Antelope House and those old tear waterfalls

I’m stripping this post back to the minimum in an attempt to try to help Jim Mackey, Jeremy Hunt and others understand the gravity of what was/is happening here. Screen grabs, minimal text and links.

Going back to 2011 when the CQC found major concerns at a Sloven run mental health unit, Antelope House, after the death of Michelle Connor.

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In response to this inspection, Percy pitched up to a Hampshire and Southampton Health Overview and Scrutiny Committee Joint Meeting to answer concerns. She typically dismissed the seriousness of the inspection report. The deeply inappropriate ‘we’re no worse’ excuse dragged out five years later when the Mazars review was published:

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And went on to state:

Overall, a shift in the culture of the organisation was needed, and bad practices of the past needed to be left behind.

Bad practices of the past, eh? A set of responses were presented, summarised here (worth reading in full if you can bear to):

  • Internal inspections were currently going on across the whole trust.
  • An audit and completion of all care records was completed within 12 hours of receipt of the CQC draft report.
  • Care plans are now subject to regular, unannounced spot checks.
  • Implementation of immediate training and training scheduled for the near future.
  • The locked door policy was not being fully implemented.
  • Patient experience is important. Sloven want to return the trust and confidence of the public.
  • And a load of other utter bollox. Including training is embedded into practice, “a very senior nurse”has been brought in to provide the clinical leadership needed. Oh, and “The CQC unfortunately did not speak with service users whilst undertaking their inspection.”

Recommendations that have been regularly and repeatedly ringing ever since. With each death and inquest. Oh, and there was the usual evidence of the (Percy) Sloven way. A focus on ‘awards’ and glitziness to distract from the serious issues.

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The meeting ended with blankety blank type shite.

A year later Hannah Groves died…

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And other unfoldings…

ah3In the meantime, Sloven took over the Ridgeway provision in Oxfordshire. Apparently experts in mental health and learning disability provision (despite all these experts having left in the previous year or so). Ms Percy was huffing her puff and stuff online, regardless.

Once the lucrative contract was signed, Sloven withdrew from pretty much any engagement with the Oxon services. The white noise they talked about in the 2011 meeting didn’t translate into action. Just words to appease vaguely interested audiences. The 12 hour urgency type stuff was fakery. The exec never took the very obvious health and safety failings seriously. And haven’t since.

Here we are. Five years on. Deaths. More deaths. And closure.

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However, Southern Health did not believe that the areas requiring improvement were of a serious nature, and were not of the scale seen on recent documentary programmes (e.g. Panorama programme on Castlebeck). [2011]

Our beautiful, beautiful boy. A life (one of many) snuffed out because the Sloven exec (and those who should have been keeping watch from above) simply didn’t.

There was a ruling yesterday by the judge in the horrific Alton Towers crash case. So much resonates here.

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Sloven’s catastrophic failure to assess risk, woefully inadequate safety procedures, failure to communicate and being a shambles explains why LB, and so many others, died. Well, with a hefty dose of arrogance, an obsession with reputation and awards, and stupidity. Typing this through a now familiar waterfall of tears and rage, I don’t understand why we are still fighting. Why people are spending their time digging through this shite, committed to exposing the grubbiness that is publicly available, when so many are paid to do so and don’t.

If anyone from NHS Improvement, NHS England, the Health and Safety Executive or Department of Health (well anyone, really) could explain why we still have no answers or accountability over three years after LB’s death, please do.

This is state sanctioned cruelty.

Candour, what candour and the Camino training

Back in March 2016, the Sloven CEO included this section in her report to the board.

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Today this family received the response to the complaint they made about their treatment by Sloven, and Chris Gordon. There was no ‘contact with the family throughout this very difficult period‘. Instead, Sloven, true to form, continue to make something so agonisingly painful, nightmarish and brutal, even worse.

