerts into a number of different clinical areas all associated with A&E were generated from the hospital. The Mortality Outlier group at the HCC continued to follow these up with more letters seeking further information.

·         By the end of 2007 the HCC mortality outlier group were becoming concerned by the number of the outliers, and by the lack of a full response from the hospital. They had still not drawn any conclusion about what this might actually mean, they were perfectly aware that the results could easily be explained by either the case load, or by idiosyncrasies in the way that the Hospital was coding cases. (In practice I think that Martin Yeates and his team would have considered that this matter would be covered by the work being carried out by Professor Mohammed of Birmingham University, at the instigation of the SHA to look at the High HSMR figures in 6 of the hospitals in the West midlands region.) The HCC mortality outliers group were however sufficiently concerned to refer their findings to the HCC Investigation team who then prepared to carry out a preliminary visit to the hospital.

·         The Preliminary unannounced visit took place in early 2008. Heather Wood describes that they were concerned about the EAU where they found an elderly lady out of the sight of a nursing station, in a dark corner of the ward, and at risk of falling out of bed. The lay out and Staffing levels that they found on this visit to the EAU was sufficient to persuade them that a full inspection was necessary.

·         Once an inspection was announced then the HCC rapidly became aware of the Cure the NHS campaign and their complaints fed into the investigation process.

·         The high level of attention given by the press to the investigation and to the Cure the NHS campaign ensured that more people came forward to tell the HCC team about their stories. Many of these people have never been directly connected to the Cure the NHS campaign, but felt that they had information which might be relevant.

How did the wider Health service see the investigation?

·         People at all levels within the health service have shown how concerned they have been about the role played by the press. Whilst no one has directly criticised individual papers yet, there is a very high level of awareness of that stories need to be managed in order to try and prevent the damage that can be done by misleading and sensationalised stories in the press.

·         There has been considerable disquiet about the length and the conduct of the investigation, and the damage that has been done to the hospital and public confidence in both the individual hospital and the health service as a whole both by the investigation and the consequences that flowed from it.

·         The investigation has clearly been extremely divisive within the health service with many direct criticisms having been made both of the process and some individuals within the team. Heather Wood made it clear that her relationship with the rest of the health service has been deeply damaged by this. The animosity that she feels towards a number of individuals was clearly displayed within her evidence. The key members of the Investigations team interviewed by the Inquiry are no longer working for the CQC.

What did the Investigation tell us?

·         When Ben Bradshhaw as Secretary of State for health had discussions about the investigation in May 2008 he asked the question “is this another Maidstone and Tunbridge Wells.” He was given the assurance – some four months after the investigation had begun that this was not the case. So this means that even after four months actively looking for problems that the HCC investigations team were not seeing anything that led them to expect that large numbers of deaths had occurred.  

·         With my personal reading of the Healthcare Commission report I saw that a very thorough trawl of information about the hospital had been done and that there were a number of real problems that had been identified. I also read with interest the sections on the statistical material which did make it clear that there were significant problems with coding which would have made the Dr Foster material unreliable.

·         A reading of the report showed plenty of areas where improvement needed to be made. The body of the report does this with a certain detachment. The Summary is much more dramatic than the report, and many people within the health service were concerned about the “sensational” way in which the report was presented.

·         Though it is completely clear that there were many things going on that will have made peoples stay in hospital undignified, unpleasant, and perhaps at times unsafe I personally found it difficult to see anything in the report that might have explained death on a widespread scale.

·         The “excess death figures” that appeared everywhere in the press and have continued to be used ever since were particularly puzzling because they simply do not appear in the report at all.

Why don’t the Excess death figures appear?

·         The figures which have formed the central assumption in every piece of press coverage from March 17^th 2009 onwards is that there were 400-1200 excess deaths as a result of poor care. These figures apparently appeared as part of an appendix in a draft version of the report

·         Sir Ian Kennedy explains that the decision not to use the excess death figures was taken by him.

·         A very limited number of people have seen this material. I am not one of them, so I cannot give any reliable account of what the document said or implied.

