NHS Inpatient Mental Deaths Triple.No investigations. Numbers unknown.

If our government really were concerned about our mental health, it would, at the very least record the number of deaths of NHS inpatients and investigate them.

Particularly as the number of MHA detentions has risen by 10% year-on-year since 2010/11.

The latest 2017 figures from Full Fact show deaths in MHA detention have tripled.

And those held under Deprivation of Liberty Safeguards have increased 56%

https://skwawkbox.org/2018/01/13/deprivation-of-liberty-deaths-soar-by-56-in-a-single-year/

But the actual number of deaths in NHS mental  hospitals is unknown, not recorded and rarely investigated.

No single body is responsible for recording children or adults deaths.

This crucial information is neither collated, analysed or made public .

And as  hospitals are increasingly owned by private corporations Freedom of Information Notices are being refused on the grounds of commercial confidentiality.

47% of child and adolescent mental health service providers refused to answer FOI requests because of their private status.

http://www.inquest.org.uk/media/pr/number-of-hild-in-patient-mental-health-deaths-not-known

So we pay up to £13,000 a week, an average £900 a day per inpatient for public NHS ‘treatment’, provided by private corporations, but aren’t allowed to know how many healthy people die and why ?

New laws introduced last year  remove those dying under Deprivation of Liberty Safeguards of their  right to a jury in a Coroners Inquest under EU Art 5  as not now in ‘state detention’.

Latest statistics from Norfolk and Suffolk NHS Foundation Trust show 140 patients suffered “unexpected deaths” in just 9 months last year .

There are no national figures to compare trusts, like for like, but the consultant used said ,

’’it did not appear that NSFT was an outlier ( out of line)in terms of high numbers of deaths or incidents.”

http://www.edp24.co.uk/news/health/unexpected-deaths-could-reach-new-heights-in-mental-health-care-1-4877737

Panorama last year served FOI requests on 57 English mental health foundation trusts, increasingly private companies like Sheffield Health and Social Care .

Only 33 responded

In 2012-13, they reported 2,067 ‘unexpected’ deaths.

By 2015-16 this had risen to 3,160.

Nottinghamshire Healthcare NHS Foundation Trust reported 113 ‘unexpected deaths’ within its mental health services in 2016/17 an increase of 76 from 2015/16 an  over 100% increase in  just a  year.

http://www.lincolnshirelive.co.uk/news/health/big-rise-unexpected-deaths-among-83896

The number of ‘unexpected’ deaths in St Andrews Healthcare is still unknown

https://finolamoss.wordpress.com/2015/08/25/how-many-deaths-in-st-andrews-northampton-who-is-accountable/

3 years ago the government reported 1,200 people, 3 a day with a learning disability died every year within our NHS due to inadequate care.

http://enablemagazine.co.uk/mencap-dismayed-by-lack-of-progress-to-stop-avoidable-deaths-of-people-with-a-learning-disability/

A Liverpool MP asked Jeremy Hunt last year how many children and young people had died in NHS care from 2010 and he couldn’t answer.

http://www.mirror.co.uk/news/uk-news/tragedy-nine-young-people-died-7729668

Why are so many young and physically fit patients dying from mental health ‘treatment’?.

We have no answer.

As there is no system requiring any investigation, let alone an independent one,at best, deaths are being investigated by the owners of the institution where they die .

With no transparency of process and in breach of the basic rule of natural justice, that no man should be a judge in his own court.

http://www.inquest.org.uk/media/pr/number-of-hild-in-patient-mental-health-deaths-not-known

The CQC and NHS England refused to investigate the 7 unexpected deaths in St Andrews Northampton in 2013/14 flagged by the local Healthwatch

https://finolamoss.wordpress.com/2015/08/25/how-many-deaths-in-st-andrews-northampton-who-is-accountable/

A 2016 study revealed that Southern Health NHS one of the largest NHS Trusts, has investigated only 13% of 1,454 of all its ‘unexpected’ patient deaths since 2010.

Investigation rates being  particularly low for elderly patients with mental health problems (0.3 per cent) and for patients in general with a learning disability (1 per cent).

This was stated not to be an outlier.
http://www.independent.co.uk/news/uk/politics/a6766961.html

So, we can therefore assume nationally, only 1 % of ‘unexpected’ deaths of learning disabled including the autistic, and 0.3 of the older patients are investigated.

