Sunday, 4 March 2012

Midstaffs: The coroners tale

Wednesday, March 02, 2011

Stafford Hospital - Some reflections on the coroners tale
The first time that I saw something approaching a crowd of both public and press at the Stafford Hospital Inquiry was for the coroner’s evidence. It was clear that this would be a significant day.
It was the first time that I had seen Andrew Haigh, and I quickly warmed to this quiet, dignified, careful, skilled, and kind man. No one would ever wish to need the services of the coroner, but if I ever did, he would be the kind of person I would wish to see.  
I have looked up a little information about the coroner’s service, and find it has been in existence since 1194, so it is one of our most ancient institutions; something that has stood the test of time.
His evidence took us through the kind of cases that he should see, the way in which they are brought to his attention, the way in which he can investigate, and the methods he has to insure that any “lessons” that can be learned from a death can be flagged up to any interested parties.
Though details of the thousands of deaths that occur in his jurisdiction pass through his office in some form, his role is to focus on those deaths where there is a need for an inquiry process, where there are questions to be asked. The coroner will only normally become involved if there is a question of an “unnatural” element in the death. He explained that this can be interpreted widely and it could properly take into account cases where lack of care had contributed to or accelerated a death, as well as more obvious accidents.
It was clear that the numbers of cases that he saw from Stafford Hospital were not in unusually large numbers.
For many of the people who had turned up to see this evidence this was clearly frustrating. What people were looking for was some hard evidence to back their belief, fostered by years of press coverage, that hundreds of “unnecessary deaths” had occurred in Stafford Hospital. They did not get this. What they did hear, was the clear statement that the kind of issues being raised at Stafford were very comparable to the other similar hospital in his jurisdiction and in the other areas where he has worked as coroner since the 1980s.  
The frustration I heard from the public room centred on how it was possible for hundreds of deaths to occur “unnecessarily”, without becoming a matter of concern to the coroner.
It is worth taking a look at where this belief of large numbers of deaths comes from. The belief is founded almost entirely on the “Dr Foster figures” These are something that came to prominence in 2007 at a time when hospitals were beginning to be “paid by results” and when “patient choice” was opening up the possibility of competition between hospitals.
It is very important to measure the quality of the health service. It is also, as the whole of the Inquiry has shown us, very difficult indeed to do it effectively. The Dr Foster system was an attempt to measure the quality of the service by measuring the difference between expected and actual deaths. This is not a simple measure. It is a construct of many different factors, and it relies on accurate information to produce meaningful results. Though the Hospital Standardised Mortality Rate has been around for a while, and had been used by many hospitals as one of many management tools, the changes of 2007 brought these figures into much greater prominence. Because it rolls up the hugely complex matter of “Quality” into a single figure that makes a striking headline it is easy to see how attractive these figures would become to the press and the media, even if no one actually understood them.
It is completely understandable that a recently bereaved person might see the high mortality rate figures in the press, without any of the detail that needs to accompany them, and make the assumption that their own difficult bereavement was in some way the tip of the iceberg It is also completely understandable that someone in this position can become fired with a sense of their “mission”.
In most cases where hospitals had a high HSMR figure at this time the Health care commission dismissed this as a statistical anomaly. In Stafford, because of the emergence of the pressure group, the perfectly legitimate concerns they were raising, and the way in which all of this was attracting a growing amount of attention in the press, the HCC decided it was the best thing to mount a full year long investigation, an investigation which did throw up the many real problems that the Inquiry is still seeking to understand.  
The origin of the claim of “400-1200 excess deaths” which came to dominate the press coverage, is still shrouded in too much mystery. It is something that I personally believe the Inquiry will need to explore further. Most of the general public believe that the claim of excess deaths came from the Health care commission report, but this is not the case. The report neither states nor implies these figures. The claim first appeared in print on the day before the publication of the Healthcare Commission report. It is a leak from an unattributed source, in an article also contains quotes from Bill Cash and from the founder of the pressure group.
The Inquiry has already thrown a little further light on this. The figures are a leak based on an appendix that was deleted from the HCC report. Most people including myself have never seen this appendix and the accounts that I have heard of its exact contents vary. Most people who have seen it tell me that it is just the Dr Foster figures, from which someone then must have extrapolated the excess death figures, one of the members of the press tells me that the speculative figures are quoted. The reasons that people give for the deletion of this material vary. Was it deleted ,as the pressure group believes, as an attempt to hide the truth; or was it deleted as the SHA and Healthcare Commission say because the information, was misleading and likely to be misunderstood? Understanding this question is central to understanding the Stafford Hospital story.   
