Philosophy of The Big Society

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Sunday, 26 July 2009

Serious Untoward Incidents - The Case of the Missing Criteria

For PatientGuard and anyone else who has a clue in regards to working through the mazes.

I have formally notified the Trust and my MP that I wish my Dad's suicide attempt to be treated as a 'Serious Untoward Incident'.

Am very keen to find out what the Care Quality Commission's rules are in regards to how they ensure Trusts are not shirking any more responsibilities.

I usually get a formal written response from MP within a few days of writing to him. However, he might be on annual leave now so can't guarantee I will hear from him before I go to Derbyshire.

Not sure where to go with this right now. I could let the Director complete his internal inquiry (before I take further action) but have concerns it is being used more as a passifier rather than to look at oversights (and there were oversights) and prevent alarm bells ringing in ears of overseeing bodies. Remember, Beds and Luton Partnership Trust is still waiting to be taken over by a bigger cheese in order to be seen as fit for purpose and gain Foundation Trust status. Hence, those in charge are trying to turn it into a leaner machine whilst talking some sort of talk that is supposed to reassure patients they are in safe hands. Hmmmmm...

Any advice would be welcomed but that doesn't mean I will act on it until I am back from my break. I need time out...FOR ME. Sounds harsh but I have only so much energy and savvy at present. If I burn out, there will be nothing left either to sustain myself with or help Dad.


  1. This comment has been removed by the author.

  2. Sorry I posted it in the wrong place :

    I think its right to insist that an attempted suicide is treated as an SUI . Its a Patient Safety Incident of very grave concern .

    Lets see what the CQC said about North West London Trust situation just recently :

    "When things go wrong, or could have gone wrong, with the care of people – incidents such as suicides, self-harm, medication errors or physical assaults to
    staff or people who use services – it is important that trusts have clear procedures for reporting and
    investigating incidents, so that lessons can be learned.

    We found that the trust had a number of different policies in place for the reporting and investigating of incidents. They contained conflicting information
    about the classification of the different types of incident, the type of investigations available and when they should be used. This led to confusion among staff, and hindered rather than helped them."

    Nuff said ..

    The point also is Trusts have become less transparent to patients and carers in the sense that it should be easy to understand procedures and they ought to outlined on Trust Websites and made available as a matter of course .. But these NHS performances classes do not like that .. They suppress information and that is not an opinion it is upheld by the NHS Confeds guidance doc to Trusts telling them to be more OPEN in the wak of the Mid Staffs deaths .

    Flame On Johnny and send for the Thing ..

    Ps. I am Crankyman With the power of flying nuts ..

  3. Oh dear...On the one hand is good the CQC have made a statement (and one that makes sense) about the NW London Trust but then moving the Chief Exec to the Strategic Health Authority is like rewarding failure.

    It is the sort of practise that is happening alot.

    Ho hum

  4. Hi Mandy
    Here are BLPT's own criteria:
    "The Trust adopts the definition of a Serious Untoward Incident as set out by the NHSLA as ‘a situation in which one or more service users are involved in an event which is likely to produce significant legal, media or other interest and which if not properly managed may result in loss of the Trusts reputation or assets’."

    Says a lot, doesn't it!

    The document itself is well hidden but I found it online here:

    Knowing how these things "disappear" you might want to save a copy to your computer, or print it off.


  5. This comment has been removed by the author.

  6. Third attempt at giving you the address - have used tiny url this time:


  7. Thanks C

    No mention of patient safety in there...all about damaage limitation for Trust's reputation. Disgusting.

    May well come in handy having that info.

  8. David Crepaz Keay27 July 2009 at 14:09

    ref media interest/reputation of BLPT


    Add " mental health " your trusts name in these "" and "serious untoward incident " as tags for this blog post or create another with something like

    "Mental Health Trust reluctant to investigate Serious Untoward Incidents "

    as the subject heading to increase chance of it picked up by google mental health alerts and run a poll , summarising events and asking your readers if they, think BLPT should carry out an SUI investigation given that complaints had already been made at SHA level about your father's treatment.

    I also note that bullying at SHA level is the top story over on HSJ site and really think the mental health charity sector should stop lining its own pockets and start to back users . Mind need to get a grip for a start.

  9. Okay Mr CK


    Although I sense that if the bullying is going on at the top level to expect any morality in the layers below is like thinking that supermarkets are really offering customers money saving offers (without clawing back twice as much elsewhere).

  10. Hi again Mandy

    Actually, I'm not sure they CAN claim this was not a SUI by their own definition in this document - see para 5.2.2:
    "This includes the principles as defined by the Strategic Health Authority for the East of England as follows: Any incident within Bedfordshire and Luton Mental Health and Social Care Partnership NHS Trust involving:
    • NHS Staff, patients, relatives, carers or visitors...

    • Causes death or serious injury or was life threatening"

    Maybe worth contacting the strategic Health authority directly for clarification as to whether this should be recorded as a SUI?


  11. Thanks C now need to search for most appropriate person at the SHA. Would that be the Chief Executive?

    Can you let me know which document you found that in? As in the name of it..then I can quote verbatum and refer them to the right paperwork.

    Appreciate you have done alot of hunting around for me. If you do this I promise not to ask anything else of you.

    Am heartened that people have made efforts for me and Dad. All of you who have.

    If someone could find me the SHA email adress, without too much fuss, that would be appreciated. If not..will have a look around for it tomorrow.

    Still waiting to have that bath. Friend rang me in crisis. She is another patient who has been left out to dry. Was quite calm but don't think I could cope with more calls like that.

    Am running bath now and then going to take a whole lorazepam and sleep (letting it all go, for today) x

  12. Note :

    NHS London Guidance Page 16 categories of SUI :

    Unexpected death
    Attempted homicide/ suicide
    Homicide / suicide
    Death on GP premises
    Prisoner in receipt of care

    I've put the document on NING as a pdf so anyone can download it from here


    Hope this link works