Just a few lowlights from the report:

  • The complaint was investigated by Capsticks who regularly work with Sloven and other NHS trusts.
  • Complaints about inappropriate comments made by Chris Gordon were dismissed because he said he didn’t make them.
  • The investigators couldn’t read board meeting notes relating to the death of this person because discussions were during the ‘private’ part of the meeting.
  • The delay of two months between Tim Smart receiving this report and the family receiving it today was because it was with Chris Gordon for reviewing. [Even though the complaint was in part about him and despite his current secondment to NHS Improvement.]

Candour and transparency clearly ain’t reached the southern regions yet. And another family left complaining about complaint handling and facing the dire Ombudsman route.

It shouldn’t be like this.

In more cheerful news, the #JusticeforLB cardboard bus has been expertly revamped by LB’s grandad and the My Life My Choice trustees began training for the #CaminoLB today.

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This film of their first walk is blooming brilliant. Keeping it real, funny, passionate and determined.

In search of rights and colour…

We must be getting closer. Surely.

An exemplar in absurdity (and conkers)

A sort of follow on from the (updated) The Talented Mr Martin and viral impact post. Underpinned by continuing incredulity at the removal of the Talentworks website. A ‘leadership’ consultancy with the tagline:

Meet the Talentworks team… hired for our large brains, love of psychology and impeccable dress sense.

Yes. Really. Well, and at least £5m of public money.

In the continued absence of any apparent scrutiny from NHS Improvement and others who should, we’re left digging deeper into shit we should never have to go near.

Talentworks. A virtual collective of people with large brains… etc have not only been getting obscene amounts of dosh from Sloven. They’ve also been working closely with Thames Valley and Wessex Leadership Academy (TVWLA). An academy led until last year by Katrina Percy.

I’m rubbish with figures but the Talentworks ‘blah blah’ work with the Thames Valley bunch (Financial Summaries available here) seems to involve a shedload of dosh for the two years Percy led the academy (around £500k and £370k)  dropping to around £20k after she stepped down. [As an aside, how could Percy dismiss Mike Holder’s safety concerns while championing Chris Martin and his jibber jabber? [howl]]

A brief browse of the Talent Management pages on the Thames Valley Leadership Academy pages:

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A teeth achingly meaningless statement. Just noise. How the Wessex leadership gang allowed this to be published on their website makes me want to weep. I’m left wondering (again) is this about stupidity, incompetence, fear, corruption, bullying, greed, narcissism or simple slumbering?  The focus on this hocus pocus crap, while staff were left without leadership, untrained and unsupported to provide the most basic care to keep LB and so many other patients alive [alive], is haunting.

More bollocks…

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Greater pipeline intelligence? A driver of culture change? It’s like the Stepford Wives meet NHS England.

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I’ve not read this blinky blonky table yet. The headings alone suggest nonsense. I just want to know who authorised payments for this ‘work’? Where were the internal (and external) audit processes? Did no one ask what is this about and is it effective?

Did Talentworks really have a blank cheque to do whatever?

What are the links between Chris Martin, Katrina/Iain Percy and others?

What does it mean that Talentworks have withdrawn their website?

What the actual fuck?

Here’s a photo of conkers we collected in the park earlier. I bloody love this photo. These are conkers. As simple and uncomplicated as.

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A bit of a #CaminoLB update

Planning for the #CaminoLB is crackling along. We will be walking for eight days, with the long walks (around 20 miles a day) in the first five days, dropping to 10 miles maximum for the last three. [25 Oct-3 Nov].

The Life My Choice crew have been busy organising or renewing passports today. It looks like there will be 3 (possibly 4) members with two supporters tipping up for the last three days. Excitement is bubbling apparently. My sis, Tracey, is coming for the second week. Rosie Tozer is joining us for the last three days, walking in memory of her son Danny. John Williams will be doing the chunk in the middle. And a few other people are thinking about pitching up at different points. [None of us are big walkers… well yet.]

