William Mead: 111 Helpline

Tuesday 26th January 2016 Commons Chamber

12:37

[Heidi Alexander (Lewisham East) (Lab)]

(Urgent Question): To ask the Secretary of State for Health if he will make a statement about NHS England’s report on the death of William Mead and the failures of the 111 helpline.

[The Secretary of State for Health (Mr Jeremy Hunt)]

This tragic case concerns the death of a one-year-old boy, William Mead, on 14 December 2014 in Cornwall. While any health organisation will inevitably suffer some tragedies, the issues raised in this case have significant implications for the rest of the NHS, from which I am determined that we should learn. First, however, I want to offer my sincere condolences to the family of William Mead. I have met William’s mother, Melissa, who spoke incredibly movingly about the loss of her son. Quite simply, we let her, her family and William down in the worst possible way through serious failings in the NHS care that was offered, and I want to apologise to them, on behalf of the Government and the NHS, for what happened. I also want to thank them for their support for, and co-operation with, the investigation that has now been completed. Today NHS England published the results of that investigation—a root cause analysis of what had happened. The recommendations are far-reaching, with national implications.

The report concludes that there were four areas of missed opportunity on the part of the local health services, where a different course of action should have been taken. They include primary care and general practice appointments made by William's family, out-of-hours telephone conversations with their GP, and the NHS 111 service. Although the report concluded that they did not constitute direct serious failings on the part of the individuals involved, if different action had been taken at those points, William would probably have survived.

Across those different parts of the NHS, a major failing was that in the last six to eight weeks of William’s life, the underlying pathology, including pneumonia and chest infection, was not properly recognised and treated. The report cites potential factors such as a lack of understanding of sepsis, particularly in children; pressure on GPs to reduce antibiotic prescribing and acute hospital referrals; and, although this was not raised by the GPs involved, the report also refers to the potential pressure of workload.

There were specific recommendations in relation to NHS 111 which should be treated as a national, not a local, issue. Call advisers are trained not to deviate from their script, but the report says that they need to be trained to appreciate when there is a need to probe further, how to recognise a complex call and when to call in clinical advice earlier. It also cites limited sensitivity in the algorithms used by call-handlers to red-flag signs relating to sepsis.

The Government and NHS England accept these recommendations, which will be implemented as soon as possible. New commissioning standards issued in October 2015 require commissioners to create more functionally integrated 111 and GP out-of-hours services, and Sir Bruce Keogh’s ongoing urgent and emergency care review will simplify the way in which the public interacts with the NHS for urgent care needs.

Most of all, we must recognise that our understanding of sepsis across the NHS is totally inadequate. This condition claims around 35,000 lives every year, including those of around 1,000 children. I would like to acknowledge and thank my hon. Friend the Member for Truro and Falmouth (Sarah Newton), who—as well as being the constituency MP of the Mead family—has worked tirelessly to raise awareness of sepsis and worked closely with UK Sepsis Trust to reduce the number of avoidable deaths from sepsis. In January last year I announced a package of measures to help to improve the diagnosis of sepsis in hospitals and GP surgeries, and significant efforts are being made to improve awareness of the condition among doctors and the public, but the tragic death of William Mead reminds us there is much more to be done.

12:42

[Heidi Alexander]

No one who watched the courageous interviews that Melissa Mead gave this morning could fail to be moved by this tragic case. I pay tribute to Melissa and her husband Paul, who have fought to know the truth about their son’s death and who are now campaigning to raise awareness and improve the care of sepsis. It is right that we should express our sorrow at what has happened, and the Health Secretary was right to apologise on behalf of the NHS. They key now is to ensure that the right lessons are learned and that action is taken. As the Secretary of State noted, the report found a catalogue of failures that contributed to William’s death, including four missed opportunities when a different course of action should have been taken. I want to press the Health Secretary on those areas.

First, the report states that William saw GPs six times in the months leading up to his death, but that none spotted the seriousness of the chest infection that cost him his life. Ministers were warned about poor sepsis care back in September 2013, when an ombudsman’s report highlighted

“shortcomings in initial assessment and delay in emergency treatment which led to missed opportunities to save lives.”

Will the Secretary of State tell us what action was taken following that report? Why was it only in December 2015, more than two years later, that NHS England finally published an action plan to support NHS staff in recognising and treating sepsis?

