First, if you can bear to read this section from our local Clinical Commissioning Group’s Quality and Performance Report, dated 25.7.13 (available online/names removed – although not sure why I’ve removed them). It refers to the unit LB was in.
In the non-acute sector
i. Trust A
There are concerns about the safety culture and quality of patient care in specialist inpatient ‘Assessment and Treatment’ services for people with a learning disability and mental health issues.
Since 2011 there have been concerns about the way in which serious incidents requiring investigation (SIRIs) have been investigated by the [Old] Trust. The concerns were around the organisational response to incidents and specifically that they appeared to suggest the lack of a robust safety culture within the organisation.
It was hoped that when the [Old] Trust was acquired by Trust A that concerns would be addressed. However [X]CCG and [X]CC have not been sufficiently assured that the required change has taken place. Currently [X] county are not placing patients in one Trust A Assessment and Treatment Service and there are conditions in place around placing patients in a second service of this type.
Many of the SIRIs [Serious incident reviews] involve the use of physical restraint. This is a high risk area which requires a clear organisational approach, strong leadership and close supervision. At CCG’s request [X]CC has issued a performance notice to Trust A around the management of physical restraint. The notice requires that the trust develops and implements a code of practice for restriction and restraint.
XCCG and XCC have been working with Trust A and continue to do so. XCCG continues to monitor Trust X SIRIs in services used by X county patients closely.
A few thoughts. I’ll keep them brief.
- How could significant concerns around a specialist service for vulnerable people drag on since 2011?
- Why are these concerns not common knowledge? We would never have let LB be admitted to the unit if they were.
- He was restrained at length in the unit even though this unnecessary practice was known to be an issue within this service, by the CCG/CC. An 18 year old pup. Heartbreaking.
- By the time this meeting was held in July, the CCG must have known about LB’s death and yet they drivel on about ‘continuing to work with the Trust’ and monitor services. Boredom, disinterest and non-action palpable.
- The CCG raise concerns about the ability of the Trust to respond effectively to ‘incidences’ and yet the Trust are still able to ‘mark their own homework’ through conducting the internal review into LBs death.
How could any of this happen? Be happening?
So. For the record.
- We have no confidence that the Trust will carry out an effective internal review.
- And we have no confidence in the County Council or CCG to do anything to improve the lot of learning disabled people.
Our son lost his life through what are obviously longstanding and ongoing, shabby, careless and stagnant practices within a state-run organisation. In “specialist” services that are supposed to provide ‘care’ to one of the most vulnerable (and my brain screams to have to keep stating this, because I despise the term so much) groups in our society.
Once again. Is anyone in health or social care with any power going to do anything about this?
Oh, and if anyone knows Ann Clwyd, MP, could you bounce this to her?
mydaftlife 
lost for words
Is the internal review the only official response you will get into LB’s death? Sorry to ask what seem such a stupid question after following you for a while, but am not sure what the whole thing looks like. Will there be an inquest when the internal review is finished? And are the police going to be involved further only if the internal review suggests it is appropriate?
I’m sorry if all these questions seem intrusive. It just seems so wrong, I just can’t get my head round it.
Not intrusive at all.. We had no idea of the process before being chucked into it. What happens is a police investigation first, followed by an internal or external investigation (looks like we’re stuck with the former rather than the latter), then the reports go to the Coroner to inform his or her decisions around the inquest that will be held some time next year (we hope). The issue we have at the moment is that the Trust are allowed to conduct an internal review which is nonsense really. LB was a very vulnerable (goes without saying) young man and really this warrants an external investigation to be as robust, objective and thorough as possible. Given our experience with the Trust so far, and with this latest bombshell that failings were already known about with the service, an internal investigation seems so inappropriate.
It does. It seems so inappropriate that you have to wonder if the person who made that decision had all the facts in front of them. And how it could be overturned.
where’s the trial ? wheres the justice? where are the police?And who’s letting the trust make up these stupid fucking rules internal review…..it needs to heard in a court room LB deserves this much.
Is it possible to ask for a serious case review? or appeal against and internal review? I’m sure if it was you would already have thought of it. But thought it was worth asking. Sending you my very best wishes and strength to manage all of this.
Thanks Noelle. We’ve requested a serious case review through our solicitor. No answer yet. Appreciate your thoughts/strength.
Has anybody discussed with you, Sara, that you, LB’s family, are entitled to submit your own report/s to the coroner? You can put in your own version of the relevant timelines, significant incidents, anything discovered subsequently to have a bearing – like this report ^. You can express your opinion that the cause of LB’s death was due to gross negligence on the part of the Unit and the supposedly supervising Trust. You can show how the deprivation of liberty, the foot-dragging of care/social services that conspired to keep LB locked up and you locked out, the refusal to engage with LB’s best interests and the best information available on him, all contributed to the fatal outcome. You can put in sections for *anything* that you think the court should take into account when determining how and why LB died.
There will be deadlines for submitting this; the Coroner’s Officer will be able to inform you.
Coroners can be lawyers or medics; some are dual-qualified. If you know who will sit on LB’s inquest, you may want to do a little research on his/her background so that you can present your report accordingly. Your academic experience will surely stand you in good stead for this, but consider using as much help as you need and can get hold of to see you through the process… putting it into a formal report is likely to be even more of an ordeal in practice than it may appear in contemplation.
Thanks for this, Kay. You’ve summed it up beautifully (from the bare bones written here) which underlines how crap the Trusts behaviour is. We have got a fab solicitor, thank goodness, so we should be on track through the process. x
shocking
Once again i am utterly bereft of words – so angry doesnt even come close. Im going to do what I can in my limited power though, im sending your blog link to the oxfordshire healthwatch who I hope will use their statutory powers to make a very big noise. Healthwatch exisits to articulate the views of people. LB’s and your voice needs to shout very very loudly it isnt good enough. Its a small thing I know x
Thank you Beth… all these ‘small’ things add up so I appreciate this. xxx
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