This whole, random, walking the #JusticeforLB bus across the Camino de Santiago to an exhibition centre in Aviles, has been oiled by the enthusiasm and simply can do attitude of the Learning Disability England team (with Spanish support). They not only organised the Justice exhibition, on December 2 in Aviles, which kicked off the whole thing but have stepped up to offer lifts, blister mopping, scouting the route for possible hazards, and the lovely Mariana (and her dog and possibly daughter) to ease our non Spanish speaking way. The bus, for those of you worried about us getting it from Santander to Aviles in one piece, has been carefully and lovingly strengthened by LB’s grandad and now has a nifty tarpaulin bag for those rainy days.

We will be a right old ragbag collective walking along the trail, in search of rights and colour. Remembering LB, Danny and the others. Carrying a cardboard bus. And hopefully having a bloody good laugh.

Pics from #CaminoLB training.

No (NHS) improvement (whatsoever)

More tales of dismal practice and bullying at senior Sloven levels are arriving in the shed. [Thank you for speaking up]. Apparently Mark Morgan, the Director for Mental Health and Learning Disability has a bit of a tawdry background. A serial interim manager, he was reported to be earning £28,000 a month back in 2014 at the Medway Foundation Trust. His director blurb on the Sloven page states:

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Bit of a funny statement about ‘pending a recruitment process’ but it turns out that Morgan (allegedly) wasn’t appointed when he was first interviewed for the post. Not very confidence inspiring and means he was an interim for longer than necessary [yes, my fingers can barely type these words, the level of absurdity is so extreme.] Prof Hatton was keeping a careful watch on the data and tweeted:

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Mark Morgan was paid just under £300,000 for 8 months work.

[Fill in your expletives here:_________________________________  I’m out]

This afternoon, a 38 page investigation report into the care of a patient at the Ridgeway Trust. This is the assessment and treatment unit that takes Oxon patients now the STATT unit is shut. The harrowing complaint, made by the patient’s mum (terribly difficult woman I’ve heard, and no doubt has “hostile” written all over her son’s files) has 29 items relating to the unit in 2014-15.

The covering letter is from Julie (scores on the) Dawes who must be wondering what she’s wandered into but I’m assuming Mark Interim Morgan must have signed it off. It’s under his remit. A tiny bit of context here for any new blog readers:

In 2013 the CQC failed an inspection of the STATT unit where LB died. It found a hideous set of failings including a lack of therapeutic environment [howl], poor record keeping, no involvement from people using the ‘service’ and so on. 

Today’s report upheld complaints in 13 different categories of complaint:

access to services, communication, discharge, nursing care, failure to follow procedures, record keeping, attitude, clinical care,funding, medication and prescribing, aids and appliances, code of openness and equipment

Some low lights:

  • A lack of active engagement with the patient’s mum.
  • Failure to record incidents on RiO or Ulysses or inform families
  • No therapeutic engagement with patients
  • Little access to the community because of low staff levels
  • A distant and unhelpful psychiatrist at the team meetings
  • Misreporting of the patient’s activities at the team meeting
  • Inconsistent communication
  • Failure to effectively minute meetings or act on action points
  • Trust and NICE guidelines were not followed around medication use
  • No specific care plans or risk assessments around observation levels* and their purpose.
  • No discharge report received ‘because of an administrative error’.

LB didn’t get to the discharge bit. Otherwise this is pretty much a repeat of the failings identified three years ago. Sloven clearly are clueless and have no learning disability and mental health expertise at senior level. They don’t get it and they don’t give a shit they don’t get it. While Dawes is cognisant of the failings the report identifies how can any patient/member of the public have any confidence that the recommendations (listed below) will actually happen? We have been told over and over and over again that lessons have been learned and improvements made.

I’ve nothing else to say about Jeremy Hunt, NHS Improvement, NHS England, Oxfordshire County Council and the Oxon CCG. It’s all been said repeatedly.

The system is clearly broken.

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* This reminds me of LB’s psychiatrist (currently missing in Ireland) who when asked by Paul Bowen to explain the difference between an observation and a ‘check’ at LB’s inquest, said “Ah, now I’d have to really drill down to do this”. These are people’s lives.

Take. what. you. need.

