Following a discussion on Twitter earlier today with Midlands journalist Shaun Lintern and various others today, it was agreed (because of the limitations of the 140-character format) that Shaun would post his comments on my blog and I’d respond.
He’s done so this evening, but rather than answer within the limitations of a response to a comment, I think it’s better to do so as a separate post, so I can place my answers alongside his points for clarity.
Shaun’s points will be inset as quotes:
I usually like this blog and have worked with Stephen in the past however I feel it is incumbent upon me to correct what is essentially a misleading article that could be used by those wishing to deny the appalling care at Mid Staffs for their own ends.
Thank you for the initial kind comment, but as you’d imagine I disagree with many of your objections.
I have been involved with the Mid Staffs scandal for over five years, interviewed countless families and victims and sat through most of the 139 days of evidence to the Francis inquiry and so I consider I can speak with some authority on the issue.Stephen has made a number of assumptions, made I assume in good faith, which are incorrect and should be altered.One simple fact before I go into more detail is that we know hundreds of people suffered poor care at Mid Staffs. Robert Francis first inquiry had evidence from over 966 patients. Volume II of his first report is full of harrowing stories – so let’s all agree that this trust failed hundreds of patients and some did not survive their treatment. To suggest there were none and maybe only one excess death is a terrible insult to the many families I have personally spoken to and shed tears with over the last five years.
I’m personally disappointed with this opening point. My original article was very explicit in saying that there was poor care, and in some cases ‘appalling’. Nothing I wrote suggested in even the vaguest way that there was no suffering. I assume there’s no ill intent as we’ve got on well in the past, but the effect of this part of your points is to set up a ‘straw man’ and argue against something I have never said.
The second disappointing thing is the lax way you’re treating ‘excess’, when I was very careful to use the terms according to their exact meanings as discussed by Francis’ counsel and witnesses.
People die in hospitals all the time, and sometimes they die through neglect, malpractice or error. Some people will certainly have died in Mid Staffs through these causes, because they are inevitable in any large institution treating tens of thousands of people.
But that’s not what ‘excess’ addresses. ‘Excess’, with regard to the HSMRs, means ‘above the national average’ or ‘above a score of 100′, which means the same thing. As we’ll see shortly, the ‘excess’ deaths at Mid Staffs were down to errors in allocating codes and errors in inputting them.
Once these errors were corrected, Mid Staffs had a below-average death rate. This means that the poor care which undoubtedly existed was not causing a higher death rate – it doesn’t mean (and I have not said) that nobody died.
Most poor care doesn’t kill people. It may cause discomfort, even pain. It may well cause indignity and embarrassment. But people generally don’t die from, for example, being left in their own waste for an afternoon.
Where the ‘excess/avoidable’ line does blur is in the statement from Dr Laker, as quoted by Counsel Mr Kark, that there was ‘perhaps one such [excess] death‘. It seems clear from the context that Dr Laker was thinking in terms of ‘avoidable’ and that he only found one case out of the 40-50 he had reviewed that might have been avoidable – but he (or Mr Kark) used ‘excess’.
Since I was quoting, I wasn’t free to change the wording and I make no apology for that. Again because it was a quote, I left it as was in the title – but in this case it also served a purpose. The limitations of title length on a blog (and even more so for the purposes of publicising it on Twitter) meant I needed a ‘shorthand’ to convey both the idea of statistical excess and that of ‘only one avoidable’ which Dr Laker clearly meant.
Here are a few quotes from Robert Francis QC who knows the facts better than anyone and cannot be considered anything but independent.“The evidence gathered by this Inquiry means there can no longer be any excuses for denying the scale of failure. If anything, it is greater than has been revealed to date. The deficiencies at the trust were systemic, deep-rooted and too fundamental to brush off as isolated incidents.“This is a story of appalling and unnecessary suffering of hundreds of people. They were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety.”
Again, you’re arguing against what I haven’t said. My article is very clear that there was poor care. What I don’t agree with is that the poor care led to a higher death rate, since that is not borne out by the evidence. People died, and some may have died because of poor care (or they might have died anyway if their care had been perfect), but the Trust’s mortality performance against the national average was not worse because of it.
That doesn’t make for such a gripping headline, but it’s nonetheless true.
Let’s consider the mortality rate figures. Stephen is right in a sense that they have been misquoted by mainstream media, that does not mean it is wrong to say hundreds of deaths. Here are the facts.
It is often reported there were between 400 and 1,200 excess deaths at the Mid Staffordshire Trust between 2005 and 2008. This estimate is regularly attributed to the Healthcare Commission and its report on the trust published in March 2009.
In fact the figure never appeared in the HCC’s final report but was contained in a draft and was removed by the HCC chairman Sir Ian Kennedy following concerns raised by former Monitor executive chair Bill Moyes and then health secretary Alan Johnson. Sir Ian denied he was put under pressure to remove the numbers.