All ‘unexpected’ deaths are supposed to be reported to a coroner so they can be investigated.

But official figures show that that of 1,115 cases recorded by the NHS, only a third, were reported to coroners over the last three years.

http://www.telegraph.co.uk/news/2016/08/09/hundreds-of-deaths-of-mental-health-patients-not-investigated-re/

Norman Lamb blamed
’ Under funding of sometimes threadbare mental health services which are struggling to cope with rising demand for care’.

Yet a fifth of our total NHS budget is being spent on mental health , the CCGs budget being up by £342m, and an extra £1.4bn is allocated by this Parliament.

How can the present £13,000 a week and minimum £900 a day even be justified, let alone insufficient ?

And would venture capital be investing their cash, as they increasingly are, in ‘threadbare’ services ?

Last year the government ploughed £433 million into safeguarding the vulnerable in their family home or individual’s non state home.

https://finolamoss.wordpress.com/2016/05/19/how-will-433-million-carers-act-implementation-money-be-spent/

With so many dying in state care, the vulnerable need to be safeguarded in state care, not removed to it,  as in such care deaths are not even recorded let alone investigated .

https://www.whatdotheyknow.com/request/385842/response/937567/attach/html/3/FOI%20416%20039.pdf.html

Simon Duffy in his NHS Slides for personalisation of services reveals the latest statistics for mental hospitals up to December 2017

• In the last 3 months 25.9% of inpatients had harmed themselves • 21.0% of inpatients had suffered an accident in the last 3 months • 22.2% of people had suffered physical assault in the last 3 months • Physical restraint had been used 34.2% of people in the last 3 months 11.4% had suffered seclusion in the last 3 months • 56.6% of people had been the subject of at least one incident involving self harm, an accident, physical assault against them, hands-on restraint or seclusion during the last three months •

Antipsychotic medication used regularly or at least once in the last 28 days for 68.3% of the people in the units

 

The bipolar cashcows. Release this 8 year Cygnet ‘Bipolar’ 4 million pound inpatient.

In the USA “ Prior to 1955, bipolar illness was a rare disorder. There were only 12,750 people  hospitalized with that disorder in 1955.

In addition,  there were only about 2,400 “first admissions” for bipolar illness yearly in the country’s mental hospitals.

Outcomes were relatively good too.

 Seventy-five percent or so of the first-admission patients would recover within 12 months.

Over the long-term, only about 15% of all first-admission patients would become chronically ill, and 70% to 85% of the patients would have good outcomes, which meant they worked and had active social lives.”

Today over 5.7 million US citizens have bipolar and are mostly unemployed, hospitalised and medicated for life.

https://www.madinamerica.com/2016/03/do-5-million-americans-really-have-bipolar-disorder/

And according to NHS Digital 2016, 2% of the UK population mainly children and under 25s screened positive for bipolar.

https://www.bipolaruk.org/news/bipolar-uk-welcomes-inclusion-of-bipolar-within-official-statistics

Yet there is no proven pathology and bipolar can be diagnosed on a few hyper episodes by those employed by corporations who gain millions from its diagnosis .

A psychiatrist commented to me fifteen years ago ‘ Bipolar is where all the money  is now’, as it appeared in soap characters  and celebrities like Stephen Fry. 

As  David Healy  noted

‘how a very few people in key positions can determine the course of events and shape the consciousness of a generation’.

Many bipolar victims have been holed up in mental hospitals on secure wards for years as they now earn £13,000 a week on secure wards and £7,000 on others for their private for profit providers paid from NHS funds.

This is not treatment under the MHA, as it is not determinable and  patients are mentally and physically deteriorating on an increasing in breach of NICE guidelines  diet of  polypharmacy, as they suffer in captivity.

They have no voice, no IMCA, no nearest relative appointed, no meaningful reviews, no future, no life, all experts and treaters are  employed by the private corporations that profits from their encagement.

The girl pictured above is just one  of the many victims.

We only know about her because her grandmother Gillian Speke, has  petitioned the government for her release from a Cygnet hospital.

She has been held medicated on a secure bipolar ward for 8 years, earning her Cygnet providers earning  over 4 million pounds of NHS money to date.

Here are comments by workers on Cygnet services.

https://finolamoss.wordpress.com/2016/12/29/comments-on-cygnets-services/

Why is this allowed to happen ?