·         The assumption made by the press is that the figures were removed as a result of pressure from the DOH. Sir Ian makes it very plain that he does not bow to that kind of pressure and that the DOH did not ask him to do this. Bill Moyes from Monitor did say to him that the figures were insufficiently robust and should not be used.

·         Ian Kennedy says that his decision to leave the figures out is based on his experience of Bristol, where there were a number of “unnecessary deaths” identified, but there was no way of connecting these to individual deaths. His concern was that if a figure of numbers of deaths were to be used by the press that this would cause a great deal of pain for many people who had lost relatives in this period. They would wonder if there was more that they could or should have done.

·         This fear is entirely borne out by the evidence given by many of the bereaved who have given evidence to the Inquiry. They believe that their loss was “the tip of the iceberg” and they feel driven to pursue to the matter so that “no one else has to suffer”. As Ian Kennedy gave his evidence I was sat directly behind a lady who has said to me in so many words “My (relative) was one of the 400”.

·         It is clear from the evidence of Heather Wood and Nigel Ellis that they felt that the figures should have been included in the report. At least in the case of Nigel Ellis he felt that the figures should be there for completeness but with strong provisos that these were theoretical figures which related to probabilities, and did not tell us that any number of people were known to have died as a result of poor care.

Degrees of certainty about the Excess death figures.

At the moment there is still huge uncertainty about these figures. This is something that the inquiry still needs to actively explore.

I do not know the following:

·         Who wrote the deleted material?

·         What is the statistical source of the excess death figures?

·         How the deleted material is phrased – is the word “If” included?

·         If the figures are based on the Dr Foster figures then has it been made clear that the NHS as a whole does not accept these as a robust indicator of quality of care?

·         If it is based on the mortality outliers then has this material been subject to peer review?

·         What do other statisticians think of it?

What I do know is that the degree of certainty with which people talk about the Excess death figures is in inverse proportion to the understanding of their statistical basis.

We can trace this through the evidence given to the Inquiry.

·         Martin Bardsley who was the person within the HCC who understood the statistical material best is very cautious about the conclusions that can be drawn from the material. He sees the Mortality outliers as management tools, there to assist in improving quality. They are not to be seen as an indicator of quality.

·         Nigel Ellis, is almost as cautious about the use of the figures. He is an investigator who will use statistics, rather than a statistician. He does see the excess death figures as telling us something about what happened at Stafford. He wanted the figures to be used with qualifying statements about what they meant.

·         Heather Wood who was the head of the investigation team says clearly of herself that she is not a statistician. She has clearly accepted from her more expert colleagues that the figures are telling her something, and she is then falling back on her own preference for dealing with what other people pejoratively call “anecdotal evidence”. It is Heather Wood who was directly questioned by the press at the press release of the HCC report, following the leak to the press of the excess death figures on the previous day, and her response to their questioning gave the press the go ahead to attribute these figures to the HCC.

·         Sir Ian Kennedy is at a further remove from this, he accepts the information that is given to him by others working within the HCC and his comment is that he thinks their methodology is sound, but that it would be unhelpful to use the figures because the press would misinterpret them and they would be into a major dispute about statistics rather than being able to focus on the real problems associated with poor care and the impact that had on individual families.

The Impact of the figures:

·         Sir Ian was completely right about the way the press would misread the information.

·         The fact that the material was not in the report and we could not see where it came from means that we have taken from March 2009 to May 2011 to see what actually happened, and that even now we do not know the detail of what was said in the appendix.

·         What perhaps could not have been anticipated is the degree of enthusiasm with which politicians then used these figures.

·         We have already seen from the evidence of Bill Cash that he had no idea where these figures came from, he simply accepted them at face value, as something he had picked up from the newspapers. He certainly continued to use these figures in his election leaflets for 2010 Even after the publication of the Robert Francis Independent Inquiry.

·         Other local politicians followed suit, and the figures were widely used in the Local election campaign of 2009.

·         We do not know what David Cameron and Andrew Lansley understood about these figures. It is possible that if they had their information from Bill Cash, or even from Ian Kennedy or Heather Wood that they may have read more into them than the statisticians themselves would have wished. What we do know is that Andrew Lansley and David Cameron have used these figures on a number of occasions, and have made Stafford a central “image” in their general election campaign.