Secondly, the report found that the NHS 111 helpline failed to respond adequately to Melissa’s call. It concluded that if a doctor or nurse had taken her call, they would probably have seen the need for urgent action. The replacement of NHS Direct, which was predominantly a nurse-led service, with NHS 111 means the service relies on call-handlers who receive as little as six weeks’ training. So when will the Health Secretary review the training call-handlers receive, and will he consider increasing the number of clinically trained staff available to respond to calls?

The report says the computer programme that call-handlers are using did not cover some of the symptoms of sepsis, including a drop in body temperature from very high to low. Does the Health Secretary have confidence that the 111 service is fit to diagnose patients with complex, life-threatening problems who may not always fit the computer algorithm call-handlers have to rely on?

Finally, may I ask the Secretary of State what he is doing to raise awareness of the symptoms of sepsis so that treatment can begin as quickly as possible? I know this is an issue that Melissa and Paul feel particularly strongly about and we owe it to them to implement the recommendations of the NHS England report and do all we can to ensure the failures in this tragic case are never, ever repeated.

[Mr Hunt]

I hope I can reassure the shadow Health Secretary on all the points she raised.

First, there has been a sustained effort across the NHS since September 2013 to improve the standard of safety in the care we offer in our hospitals. An entirely new inspection system was set up that year. It has now nearly completed inspections of every hospital, and it has caused a sea change in the attitudes towards patient safety. Sepsis is one of the areas that is looked at. In particular it is incredibly important that when signs of sepsis are identified in A&E departments the right antibiotic treatment is started within 60 minutes. That is not happening everywhere, but we need to raise awareness urgently to make that happen, and that inspection regime is helping to focus minds on that.

On top of that—I will come to the issues around 111, and I agree that there are some important things that need to be addressed—a year ago I announced an important package to raise awareness of sepsis. It covers the different parts of the NHS. For example, in hospitals a big package on spotting it quickly has been followed from December 2015, with NHS England publishing the cross-system sepsis programme board report, which is looking at how to improve identification of sepsis across the care pathway.

The hon. Lady is right to raise the issue of faster identification by GPs. That is why, in January 2015, I announced that we will be developing an audit tool for GPs, because it is difficult to identify sepsis even for trained clinicians, and we need to give GPs the help and support to do that. We are also talking to Public Health England about a public awareness campaign, because it is not just clinicians in the NHS, but it is also members of the public and particularly parents of young children, who need to be aware of some of those tell-tale signs.

So a lot is happening, but the root cause of the issue is understanding by clinicians on the frontline of this horrible disease, and it does take some time to develop that greater understanding that everyone accepts we need. I can reassure the hon. Lady, however, that there is a total focus in the NHS now on reducing the number of avoidable deaths from sepsis and other causes, and that is something the NHS and everyone who works in it are totally committed to.

With respect to 111, there are some things that we can, and must, do quickly in response to this report, but there is a more fundamental change that we need in 111 as well. One thing we can do quickly is look at the algorithms used by the call-handlers to make sure they are sensitive to the red-flag signs of sepsis. That is a very important thing that needs to happen. NHS 111 has in some ways been a victim of its own success: it is taking three times more calls than were being taken by NHS Direct just three years ago—12 million calls a year as opposed to 4 million—and nearly nine of out 10 of those calls are being answered within 60 seconds.

When it comes to the identification of diseases such sepsis, we need to do better and to look urgently at the algorithm followed by the call-handlers. Fundamentally, when we look at the totality of what the Mead family suffered, we will see that there is a confusion in the public’s mind about what exactly we do when we have an urgent care need, and the NHS needs to address that. For example, if we have a child with a high temperature, we might not know whether they need Calpol or serious clinical attention.

The issue is that there are too many choices, and that we cannot always get through quickly to the help that we need. We must improve the simplicity of the system, so that when a person gets through to 111, they are not asked a barrage of questions, some of which seem quite meaningless, and they get to the point more quickly and are referred to clinical care more quickly. We must simplify the options so that people know what to do, and that is happening as part of the urgent emergency care review. It is a big priority, and this tragic case will make us accelerate that process even faster.

