I’ve been weaving my way around NHS/social care spaces online where minutes of meetings are tucked away. Safe from view if you don’t know to look for them*. I’ve read the Trust Board Meeting minutes and more Clinical Commissioning Group papers (which I was alerted to a while back because of poor service concerns in the unit since 2011). I drew a blank at uncovering the Adult Safeguarding Board minutes but given their website is fairly archaic, they may still be typing them in duplicate.
It was a fairly informative (depressing) activity.
Back in July, the Trust Board made reference to LB’s death;
A Serious Incident Requiring Investigation (SIRI) occurred in one of the Trust’s Learning Disability in-patient facilities, leading to the unexpected death of a service user. The postmortem indicates the user died of natural causes and early investigations indicate all appropriate systems and processes were in place and being followed leading up to the incident, however a full investigation is underway, in line with the Trust’s agreed policy.
I don’t think they should have drawn these conclusions from what was known at that time really. In a public document. Why make such a jump?
I also don’t think, given these are publicly available documents, they should be so fucking clinical. (On a pedantic note, a SIRI didn’t lead to LB’s death, but hey ho). He was a young man, a young person, even a patient. Someone with his whole life ahead of him. Not a ‘user who died’… What sort of people sit in these meetings? How would they feel if it was their son, their brother, dad, grandad being dismissed so carelessly? If these documents are publicly available, you really (surely?) have to think about how you discuss/minute things sensitively?
These documents (Trust, CCG, and I’m sure social care if I could find em) are pretty remarkable/astonishing. Consistently diluting, denying, defending, protecting, spinning, reducing and embellishing. With so much jargon I wonder if they use an app to generate large sections on a rotational basis.
But back to the unfolding ‘story in minutes’. By October, the Trust was clearly forced to shift a bit on the whole ‘natural causes’/’everything was done properly’ position. Although spin and dilution continued. Things had got a bit more serious for them. LB became a ‘patient’ and there was a fairly pat, ‘everything is as it should be, following appropriate systems’ type statement about the internal investigation. This included the statement; the patient’s mother is engaged in the process and is identifying an advocacy group for us to work with.
For the record (to redress partial story syndrome), we were on the verge of withdrawing our engagement with the process seconds before the investigation was handed over to an external investigator. We’d been messed around by the Trust to a point that we could no longer realistically engage with them. The nonsense, contradictory, bizarre actions around our advocate (Fran) were unbearable and the attitude of the Trust towards us appalling.
Fran was put in a completely impossible and unworkable position. She received phone messages ordering her not to share the confidentiality agreement she’d been given with anyone (not even a solicitor). The Trust’s solicitor wrote to express concern about my twitter activity. They’d already flagged up they were aware of (monitoring) my social media activity (twitter, facebook and this blog) but I’d gone on to ‘particularly disappoint’ them around this time.
The pressure and stress of dealing with these hostile, defensive and unnecessary actions was immense.
Because we weren’t sitting quietly and letting things be dictated by the Trust.
Eh, this can’t be right. What about (post) Winterbourne? Francis? Keogh? Berwick? It’s all about duty of candour now, transparency and patient centredness (or bereaved family-centredness) silly…
Who? What? Post what? Bereaved family? Where?
We feel deeply angered by the way in which the (completely avoidable) death of our beautiful dude has been handled, both in interactions with the Trust and in these online (semi-hidden) records.
The worst happening imaginable has been made so, so much worse.
*Google ‘the Trust name/local authority or Clinical Commissioning Group’ and ‘minutes’,’papers’ and/or ‘meetings’
There is no compromise when it comes to corruption. You have to fight it…….. my support to you and your family – SOLIDARITY…..xx
Oh Sara! ‘Appropriate systems and processes ….. ‘ … and the nerve to actually put that in writing! They mean they usually allowed young people with epilepsy to take baths ? Unbelievable that they actually have baths in a unit catering for people with learning disabilities and or epilepsy. It’s time for Trusts / Managers to honestly admit that their ‘systems and processes’ are sadly lacking – in fact totally inadequate. What is wrong with honesty in this world? Stay strong, xx
It is unbelievable – all of it. x
Are you allowed to say what you did to “particularly disappoint” them? These people are prone to dramatic disappointment. I disappointed the social worker and the unit for complaining that all Steven’s clothes were being ripped
They were disappointed because they thought that a tweet in which I’d written ‘murdering bastards’ referred to Trust staff.
The defensive depersonalising language used is so significant. This is how organisations and the people working within them depersonalise people. The fact that they are someone’s brother, son, loved friend made invisible allowing them to be treated as less than human. I am so very very sorry. It is time for us all to challenge and change this terrible and dangerous culture.
I completely agree, Noelle.
Why cant they be honest and just put their hands up and say, we got it so wrong? The system sucks and we need to change it. xxx
I would just like to say how sorry I am for your loss. I only found out today what happened. I worked with your gorgeous son for a school year (September 2007 – July 2008) and he will always have a place in my heart.
Sob. Thank you Sarah.
thoughts are with you for tomorrow
I’m just sorry you only “particularly disappointed” them – I wish there was some way you could have put the fear of god into them, frankly. If only you had real power to shake them out of their fatal complacency. Thoughts are with you.
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