·         I am not certain that they have used the figures since the statement on the publication of the Robert Francis Inquiry, with its clear indication that the figures are unsafe, Though David Cameron did use the figures in PMQs immediately before the statement. What I can say is that they have never attempted to correct the impression that they have repeatedly given that Stafford is proof of the failure of the health service, and is a justification for major reforms of the health service.

Is anyone to blame for the confusion?

I came to the evidence of the HCC sharing the anger felt by many people within the Health service about the way in which the Stafford hospital story has been sensationalised and the way in which misleading material has been used. I was prepared to blame individuals within the HCC for what had happened.

Having listen to and read the evidence so far I am able to see understand the motivation of the individuals concerned much more clearly.

Everyone who I have seen from the Health service at the inquiry has been genuinely concerned to try and deal with the real challenges that the health service is experiencing. They want to find ways to help the health service deliver the best possible standard of care. They each bring different skills and different approaches to this task.

The task that the PCT, The SHA, the HCC, and now the Care Commission are all seeking to perform is finding ways of seeing how good the quality of care is and how it can be improved. This is an ongoing task. We are not talking about some perfect time in the past when we could clearly see this information, the tools for doing this job have been under active development for the last decade or so.

Targets were a step on the way, The Dr Foster HSMR figures were a step on the way, The Clinical Dashboard developed by the SHA is a step on the way, The Mortality outliers system being developed by the Dr Foster Unit and HCC are a step on the way.

All of these things are tools designed to assist managers to manage. They are not and should not be used as hard and fast indicators of quality of care, in a way that the Press and public can use as a single headline indicator of how good a hospital is.

These are good systems, being driven by good people for a good reason. They are also highly confusing.

The problem only arises when they are used for a purpose that they are not intended by the press and politicians.

Stafford Hospital: The Inquiry enters a new phase.

Over the next couple of weeks the Stafford hospital inquiry will enter an interesting new phase.

We have heard from the group of patients who undoubtedly suffered poor care, and from the many different groups of people, including the GPs, Hospital board, Scrutiny committees, elected representatives, and patients participation groups,  who “failed to see” anything particularly unusual at Stafford. We have heard from many people from within the hospital about the challenges they faced, at a time of re-organisation and cut backs, and we have heard from the Primary Care Trust and Strategic Health Authority who have the task of monitoring and supporting the health service providers in their area.

Questioning of the PCT and SHA looked at why they “failed” to see the problems in Stafford. There are several parts to this answer. These organisations both underwent major top down re-organisations. Roles were being redefined, relationships with other key organisations were unclear, and key posts vacant. With the systems and staffing they had at the time these organisations saw nothing to make Stafford stand out from the 43 other hospitals that the SHA was managing.

Mortality figures are central to the inquiry. About a third of the questions each day relate to these. I find it interesting that none of this has so far been reported by the press. Maybe this is because it challenges the assumptions that they made. The assumption made by the press, from the release of the Dr Foster figures as a league table in 2007, is that these figures are a true reflection of the quality of care in a hospital.

Stafford and five other hospitals in the SHA’s area all had high mortality rates. The PCT and SHA responded robustly to these figures, but they responded as scientists and as managers. They began by in depth discussions with the hospitals, and by triggering a process for the hospitals to demonstrate that they were managing effectively.

The health service had been shocked by the publication of the Dr Foster league table, because there were major doubts that these figures were sufficiently robust to be used in this way. The PCT and the SHA both triggered a series of investigations to look into the accuracy of the figures.

These investigations showed that poor coding was endemic throughout the NHS, and that correcting the coding would quickly have a dramatic effect on reducing the mortality rate for hospitals as it did straight away with Stafford. Stafford’s figures fell from 127 to 101 immediately, and continued to fall until Stafford shows as the ninth “safest” hospital in the county.  