[Dr Sarah Wollaston (Totnes) (Con)]

I join colleagues from across the House in sending deepest condolences to William’s parents. I welcome the Secretary of State’s response that he will put into action the recommendation from today’s report. May I draw out one aspect that has not been touched on so far, which is the comment in the report that out-of-hours services did not have access to William’s clinical records, and that had they been able to do so they would have seen how many times a doctor had been consulted, and that that would have been a clear red flag? Will he reassure me that that matter will be addressed across the NHS, so that all services have access to patients’ clinical records—of course with their consent?

[Mr Hunt]

My hon. Friend is absolutely right. There is so much in this report, but we must not let some very important recommendation slip under the carpet, and that is one of them. We have a commitment to a paperless NHS, which involves the proper sharing of electronic medical records across the system. We have also instructed clinical commissioning groups to integrate the commissioning of out-of-hours care with the commissioning of their 111 services to ensure that those are joined up. It is a big IT project, and we are making progress. Two thirds of A&E departments can now access GP medical records, but she is absolutely right to say that it is a priority.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Like others, I add my condolences to the family. It is hard to imagine anything worse for a family to face. Like many deaths in the NHS, it is always sad to look back and see that it was a catalogue of missed opportunities and errors. One thing I should like to pick up on is the fact that young children are very hard to assess. It is quite hard for a doctor to assess them when they are actually seeing them; they can be running round one minute and then keeling over half an hour later. It is particularly hard to pick up clues about their health over the phone. When NHS Direct services were started throughout the UK, they were based in local out-of-hours GP centres, which meant that the nurse could just pass the phone and say, “Can you come and chat, because I am not sure.” We had rules in our local one that if a young child was involved, they got a visit from our mobile service. Instead of such cases being put through call centres, I hope that the Secretary of State will agree in this review to have some dissemination back to a local system, so that these cases can be accelerated easily to a clinician.

[Mr Hunt]

I agree with the broad thrust of the hon. Lady’s remarks. Of course she speaks with the authority of an experienced clinician herself. In this case, the tragedy was that there was actually a doctor who spoke to the Mead family on the night before William died, and he did not spot the symptoms. It is not simply a question of access to a doctor, but ensuring that doctors have the training necessary. However, as she says, dealing with cases such as this can be very difficult. The doctor’s view on that occasion was that, because the child was sleeping peacefully, it was fine to leave him until morning when, tragically, it was too late. Other doctors would say that that is a mistake that could easily have been made by anyone, which is why the report is right to say that it is about not individual blame, but a better understanding of the risks of sepsis. She is right in what she says. As we are trying to join up the services that we offer to the public, it is a good principle to have one number that we dial when we need advice on a condition that is not life-threatening or a matter for a routine appointment with a GP, and 111 is an easy number to remember. However, we need to ensure that there is faster access to clinicians when that would count, and that those clinicians can see people’s medical records so that they can properly assess the situation.

[Mrs Cheryl Gillan (Chesham and Amersham) (Con)]

As chair of the all-party group on sepsis, may I also pay tribute to the Mead family, who are now campaigning to ensure that no other child suffers in the same way as William? The Secretary of State has taken a great deal of interest in the UK Sepsis Trust and the work that it has been doing with the APPG. He will know that we are pressing for a campaign similar to the F.A.S.T campaign for strokes, as early diagnosis can save lives. Will he now consider very seriously funding such a campaign for sepsis, because there are thousands of deaths that could be prevented by a campaign that makes everyone aware of the signs of sepsis?

[Mr Hunt]

I am happy to undertake that the Under-Secretary of State for Health, my hon. Friend the Member for Battersea (Jane Ellison), will look urgently into whether such a campaign would be right. I can reassure my right hon. Friend that the package that we put together and announced last January did contain what most people felt was necessary, but we can always look at whether more needs to be done. I commend her for her campaigning on the issue of sepsis. On a more positive note, when the NHS has decided to tackle conditions such as MRSA and clostridium difficile, it has been very successful. In the past three years, the number of avoidable deaths from hospital-acquired harms—the four major ones—has nearly halved, so we can do this. We should be inspired by the successes that we have had to make sure that we are much, much better at tackling sepsis.

[Mr Ben Bradshaw (Exeter) (Lab)]

One reason why the number of calls to 111 has trebled is that people find it impossible to get to see their GP. As well as the shocking failings of this family’s GP, is it not the case that the Government were warned of the consequences of abolishing the popular and successful NHS Direct and of replacing it with a non-clinician led service? Will the Secretary of State look personally at the performance of 111 in the south-west, which has been bedevilled by failings ever since it was set up?