Can she not be more effectively treated under a treatment order in her community.

When, if ever would she be released ?

Here are the words of her grandmother from her petition, please sign it, this young woman  and  thousands silently suffering need our help.

‘My name is Gillian Speke.

Please help release MY GRANDDAUGHTER from CYGNET HOSPITALS by signing our petition.

She needs to be near to her Nan. 8 YEARS she has been incarcerated. Her physical & mental health have deteriorated, she has had no help from a Nearest Relative because this has not been attended to.

Her weight has doubled due to the long list of meds she is forced to take. She has to stay on a secure BIpolar ward, she gets no fresh air or exercise, there is no structure, no organised activities except for Mindfulness & she has been denied access to education for the past 11 YEARS.

She has not had an assessment for a move to the community as promised in 2016. She is DYING in there. She does not deserve to be punished. She is a vulnerable woman who needs help for Trauma (PTSD) ‘

https://www.thepetitionsite.com/en-gb/798/440/513/release-my-grandayghter-from-detention-in-cygnet-private-hospital/?taf_id=44510916&cid=twitter

Is this how you want our NHS money spent ?

Here is the list of medications this lady is forced to take and originally her stay  was estimated at 2 to 3 years.

Regular Medication:

Sertraline 200mg mane; Depakote 750mg BD; Mebeverine MR 200MG BD; Metformine 1G bd; Atorvastatin 40mg OD; Omeprazole 20mg mane;  Furosemide 50mg mane; Dapaglifozin 10mg mane; Diazepam 5mg TDS; Colecalciferol T OM; Kwells 300mg TDS; Clozapine 225mg BD .

PRM Medication:
Ibrufen 200-400mg up to QDs; Epipen 0.3mg up to 0.9mg; Cyclizine tab 50mg up to 150mg;  Procyclidine 5mg PO max in 24 hrs 10 mg; Olanzapine 2.5-5mg max 200mg (PRN + regular); Promethazine 25-50mg max dose 100mg in 24 hrs;  Salbutamol 100mcg; Glucogel/Glucsgon T; Corsodyl ; Lactulose;  Stat dose of Clopizol Acuphase given on 3 occasions since admission – forcibly injected.

https://psychiatricabuseuk.com/

And read here the full story of the horror of this lady’s very expensive minimum £900 a day ‘treatment’

https://m.facebook.com/story.php?story_fbid=1623331831021618&id=1609298589091609

 

And, there appears systemically, no effective accountability for health services, as under the Health and Social Care Act 2012, NHS England and not the Department of Health is liable for services but are also the commissioner and regulator of these services and liable if inadequate.

So there is a huge conflict of interests between these roles of regulator and commissioner, which equals no accountability.

 ‘ My sister is dead after 4mths after being placed at Cygnet Hospital  Derby ‘

was posted as a comment to this petition in November 2017.

 

 

 

 

 

 

Serco, Priory and Mydentist – A tale of monopoly venture capitalism and leadership.

The Priory Group is the UK’s main provider of mental health, learning disability and specialist education services almost exclusively financed by public funds via NHS clinical commissioning groups and Local Authorities.

Tom Riall joined the Priory from Serco in 2013, where he had been Chief Executive of their Global Services Business.

He continued to build on the strength of the Priory’s care pathway service ensuring the business was well positioned to manage the transition of the healthcare commissioning reforms.

Ensuring Global investment groups made profit.

Riall sold the Priory Group to venture capital backed US Acadia for 1.28 bn last year.

Venture Capital by definition is only used for business not otherwise able to get funding , not those gov/NHS pay millions of guaranteed, increasing money

And in May this year moved on to Integrated Dental Holdings Group, who own UK’s largest NHS dental chain Mydentist which also provides private treatments.

https://www.mydentist.co.uk/about-us/investors/archive/lists/investors/2017-03-21—announcement-of-new-chairman-and-chief-executive

https://finolamoss.wordpress.com/2016/11/06/us-acadia-group-pay-1-28bn-for-the-priory-group-mental-health-feeds-venture-capital-profit/

Did Riall’s sojorn in the Priory Group improve services ?