The Stafford Hospital story has focused a lot of attention on to the Dr Foster system. One of the recommendations of the Robert Francis Independent Inquiry was that an expert working party was needed to overhaul the mortality rate system. This group has done its job. It has now fully recognised the inherent problems within the HSMR system, and the way in which it was misused. The system will cease to be used in the same way and a new system, of which little is yet known, is being put in its place.
So to return to the Coroner. What we saw in the Inquiry room, and what upset some of the members of the pressure group was a clash. We saw an ancient system which has been tested by centuries of use. This system depends on the trust that people will raise concerns when they should, and that careful wise inquiry can find the answers to difficult questions. In Stafford this system came up against a passionately help belief, founded on the misuse of data from a complex and flawed statistical system which came to prominence in 2007 and will come to an end in 2011.
So is that an end to the matter? Probably not. Robert Francis indicated at the start of this Inquiry that it is unlikely that we will ever have an answer to the question “so how many people did die unnecessarily”. Having now heard the coroner’s evidence I can see what he means. The basics of the coroners system is sound, and should not be tampered with, but there may be a need for something additional, to take advantage of modern data handling tecniques.
We know that the commonly quoted excess death figures are ill founded, and were actively promoted by prominent figures like Bill Cash on the basis of no understanding of how they were constructed or why they were problematic. We now know a great deal about why the figures are so misleading, (this is inherent within the inquiry evidence - I will blog about it in more detail later) and we know that the route by which they came to dominate the press and media are unsatisfactory and may require reform of the rules of the press.  
But to my mind, as well as to the minds of the pressure group there is something missing. What I think we do not have in place, and perhaps need, is a better means of monitoring trends in mortality. Though we begin with looking at trends in one individual hospital it makes no sense to look at this in isolation. We need to understand trends in our communities and in the country as a whole. It is becoming increasingly clear as we go through the Inquiry process is the real difficulty that most people (in which I include most experts) have had in understanding the systems for measuring mortality rates, and for judging from it if the health system and public health system are performing as they should.
As the government puts more emphasis on patient choice, and the “market” in health provision, quality is not merely an end in itself, it is an economic imperative. Because of this, monitoring systems are likely to get more rather than less complex. In Stafford it is inexpert interpretation that has led us to where we are now. We may need to employ specialists who can understand the systems well enough to pick up clusters and changes in patterns of deaths under a series of different variables.
What we have now is the ill founded interpretation of some flawed statistical data which suggests large numbers of deaths occurring.  We also have a whole series of different monitoring systems and individual expert impressions which suggest that this is not in fact the case. What I am looking for is some means looking at a discrepancy of this nature and determining if these figures that were supposed to act as an early warning system did tally with what was happening in reality. If something of this nature had been in place in 2008 this would have saved Stafford three years of torment, and saved the taxpayer many millions.
This is not a simple task that could be tagged onto the coroners job, or could easily sit within the very specific task that a coroner does, but it would make sense for this monitoring to cover an entire geographical area, and therefore it may require a new role attached to the coroner’s office. This would need to be aggregated to a national level in order to be able to provide meaningful comparisons.
I would expect that such a system would highlight issues that go way beyond what may or may not have happened in one hospital, and will show the huge discrepancies in health and mortality that exists between different sections of the population.
Given the trend towards localism that is central the Health Bill, a national monitoring service may be a necessary protection against the growth of health inequality. If I were conducting the Inquiry this is a recommendation I would make.
I would make another recommendation too. There has been a lot of focus on what went wrong, who is to blame, and how to give patients greater power. In part this is about building a responsive complaints system, and having independent bodies to give patients support if they need it, but perhaps one of the most positive things we could do is put in place more professional support for people who are about to lose or have lost a relative.
There are bereavement officers, and there are chaplains. These are very demanding roles. Doing them well makes a huge difference to the people who receive this service. It is essential for there to be enough staff working in this capacity to support people at difficult times. Their role should be sufficiently flexible to include picking up any concerns that people want to express.
More support at this level may have meant that some of those people would get the skilful help they needed to make sense of their experience. It might also have meant that some people who had just experienced a difficult death might have been directed to the coroner and might have had the satisfaction of knowing that their concerns were noted and carefully explored.

Posted by Diana Smith 

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