The figures were leaked to the press ahead of the report and have been repeatedly quoted ever since. In his first inquiry into the Mid Staffordshire scandal Robert Francis QC found the actual number of excess deaths between 2005 and 2008 was 492 and between 1996 and 2008 it was 1,197.
I took this up earlier with the Guardian’s Randeep Ramesh on Twitter. Francis 1 did not find that there were 492 excess deaths from 2005-2008. That’s a very sloppy (albeit understandable) interpretation of what it does say.
(Edit – here’s a very apposite quote from Francis 1 that Richardblogger provided as a comment on the original post:
“Taking account of the range of opinion offered to the Inquiry, including a report from two independent experts, it has been concluded that it would be unsafe to infer from the figures that there was any particular number or range of numbers of avoidable or unnecessary deaths at the Trust.”)
Francis 1 said that the statistical ‘observed’ death figure, minus the figure for ‘expected’ deaths left a figure of 492. This does not mean 492 avoidable deaths – it means a statistical excess of 492, which is not the same thing at all.
In such cases, it can be that the ‘excess’ was real - if every single piece of data entered is correct, and is entered correctly.
But because every condition has its own expected death rate, then if the ‘first diagnosis’ is wrong in some cases, or co-morbidities were not entered correctly, or the Z51.5 ‘palliative’ code wasn’t used when it should have been, then the ‘expected’ figure would be wrong – and therefore the ‘excess’ would be wrong too. If all 3 errors existed in the data, then the ‘expected’ figure could be massively wrong.
The evidence given to Francis 2 strongly indicates that all 3 errors were very present in the data. Along with the fact that the new coding manager’s coding-correction exercise resulted in the revised HSMRs being below the national average, this makes it certain beyond reasonable doubt that the ‘expected’ death figure was massively wrong – and therefore the ‘excess’ likewise.
HSMRs are a statistical estimate, with all the associated problems that come with statistics, they do not relate to real people and it is true to say we will never know the true number of individual deaths at Mid Staffs as a result of poor care. You can’t say with certainty there were 1,200 deaths, neither can you say there weren’t.
There were certainly many more than 1,200 deaths – but there is no evidence at all, from the statistics, that more people died than would be expected to die anyway. Again, this is not to say that there wasn’t poor care, or even appalling care in a few places. But the statistical appearance of ‘excess’ deaths doesn’t stand up to an analysis of the data issues.
But the numbers for Mid Staffs were 27% per cent above the national average at their highest and coupled with the real families who have come forward it is quite clear the use of the word hundreds is perfectly accurate and could even under play the true numbers. Robert Francis himself has accepted the argument that hundreds of people were affected.
As observed by even Professor Jarman, PricewaterhouseCooper’s analysis of the statistics and the data concluded that the figures were 25-30% wrong directly because of coding issues. This alone would bring down Mid Staff’s HSMRs down to, or below, the national average.
The fact that the Trust’s second, far more cautious recoding exercise brought the Trust’s scores down further still means the level of distortion caused by data/coding issues may well have been even greater – but if you want to just go with PwC’s figure, it still changes the picture completely.
Clearly in a news story the media cannot explain the statistical methods behind HSMRs without losing the interest of the reader or listener – I’m afraid Stephen has done exactly what he has accused the media of in the title of this blog and its conclusion.
I’ll repeat what I said near the beginning of this response – this is because of lax use of the terms in your understanding of my article, when I was being very exact in how I applied them (except where I was quoting someone else).
Coding of deaths was of course a factor, but Robert Francis has examined this and he concluded it did not adequately explain the numbers of deaths and complaints coming out of the trust.
I don’t believe that’s true at all. In his 1st report, he left in the ‘excess’ figure of 492 – but it has to be understood in the exact statistical sense.
By report no.2, he had decided to leave out any mention of a figure. This strongly suggests he’d realised that the excess figure didn’t stand up. Instead, he concentrates entirely on ‘poor care’ and ‘suffering’ – all of which are bad enough, but can be put down entirely (or very nearly) to understaffing (which is a regular refrain in Francis 2).
The issue of coding has been widely put forward by those wishing to downplay events at Mid Staffs and Robert Francis has repeatedly, and clearly, said it does not explain away what happened. It is a smokescreen behind which deniers of Mid Staffs and problems in the NHS hide.
For the reasons already outlined, this is a completely incorrect assertion.
HSMRs as Robert Francis, Sir Bruce Keogh and almost every other senior NHS figure have accepted are useful warning signs.
And I would agree: they are useful warning signs. But they can easily be a false alarm because of their dependence on the accuracy and correctness of the input - which nobody at DFI or DFU was checking. Neither body was providing any kind of adequate training to those entering the data or allocating the codes to improve the quality of the data either.
Wherever a trust has been found to have a high HSMR other significant patient care problems are often identified. Trusts with low HSMRs generally don’t. HSMRs, whilst not perfect, do serve as smoke signal for deeper issues.