Deaths spark fears at Priory Hospitals.
https://www.thetimes.co.uk/article/deaths-spark-care-fears-at-prioryhospitals-jdtf38khp

Coroners have issued five formal notices over the past five years, highlighting care failures after deaths of patients in the care of the Priory Group’s hospitals.

Among the recurring problems highlighted in the coroners’ “prevention of future death notices”, are a failure adequately to monitor patients at risk of self-harm, failures in training and inadequate record keeping

Riall’s meteoric climb began 25 years ago with the advent of monopoly corporatism and outsourcing.

He held senior leadership positions in the Onyx and Reliance Groups working with local authorities and central government across the UK.

And oversaw Reliance’s successful tender in 2003 for the use of private contractors to transport prisoners in Scotland.

When the firm mistakenly released a number of prisoners, including a convicted murderer in 2004, Riall offered an apology but defended his company’s performance, before joining Serco’s Civil Government and Home Affairs divisions

Riall spent eight years at Serco , most recently as chief executive of Serco’s global services division, spanning 12 countries.

Serco provides a variety of services and products relating to defence, home affairs, aviation, and transport.

Since the 16 October 2017, Integrated Dental Holdings Group, who own Mydentist has had Omar Shafi Khan as its Chief Financial Officer and Board member.

Omar joined IDH with a wealth of experience and  strong track record in financial leadership, strategy, business development and treasury.

He was previously Group Chief Financial Officer at Innovia Group, a private equity backed leading advanced polymer solutions company, and prior to this spent 16 years at Royal Dutch Shell.

So can we expect a venture capital purchase of our NHS dentistry soon ?

In just 17 years, Mydentist  developed from just 3 NHS practices in North West England to the largest dental corporate in the world with over 672 Practices across the UK.

Their core business is the provision of primary NHS  dental services, but the majority of dental practices also provide private dentistry services including dental replacements.

Practices can make over £500,000 a year just from the NHS, if they see 60 patients a day.

IDH also own the dental supplies and equipment to their practices.

But will it help our teeth, particularly with our government’s policy for ‘preventative’ dentistry?

See my recent experience of Mydentist

https://finolamoss.wordpress.com/2017/10/10/my-private-corporate-preventative-nhs-dentistry/

http://www.dentistry.co.uk/2017/03/06/another-mydentist-practice-closes/

My Private Corporate ‘My Dentist ‘Preventative’ NHS Dentistry.

My sojourn with Sheffield dentists started back in 1994 when I was recommended Mary Taylor NHS .

She was dedicated and served me and my teeth well until the new NHS contract of 2006 started to pay dentists on the number of ‘units of dental activity’ performed each year.

This, and no doubt the fact that the funding structure made it more profitable to remove rather than save teeth, forced Mary’s early retirement.

So I moved to the NHS practice my husband and daughter used.

But within 3 years it went private, one dentist left to work for a NHS practice and my daughter and husband followed her.

Trusting my own dentist I stayed until last year when his bill for my fillings lead me to consider the savings of NHS dentistry.

My husband and daughters dentist was fully subscribed so I was allotted a new kid on the block .

I arrived at the bright white reception bedecked with large photographs of happy smiling teeth and filed my two forms up.

And was promptly lead into the treatment room by a young dental nurse and greeted by an even younger dentist ,who I regaled with nervous chatter about my front gum being inflamed but treated with corsodyl , my lack of oral hygiene due my horrendous home life, and that my smoking didn’t help my gums.

Had I known the government had just released an agreement on preventative dentistry, l’d have kept my mouth literally and metaphorically shut.

http://www.dentistry.co.uk/2017/02/13/nhs-contract-reform-are-you-ready/

https://www.pcc-cic.org.uk/article/dental-contract-reform

But the dentist made no comment other than ask why I didn’t have an accent and where I was from.

20 minutes passed as every tooth was fastidiously x- rayed and noted by the nurse .

I was impressed by such attention to detail, the first time in over 20 years.

The dentist cleaned around my sensitive gum area, but did not inspect or poke my other teeth which I thought a bit odd.

And ended with the ominous words, ‘I’ll have to see how many I can save’, peering at my x rays .

Having never had a tooth out, I began to wish I’d brushed more often, didn’t smoke and gone to the NHS sooner.

But  wondered how my teeth could have deteriorated so badly in the 8 months since by private dental check up and fillings.

When I found out from the receptionist I would need three more appointments, my concern grew but was partially dismissed by the NHS’s obvious  thoroughness.

