Hundreds of times, in waiting rooms outside Intensive Care Units I have looked into the eyes of sons and daughters, spouses and partners of patients, held their hands and said, “We did all we could. I am so sorry for your loss.”
When Saagar died, no one looked into my eyes and said that to me. They had not done all they could for him. The hospital carried out a sham investigation, a futile exercise in ‘being seen’ to be doing the right thing.
The GMC found everything to be hunky dory. The doctors ‘looking after’ Saagar had done their jobs to perfection. Just too bad the patient was dead. They did not deem Saagar’s case worthy of an investigation. GMC’s role in its own words:
“We work to protect patient safety and support medical education and practice across the UK.”
The Coroner’s report shone some light on the holes in Saagar’s care. It clearly pointed out the things that South London and Maudsley (SLaM) Hospital got wrong.
There was a general failure to identify the diagnosis on the discharge summary from the Home Treatment Team to the GP.
There was a general failure to communicate thoroughly enough with the parents about the relapse symptoms, what to watch out for and where to go for help in the future.
Last June, I wrote to the CEO of SLaM, requesting an update on the changes that had been made in his organisation in response to the Coroner’s findings above. He said someone would get back to me and I heard nothing. This June, I sent him a reminder and again he said someone would get back to me and I am still waiting.
What are my rights as a parent? Is this too much to ask?
What were Saagar’s rights as a young man with a mental illness?
Are our lives not as important as anyone else’s? Black or white or brown? With Cancer or Diabetes? Or Bipolar Disorder?
Everyone deserves to be heard and seen. With respect.
Last week we got a call to assess a patient for a possible transfer to ITU. Our team of three anaesthetists went along with all our kit and PPE. From a distance, he didn’t look too unwell. And he looked young. I hoped he wouldn’t need too much intervention. We donned out protective equipment and looking like aliens, entered his cubicle. I checked his name and date of birth. He was born in the same year as Saagar. After making a quick assessment, we decided that his breathing needed support. We spoke to him about getting him off to sleep so that we could place a tube in his wind-pipe and assist his breathing. We explained to him that we would transfer him to ITU for further care.
By this stage he was shaking, his eyes swollen with fear. He asked to make a call to his mum. We stood back while he called her. He held the phone to his left ear while oxygen hissed through his face mask. We waited, watching his face slowly relax, his fear melting into tears that dripped down his cheeks. After what seemed like a long time, he said bye to her, told her he loved her, composed himself and said he was ready to go to sleep.
It was like watching the dance of life and death. Love and separation. Help and helplessness. I was grateful and pleased that this mum and this son could connect at this crucial time.
Saagar didn’t have this luxury. He didn’t get to call his mother. No words of comfort fell into his ears. No tears of relief spilt from his eyes. Nobody offered him their understanding. I felt sorry for his mother too. She didn’t have a chance to say good-bye, to tell him that she loved him, that she would pray for him and that she wished him the very best.
When there is political will, governments can bring countries to a shrieking halt, the world can come to a stand-still.
When it is a physical illness, millions of pounds can be spent in seconds. New hospitals can be erected within weeks. Multiple trainings can be put in place for the front-line staff. Awareness campaigns are everywhere. What to do, what not to do, repeated endlessly. Retired doctors can be redeployed. National economies can be allowed to crash. Everything else can be put on hold.
When it is a mental illness, there isn’t enough money. There isn’t enough time. Not enough people. Very little expertise. No effective awareness-raising campaigns. No appropriate spaces. Not enough beds. Not enough research. The bottom-line is that there just isn’t enough respect for the fact that people with mental angst suffer the same, if not worse than those with physical ailments. That on many occasions they too, die alone.
Biggest cause of avoidable deaths in children and young people – Suicide and self-inflicted injuries
The Office of National Statistics published a report in 2015 saying that the single cause with the highest number of avoidable deaths in children and young people was suicide and self-inflicted injuries (14% or 206 deaths of all avoidable deaths in this age group).
Of the top five causes of avoidable deaths among children and young people, suicide and self- inflicted injuries was the only cause to see an increase since 2014 by 13% or 24 deaths.
Avoidable mortality accounted for 3 out of 10 deaths of children and young people (aged 0 to 19 years), nearly the same as in 2014. Males accounted for almost two-thirds (63%) of avoidable deaths in children and young people.
The other top causes each saw a decline since 2014, with accidental injuries, which was the leading cause in 2014, experiencing the largest decline of 8% or 15 deaths.
Key Points for London
The rate of avoidable mortality in London has increased to 210.4 deaths per 100,000 population from 204.6 in 2014. This is significantly lower than for England (222.9).
The South East, East of England and South West Regions have lower rates of avoidable mortality than London. The highest rate is in the North East (266.4).
As in all other regions, avoidable mortality rates in London are higher for males (274.0 deaths per 100,000 population) than for females (152.9). Rates have increased for males (from 259.9 in 2014) and slightly reduced for females (154.3 in 2014).
Every investigation into an avoidable death is a learning opportunity for Trusts, clinicians, families, wards, patients, management, boards and the community. The lessons learnt can be passed on to other organisations and future generations. But unfortunately, often investigations are done in order to not find any deficiencies. They are defensive in nature rather than exploratory. They are reductive and analytical (Root cause Analysis) rather than holistic and empathic. Both approaches bring value to an investigation but often the greater good that can come out of them is overlooked.
200 avoidable deaths take place within the NHS every week. Each of them holds valuable lessons for the future but they are buried. Hence the same mistakes happen over and over again, costing more and more lives. In some organisations serious near-misses are recorded as ‘no-harm caused’.
We need collective intelligence, not individual genius. We need responsibility and accountability, personal and professional, shared and individual.
In 2015, a report was leaked to the BBC from Southern Trust that looks after 45,000 people. They had 1454 unexpected deaths over a 4 year period, 2011-2015. Of those, just 195 (13%) were treated by the trust as serious incidents requiring investigation. Deaths of adults with mental health issues were most likely to be investigated (30%). For those with learning disability the figure was 1%, and among over-65s with mental health problems it was just 0.3%.
“To err is human, to cover-up is unforgivable, to fail to learn is inexcusable.”
– Sir Liam Donaldson.