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.
Who should have been observing LB in the bathroom to make sure he was safe? Why weren’t they doing that? You are right Sara, it could so easily be ANY of us asking all the questions about our own son/daughter/niece/nephew/parent/cousin….. my heart bleeds for you xxxx
It could so very very easily have been me, us. Still could be, and it is terrifying.
My daughter suffered lethal, uncontrolled epilepsy for a number of years. Part of me does believe that I kept her alive through sheer will power, only too aware that my level of vigilance would not be provided by anyone else. She can also, when upset, have meltdowns that are difficult to handle (or understand) With people who love and understand her, these are manageable and a lot less frequent. Our children need skilful, extra care – but how to ensure they get it?
What I don’t understand is how the 2011 CQC report correlates with the recent one. What is going on? Is it possible that there was such a drastic deterioration? Having some experience of official inspections, assurances that everything is for the best in the best of all possible worlds fail to convince. Why, on earth, are you being subjected to the things that are happening to you? How can anything change when their is such a defensive refusal to look at the origins of such disasters, and complacent assurances about those lessons being learned? The care that is needed seems impossible to achieve – just how bad is the care that is available? Transparency and honest admissions of failure might be preferable and a start of some change.
Because it could have been any of us, I hope it is some very slight consolation to know that others care.
Hi Liz, yes I can believe that it was your vigilance that has kept your daughter safe.
There was a change in NHS Trust between 2011 and now which may account for some of the deterioration. I got a letter from our local MP today (who is following this up. He said he’d written to the county council when the change happened to say he was worried about how this would affect care. Still hard to believe such a deterioration though. There was something so badly wrong when the CQC went in to inspect in September it is almost impossible to understand or make sense of.
I also agree with you about the defensiveness and how that’s both experienced and is ultimately unproductive in terms of changing things. They’ve made things so much worse, and that is beyond unforgivable given what happened. I suppose we’re in a slightly different world now where minutes are available online, allowing us to see the careless dismissal of LB’s death and the instant trotting out the old ‘procedures were followed’ line. If procedures were followed, how could an otherwise fit and healthy 18 year old die as he did?
And it is some consolation to know people care, so thank you.
Reblogged this on altwoodmoon's Blog and commented:
still no words…
I’m quite shocked that none of the people responsible for the shambles at Slade House are facing the sack and that the Trust said they would be “supporting their staff”. If a construction site had such a miserable health and safety record and someone died, someone would get the sack and would quite possibly face prison time. Yet when it’s people with disabilities who have not chosen to be there and are vulnerable and this is all known to the staff, they are “supported”.
People with more power in my observation tend to have less responsibility — that means, if you screw up and someone gets badly hurt or killed, it is you who faces the possibility of punishment. If a truck driver fails to secure a loose part on his truck and it swings and hits someone, he goes to jail. If a gas fitter makes a mistake and a customer is gassed, he goes to jail (both these things have happened). Yet, if social workers split up a family on the basis of mistaken assumptions or prejudice, they don’t even get demoted. If a group of NHS doctors and nurses deny water to a patient who desperately needs it and he dies, it’s just “the culture” that’s to blame, not them. If an NHS nurse runs such a shoddy outfit as this, their bosses support them. There’s no sign of their bosses’ heads rolling, either. So-called caring professionals will usually support each other, even against their own family. I’ve seen this myself.
It is not Slade Site but STATT. There are 2 other units there.
Under his care plan (which had come to light was in fact out of date) that obs were to be done every 15 minutes, which is totally incorrect for a service user with epilepsy. I agree people should be made accountable for this tragedy. We all needed some sort of support after the death because some of us actually did our best for him. The unit will be shut down after Christmas and staff deployed to other units.