It is as a result of the investigations into mortality rates that the “league table” which is so loved by the press has now been discontinued, and there a much more sophisticated way of measuring hospital “quality of care”.   This for those who are interested in such things involves a clinical dashboard which brings together a whole range of key indicators, and displays them across a range of hospitals. As someone who knows the limitations of most statistical systems, this “richer” approach to monitoring looks much better to me.

What I expect to hear in the next couple of weeks is the Healthcare Commissions defence of its reasons for choosing to single out Stafford Hospital from the 54 hospitals which were identified by the Dr Foster 2007 figures as problematic. I believe that a lot of reference will be made to what they saw in the press and the political imperative to respond to the “public concern” that this indicated.  

The HCC will also get an opportunity to defend itself against the many criticisms we have heard about the conduct of the investigation, and I believe that we will see differences of opinion emerging from within the HCC.

This is an interesting slow burning drama, but it is more than that. We should remember that the major “reforms” that are now threatening the future of the NHS as we know it, have been justified by the “failure” of the PCT and SHA. Maybe it is worth asking the question, what if they did not fail?

Footnote: I have been looking, for the sake of balance, for a really good defence of the proposed health reforms. Just found this which is billed as the best defence we can read.

Helen’s Story: Stafford Hospital

The first time that I became aware of Helen Moss was at the Midstaffs foundation trust AGM in 2009.

To call this a lively meeting would be an understatement. The pressure group were out in force and well organised. It was the first time that many ordinary members of the trust were exposed to the level of anger the pressure group is capable of producing. In the AGM Helen Moss was called to answer a question on “hand overs”. The group all stood up with placards, and shouted “we want you to go”.  The ordinary members in the room were visibly shocked.

Over the following weeks there were frequent photographs in the local press of the protest group holding placards demanding the resignation of Helen Moss. The reasons for their demand were never explored.

Eventually the protest group got their way. She gave up the job and moved away.

Earlier this year there was an interview in the local press with the head of the protest group which set this in context. I have no way of knowing how accurate this account may be. The report indicates that It came back to a phone call from her to Helen. It was clear that there was no meeting of minds. The head of the protest group describes “a switch” going off in her head, and she made up her mind to get Helen out of her job.

There have been demands from the protest group for the sacking of all the staff, and for closing the hospital ward by ward and clearing out any staff that were not up to their jobs, but in the case of Helen it was personal.

28^th March 2011 was the first day in which I had an opportunity to hear Helen’s story. Full transcript here She is a quietly spoken, intelligent woman, trying hard to answer difficult, and at time hostile questions with precision.

It is clear that she took up her job as director of nursing at a very difficult time. The staff numbers had been allowed to run down as part of the cost saving exercise to get the hospital back into line financially. The pressure of working constantly with not enough staff was beginning to tell and staff morale was low.

Helen gave the best description I have yet heard of the peculiar culture that is said to have existed at the hospital. There was nothing at Stafford to attract ambitious young nurses, Stafford did not look like a hospital that offered a career path. Many of the nurses that came did so directly from the university, and therefore did not gather experience in the wider world of the NHS. It was, as we had heard from other witnesses an enclosed world, with not enough challenges from outside. There were things that were being done to ensure greater quality in many hospitals which did not seem to have taken off in Stafford.  (All of these issues have been actively addressed now).

Helen was faced with a big problem. She needed to do what she could to change the culture of the hospital, and she also had the task of trying to recruit more nursing staff to get things up to “establishment”. She did not have as much money as she felt she would need for this task. This is a task that was as time went by becoming increasingly difficult. Nurses were reluctant to come into a hospital which was understaffed The effects of the under staffing led to the complaints from the pressure group. As the pressure group’s campaign gathered force there were the growing pressures of media attention.

It became impossible to recruit the full time staff the hospital needed at the speed that it needed to do it. This was like running a bath with the plug out. Recruitment was going on constantly, but staff turnover was accelerating. 

This article which takes us back to October 2008 before the issues of the health care commission report gives us a snap shot of the growing pressures.

The Health Care Commission investigation was experienced by the staff who were trying to make the hospital work as an additional burden. Helen, like many of the staff who have spoken before, talks about how difficult and hostile this investigation process was. It was clear that the HCC was not there to help the hospital.