[Mr Hunt]

I gently say to the right hon. Gentleman that when 111 was set up it had the support of the Opposition. The shadow Health Secretary at the time looked at the risk register. The number of calls has increased dramatically partly because demand for NHS services has increased dramatically. That does not mean to say that there are not important things that need to be improved. We need to look honestly at what went wrong. The 111 service was one of the four areas where we should have done better. I am happy to look carefully at what is happening with 111 in the south-west. One improvement is that, in many areas, we are integrating the commissioning of 111 with the Ambulance Service, and that is something that happens in the south-west. On the whole, that has been a positive experience, but I know that there have been problems in the south-west, and I am happy to look further at them.

[Mr Robin Walker (Worcester) (Con)]

May I associate myself with those who have paid tribute and expressed condolences to the Mead family? Given the seriousness of this case, which we learned about today, what more can the Secretary of State do to reassure us about the clinical input and expert oversight of the NHS 111 service and its methods?

[Mr Hunt]

All 111 services have clinicians present at call centres, so it is about not the availability of clinicians, but the speed with which they are involved in cases where they can make a difference. It is also about the training of those clinicians so that they can recognise horrible infections such as sepsis quickly. It is a combination of things. The important thing here is that if we are to give the public confidence in a simpler system where they have a single point of contact—albeit a phone line or a website—they need to be confident that if they are not immediately speaking to someone who is clinically trained they will be put through to such a person if it is necessary. We have not earned that confidence yet, which is why it is so important that we learn lessons from what happened in this tragic case.

[Ms Gisela Stuart (Birmingham, Edgbaston) (Lab)]

I was the Minister who set up NHS Direct, and one of the first cases that caused us to review the algorithms was a meningitis case. May I therefore say to the Secretary of State that just looking at the algorithms used by call-handlers will not be sufficient? It is clinically exceptionally difficult, and his review is too limited to address the problem.

[Mr Hunt]

I understand what the right hon. Lady is saying, and of course I would listen to her because of her experience, but I reassure her that that is not the only thing that we are doing; we are doing lots of other things. The report makes many recommendations, one of which is to look at the algorithms that the call-handlers use to make sure that they are more sensitive to some of the red-flag signs of sepsis, meningitis and other conditions. There are lots of other recommendations. They include earlier access to clinicians where appropriate, and recommendations on the training of clinicians in the out-of-hours service, the training of GPs and the training of people in hospitals. So we will be undertaking a much bigger body of work as a result of this review.

[Chloe Smith (Norwich North) (Con)]

I welcome my right hon. Friend’s commitment to support CCGs to commission the 111 service and the out-of-hours service together where appropriate. He may be aware of some concerns in Norfolk about our out-of-hours service. What else is he doing to recruit, retain and support GPs in providing the round-the-clock care that people clearly need?

[Mr Hunt]

I have said before at this Dispatch Box that successive Governments of both parties have under-invested in general practice, and that is part of the reason why it takes too long for many people to get a GP appointment. It is why we have said that we want to have about 5,000 more doctors working in general practice by the end of this Parliament. That is an important part of what we want to do.

The other side is improving our offer to the public. When you have a child with a fever, and you are not sure, and it is the weekend, very often you have a choice between an out-of-hours GP appointment, a weekend appointment at your GP surgery, calling 111 or showing up at an A&E department. It is just confusing to know the right thing to do. If we are to improve standards of care, we need to standardise safety standards across the NHS, including for spotting potential sepsis cases, and that means a much simpler system.

[Tom Blenkinsop (Middlesbrough South and East Cleveland) (Lab)]

My hon. Friend the Member for Lewisham East (Heidi Alexander), the shadow Secretary of State for Health, commented on the concerns expressed in the report about the quality and effectiveness of the tools at the disposal of call-handlers at the 111 service. How many other cases have been misdiagnosed by the 111 service?

[Mr Hunt]

We believe from the independent case note analysis that has been done across the NHS, not just for sepsis but for hospital deaths, that there are around 200 avoidable deaths every week. That is something we share with other health systems; it is not just an NHS phenomenon. It is why we are asking hospitals to publish their estimated avoidable death rates, and we are having an international summit on that next month.

