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‘Care means care, Justice in care’ – Guest blog from Mr John Barrass

February 1, 2016 By Steve Turner

JB1

Mr John Barrass never imagined he would become a campaigner until his mother became ill. Read his story, featured here in full.


 ‘CARE MEANS CARE , JUSTICE IN CARE .’

‘THE NURSING HOME SECTOR is in crisis it has been in crisis for the last 20 years and has no one other than the trust lawyers practicing Orange County to help them to handle this crisis.

No rights, No justice, for any of the frail, vulnerable, elderly, it needs a massive political debate of all colors to change it! With the estate planning law firm serving Minneapolis supporting this cause, then it will turn into a revolution to make sure that all the elders receive honor and respect and will never be ill-treated in the future.

Please have patience to read this DOCUMENT to the end.

Thank you.

John Malcolm Barrass.

29 th October 2015.


THIS DOCUMENT ‘ CARE MEANS CARE ‘ , ‘ JUSTICE IN CARE ‘ .

THIS INVESTIGATION AND THESE RECOMMENDATIONS OF MINE WOULD SEE THE BIGGEST CHANGES AND REFORM SINCE JOHN MAJOR CLOSED LONG TERM WARDS DOWN BACK IN 1989, 26 YEARS AGO !!

WILL YOU READ A HARD STORY TO TELL AN INNOCENT PRISONER , AND THE INVESTIGATION ,WITH RECOMMENDATIONS.
THANK YOU
JOHN MALCOLM BARRASS 4 TH APRIL 2015 .

In this country , if you are old , frail , you are not only vulnerable , you are bottom of the pile , end of your life , so what ,it doesn’t matter.
We have had 20 years or more of appalling care to prove this, had documentaries made , appalling stories told !
Nothing has been done about this.

THE FACTS

Figures released by estate planning attorneys tells that from age UK 2012- 13 approx. 50,000 of the vulnerable elderly suffering mistreatment , abuse , neglect ,in nursing homes .
Radio 5 live 22nd Feb 2015, thousands of safeguarding complaints ,elderly , vulnerable ,2013-14, 1 in 5 homes failing key tests .
In the last 5 years, according to the estate planning law firm in Cedar Rapids, 400 small nursing  homes closing down, putting  the frail elderly vulnerable in larger homes , without enough staff and qualified staff to deal with them , southern cross and many others that charities know about, prove this.
In the next 15 years there are going to be twice the amount of 85 year olds , and 3 times the 65 year olds picking up there pensions.
The system is in CRISIS now .
CQC  Chief Inspector Andrea Sutcliffe told BBC Breakfast TV in Oct 2014 ” the standard of care homes in England is not good enough at the moment “.
CQC Chairman  David Prior said at the start of the CQC annual accountability at the healthcare select meeting on 16 th Dec  2014 , the CQC are still not fit for purpose “we have not got where we want to be. “
The Parliamentary Healthcare   Ombudsman , Dame Julie Mellor has been forced into raising the investigation figures using only the same staff by spending less time than before accessing the cases and more time investigating the cases , still spending less time than before, pushing the investigating figures up from 400 to 2000 .
When you are spending less time doing both what happens to the serious cases as before as my mother’s , and cases like the Titcombe  babies case , and the Sam Morrish  boy’s case   down here in Devon.
But what purpose are the Ombudsman there for they are not there to investigate nursing homes , they are there to investigate government depts. and the NHS hospitals.
The total cost to the taxpayer together is in excess of £400 million .
What are they getting for there money , an antiquated system , falling apart at the seams.
There are many many other revelations I could go on and on about .
That is why charities like the patients association  , and many more are inundated with complaints that the Ombudsman are not looking into there cases properly .
Mr Barrass asks “when will this appalling treatment under the name CARE for the vulnerable ,elderly,frail ,in nursing homes in this country end ” .
The answer he believes after investigating the system for 5 years is in this document below. On the 26th May 2005 my mother suffered in the medical terms a dense right sided hemiparesis total anterior circulation, stroke left her aphasic , with a dense right hemiplegia.
A serious stroke needing 24 nursing care , having multiple health problems and multiple health needs.
This is what care she received  and how she had to die.
AN INNOCENT PRISONER.
THIS IS A HARD STORY TO TELL.
Imagine what it must be like to be paralysed on one side ,unable to talk or call out for help ,press a buzzer, eat or drink, unable to walk , then imagine being fed and watered via a tube, the only quality of life you have is to see and hear people.
You are told you need a stimulating environment and responsive therapy.
Instead you are placed in a nursing home which is unsuitable for your needs.

