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The steep climb towards honesty and respect for grieving families

The responsibility of the NHS to be honest and open in its dealings with the public when things go wrong is a subject that came up frequently in the press last year, not least when the NHS LA chief executive Helen Vernon said that she intended to reduce the need for expensive litigation by using more mediation, early transparency, saying sorry and demonstrating that lessons have been learned to prevent the incident happening again.

Ms Vernon's comments are extremely positive, but will only mean anything if they genuinely generate a complete change of ideology in the way the trusts and medical practitioners view their relationship with the public.

A recent report by the Care Quality Commission – the independent public body responsible for monitoring NHS and independent health and social services in England – makes damning reading, highlighting the mountain Ms Vernon has chosen to climb. Its contents are outlined in Mark Bowman's recent blog.

When something does go wrong in an aspect of care offered to a patient, all health professionals have a duty to help explain to those affected by the injury or death of someone they love what happened to cause such a tragedy, and what they and their employer will do to prevent something similar happening to anyone else.

This isn't voluntary – it's written into each person's code of conduct employed by the NHS and should underpin every dealing, however painful, a trust and its employees have with patients and their families – in other words, with you and I and everyone we know.

The report, unfortunately, makes it very clear that when something bad happens and it is investigated internally and externally in an effort to learn from that failure, too often the NHS simply turns it back on families dealing with terrible trauma, ignoring them and leaving their questions unanswered.

Families questioned say they are not routinely told what their rights are a relative dies and what support is available to them, they're not told about investigations nor kept up to date with important developments, are not listened to, with their experiences not taken into account.

All in all, a  case of adding insult to injury at possibly the worst time for a family – when they've lost someone they love, who was meant to be in the care of professionals.

Perhaps even more damning is the evidence in the report that this careless response to a death is even more prevalent when it involves mental health patients or those with learning disabilities – a group already more likely to die earlier than the general population.

I am currently in exactly this position – of waiting for answers for a family grieving for a man with dementia who killed himself jumping out of the window of a privately run care home.

Obviously, his wife and sons have been left devastated, not least because they don't understand how someone with a known risk of climbing out of windows in the months before his death was left unattended and able to get to a window on the third floor and jump out. On the day he fell, he even explicitly told a carer he intended to jump out of a bedroom window.

Despite recommendations from the hospital psychiatric team for constant supervision, this patient was not restrained in any way at the nursing home, nor was there emergency protocol in place to protect him. CCTV footage of the evening he fell shows no sense of emergency in the interval between him telling staff he intended to jump and his doing so.

To make matters worse, giving evidence, the care worker involved said she believed the locked windows were safe. Two years previously, following the death of a patient who fell from a second-floor window of a mental health crisis house, the Government's Health and Safety Executive issued special guidelines to care homes about window restrictors, saying that although most conformed to current British safety standards, they were not strong enough to withstand the force of someone trying to open them and did not protect vulnerable patients.

The coroner involved in this earlier case advised the Health Secretary that urgent action was needed to prevent further deaths.  

All in all, a preventable tragedy, causing terrible suffering to the family involved. His wife is struggling to get over the traumatic way her husband died and finds it impossible to do things like listen to music, which he loved, or to socialise.

We are still waiting for answers from the care home more than a year after the death about how this could have happened and for a response to our allegations of negligence.

Considering the CQC report, we will likely have to wait a lot longer. In the meantime, let's hope for a change in mind-set to spread through the medical community, encouraging it to accept its responsibility of offering honesty and respect to the relatives of patients who die as a result of poor care.

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