Day 89: Calling for candour #107days

Day 89 was adopted by Lisa Hinton, who works with Sara. This is why she wanted to be involved, and what she did:

I’m a colleague of Sara’s, and have followed her passionate blog about LB’s time in the unit, and the enormous struggles she and the family have had since he died. I wanted to do something for the 107 Days of Action. A former journalist, I decided to put my old journalists shoes back on. What could we do to raise awareness of what happened to Connor and the failings of the health and social care system in responding to his death?

After considerable thought Lisa decided to contact an expert in patient safety, who has been explicit in the need for candour in cases such as LB’s. This is what happened next:

This led me to Peter Walsh, Chief Executive of Action against Medical Accidents (AvMA) the UK charity for patient safety and justice.

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AvMA provide advice and support for the victims of medical accidents and campaign to improve patient safety in the UK. Peter agreed to meet me and we talked about why learning disabled people get such a raw deal in the health and social care system, why families have to fight so hard to get justice, and what changes need to be made to ensure that what happened to Connor never happens again.

What follows is two videos of the interview between Lisa and Peter.


The first video covers introductions to Peter, to AvMA and it’s work. The lamentably slow progress to improve services for people with learning disabilities is discussed, the lack of priority given to provision for people with learning disabilities and the need for greater priority to be given to the safety of patients with a learning disability. The role of tragic cases like LB’s is discussed, as is the progress in patient safety since the Confidential Enquiry into Maternal Deaths was established sixty years ago. Advice for parents of people with learning disabilities is touched on, as is advice for bereaved parents.


The second video discusses LB’s situation in greater detail, including corporate manslaughter. It touches on the language, and reporting of never events, factors that contribute to system failure, and the yet to be introduced, new offence of Wilful Neglect. The Francis Report, the duty of candour, and what needs to change is also discussed.

Peter finishes with the following statement, one that we wholeheartedly support:

Families, families like Connor’s in particular, make an amazing difference. But it shouldn’t be so hard for them. They shouldn’t have to make so much noise. So the system has to be more responsive, the system shouldn’t need to be dragged kicking and screaming to the door of taking action to improve safety. And that’s the kind of approach we would like to see in the future.

We sincerely hope that Southern Health, and others in a similar situation, are paying attention to Peter’s advice. It really is time to move to a culture of candour.

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