We think there are about 12,000 avoidable deaths from sepsis every year, and that is as a result of a combination of different parts of the NHS—GP, hospital or the 111 system—not spotting the signs earlier. That is what we are determined to put right.

[Mrs Anne-Marie Trevelyan (Berwick-upon-Tweed) (Con)]

Looking across the NHS at how we ensure that learning and behaviour change, can the Secretary of State update the House on how the hospital payment system is changing to incentivise new diagnosis and better outcomes?

[Mr Hunt]

My hon. Friend is right to say that we are doing that for hospitals. When I talk about 200 avoidable deaths every week, that is hospital deaths, not deaths as a result of problems in the 111 service. It is much harder to quantify avoidable deaths outside hospital, but we are determined to do that, and we are going further and faster than any other country that I am aware of as part of our commitment to make the NHS the safest system anywhere in the world.

[Clive Efford (Eltham) (Lab)]

The Secretary of State said that the report was

“far-reaching, with national implications.”

I have to say that this should have been a statement, not an urgent question. The right hon. Gentleman did not answer the question about the number of misdiagnoses on the 111 system. He needs to give more detail. The report suggests that other deaths of young children may be associated with misdiagnosis by 111. How many other cases are under investigation?

[Mr Hunt]

No one could have done more than this Government to tackle the issue of avoidable deaths across the NHS. It is much harder to identify when a death was avoidable when it happens outside hospital. As part of our work on reducing the number of avoidable deaths in the wake of what happened at Mid Staffs, we are looking at how we could improve primary care generally. Our first priority is to reduce the number of avoidable deaths in hospital and to learn from reports such as this one when they point to improvements that need to be made in the 111 service.

[Victoria Atkins (Louth and Horncastle) (Con)]

I join in the condolences that have been expressed in the House. By way of tribute to Mr and Mrs Mead’s campaign to raise awareness of sepsis and its symptoms, I wonder whether each and every parent can take a small but practical step today and google the symptoms of sepsis so that we know when things are not right with our children and are better armed to tackle doctors when we are not getting the answer that we need. I did exactly that this morning after hearing Mrs Mead’s very moving interview on the radio.

[Mr Hunt]

I thank my hon. Friend for that important intervention. If we are going to deal with the 1,000 tragic sepsis deaths among children every year, it needs a sustained effort from all of us, not just the NHS. I will take away the action of looking at what Public Health England is doing to raise public awareness. The Minister for Public Health, my hon. Friend the Member for Battersea (Jane Ellison), will look at what health visitors can do to boost awareness of sepsis, but in the end we all have a responsibility to understand the symptoms better.

[Peter Kyle (Hove) (Lab)]

Last November, I contacted the Minister because the South East Coast Ambulance and 111 service carried out a trial that failed through poor governance, putting patients at risk. It turned out that the Department for Health heard about this only after Monitor contacted it. Is not his Department becoming reactive and simply not proactive enough to tackle these issues before they end up becoming statements and urgent questions in this House?

[Mr Hunt]

Not at all. I gently urge Opposition Members not to fall into the trap of trying to make political capital when tragedies such as this happen. In the wake of the Francis report on Mid Staffs, this Department has done more than any Government have ever done to improve the safety of care in the NHS. If you take the four most common harms—urinary tract infections, venous thromboembolisms, pressure ulcers and falls—the number of deaths in hospitals has fallen by 45% in the past three years. We are making sustained progress in improving the level of safety and care in the NHS, but we are never complacent, which is why are taking so seriously the report issued today.

[Kevin Hollinrake (Thirsk and Malton) (Con)]

This is a tragic case, and our thoughts today are with the Mead family. Reluctance to prescribe antibiotics due to the dangers of antimicrobial resistance played a key part in this tragedy. Does the Secretary of State agree that this is a significant global problem, and we need to commit significant investment to it?

[Mr Hunt]

I am grateful to my hon. Friend for raising that issue, which has not been raised so far this afternoon. He is right. We have a pressing global need—not just a UK need—to reduce the inappropriate prescribing of antibiotics. That is why training of clinicians is so important. In the case of sepsis, not only is the prescribing of antibiotics appropriate but it is essential and it is essential to do it quickly. We need to make sure that, as we train GPs to reduce their prescribing of antibiotics so that we do not develop the resistance to antibiotics that could be so disastrous for global health, they do not avoid prescribing them when they are absolutely essential.