I was at the Disability Studies Conference at Lancaster a week or so ago where I met a small group of Icelandic academics/self advocates. I was delighted to hook up with them because I love the work of Kristin Bjornsdottir and team. And their campaigning. The George Fox building, where the conference was held, was dotted with these posters…

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Kristin talked about using #JusticeforLB in teaching and subsequently posted this:

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Wow.

Tim Smart resigned unexpectedly (but not surprisingly) today. Both Sloven and NHS Improvement demonstrated what Chris Hatton described as ‘a mulish aversion to honesty’ in their press statements about his resignation.

There is no candour. No honesty. We’re left with a ‘trust’ with an interim CEO, no Board Chair, no Chief Operating Officer, no Communications Director and 8 governor vacancies. Well, and financial irregularities over contracts worth millions. And a dodgy new (or old) made up post for Katrina Percy costing around £250k. And left with a deputy board chair who shared the findings of the Mazars review pre-publication with his teenage son who rubbished the findings on social media.

Wow.

What a complete and utter (chilling) shambles. Meanwhile, Jeremy Hunt repeatedly deflects MPs questions with non answers.

It’s more than apparent that the likes of Jim Mackey and gang, the remaining Sloven senior exec and ex-CEO, really need to take what they need. And act accordingly.

Or do one.

 

The talented Mr Martin and viral impact

I wrote about Talent Works when the scandal of a £300k leadership training contract turned into £5m spoondoonies for Chris Martin and crew first broke. Since then, a few staff members have got in touch to describe their experiences of the training. Not good.

I went on Going Viral while at SHFT. It was compulsory regardless of how busy you were. Insistent on overnight stay in the hotel even though I lived 20 mins away. It was awful. Crap management twaddle. Every session we had to “check in” no thought for people like me who were not comfortable sharing in public. I gained nothing from the whole hideous experience.

Yes I’m embarrassed to admit I’m a Southern Health employee. I don’t have anything to whistle blow, and I’m sure no satisfaction to offer you and similar families but suffice to say there are a lot of us within my immediate colleagues of middle management and below who find no surprises in the latest round of revelations of farcical nonsense. Some of us have been on Going Viral and Gone Viral (there really is no opt out for certain pay bands) and while of course finding some of it interesting and sort of useful (especially meeting clinical staff and even patient advocates and hearing about their challenges) have come away feeling it’s too much corporate nonsense with ice breaking tasks and dreaded role play scenarios.

Apparently it costs £6k per person to attend, is compulsory and you have to stay the night at an expensive hotel. (Sloven spent £135k on accommodation in 2013/4 for staff to attend.)  Here’s the Talent Works partner, Sarah Law, talking about the Going Viral programme two years ago [cringe warning]:

I know Katrina is really keen for everyone to get the chance to get involved in this...” Yeah. Of course. At £6k a pop. Sadly, she wasn’t as keen for staff to be trained in epilepsy care or to remove ligature risks.

What the training involves isn’t clear. But hey ho. A little look at the Talent Works website reveals more work with Sloven who were one of the pilots for this gig:

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Bizarrely, Talent Works evaluated the pilot themselves (yes, really). Eleven staff took part in the pilot but only 7 provided feedback on it. That, in itself, should get alarm bells ringing somewhere but apparently didn’t. And the farce continues with this nonsense:

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So, there was no way of effectively evaluating whether the pilot was effective or not. Asking people to remember how they felt before doing something is simply ludicrous. One person was apparently worse after the intervention, the others the same and yet this is a ‘successful pilot’. This reminds me of the equally nonsensical appreciative inquiry gig Sloven funded recently. The senior management/exec are clearly not very bright if they keep swallowing this shite. And, as always, NHS Improvement are hands firmly clamped over the ears and eyes shut.

Meanwhile, at Sloven’s annual public meeting last week, the finance bod, Paula Anderson, was asked about the Talent Works contract (from 1:01:46):

She clearly states; It’s fair to say when we’ve looked at it we’re not happy with the procurement process and there are issues with that. Stating the bleeding obvious but there’s definitely no governance issues here, are there Mr Smart?