The first, on the 13th April but not a Friday arrived, and I was promptly ushered into the surgery room .

And my  chair tipped back as the dentist exclaimed, ‘We’ll be doing an abstraction today, the one at the back’ and threw a mirror on my almost horizontal chest.

I assumed it to be the small top tooth at the end, but had no time to reach the mirror let alone have a look..

So with the shock of my gums being worse than I’d thought, but at least I wouldn’t miss such a tooth, so had got off lightly, I braced my self for the inevitable, already prepared injection, willing the ordeal over.

Within 5 minutes on an aggressive wiggling and tugging, and a request from the dentist,’ to let me see that root’, but no further comment, except for how well I’d done, bunged, with blood poring I was ushered out with a leaflet entitled ‘After your extraction’.

The bung seemed large, but again I put it down to more NHS thoroughness.

Many ibuprofen later on removing it I discovered my upper molar was gone, leaving an inch gap in my mouth.

I pondered how this could result from gum inflammation under my front tooth and why it was needed, as the tooth had never ached.

And read my leaflet telling me I might lose some self esteem, but could avail myself of a replacement bridge or implant  the expense measured in carrot symbols.

Only  then  did I question my experience and the ethics of NHS dentistry.

Resorted to my Google friend, searching ‘unnecessary tooth extractions’ and found this

http://www.dailymail.co.uk/news/article-3726896/Dentists-pull-THOUSANDS-teeth-unnecessarily-year-NHS-rules-pay-simple-extraction-complex-surgery-probe-finds.html

And beat myself up for weeks for being such a trusting idiot, vowing never to go back to the NHS.

I couldn’t face more bureaucratic professional fights which couldn’t be won, so asked my husband to ring and cancel my next two appointments.

When he asked what they were for, the receptionist happily trotted out two more extractions with teeth references to a lower molar and a wisdom tooth.

But no mention of their Complaints Procedure.

Months later, as if to add insult to injury, a letter of concern that I hadn’t been back reminding  me of the importance of dental care  arrived.

And received  this standard survey to complete for Corporate PR and Self Regulation in November 2017.

https://mail.google.com/mail/u/0/?tab=wm#inbox/15f9665dda9854a5

As a lawyer I know this was not informed consent, nor appeared necessary treatment, but the stress of a risk adverse complaints system, fighting corporate lawyers, risking their costs and wasting so much time was not worth facing.

I went back to my trusted non NHS dentist, and over three half hour appointments, with the effective loss of two more healthy teeth, drilled to hang a bridge on, and £ 980, the hole in my mouth was filled, as was a small filling that NHS had not noticed.

My old dentist could not understand why the tooth had been removed nor why two more needed removing.

But did say that he’d had a similar story that week from another patient.

So my trip to the NHS cost me a molar and two healthy teeth, but two other teeth could have gone.

With no toothache, or reason given, and 7 months on still no pain  and gums now healthy.

Lead me to ask, in whose interest is ‘preventative’ dentistry and why is our government pushing it ?

And beware of private NHS dentists

s4 and s5 Mental Capacity Act – No blame, total control ‘care’ only ?

Despite the unworkability/illegality of capacity assessments and the draconian, no rights nature of the Mental Capacity Act.

And the secrecy of all process. and lack of independent representation. by appointed Official Solicitor, of the ‘incapacitated’ in the Court of Protection, the executive appears intent with its latest Law Commission Report on Deprivation of Liberty Safeguards, renamed Liberty Protection Safeguards, to allow LA/NHS executive and not COP to enforce the present MCA practice, to aid ever more efficient private care profit and speedier pathways.

And protect Care for profit companies from legal claims, to avoid expensive Insurance claims

http://www.communitycare.co.uk/2017/03/13/law-commission-reveals-deprivation-liberty-safeguards-replacement/

Incapacity of a person is the gateway to MCA power And its decision, and under new Liberty Safeguards is left to The executive LA/NHS commissioners of the care home services they also oversee

A huge conflict of interests, and worse as capacity has illegally been extended by courts to include ‘fluctuating capacity‘ not provided by the MCA

tHIS CAN BE used to allow anyone, assessed capable to be assessed incapable on a daily basis

 under Act anyone can assess them and Liberty Safeguards preclude any check

on system via application to court.