Denied a correct chair for your quality of life, you cannot get out of your room for 4 months, then given a standard transit wheelchair deemed to be unsafe, under the health and safety factor ( had to support mums head once for 2 hrs with my own hand whilst wheeling her around in this chair ) , had to use this chair for 8 months, then when given the correct chair, but not enough staff to get out you out of your room on a regular basis.

Imagine being left in a soiled bed for 1 to 3 hrs,(one time left for 1 hr 20 mins the staff preferred to have there tea break first) However your mouth is not swabbed regularly so you develop crusty lumps around your teeth and on your tongue , nearly die in the first month of care , due to a chest infection not dealt with properly and promptly, blood tests not done on time, and then develop the worst case of constipation a hospital Dr has seen in 9 years, because you were not given the correct bowel medication, care home Dr say your family are fixated on this.

ALL THIS HAPPENED IN A NORTH DEVON NURSING HOME ,DEEMED TO BE ONE OF THE BEST IN DEVON.
WHAT MUST ALL THE OTHERS BE LIKE?
ARE YOU SHOCKED AND APPALLED.

On 23 rd October during the early hours of the morning , my mum died in a North Devon Hospital.
The last 6 days of her life saw her experience great suffering beyond anything she had already endured in the 4 years leading up to this time and place

THESE ARE MY MUMS FINAL 6 DAYS.
Her feed tube needed changing ,could and should have been changed one month earlier. Due to this, complications set in .
( which involved a drug , flu vaccination, super public catheter ) .
Mum’s last 6 days not checked by a Doctor , no management on at the weekend, allowed to have a feed tube change on Monday, when clearly condition at weekend needed looking into.
After being administered a Flu Jab one afternoon by the evening she had mucus / saliva running from the corner of her mouth like a water tap switched on, this continued for 4 days, then subsided for 6 days.

Day one Saturday. However when swabbing mums mouth I noticed a massive / piece and amount of mucus / saliva heavy phlegm . Staff told us it was only phlegm and did not call a Doctor.

Day two Sunday. Mum has vomited brown liquid, staff said it looks like dried blood, they did not call a Doctor , nor the home management.
Day three Monday. Mum went into hospital to have her feed tube changed (endoscopy) . When she arrived back at the home, her tongue and lip were swollen followed later by difficulties with congestion (upper throat and chest) , still no Doctor called. A temperamental red suction machine has been left in mums room.
Day four Tuesday. Mum still has congestive problems with a swollen tongue and lip with bruising under her chin again no Doctor called. Arranged to see the nursing home Doctor tomorrow, on his regular Wednesday visit.
Day five Wednesday. I discovered mum had a tooth missing , which no one recorded or explained to us how where and when it happened , yet two nurses told us they noticed it missing? , I noticed a hospital suction machine left in mum’s room (serious issues arise from this discovery ) the nursing home Doctor who we asked to see the day before had disappeared before we got there? , told by staff he had ordered antibiotics for mum.
After this the emergency Doctor was called who immediately rang for an ambulance and oxygen for mum.
Mum arrived at the hospital 4 blood tests were taken.
One arrived within 30 mins , found she had a major infection, put her on antibiotics , she was transferred to the medical assessment unit, her breathing has eased a little.
Day six Thursday. I arrive to see mum it feels if she has been given up on, I am told she is very poorly. She has been taken off the antibiotics and saline drip . Her breathing and congestion has got worse. Why has she been left to die like this just 3 days after all she went through?
It is a shock and more than I can bear.

QUESTIONS ARE RISING FROM ALL OF MUM’S CARE AND LAST 6 DAYS!

1. The parliamentary ombudsman would not investigate this only access!
2.We have 20 questions and issues unanswered by the p ombudsman!
3.Find they had 9 limited powers to investigate!
4.The legality side, costs outweigh compensation for the elderly.
5.After 5 years investigating this , nowhere to go to get this looked into properly or fairly!
6.This raises serious questions for everyone!
7.If they cant look into mum’s case properly or fairly !
8.They cant look into anyone else’s properly or fairly!
9.How can this be right!

WHAT WE WANT ANSWERS TO ARE :-
Why did my mother go to have a feed tube change to keep her alive , to die 3days after!
Why was my mother put through all of this !
For what reason!
I simply ask the question WHY.

