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[Image: Wellcome Library, London] Between Christmas cake and 1001 leftover turkey recipes, I’ve been mulling over the Mazars review of deaths in Southern Health NHS Foundation Trust and how they were (not) investigated (see https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/12/mazars-rep.pdf ). In particular, I’ve been wondering: 1) whether the NHS England/DH attempt to shut this down by publishing it within a couple of hours of parliament going into recess before Christmas will be successful; and 2) whether the squawks of outrage press released by various charities will be quietly shelved for ‘business as usual’ at the usual DH and NHS England tables in the new year. In my own mind, I’ve never really resolved the insider-outsider conundrum. Is it better to be working ‘on the inside’ to get something done, even in profoundly unpropitious circumstances, with all the attendant compromises involved? Or is ‘influence’ a comforting illusion which can begin to look like collusi...

Blog: Heart of darkness The long-delayed Mazars review is out today (see here https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/12/mazars-rep.pdf ). For those of you unfamiliar with the Mazars review, this is a review of all deaths of people with learning disabilities and people with mental health problems in Southern Health NHS Foundation Trust services over a four-year period, from April 2011 to March 2015. After meeting @sarasiobhan, one of David Nicholson’s last acts as CEO of NHS England was to commission this review, to find out how many people had died as Southern Health patients and (given Southern Health’s attempt to categorise LB’s death as due to ‘natural causes’ and therefore not requiring an inquest) how Southern Health had investigated (or not) and done something about (or not) their services in the light of these deaths. (Kazimir Malevich, Black Square) The review has been conducted by Mazars, an international ‘audit, tax and advisory firm’ that on the fac...

I’ve not wanted to blog anything about the #Mazars report into deaths at Southern Health until I’ve had a chance to see and digest the final report. But this internal briefing [update and correction - my error - this wasn't an internal briefing but a statement that was sent to universities with students at Southern Health] from Katrina Percy, tweeted by @sarasiobhan earlier today (see below), shows such a catastrophic (wilful?) lack of understanding that I need to say something quickly before such misunderstandings become entrenched. Where to start with this?  The Confidential Inquiry into the Premature Deaths of People with Learning Disabilities (CIPOLD), conducted by the University of Bristol, should be required reading for anyone wanting to understand the issues involved (see here for the full report http://www.bris.ac.uk/media-library/sites/cipold/migrated/documents/fullfinalreport.pdf ). Page 34 in the full report defines an unexpected death as a “death which was not anticipat...