So a little summary of what is deeply wrong:

  • The contract was originally awarded to the CEO’s mate for £300k.
  • Sloven eventually paid Talent Works over £5m.
  • There is no outcome measure to know if there is any benefit of doing the Going Viral training (and given the leadership failings, I think we can probably say there ain’t much benefit at all).
  • Apparently this doesn’t matter and Talent Works are being funded (by who? NHS England?) to extend their biz across other trusts…

It’s truly, truly obscene. And in one last little joining of the dots, one of Talent Works partners is, erm, the charity set up in memory of Percy’s brother, Iain’s, sailing partner. Another grubby, sordid little tale.

Update [23 September 2016]

In addition to the illuminating comments below (including evidence from John Green that the Going Viral course is rubbish), we got sent a copy of a timetable…

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And this analysis:
3 overnight stays, = 6 days lost + 2 days for launch and review + 2 0.5 days for learning sets = 9 days of work lost. On one course, there were three consultants. Assuming they were newly qualified, it would cost around £5.6 of service loss for the 9 days on the course. If at the top of the scale, £7.5k (not to mention the loss of outpatient appointments or the cost of backfill).

 

Talentworks removed their website today. Shortly after their tagline was shared on twitter:

‘Meet the Talentworks team… hired for our large brains, love of psychology and impeccable dress sense’.

Removing your website can only be an admission of guilt…

The Sloven senior exec allowed £5m of public money to go into the pockets of Percy’s mates. For training not fit for purpose. In the meantime, they failed to ensure that staff were trained in the basics and that the environment was safe.

This is sounding increasingly criminal to me.

Down but not out…

Levels of incredulity at the continuing unfoldings down Sloven way – apparently supported and endorsed by NHS Improvement – have reached crisis point. Even our brilliant, informal, campaign media archivist, is flailing…

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Behind this battering is a peculiar situation which seems to be baffling pretty much everyone apart from the Sloven exec (plus Katrina Percy), NHS Improvement and Jeremy Hunt. Even Simon Stevens, CEO of NHS England, has publicly said Sloven have let down patients and families…

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There is sensible and widespread condemnation of the recent sidestepping of the CEO into a new (or old depending on who and when you ask), part time role at the same salary and perks as a CEO (on top of the other, well documented failings). Including this statement from Philippa Russell on behalf of the National Valuing Families Forum.

The story of Smart’s stint as Interim Board Chair which only started in May is that he apparently commissioned two (yes two) so far mysterious reviews which found that the Sloven board are fit to practice. This was announced on June 30 without any engagement with families (other than an ‘accidental’ meeting with My Life My Choice who have since decided to no longer engage with Smart). The annual board meeting held last week demonstrated woeful engagement with families and patients (forced, as always, to sit through interminable presentations/talk with public question time compressed to barely any time at the end). This seems to last as long as Smart’s patience (if you can bear to listen to the audio recording). Appalling senior action still from a trust who have been in the public spotlight relentlessly for failing to engage with patients and families.

Strangely, Smart has agreed to the secondment of two directors (including the Chief Operating Officer).  Chris Gordon to NHS Improvement and Sandra Grant to another trust or commissioning group. And unilaterally (it appears with NHS Improvement dove from above agreement) agreed Percy’s new or old position.

Just a few questions. [No answers expected…]

  • Why would you insist a board is fine and then allow the secondment of (key) execs when the terrain is rocky?
  • Is there now no Chief Operating Officer or Communications Director alongside an interim Board Chair and CEO?
  • Is anyone at the highest levels of the NHS, in this foul and grotesque tale of abuse, deceit and pantomime, going to find it in themselves to stand up and act with integrity?

I suppose, if nothing else, a necessary light is being shone with a bloody big torch not on only Sloven murkiness but also the gaps, limitations, failings, impotence, pointlessness, corruptness and fatcattery that exist within and among senior NHS spaces. I dunno how you sleep at night.