‘Wherever’ is an over-assertion. During Brian Jarman’s & Roger Taylor’s testimonies, the issue was discussed of Trusts with poor scores who were then assessed as ‘good’ or ‘excellent’ by on-site assessments. Similarly, Trusts had been identified to have excellent HSMRs and then found to have poor care.
On the issue of rebasing HSMRs the point is that all hospitals will seek to have less patients die and continued improvements will try to be made. A trust that doesn’t improve its mortality from one year to the next, while the rest of the UK does, should surely be a concern to be highlighted and the rebasing would serve as one method to do this.
It’s perfectly possible that a Trust is doing very well in regard to mortality and is honestly and correctly entering its data, but appears to be standing still or getting worse because of improved performance or dishonest coding at other Trusts. Prof Jarman touched on this when he mentioned that in other countries they don’t rebase, but allocate reducing/increasing scores to reflect changes in performance, rather than resetting what ’100′ means every year for the ‘simple-minded English’.
The Laker review.
Dr Mike Laker, who led the Independent Case Note Review, was NOT asked to look at every contentious death at Mid Staffs. This review was made available to those families who REQUESTED it. In total 219 families requested a case note review, which was handed to the local PCT to complete. Many did not because the review was initially handled by the trust and in fact Dr Laker ended up in a dispute with the trust due to its handling. He did not work on the whole review.
It was still recognised as an independent review and Dr Laker fought hard to change the oversight to make it more so. Since nobody in the inquiry seems to doubt his integrity or competence, and Mr Kark certainly would have found it worth mentioning in his final submission if Dr Laker had considered the ICNR to be inadequate or its conclusions unreliable, the conclusion has to be that the cases that were reviewed were those that needed to be.
In the absence of evidence that ‘many did not’ ask for the review for the reasons you stated, it has to be supposition. If anyone was free to ask for the review and chose not to, it has to be concluded that most, if not all, of the cases that needed review made it into the reviewed set.
If there were 219 requested reviews and Dr Laker found (perhaps) one ‘excess’ (avoidable) death when he personally edited 40-50, the most that you could reasonably extrapolate from that would be 8-10 avoidable deaths over a 3 or 4 year period.
The review was flawed in that it was under resourced and poorly run. It also relied on the medical notes of patients – many notes were lost; many were inaccurate; not completed at all; and in some cases referred to the wrong patient. To draw any conclusions about the wider scale of poor care at Mid Staffs from this review is extremely risky and open to significant error.
Is Dr Laker under disciplinary action from the GMC for his conduct of the review process? If not, then your ‘poorly-run’ comment is questionable and possibly libellous. I’m sure it’s anything but uncommon for notes to be mislaid etc, but it’s the nearest to objective evidence that was available – the accusations of grief-stricken relatives cannot be considered reliable evidence, however understandable their grief.
What is still absolutely clear out of all this is that the 400-1200 figure that the media ran with has no basis in reality. It was drawn from faulty statistics (as evidenced by the massive range it covers) and even the worst-case interpretation of the case notes and even anecdotal evidence would not get anywhere near those figures.
Stephen makes some good points in this blog and it is not all completely wrong.
I’m delighted you think so!
But the simple fact is hundreds of people did die at Mid Staffs. The true number will never be known but we know at least 219 requested a case note review (not all those affected did), 966 witnesses gave evidence to Robert Francis’ first report.
Of course they did – as they did in every hospital during the period in question. But for all the poor care at the hospital, once the input data were corrected, the poor care didn’t lead to a higher mortality. And that’s the issue my article was addressing – the press spun misleading and ultimately incorrect stats into “poor care killed hundreds of people”, and the claim is simply unfounded.
Former Chief Executive Antony Sumara estimates he personally met with more than 200 families.In short Stephen has got lost in the details of the HSMR which I accept are being wrongly quoted as 400-1200 deaths but can correctly be quoted as hundreds. They are a useful descriptor of the scale of the problems at Mid Staffs.
For the reasons already stated, I disagree utterly – the figures have provided a useful club for certain vested interests to exploit and bash the NHS with, but they are not based in reality. And, just to be sure you’re understanding me – I’m not saying this means there was not poor care (which according to Francis appears to be solidly rooted in understaffing and in management that led to understaffing).
As a final point – anyone who doubts that Mid Staffs was the worst disaster in the NHS should do two things….
One – stop reading blogs and articles written by people who were not there and do not know all the details.
Two – read the summaries of the first Francis report and the recent public inquiry report. You will be unable to deny the scale of this catastrophe. Better yet read the actual reports including volume II of the first report.
If you still think there were no excess deaths at Mid Staffs then I am afraid you are beyond help.
It was certainly a disaster – just not of the type or scale that it’s been made out to be. It’s an object lesson of what will happen if hospitals are put under constant pressure to reduce cost and then respond to that by cutting staff numbers to untenable levels. But it’s not a story of poor care killing many more people than would have died anyway – as the properly-corrected HSMRs show.
That doesn’t make for great headlines, though – and it’s less politically useful for a government that is looking for ways to erode public affection for the NHS. That’s why the HSMRs were misleadingly used instead.