7 "unexpected" deaths South Essex Partnership University MHT

L Cowling made this Freedom of Information request to Care Quality Commission

The request was partially successful.

From: L Cowling

22 November 2009

Dear Sir or Madam,

Thank you very much for answering my previous FOI questions.
However, through another FOI request for minutes of Governors' and
Directors' meetings at South Essex Partnership University MHT as
they were not being published on the website (Still not!), there
was mention of 7 "unexpected" deaths for the first quarter of this
year.

This does seem to be a particulary high number and must raise
questions regarding patient safety.

What action is the Care Quality Commission taking with regards to
this revelation?

Yours faithfully,

L Cowling

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D. Speers left an annotation (23 November 2009)

I met with CQC recently and they have recently been given more enforcement powers on Safety and Quality of Service. These 16 new regulations can be found in "(Draft) Guidance about Compliance with the Health and Social Care Act 2008" on the CQC website: www.cqc.org.uk

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From: Thomas, Dunstan
Care Quality Commission

23 November 2009

Dear Mr. Cowling,

Thank you for your email dated 22 November 2009 containing an information access request in accordance with the Freedom of Information Act 2000 which the commission received on 22 November 2009.

The Commission will respond as soon as it can but in any event within 20 working days following the date of receipt of your request. You can therefore expect a reply by 18 December 2009.

Please feel welcome to contact me if you need further assistance.

Many thanks,

Dunstan Thomas
Information Governance Officer
Secretariat - Information Governance Team
Care Quality Commission
Finsbury Tower
103-105 Bunhill Row
London
EC1Y 8TG

Email: [email address]
Direct Tel: 020 7448 9417
Internal Tel: 3417

Statutory requests for information made pursuant to access to information legislation, such as the Data Protection Act 1998 and the Freedom of Information Act 2000, should be sent to: [Care Quality Commission request email]

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L Cowling left an annotation (24 November 2009)

Having looked at the National Patient Safety Association figures for this Trust, the 6 months from 1st October 2008 to 31st March 2009 showed 1 death so 7 in 3 months is a considerable outlier.

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From: Thomas, Dunstan
Care Quality Commission

18 December 2009

Dear Mr. Cowling,

Thank you for your email dated 22 November 2009 containing an information
access request in accordance with the Freedom of Information Act 2000
which the commission received on 22 November 2009.

You requested the following:
Action taken by Care Quality Commission with regards to the revelation of
7 "unexpected" deaths for the first quarter of this year at South Essex
Partnership University MHT.

In replying to your above query, Care Quality Commission confirms that
unexpected deaths and/or mortality rates at Mental Health Trusts is not
something that is measured within Mental Health Trusts' National
Priorities Assessment. The answer is that CQC does not routinely monitor
mortality. However, if individual concerns are raised, like this one, then
we have processes for dealing with them.

Please access the following web links for more information on:
1. Criteria for Investigating or Intervening
[1]http://www.cqc.org.uk/usingcareservices/...

2. Mortality outliers
[2]http://www.cqc.org.uk/usingcareservices/...

Further according to our Mental Health Team records we have 2 Natural
Causes of Deaths at that Trust - one in April 2009 and one in October 2009
- and these were patients that were detained under the Mental Health Act
1983.

At the moment, we are not planning to extend the approach we have on
mortality to Mental Health Trusts. This is due to the fact that the deaths
in Mental Health Units tend to follow a different pattern to those in
Acute Trusts, for several reasons:

In Acute Trusts, we group episodes at admission, so that we can build a
profile of groups of patients who may be expected to experience a similar
episode of care, and then concentrate in cases where outliers appear to be
present. In Mental Health, any death might have been caused by a number of
different factors which may or may not have a relationship to the
condition the patient had been admitted for; this makes it more difficult
to build groups on the basis of which the outliers can be identified;
there are many fewer deaths for patients in Mental Health Units; this
makes the deaths that do occur much harder to examine as death rates would
generally be low; patients are much more likely to be transferred to other
provider units after a near-fatal event.

As part of the reviews and studies programme we are however working on a
model to enable us to identify adverse events such as emergency admissions
for conditions that should have been treated earlier, this model ought to
give us a grasp on cases where the physical care of the Mental Health or
Learning Disabilities Patients was below average and give us means to
intervene at a much earlier stage than mortality would.

Please email [3][email address] to raise any concerns on
the above subject and our invetigations team will be able to assist you
further.

If you are not satisfied with this response you may request an internal
review of the Commission's decision.

Please contact:

The Information Governance Team

Care Quality Commission

Finsbury Tower

103-105 Bunhill Row

London

EC1Y 8TG

Alternatively, you may complain via email to:
[4][Care Quality Commission request email]

Please clearly indicate that you wish for an Internal Review in the
subject of the email.

Further rights of appeal exits to the Information Commissioner's Office
([5]www.ico.gov.uk) once the internal appeals process has been exhausted.