QUESTIONS I ASK DURING MY MOTHERS TREATMENT,AND MY 5 YEAR INVESTIGATING THE SYSTEM IN GREAT DETAIL ARE :-
1.Are the parliamentary Ombudsman fit for purpose to look into private nursing homes?
2.Are the CQC fit for purpose when they still do not look into individual cases in nursing homes?
3.Have nursing homes got enough staff and quality staff to take care of vulnerable patients who need 24 hour care?
4.Should patients like my mother ever have been put into these homes ?
5.Should there be special NHS units for 24 hour care patients with multiple health needs like my mums ?
6.What rights have the old , frail, and vulnerable got in private nursing homes?
7.Continuing health care funding for the very vulnerable paid by the tax payer to private nursing homes, yet have loopholes in the system not to be investigated thoroughly ?
8.Care means Care whether it is Private or NHS, when anything serious happens in nursing homes, and it involves the hospital NHS, both sides will not comment what the other side have done , yet are both caring for a patient, so the patient gets caught in the middle of all of this not getting clear answers to what has happened to them?
9.Equipment ie specialist equipment , profiling beds etc, no law to make the nursing homes provide , the CCG were set up to deal with this, but still problems with no law to provide?
10.Because of the system as it is ,when anyone finds anything out no one will talk after fear of legal action, there has to be a new system free from legal interference?
11.Because of continuing health care paid for 24 hr vulnerable patients, paid by the taxpayer, it is the Government NHS responsibility not the legal responsibility to investigate accountability and answers for the families of love ones who have been affected ?

MY RECOMMENDATIONS!

1.A big political debate about all my investigation raises!
2. The PASC should hold meetings only about the nursing home sector and nothing else ,so they know more and can scrutinise more!
3.The CQC and the parliamentary Ombudsman are not fit for purpose anymore to inspect , regulate , and investigate nursing homes and a new one body only needs to be set up , with more powers to regulate , inspect ,investigate nursing homes doing the job together, to investigate all individual cases , to get accountability , free from legal interference .
4.Because the system as it stands at the moment , no one will ever get justice.

No one under the word ‘Care’ should ever have to go through this .

Don’t let this happen to anyone’s mother again.

When independent consultant nurse Lynne Phair said in the Panorama Documentary ‘Behind closed doors ‘ on 30th April 2014 ” To pull out a vulnerable patients buzzer is to cut there lifeline , and to imprison them “.
That must be what happened to my mum , she was imprisoned for a crime she did not commit.
I believe these deplorable events must be brought to the public’s attention to prevent similar things happening again, after all , anyone of us who cannot talk , shout out for help without enough staff and quality staff to look after us must be in prison too.

Thanking you all for taking the time to read this,It is desperately important this gets out to the public.
Anything you can do to help will be appreciated .
Yours Sincerely
John Malcolm Barrass.
Thursday 26 th March 2015. ‘

JB2

Click here for a one page commentary by Steve Turner

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Filed Under: Care Homes, Care Right Now, Elderly care, Transparency, Uncategorized

My Story – Steve Turner, Campaigner for safer healthcare

December 8, 2015 By Steve Turner

My Story – Steve Turner, Campaigner for safer healthcare

092Jessop

 

Steve Turner is a man on a mission – to create a better climate within our National Health Service where people can speak out about unsafe practices without fear of losing their jobs.

He’s a rare breed of health professional whose career spans hands-on nursing, training and innovation as well as campaigning for greater transparency within the NHS.

Steve began his career as a nurse specialising in mental health inspired by, and slightly scared of what happened to his grandfather who had suffered major depression all his life.
His appetite for learning took him through a degree in Social Policy and then into the world of healthcare IT. Steve spent the next decade working on clinical systems for American giant Shared Medical Systems, progressing from project manager to Senior Strategic Services Consultant of the US arm of the company, working with leaders of clinical teams in the UK

Steve then returned to the NHS, successfully revamping the Information and Technology department at Tunbridge Wells prior to a trust merger.

A spell in consultancy for the Kent and Medway Cancer network followed, with Steve leading two multi-organisational projects to identify the most effective information and prescribings systems . These brought clinical teams together to manage a complicated buying system in a much more efficient and cost effective way.

Then came a career crossroads. Steve and his partner decided it was time for a lifestyle change. They had enjoyed many holidays in Cornwall and decided this was the place to be. Plus Steve wanted to return his first love of hands-on nursing. He did a Return to Practice Nursing course and began work as a community mental health nurse in St Austell. Then he moved to an assertive outreach team based in Truro and dealing with some of the most vulnerable people in the community. This involved long term relationships and building trust with patients, something Steve much enjoyed. He also became a Nurse Prescriber, specialising in drugs within the mental health framework.

However in 2008, with proposed cutbacks on the horizon, Steve gently told his patients about the changes and that he might not necessarily be their regular nurse in the future, a step he thought was an important part of good care planning.