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Walking back from the original gingerbread protest at Jubilee House earlier this summer.

A cheeky bit of media advice to Smart and gang

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We’re weary in the Justice shed. Weary of the continuing horrors, absurdities, scandals, lies, deceit, cover ups, failures in accountability, delay, obstruction, lack of decency, sense and fairness. Broken Trust, shown this week, was pretty horrific and devastating for families involved to watch. In the spirit of productiveness, and to distract from raging, I thought it might be useful to offer Tim Smart and other senior NHS bods a few pointers in engaging with the media. His interview (and Katrina Percy’s) with David Fenton was an exemplar in how not to. Just a few twitter responses:

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Now I certainly ain’t no expert in media appearances. We have no comms team/resources behind us. In fact the only time I was on local radio before this devastating unfolding, was for work. I forgot the third (stereotypical) characteristic of autism through a rabbit in headlights/fear situ. Deeply awkward and embarrassing at the time. Now just budgie feed.

Here’s the transcript of the interview with Smart with thoughts and suggestions added in red. Please feel free to add further reflections/advice in the comment section below. There is clearly plenty to learn.

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1Obviously this interview will have been edited and mucked about with. But the ills and errors were spoken and so available to produce this version. Thoughtfulness, care, honesty, reflection and openness are the very basic ingredients. With knowledge, underpinned by experience, and broader understandings of and engagement with the wider context essential at such a senior level. At a senior level, and on these massive salaries, I’d also expect a clear understanding of media engagement (and the potential pitfalls) and some ease (taught or otherwise) of sitting in front of a camera or microphone.

The third ‘autism characteristic’ I forgot, back in the day, that afternoon at BBC Radio Oxford, was ‘theory of mind’. I was mortified at the time. I resolved to avoid announcing a number of things, in advance of listing them, and to prepare a list of key points in advance. I hope Smart, Percy, and those around and above them, are revisiting the seriously gut wrenchingly awful presentation of Sloven senior culture presented in Broken Trust. And that serious questions are being asked around what has, and continues to happen, at higher levels. 

Unpacking the Smart move

Blimey. Does anyone know what’s going on? Record breaking levels of absurdity… I recommend watching Broken Trust which was shown last night on BBC South. Just contrast the contributions of the families, public, rebel governors with the performances by Percy and Smart. [A limitation to the programme was it didn’t shine the spotlight on the other, good for nothing, crap execs and non execs (Gordon, Grant, Stevens, Spires and Bezzaman and co) but it was only 26 minutes long…]

To summarise where (I think) we’re at (for the next 12 hours or so…) and not spelling out the crapitude both Smart and Percy demonstrate in this film (and their actions).

  • KP is no longer Sloven CEO.
  • She moved into a “new role” at the same salary and without following HR processes and procedures.
  • She moved because of media attention.
  • She then allowed a film crew to follow her for a day and coax utterly reprehensible reflections out of her.
  • She is “uniquely qualified” for this, so far, unnamed new role.
  • We don’t know what those unique qualifications are, but I think most of the UK population following this sordid little tale would agree, they ain’t jumping off the page and really, we should know if there are any.
  • The new role is now not a new role.
  • It’s part of her old job (CEO).
  • Apparently the part that took 1 day every two weeks.
  • She will be doing this new tiny part of her old job for 12 months on a CEO salary.
  • Smart’s definition of corruption doesn’t include lies, cover ups or deception.
  • Smart’s credentials for trouble shooting a failing trust are looking pretty flakey.
  • He has managed (with the apparent blessing of NHS Improvement) to piss on the lives of families shattered by sustained failings over the last five years.
  • It hurts him to meet bereaved families.
  • A patient left Sloven’s mental health services alive [positive end piece].

We are in Laurel and Hardy territory.

Stay classy y’all.

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Postscript: In case anyone missed it, My Life My Choice have washed their hands of the Sloven leadership (and feature in the programme). Telling it like it is. You delivered nothing.