The contact details are:

Information Commissioner's Office

Wycliffe House

Water Lane

Wilmslow

Cheshire

SK9 5AF

Telephone: 08456 306060 or 01625 545745

Fax: 01625 524510

Please feel welcome to contact me if you need further
information/assistance.

Many thanks,
Dunstan Thomas
Information Governance Officer
Secretariat - Information Governance Team
Care Quality Commission
Finsbury Tower
103-105 Bunhill Row
London
EC1Y 8TG

Email: [6][email address]
Direct Tel: 020 7448 9417
Internal Tel: 3417

Statutory requests for information made pursuant to access to information
legislation, such as the Data Protection Act 1998 and the Freedom of
Information Act 2000, should be sent to: [Care Quality Commission request email]

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From: L Cowling

19 December 2009

Dear Thomas, Dunstan,

The 7 "unexpected" deaths occurred April-June 2009 so the October
death would not be in these figures.

Please could you answer my question as to what action the Care
Quality Commission have taken regarding the remaining 6 deaths as
you have not made it clear.

I would suggest that mortality figures in Mental Health care
settings, inpatient and community, could indicate poor care and
system failures. Therefore mental health patients are not afforded
the same protection as patients with physical illnesses, there is
no Dr Fosters or CHKS data to supplement other information. In
particular, the clinical coding in Mental Health Trusts is general
incorrect and therefore misleading.

I look forward to your response.

Yours sincerely,

L Cowling

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D. Speers left an annotation (19 December 2009)

This response highlights the appalling inequalities within our healthcare systems.
"The answer is that CQC does not routinely monitor mortality. However, if individual concerns are raised, like this one, then we have processes for dealing with them"

The question must therefore be: 'Why should taxpayers have to identify systemic failures, when they are already funding regulators and data systems to oversee professional care which is said to be available.The most basic human need......aka professional care when illness leaves one vulnerable must be the main focus but if CQC "does not routinely monitor mortality." then who does?

I have been advised that "mortality outliers do not apply to mental health" so therefore when National Suicide Prevention policy, local and national suicide indicators are withdrawn next year, how will CQC be able to implement their 'new model'?

CQC state: "As part of the reviews and studies programme we are however working on a model to enable us to identify adverse events such as emergency admissions for conditions that should have been treated earlier, this model ought to give us a grasp on cases where the physical care of the Mental Health or Learning Disabilities Patients was below average and give us means to intervene at a much earlier stage than mortality would."

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From: Thomas, Dunstan
Care Quality Commission

21 December 2009

Dear Mr. Cowling,

Thank you for your email dated 19 December 2009, this is to acknowledge that we have received your email.

We will write to you as soon as we can with the requested information.

Many thanks,

Dunstan Thomas
Information Governance Officer
Secretariat - Information Governance Team
Care Quality Commission
Finsbury Tower
103-105 Bunhill Row
London
EC1Y 8TG

Email: [email address]
Direct Tel: 020 7448 9417
Internal Tel: 3417

Statutory requests for information made pursuant to access to information legislation, such as the Data Protection Act 1998 and the Freedom of Information Act 2000, should be sent to: [Care Quality Commission request email]

show quoted sections

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D. Speers left an annotation (22 December 2009)

The answer seemed to relate to just hospital admissions and not take into account deaths in the community. Also the emphasis is on the "physical", although extremely important, no concern for deaths due to psychiatric conditions.
Most importantly I feel, if “care in the community” is “the way forward” then not accounting for deaths in the community gives too many trusts a ‘get out of jail free card!’ We must have a mandatory system which will take all reasonable precautions for all deaths from illness….whether physical or psychiatric. We must expect to be treated as a whole….mind, body and soul! Doesn't each affects the other? Maybe psychiatry is not as exact a science as physical health, but it doesn’t stop zillions being sought and spent on ‘oft quoted’ research documentation, which rarely translates onto ward or community!

If research on psychiatric conditions is used to write robust mental health policy but is seemingly not always shared as part of training then what’s the point

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daniel abbott left an annotation (22 December 2009)

Oh My God!

D. Speers & L. Cowling, both sound very BENEFIT THIEVES!

These people work in NHS & Private Healthcare do alot more than what you think on this small forum online. You will realise how hard it is when you start working as Health Care Assistants and wipe dirty bums every morning in the care home or trust you working.

Job in the BBC - British Bum Cleaning

For god sake, go find a better job!

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D. Speers left an annotation (23 December 2009)

Oh Daniel,

How wrong can you be....and how dare you assume we don't know what its like at the front line!
Having tragically lost family to appalling failures in care, there are more questions than answers sadly. We are questioning the systems that should support HCAs and their BBC. We are not being critical of front line workers but trying to support that work by having open, honest management. Believe me BBC is something we are well versed in!
Happy Christmas.
D.

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