Following the standard procedures, he raised his concerns with the Cornwall Partnership NHS Foundation Trust. His only mistake was to copy his grievance letter to three GPs with whom he’d been working closely.

An attempt was made to discipline him but he accepted that what he had done was outside the policy of the Trust.

However the matter didn’t end there. The cuts had particularly upset two of Steve’s patients who realised that their continuity of care was being threatened and so they filed formal comments about the changes. But once these forms reached the desks of senior management, Steve was accused of bringing the organization into disrepute and suspended from work. Realising that the Trust would be pressing on with the cutbacks, and that his hopes of eventually winning a senior clinical job were scuppered, he resigned.

Steve returned to his training skills, developing medicines management training for staff at the Trust and worked on some major projects involving clinical governance and prescribing for patients with substance issues.

However by 2013 he was becoming increasingly concerned at the plight of the mental health staff he was training. They were becoming tearful in training sessions and were clearly stressed. They told Steve they were afraid to speak out for fear of victimisation as there was no alternative employer within travelling distance.

Steve attempted to discuss his concerns with the Trust but he quickly hit a brick wall. The Care Quality Commission were more sympathetic and arranged for an external person to review his complaint. However he was shocked to be left out of the loop, and merely told there had been ‘ recommendations.’ He heard nothing more.

This process cemented Steve’s ambition to campaign for better transparency in the NHS. He decided to set up Care Right Now as a structured company with an ethical base, delivering change management consultancy within health care, and a new breed of patient led education for clinical staff.

He has also created a movement to bring together people who raise concerns about patient safety and share their experiences, with Turn Up the Volume! on Patient Safety, a new initiative run on a charity basis. With a highly successful inaugural conference in Bristol under its belt, the movement is swiftly gathering momentum.

Does he have any regrets about what he did?

None at all, Steve says he would do it all over again. But he admits it took its toll on his personal life, taking him to the verge of bankruptcy, affecting his home life and linked to episodes of major depression.

It takes more than just courage to report concerns about patient safety, as Steve Turner discovered firsthand. Now he wants to make that path smoother for others in the future.

When NHS staff can report concerns without fear, he says, we will have achieved what we have set out to do. Ultimately this about patients’ lives – and staff’s.

 

Updated: 20/03/2018

 

 

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Filed Under: Care Right Now, Human Factors, Organisational Culture, Transparency, Uncategorized, whistleblowing

Why I set up Turn Up The Volume! (3)

October 18, 2015 By Steve Turner

Now the event is complete three things stood out for me:

  1. That this is a  movement not just a  conference

  2. That between us we have the answers if we work together

  3. The need for truth and reconciliation

 

Click here for the resource pages.

 

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Filed Under: Care Right Now, Human Factors, Leadership in Health, Organisational Culture, Transparency, Uncategorized, whistleblowing, Workshops

Children’s medicines – how listening to parents led to safer care

August 22, 2015 By Steve Turner

iStock_000009289937_Medium (2)

Case Study:

Background:
From 2008 to 2014 my company ran education sessions on managing medicines in a mental health trust. In common with some other mental health trusts the provider also looked after paediatric community services. This is not a mental health service. It covers children with complex health needs including enteral feeding tubes, ventilation; epilepsy and rapidly changing medicines. Children under the care of this service may be taking in excess of 15 different medicines per day, have complex titration regimes, emergency drugs with associated care plans, plus numerous ‘as required’ (prn) medicines.
It is not unusual for children with complex conditions to be under the care of up to five different providers, and to move between three different providers in one day. For example, from a Home Care Service to the Special School, to a Short Break House, maybe also being seen in an Outpatient Clinic on the same day too. As a result parents frequently have to repeat the information on their child’s medicines every time they move to another service, or a new person is involved.

Where to start?
The idea for change came about because of concerns that the staff in Children’s Short Break Houses were not learning what they needed about children’s medicines, as the learning was geared to the majority of staff who worked in mental health. So a new learning package for children’s staff was commissioned.
Part of the work to design the learning package included a baseline assessment which was conducted with parents and staff. This soon revealed that training alone was not the answer. It showed delays in medicines information reaching GPs, workarounds for obtaining information in order to administer medicines in the houses and a general lack of confidence in the whole process.
As a result we looked at the whole system starting with the area where most concerns had been raised, which was having an up to date complete list of a child’s medicines available at all times (medicines reconciliation). The system in place for Short Break Houses involved paying a local GP (not usually from the child’s GP Practice) to write up a medicines chart for each child. The process was fraught with difficulties and delays and widely disliked by everyone directly involved.
So we set about looking for a new way to manage the lists of medicines with more training and more input for the staff in the services involved. We came up with a new (and much more robust) process for medicines reconciliation in the Short Break Houses. This was fully documented in a new policy, and involved cross checking by both the staff and the parents.
Just before this went live, we asked the parents to review and comment on it and they said
‘If you’re producing an accurate and up-to-date list of my child’s medicines, why keep it the Short Break House, can’t it go with my child?’
So the My Medicines chart, which travels with the child, was born.

