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premature deaths

However, the Mencap York domiciliary how it responds after a person has died in
care service, which included the home Good practice: your their care.
where Danny lived, was rated as requiring Just looking through press statements
improvement in all areas in a Care Quality help is appreciated after a death tells us a lot about the
Commission inspection report published culture of the organisation.
in March 2016 shortly after his death. Please get in touch if you can help “Mr and Mrs Tozer felt that at times
Mencap relied on the coroner’s verdict Dying to Matter with these questions Mencap fell short of the high standards
to determine their responsibility and action – we are keen to hear your stories and which we set ourselves” (Mencap, 2018)
around his death, although the scope of the identify good practice. can sound like a standard deflection of
inquest had been limited at their request. responsibility by an organisation after a
There is also a strong case that inquests Providers: What are you doing to death or serious injury.
in general do not take into account the listen to the concerns of the people It could make a huge difference if
wider issues surrounding deaths in care you support and their families? organisations just accepted that
and rarely have a finding of neglect, even responsibility and said: “We fell short of
if it can be argued that the person who Providers and law practitioners: we the standards we set ourselves.”
died was neglected. would like to hear about how the issue The other lesson is that the importance
Of course, Mencap is not alone in how of not apologising to families after a of a genuine, heartfelt apology to the
it responded to such an incident. Being death can be resolved without fear of family when something goes wrong
prosecuted is a fear for health and social legal repercussions. cannot be underestimated. Leaving a
care providers, even if in practice it family in limbo until an apology comes – if
rarely happens. l www.dyingtomatter.org.uk it ever does – is cruel. We have got to find
a way for organisations to be human in
Don’t apologise, say lawyers these difficult situations.
I have asked providers why they would not I would say our main learning to date is We’d like to hear from care providers
just put their hands up and say “we got it that sometimes the truth of what and legal people on how this issue can be
wrong” and apologise – the response was happened will never be found. Varying resolved legally. Does it really matter if an
that their lawyers would not allow it. accounts and poor memories mean organisation is prosecuted for failures? Is
Reputation, I’m sure, plays a big part in getting to the bottom of what happened holding back something so profoundly
how health and care providers respond. will not happen unless a key witness or important as an apology worth it to avoid
Mencap has a lot at stake when it comes witnesses come forward. prosecution? Tell us your stories please.
to reputation. The Tozers said that their concerns Finally, we want Dying to Matter to be a
It described itself until recently as the about the quality of care were ignored, place where families can share a
“voice of learning disability” and and this is a regular theme that comes up memorial of their relative with a learning
admitting to getting things wrong can put after a death in care. Simply listening to disability and we can celebrate their lives.
that proclamation into question. the concerns of families and acting on Please send us details in the link on our
This was evident in the BBC questioning them will go a long way in preventing website at http://dyingtomatter.org.uk/
of the Mencap chair after Danny’s death, deaths, but that is easier said than done. uncategorised/post-a-memorial. n
where it was pointed out that national
disability charity Scope had decided to References
end all service provision because of I had always believed that this BBC Breakfast. Mencap report and interview.
precisely this conflict of interest between 1 May 2018. https://youtu.be/0ma8lFEJC0E
campaigning and service provision. kind of community support Care Quality Commission. Mencap York
domiciliary care. Inspection report. 2016.
I would suggest that refusing to engage would naturally protect https://tinyurl.com/yeu6x6p8
with accusations that cause reputational Mazars. Independent review of deaths of
harm is one thing that harms reputations. people from poor care people with a learning disability or mental
Most importantly, evasive behaviours health problem in contact with Southern Health
and tactics can stop us from NHS Foundation Trust April 2011 to March
understanding what we need to do to What are you doing in your organisation 2015. 2015: 10. https://tinyurl.com/bm6f6pxx
prevent deaths of people with learning to listen to the concerns of the people you Mencap. Death by indifference: 74 deaths and
disabilities in the first place. support and their families? Please tell us counting. A progress report 5 years on. 2012.
Dying to Matter is an initiative by about it at Dying to Matter. We are keen https://tinyurl.com/4swx6azu
journalist Katharine Quarmby and myself to identify good practice. Mencap. Daniel Tozer inquest. Press release.
to unpick what happens surrounding an Another issue is commissioners 26 April 2018. https://tinyurl.com/3bp9bcz8
individual death in care, or an issue such continuing to pay for poor care. In the United Response. How Richard Handley’s
as support for people with epilepsy that past decade, we have watched local death has changed United Response. 2018.
means people with learning disabilities authority funding reduce and the good https://tinyurl.com/5rtartep
are dying preventable deaths. It aims to practice built up in commissioning under Quarmby K. Danny Tozer – a preventable
death? Dying to Matter. 2021. https://tinyurl.
hear a range of perspectives that help us Valuing People decline. com/2p9zd2mc
understand more fully, and to move away Funding for social care has been massively Tozer K. “We felt our concerns would now be
from blame and towards understanding. problematic for providers and we cannot believed. We did not anticipate the inertia and
Our first investigation is into the death ignore the fact that this will contribute to lack of responsibility.” Community Living. 2021;
of Danny Tozer and the story so far can be poor care. 35(2):22-23. https://tinyurl.com/3rv67dzp
found on the Dying to Matter website The culture of an organisation is central Verita. Independent investigation into the
(Quarmby, 2021). to how it works to prevent deaths and to death of CS. 2014. https://tinyurl.com/3n8xfdye

www.cl-initiatives.co.uk Community Living Vol 35 No 3 | Spring 2022 13