I thought it was about time we reduced time frames. The press release by the ‘Post’ cough cough Winterbourne concordat was two years on. Too long. I also feel a bit of alarm about any body/group with such a grand title. A hasty response/performance to the horrific abuse uncovered by the (in my eyes) remarkable journalists. Without tools, thought or a clear plan about what to actually do. A concordat without backbone or bite. More concustard. And the press release said nothing.

What’s happened since Panorama aired back in May 2011? Well the unit shut. Good but doesn’t resolve the issue of the other 3000 or so learning disabled people in other units. Some people went to prison. Good. But I don’t think any managers/healthcare professionals were punished (or even lost their jobs – brain melt). And really, if this unit had been effectively managed/commissioned, abuse wouldn’t have happened. The patients are now scattered, many in other unsatisfactory, or unknown, settings.

There was some solid contextual research by the Improving Health and Lives Learning Disabilities Observatory. And meetings. A lot of talk, huff and puff. Mencap, clearly frustrated at the inaction, are focusing their efforts on the 40 or so patients who were in Winterbourne View. Understandable focus in a way. But possibly a bit simplistic. Winterbourne wasn’t some random, outlying occurrence. The CQC report of the Short Term Assessment and Treatment Unit, Slade House, published a week ago (yep, lets keep this baby moving) identified potential abuse happening in full view of the inspection team. Institutional abuse and neglect.

And the screaming question that will haunt me forever (one of several); if it happened in front of the inspectors what was happening when they weren’t around?

There are so many layers of wrongness here that it’s hard to keep tabs on them all. Details like the missing battery in the defibrillator. How you can remove a battery from such a piece of equipment and not replace it is beyond comprehension. How you can then tick a form to say it’s been checked is the point at which I’m almost ready to chuck the towel in. Not a single interaction between the nurse and person they were looking after in a 35 minute observation?? And this wasn’t an understaffed ward. This was a cushy number with 4/5 patients and a minimum of 4 staff on duty 24 hours a day. Backed up by an army of psychiatrists, doctors, OTs, essential lifestyle planners and so on. What were they all doing? The unit was overstaffed, cost around £3,500 per week per patient and provided care that was at pond feeder level.

But no jobs will be lost said the awkwardly nervous Southern Health representative on the news. What sort of gig do the NHS/social care run? A catalogue of beyond damning, and ultimately catastrophic, failure. With no apparent reflection on what it is like to experience living in such hell holes.

I have so many questions but I’ll stick to a few here. Just to keep you updated, the CEO of Southern Health hasn’t responded to my letter yet. Bit tardy. But I’m not sure that these questions relate only to Southern Health.

• Who is going to do something about how such appalling provision could exist? And I don’t mean what are we going to learn from this failure. We went through the whole hand wringing, serious case review, Concordat development and lessons learned bullshit with Winterbourne View.
• Who is going to hold the various agencies that were complicit in what was happening at STATT to account? Southern Health, Oxfordshire Clinical Commissioning Group, Oxfordshire County Council. All aware. All breezing over obvious failures because clearly these people aren’t important. Not human enough to bother about. (Note to all of the above; filing learning disabled people away as other is clearly a recipe for disaster.)
• And when are we going to say enough? LB died. He died. I know he’s our son, our dude. But with a different throw of the dice it could have been your child. Your brother, grandchild, nephew, niece. Your friend, your pupil, your dude. When are we going to collectively say “Enough. Things must change”? With backbone and bite.