What was involved?
The My Medicines process led to the design and production of a new chart which has to be signed and checked by the parents.
It resulted in 40 children with complex conditions being offered a hand held paper record of their medicines (produced and validated by clinicians), which they take around with them wherever they go.

Benefits:
The new process, which continues to evolve, means that the child’s GP is now directly involved in day to day medicines reconciliation (they weren’t before); the parents are always asked to check and sign the charts (they weren’t before); verbal messages about medicines are never taken, and incomplete (or missing) directions are rapidly rectified (never worked around).
Some specific benefits of the new process include:
• It has reduced the risks of error, by providing full and accurate information on children’s medicine across their entire pathway.
• It cuts out the need for parents to keep having to repeat what medicines their child is taking to different professionals and care agencies.
• It frees up medical and clinical time which was previously spent chasing missing information.
• It has reduced the number of third part handovers and transcribing of prescription information.
Looking back it’s hard to believe that the old ways of working, which caused so many difficulties (especially for front line staff), were carried out for so long. These risky practices, or similar, are believed to still be commonplace in England.

Revealing hidden incidents and near misses:

In the first month of the project we raised 17 medicines incidents or near misses. Of these 11 related to problems with communication of information across the child’s pathway.
Resolving these has resulted in improved communication and engagement between different clinical groups and providers, and a desire from all quarters to take the project further. Previously many of these incidents were not logged or tracked across organisations. In some cases it was only due to the vigilance of the staff and parents that they were spotted and errors avoided.

Accepting the changes:

The project was well received by parents and staff, and resulted in improved communication and engagement between different clinical groups and providers. This included the Consultant Paediatricians (working for the secondary care provider), who were initially sceptical.
The project was less well received by the relevant medicines and prescribing committees, who were understandably concerned about who owned the My Medicines chart and had agreed its content. Explaining this was made more difficult because it is hard to get across the complexity of the arrangements, due to the critical nature of the children’s illnesses, in a committee setting.
I make no apologies for ensuring from the outset that it was the parents who owned the charts, which were designed by the project team (not a committee) to meet all best practice standards. It always worries me that when it comes to cross- organisational working the formal committees and systems in place can inadvertently act as a barrier to safety rather than promoting it. There is no doubt we had designed a safer process and my company was happy to take accountability for any associated risks.
As a legacy of the project, a Community Paediatric Pharmacist was appointed specifically to work with this group of children. So whatever evolves will now be based on inter-disciplinary thinking and working and will have clear safety parameters. I am grateful to the enlightened thinking of the leaders who commissioned this work and supported this novel approach.

Steve Turner

Managing Director Care Right Now (CIC)

This example is incuded in the NICE Shared Learning resource and was  highly commended in 2015.

Click here for the poster.

Last updated: 06.12.2021

CRNAnimationTestFor more information contact: info@carerightnow.co.uk

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Filed Under: Care Right Now, Children Health, Leadership in Health, Medicines, Medicines Optimisation, NHS, Organisational Culture, Prescribing, Transparency, Uncategorized, Workshops

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June 8, 2013 By Laurens van der Eyken

Care Right Now (CIC) is a Social Enterprise Company delivering healthcare systems development through innovative approaches. We have expertise in helping patients / users of health services achieve improved health outcomes.

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Filed Under: slides, Uncategorized

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Delivery plan for tackling the COVID-19 backlog of elective care...ambitious transformative 3-year plan from #NHSEngland View video 📺 lnkd.in/ehBmwGnk Submit a video for the #MedLearn series. It's FREE for the #NHS💙& #Patients💚 #TeamSurgical #TeamNHS 💙 #TeamPatient 💚 pic.twitter.com/K66f…

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#Montgomery v Lanarkshire Health Board | Informed Consent in #Medical procedures Very helpful short vlog from Prof. Suresh Bada Math @sureshbadamath youtu.be/OSsHIVrkXq0… #capacity #consent #MedEd #clinicaleducation #TeamPatient #TeamNHS #NMPPU #SOMNMPCPD #ethics #law #NHS

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Unit 22, Callywith Gate Industrial Estate,

Launceston Road,

Bodmin, Cornwall,

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E: info@carerightnow.co.uk

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