[Diana Johnson (Kingston upon Hull North) (Lab)]

The Health Secretary said that NHS 111 was a victim of its own success. I agree with what my right hon. Friend the Member for Exeter (Mr Bradshaw) said, which is that it is used because it is so difficult to see a doctor. On 2 January, the Hull Daily Mail reported that Hull Royal Infirmary was telling people not to come to A and E but to use services such as NHS 111. In the light of the findings of this investigation, which have national implications, does the Secretary of State agree that there should be more clinicians at NHS 111?

[Mr Hunt]

I do agree that we need more clinicians in primary care. We also need to invest in secondary care, which is why the hon. Lady has a new A&E centre opening in Hull, which I am sure she welcomes. We need more clinicians in primary care so that we can deal with these issues more quickly, before people need hospital care and to spot conditions such as sepsis. This Government are investing £10 billion in the NHS annually in real terms in order to step up the improvement in the services that we offer.

[Nic Dakin (Scunthorpe) (Lab)]

So will the Secretary of State put a higher proportion of clinicians in 111?

[Mr Hunt]

We will certainly look at whether we need to have more clinicians in 111. We do have clinicians available in 111. My own view is that it is the separation of the out-of-hours services and the 111 service that is at the heart of the problem that we are looking to deal with, but as part of the review we will look at the availability of clinicians in 111.

[Greg Mulholland (Leeds North West) (LD)]

I, too, add my condolences to the Mead family. I can only imagine their anguish at having been told “not to worry” and that this was “nothing serious”. There was a catalogue of failures, not just with 111. Is consideration being given to the decision by GPs not to take William’s heart rate, as clearly should have happened? Is there in any sense a reluctance to refer young patients to the acute sector? If that is the case, advice to GPs needs to be changed.

[Mr Hunt]

I can reassure the hon. Gentleman that we are looking at all these things. As with the issue of the prescribing of antibiotics raised by my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake), of course we want GPs to avoid inappropriate referrals to secondary care, but it is vital that where a referral is needed, it happens. We see this not just in cases of sepsis, but in cases of cancer. It is vital that we get better at catching cancers earlier if there is to be a successful outcome to the treatment, so the hon. Gentleman is absolutely right. That will be looked at.

[Jenny Chapman (Darlington) (Lab)]

I commend the shadow Secretary of State on securing this urgent question. Earlier, the Secretary of State said that he felt that people had confidence in 111 because of the high call volumes, and that those had increased. I do not think that is the case. Confidence in 111 is shaky at best and this case could well shatter that confidence even further, unlike the confidence that we all felt in NHS Direct when we had young children. What is he going to do to make sure that as well as listening to the people whom he has mentioned already, he involves patients in determining what they need in 111 to give them back the confidence that we need them to have in order to avoid some of the pressure on the rest of the service?

[Mr Hunt]

The hon. Lady is right about the importance of involving patients when such tragedies occur, and I said in my response to the urgent question how grateful I was to the Mead family for their co-operation. One of the things the report identifies as important is earlier involvement and more listening to parents and families in such situations. I caution the hon. Lady against a blanket dismissal of the service offered by 111. There are many clinicians and call-handlers who work extremely hard and who deal with about a million calls a month, and the vast majority of those cases have satisfactory outcomes. But does that mean that there are not significant improvements that we need to make to that service? No, it does not. Of course there are things that need to be done better and we must learn the lessons from this terrible report.

[Rachael Maskell (York Central) (Lab/Co-op)]

My thoughts, too, are with the Mead family today. The diagnosis of conditions, including sepsis, must be carried out by those with the highest level of clinical skills. Triage by algorithms is unsafe. Can the 111 system be put back into the hands of highly trained clinicians, those trained to drill down in diagnosis, instead of non-qualified staff?

[Mr Hunt]

I think that is a misrepresentation of what happens with 111. There are clinicians in every 111 call centre. There are not physically enough doctors and nurses to have doctors and nurses answering every single call, and indeed the advice from the clinicians in the NHS responsible for the 111 service is that that would not be appropriate. If we are to do the triage that the hon. Lady talks about, what matters is that where a clinician needs to be involved, they are involved more quickly than happened in the current case. That is the lesson that this Government are determined to learn.