SPOT THE DIFFERENCE.

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The Continuing Concealment

Of a Tragedy.

Regular readers of this blog will be familiar with the tragic case of Elizabeth Rourke, whose avoidable death during a routine operation was a manifestation of the utter incompetence of the senior management of Jersey Health & Social Services.

The ‘cover-up’ is the automatic response of all authorities in Jersey when faced with a disaster. The senior civil service are bound by an unwritten code-of-dishonour – whereby it simply isn’t the ‘done thing’ to make life awkward for your colleagues.

Especially so when you know perfectly well that if the spotlight of real scrutiny were to be shone on your particular area of responsibility – your own back-catalogue of malfeasances would be exposed.

So – in a culture profoundly detrimental to the public good – the civil servants responsible for the gross errors launch into survival mode – secure in the knowledge that they’ll always have the full backing of the Chief Executive, Bill Ogley, or whoever replaces him shortly, and the rest of their senior colleagues.

And so it is in this most serious of cases.

Everyone – and I mean, everyone – truly familiar with the facts of this case knows what happened – and why it happened.

A cascade of systems failures and clinical governance errors, caused by gross management incompetence, culminated in events in the operating theatre – and the needless death of a person.

So – guess what? The senior managers at Health & Social Services have hurriedly decided that they’ll now commission an “independent” investigation into what went wrong.

And even less surprisingly, to make damn sure this soi disant “inquiry” arrives at the “correct” conclusions – its terms of reference have been written by the very self-same senior managers who are culpable for the death of Elizabeth Rourke.

Written, that is, with a little help from the firm of glorified spin-doctors who the culpable managers chose to be “investigated” by.

On the 26th March, this farrago was announced to the island’s media.

The press-release even concluded with the sentence, “For more information, please contact Rose Naylor.”

Though – by some accidental oversight, I’m sure – it neglected to mention that Rose Naylor is responsible for clinical governance in Health & Social Services, and is thus centrally responsible for the events which led to the death of the patient.

Which – things being what they are down here on the rock – will be precisely why her equally culpable colleagues were very happy to put her in charge of the spin-doctoring required.

That’s ‘The Jersey Way’ for you.

Now, I had been waiting for this “investigation” to be announced with great interest – as I wanted to see what the terms of reference were going to be – before finalising my proposition which will be debated by the States, and which will seek to take the investigation entirely out of the hands of H & SS – and instead commission a real inquiry.

So when the document appeared on my e-mail system – in the same form as issued to the island’s media – I read it closely – and in the doing, compared it with the ‘real’ terms of reference as supplied to me by several moles, and, in turn, supplied by me to the JEP.

And – sure enough – there was a striking and significant difference between what H & SS management had told the media and the rest of us – and what they had secretly agreed with their preferred investigators.

I reproduce below the press release which purported to explain the purposes of the “investigation” to the media.

And then, below that – I reproduce the real terms of reference.

Once you’ve read both documents, give some thought to these two questions:

1: What is the difference between the two documents?

2: What does that difference tell us about the motivations and ethics of H & SS senior management?

And if you are a Jersey resident, when you’re thinking about your answers to these two questions, remember – your taxes are paying for this collection of clowns and shysters.

And of central importance, it could have been a loved one of yours who lost their life.

Stuart.

Health & Social Services Press-Release as Issued to the Media and Plebs to “Inform” us of the Terms of Reference.

Independent (sic) Investigation into the Care, Treatment and Management of Elizabeth Rourke.

The Health and Social Services Minister has commissioned an independent investigation into the care, treatment and management of Mrs Elizabeth Rourke who died during a routine gynaecological operation at the General Hospital on 17th October 2006. A subsequent police investigation led to the locum registrar who operated on Mrs Rourke standing trial for manslaughter. At the trial, which concluded in January 2009, the defendant was found to be not guilty.

The purpose of the independent investigation is to:

• Examine the care, treatment and management of Mrs Elizabeth Rourke from her related GP referral up until the start of the police investigation.

• Review the main actions taken by the Health and Social Services Department in response to her death including its own internal investigation.

• Review progress made against the recommendations of the interim internal investigation.

• Identify any further actions that the Health and Social Services department should take to improve patient safety and quality of health services.

The independent investigation will be carried out by Verita, a management consultancy that specialises in reviews, investigations and inquiries in health and social care. Three of Verita’s most experienced investigators will carry out the work: Managing Director Ed Marsden, Director of Client work, Derek Mechen and Senior Investigator Dr Sally Adams.

The investigation team aims to conclude its work by September 2009 and will provide a written report with recommendations to the minister.

No further information about the investigation or its findings will be released until the investigative team has concluded its work.”

Health & Social Service Secret Document which Explains the Terms of Reference.

Independent (sic) Investigation into the Care, Treatment and Management of Elizabeth Rourke.

The Minister for Health & Social Services, States of Jersey, has commissioned this independent investigation as part of his general obligations to ensure the safety of health services and improve the quality of care for patients. The investigation has no disciplinary remit and will not consider the acts and omissions of individuals. Rather it will provide a narrative explanation of the incident and consider organisational system and processes.

The purpose of the independent investigation is to:

• Examine the care, treatment and management of Mrs Elizabeth Rourke from her related GP referral up until the start of the police investigation.

• Review the main actions taken by the Health and Social Services Department in response to her death including its own internal investigation.

• Review progress made against the recommendations of the interim internal investigation.

• Identify any further actions that the Health and Social Services department should take to improve patient safety and quality of health services.

The independent investigation will be carried out by Verita, a management consultancy that specialises in reviews, investigations and inquiries in health and social care. Three of Verita’s most experienced investigators will carry out the work: Managing Director Ed Marsden, Director of Client work, Derek Mechen and Senior Investigator Dr Sally Adams.

The investigation team aims to conclude its work by September 2009 and will provide a written report with recommendations to the minister.

No further information about the investigation or its findings will be released until the investigative team has concluded its work.”

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