Why ? – LIBERTY SAFEGUARD and FLUCTUATING CAPACITY CHANGE- ONE BY LEGISLATION OF MAY OTHER BY COURTS ?? 

It  appears that without ‘incapacity’, care providers are reluctant to provide care, as they wish to avail themselves of the protection from liability the Mental Capacity Act s5 affords them.

And control the service provided by making all decisions in a person’s best interests as allowed in s4.

s 5  states;

Acts in connection with care or treatment
(1)If a person (“D”) does an act in connection with the care or treatment of another person (“P”), the act is one to which this section applies if—

(a)before doing the act, D takes reasonable steps to establish whether P lacks capacity in relation to the matter in question, and

(b)when doing the act, D reasonably believes—

(i)that P lacks capacity in relation to the matter, and

(ii)that it will be in P’s best interests for the act to be done.

(2)D does not incur any liability in relation to the act that he would not have incurred if P—
(a)had had capacity to consent in relation to the matter, and
(b)had consented to D’s doing the act.

And s 4 states;

Best interests

(1)In determining for the purposes of this Act what is in a person’s best interests, the person making the determination must not make it merely on the basis of—
(a)the person’s age or appearance, or

(b)a condition of his, or an aspect of his behaviour, which might lead others to make unjustified assumptions about what might be in his best interests.

(4)He must, so far as reasonably practicable, permit and encourage the person to participate, or to improve his ability to participate, as fully as possible in any act done for him and any decision affecting him.

(6)He must consider, so far as is reasonably ascertainable—

(a)the person’s past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity),

(b)the beliefs and values that would be likely to influence his decision if he had capacity, and
(c)the other factors that he would be likely to consider if he were able to do so.

Barrister Alex Ruck Keene author of LAG Court of Protection Handbook, authority and practitioner says,

‘ many professionals behave as though section 5 provides an authority to act.

Worse still, in doing this the professional might be motivated by a desired outcome from the start, followed by the question: ‘does this person have capacity?

In effect, some professionals want the person to not have mental capacity, in order to authorise their decision making, conveniently forgetting about principles 4 and 5 of the MCA, and section 5.

The MCA then is frequently skewed in practice, not to enable the person, but to provide a dubious mechanism for going against the person’s will.’

Exactly the opposite to the Parliamentary justification  for the MCA, which was to safeguard people who had capacity from  others making  their decisions, and to maximise a person’s capacity, and if this proved impossible to give effect to the ‘incapacitated”s wishes and involve them in the decision making.

http://www.communitycare.co.uk/2017/09/27/mental-capacity-act-10-years-still-misapplied-used-people/

So  professionals employed by the care providers will not be liable for any act done to the reasonably suspected incapable, if they reasonably believe it is in  that person’s best interests.

That is a lot of ‘reasonable beliefs’ and protects a lot of people and corporations in fact everyone.

In  no  other service, do we have such whole scale exemption.

And, as these actions are done to  our most voiceless, in secret, with no independent voice, or possible whistle blower for profit, scrutiny and liability should be the highest possible not effectively non existent. .

In addition, it appears service providers are  assuming ‘incapacity’ to enable all care decisions to be made by them,  even in respect to decisions a person is capable of making, despite the s1 overriding provision stating capacity must be presumed and this presumption rebutted by evidence on the balance of probabilities.

‘Incapacity’ can in any event,  be bureaucratically  tick boxed, by a non engaged expert assessment.

But even this is often not happening, as providers are relying on s5 that they reasonably believe a person is incapable and then making all their decisions under s4, purportedly in their best interests.

s4’s requirements that ‘so far as is reasonably ascertainable the person’s past and present wishes and feelings’ and  the need to involve them in the decision making process is being ignored.

As who will argue and check they have  been complied with ?

And what in any event would be the sanction ?

If a Company’s prerequisite for provision of services is the avoidance of any liability. and control of  all  the service users’ decisions, what is that saying about the service ?

s4 and s5 are  very dangerous provisions, particularly in the for profit , commercially aware , secret world of the itinerant care of those without a voice.

Particularly, as the courts will not in anyway interfere into the provisions of services. and under Liberty Safeguards courts are removed.

https://finolamoss.wordpress.com/2017/05/06/best-interests-no-choice-no-outcomes-no-accountability-the-story-of-mn/