LEARNING LESSONS

1. LEARNING LESSONS All Part of the Service

2. Centre for Social Policy Seminar 17-18 June 2009 • Learning Lessons; Using Inquiries for Change, Journal of Mental Health Law Spring 2009 Edition No. 18 pages 57- 69, Gillian Downham and Richard Lingham • The MN Inquiry follow-up • Cross-agency relevance • The need for data • Future research • Future policy directions

3. Questions for consideration • Is the process of carrying out investigations, reporting and ensuring recommendations are implemented part of a service? • Is it/should it be embedded in each specialist area – children’s services, mental health, domestic homicide? • Should it be independent of the services? • If so, where might this be located?

4. MN Inquiry was unusual • Terms of Reference stated ‘the Inquiry Panel will conduct a review of progress against an agreed action plan six months after publication of the report’ • In fact the Panel was commissioned to review progress for 21 months after publication • Two progress reports by the Panel were presented in public session to the Strategic Health Authority and privately to the families

5. The victim’s family’s questions • “How long does it usually take for an inquiry’s recommendation to be implemented?” • “Is 75 per cent compliance with an audit standard after two years satisfactory?” • “How would we know whether the MN recommendations had been implemented?” • “How would we know whether the lessons had been learnt?”

6. The commissioner’s questions • Commissioners and providers asked us if there was guidance on the process of implementing recommendations • There was no standard, no guidance and no data on this topic • This prompted our own analysis of the MN Inquiry’s follow-up

7. Analysis of MN Inquiry follow-up • Categorised 8 recommendation types • Identified 7 principles applicable to follow-up stage • Realised these were not specific to a mental health inquiry • Could be applied to other kinds of independent inquiry, investigation and review

8. 7 principles • EVIDENCE • INDEPENDNECE • ACCOUNTABILITY • FULL IMPLEMENTATION • PLANNED REVIEW • NO BLAME • COMPLETION

9. 8 recommendation types • PRACTICAL • COMMITMENT • POLICY AND PROCEDURAL • PROFESSIONAL PRACTICE • MAJOR ORGANISATIONAL CHANGE • COMMISSIONING • NATIONAL • COMMON THEME

10. Advantage of follow-up by inquiry team • Satisfies need for public and victim accountability • Article 2 European Convention on Human Rights • Familiarity with recommendations • Will improve quality of recommendations made • Knows when satisfactory progress made • Progress report follows directly from the inquiry • Objectivity and impartiality • Continuity and momentum

11. Responsibility for follow-up • At levels ranging from top downwards – national, regional, local and the individual investigation • Across agencies – mental health, children’s services, police, probation • With different approaches – legal, professional, managerial

12. Cross-agency relevance • We say that wherever and however recommendations from investigations are to be implemented, the principles and recommendation types identified in MN can and should be applied • Problems with implementation of recommendations are common to all services

13. Orville Blackwood Inquiry, 1994 ‘It should be part of any inquiry that the team is reassembled to comment upon the implementation of their recommendations locally’ J Crichton and D Sheppard, 1994 following Big, Black and Dangerous: Report of the Committee of Inquiry into the Death of Orville Blackwood and a Review of the Deaths of Two Other Afro-Caribbean Patients

14. An Organisation with a Memory, 2000 ‘..inquiry recommendations are not always sufficiently helpful or focussed; implementation and follow-up is patchy; and there is no systematic mechanism for disseminating learning from individual local investigations’

15. Use and impact of inquiries in the NHS, 2002 ‘Inquiries rely on their credibility and persuasive power to achieve change: they have no formal powers or authority…. The consistency with which inquiries highlight similar causes suggests that their recommendations are either misdirected or not properly implemented. Certainly there are few formal mechanisms for following up the findings and recommendations of inquiries’ Walshe and Higgins, BMJ

16. Rocky Bennett Inquiry, 2004 ‘Many of the recommendations made in that [Orville Blackwood] report are disturbingly similar to recommendations that we include in this report but it is disturbing to find that little action has been taken upon them…..we express our grave concern at the apparent lack of reaction by anybody in authority to attempt to implement these and other recommendations made in that report'

17. Study of serious case reviews 2001-2003, 2008 • In 30 out of 40 cases the SCR action plan specified what action should be taken and by whom • In only 15 out of 40 cases SCR’s stated ‘what outcomes these actions should bring about’ • In only 12 out of 40 cases SCR’s explained ‘how the agencies will review whether the outcomes have been achieved’ • Wendy Rose and Julie Barnes

18. Learning Lessons, taking action, Ofsted, 2008 • ‘…lack of recommendations [in SCR overview reports] that clearly specify how lessons learned will be translated into practice; recommendations limited, not relevant to findings, vague and unspecific about time scale for implementation; action plans with no clear process for monitoring the implementation or impact of the action plan, in particular no formal role for the Local Safeguarding Children Board in monitoring and evaluating the impact of the action plan on inter-agency working’.

19. Protection of Children Progress Report, Lord Laming, 2009 ‘…insufficient focus by LSCBs on whether lessons are being learned from a child’s death or serious injury and whether action plans are subsequently implemented. This needs to be addressed urgently to create a more streamlined learning process’

20. Suggested solutions • Setting up national structure – National Patient Safety Agency • Developing tools – Root Cause Analysis • Disseminating/sharing recommendations • Urging greater speed and attention to learning lessons • Improving national oversight, guidance and inspection of reviews and learning lessons

21. Suggested solutions - NHS • ‘A system which ensures that lessons from adverse events in one locality are learnt across the NHS as a whole. The system will enable reporting from local to national level’ • Building a Safer NHS for patients: Implementing an organisation with a memory, 2002 on setting up the National Patient Safety Agency

22. Suggested solutions - children • Local Safeguarding Children Boards ‘should put in place a means of auditing action against recommendations and intended outcomes’. • ‘Reviews are of little value unless lessons are learnt from them. At least as much effort should be spent on acting on recommendations as on conducting the review’ • Working Together to Safeguard Children, 2006

23. Suggested solutions - children • ‘Local Safeguarding Children Boards require more guidance and support. Given the important findings in this report, Ofsted will produce further annual reports of our evaluations in order to support continuous improvement in practice and in the way reviews are conducted’ • Learning Lessons, taking action, Ofsted, 2008

24. Suggested solutions - children • Ofsted should ‘share SCR reports with HMI Constabulary, CQC and HMI Probationto enable all four inspectorates to assess the implementation of action plans’ and ‘produce more regular reports, at six-monthly intervals, which summarise the lessons from SCR’s’ • Protection of Children Progress Report, Lord Laming, 2009

25. Suggested solutions - domestic violence • ‘Multi-agency Domestic Violence Murder Reviews should be put on a national footing’ • Recommendations should be taken forward at ‘three levels: the agency, nationally and regarding legislation’ with a ‘national warehouse/post-box’ so that [reviews] are accessible to all’ • Findings from Domestic Violence Murder Reviews, 2003

26. Conclusions: the missing link There is no structured examination of the process by which recommendations arising from investigations are followed through to completion This is the missing link in the chain which should exist between the incident, the investigation and the lessons learned

27. Conclusions: need for data • Lack of basic data • No-one knows how many or what proportion of recommendations have been implemented • No identification of factors which might assist or impede progress with implementation • Lack of standards • No means of comparing or assessing progress • Lack of guidance • No models of good practice

28. Seminar and research proposal • Cross-agency seminar to • examine the general conceptual framework which underpins the policy and practice of implementing recommendations • consider whether there is the potential for cross-agency research to • Identify core features of implementation process • Start building a database • Begin developing a cross-agency knowledge base for use as guidance