The inquiry focused in on Helen’s understanding of the mortality figures. This is now a standard part of the questioning to virtually all witnesses. Helen’s evidence here is important because she was there and in charge of clinical governance at the time that the figures were an issue. Her testimony is in line with that we have heard from all those people who were part of the hospital and had reason to understand the mortality figures.

The Dr Foster figures first became an issue in 2007. This was the time at which the Dr Foster system was shifting from being a management tool that some hospitals had brought into, to being a tool that foundation trusts, or hospitals seeking to become foundation trusts, were required to use in order to show their “performance”. It was clearly know in the hospital from before the issue of the figures, that their coding of cases was not being done properly.

They had expected to come in with a coding figure of 114 which was moderately high, but a last minute change in the methodology by which the Dr Foster company generated the figures led to a significantly higher figure of 127. This put the hospital in the “worst” 5 in the country.

The hospital were alarmed by this and immediately sought advice. The Dr Foster company provided re-assurance. It was clear to them too that the coding was “shallow” and that this would have led to an elevated HSMR figure. They thought that the high figures could be adequately explained by this.

The Hospital did not leave it at that they took a series of steps. They recruited a new coding manager. This was necessary, because funding was now partially dependant on HSMR level. The coding manager worked with a newly formed mortality group, which reviewed deaths over the previous year. This we have heard from Eric Morton was cross referenced by the PCT with GPs case notes, and it verified that the coding had been done wrongly in many cases, and that a misleading figure was therefore produced.

The Mortality group began the task of focusing in on the fine detail of mortality figures to see if there were any patterns. Or any indication of underlying problems.

As the coding manager began to take on new cases, the mortality rates being produced by this new “robust” data dropped steadily from high, to average, to well below the national average.

The hospital sought advice from the SHA and Birmingham university. Research was carried out into the Dr Foster Methodology.  (This has led in 2010 to changes in the way in which mortality is measured on a national basis.)  The Birmingham research did also spell out that the Hosptial should not rely exclusively on the coding, and should explore ant other areas of weakness which might account for the high figures. This feeds back to the work that the mortality group was undertaking.

The hospital took on board the advice from the university that the HSMR figures in themselves could not provide a reliable picture of the quality of service and advised on looking at other ways of measuring the quality of work including performance dashboards, which look at a wide range of indicators.

Through all this careful painstaking work there were problem areas being identified, and the hospital sought expert advice from the college of surgeons to produce a report on one specific area where concerns had been raised.

The Healthcare commission for reasons which have yet to be explored chose not to accept the line which was accepted by the Hospital, the PCT, the SHA, Birmingham university, and even we hear from the Dr Foster company, that “it was the coding” and they came in to carry out their investigation.

The HCC did not share information with the hospital during this process, and because of that the hospital called in Price Waterhouse Cooper to give them advice on what they needed to do to improve matters.

Helen was asked about her reaction to the horror stories that are now so familiar to everyone through the press about poor care in the hospital. She like virtually all the people who have been asked this question expressed the shock she had felt. She also showed that there was nothing in her own experience of the hospital that prepared her for these stories.

She did carry out regular visits to wards all over the hospital as a key part of her job. She had staff expressing to her their frustration about staffing levels and staffing mix. She was actively working to satisfy this through the recruitment process, and through a staff mix review, that was put in place to help push for the extra funding that was needed to bring staffing up to the right levels. She did not in her frequent visits to the wards see anything in line with the stories told in the press, and she did not have nursing staff coming to her and saying that the staffing levels had reached the point where it was impossible for them to do their job.

The impression that I was left with at the end of this evidence was of a genuine caring and hardworking person, who had tried to do a difficult job under difficult circumstances, and was in the end defeated by a unique set of circumstances. This article shows the kind of pressure that she was under.

I would have liked the inquiry to invite her to say what she had felt about being on the receiving end of such pressure. I am sorry that they did not ask her this.

Helen gave the apology to the bereaved which is now a standard part of most people’s evidence.

Here is the coverage of the day from BBC and Express and Star.