Not an awful lot to say about this snippet from the paperwork prepared for the next Governing Body meeting of the Oxfordshire Clinical Commissioning Group (30th Jan).

Other than what other part of the NHS would/could possibly report such statements?

Because STATT closed, commissioners have had to place patients in the Ridgeway Centre in Wycombe. A unit they’ve had ongoing safeguarding concerns about. Seriously? We’re talking about a hugely vulnerable group of patients here. So there were concerns about STATT that were ignored for a few years. The CQC (pah, pesky interfering bunch) identify serious failings, so patients are sent to another Southern Health provision where there are, er, ongoing safeguarding concerns. Am I missing something?

The decision has (now?) been made not to place in the Ridgeway Centre. Blimey. So a service is being commissioned that isn’t fit for purpose. How does that work?

A few questions that bounce around my (lay) head:

• Do the commissioners give a flying fuck about the patients they seem to be consistently consigning to substandard care?
• Have they considered commissioning effective support that might prevent the need for admittance to an assessment unit?
• Has any thought been given to commissioning services that aren’t crap?
• How crap do Southern Health have to be before decisions are made about not commissioning them at all? The evidence is stacking up like billy-o.
• Does Southern Health have some sort of hold over Oxfordshire commissioners, local authority, safeguarding board? Some skelos in the cupboard? There must be an explanation for this consistent audit trail of utter shite.

Answers on a postcard please. You can buy some cracking ones here; http://sarasiobhan.wordpress.com/fundraising/

I’ve spent the week walking round with the internally commissioned external report into LB’s death in my bag. All 115 pages of it. The saddest of saddest times.

Since receiving the report there have been so many moments where I’ve wanted to pull it out, wave it under people’s noses. And say “Look. Look at this. Look at what’s written here…” On the bus, in meetings, with friends, in the street, at work, at home.

A horrible, raging inability to make any sense of the incomprehensible. Combined with a desire to make this incomprehensibility more social. To find a way of making it understandable.

I can’t do this of course. The report is confidential. If you didn’t know. And staff names have been redacted.

The covering letter from the Clinical Director of the Learning Disability Division that came with the report has five paragraphs. Summarised as:

1. Very sorry to hear about LB’s death (six months on). Please accept my condolences.
2. Report enclosed. Appreciate reading this report will be difficult.
3. Names of staff have been redacted. Duty of confidentiality as an employer. Action will be taken as necessary in accordance with appropriate Trust policy.
4. You can discuss report and redaction of names at meeting with Southern Health/investigators on 23.1.14.
5. Report is confidential. Don’t disclose content.

If you’d read the report, you’d probably wonder (as we have) how anyone could write such a covering letter, focusing largely on staff protection and confidentiality. And how the person (legal team) who wrote this letter could continue to chuck out such meaningless statements as “in accordance with appropriate Trust policy”. Was there no “duty to keep patients alive as a healthcare provider”?

Does anyone at Southern Health (the CCG, Oxfordshire local authority/social care, Adult Safeguarding Board and wider…and yes, you are all implicated) have any understanding of what it must be like to leave your child in the care of a specialist NHS hospital and for him to die? I learned on Monday night that research into the views of the ‘Winterbourne View families’ found that they felt they were the only ones who actually cared about their children. There is little evidence that LB was cared for/about in the unit, or that anyone involved has given a toss since. Other than about reputations of course. It’s been process and procedure all the way. Most obviously led by the “Southern Health Manual of Muppet Rules and Policy”.

There’s a lot of interest – media and otherwise – in the content of this ‘confidential report with the names redacted’. We postponed the meeting planned for today with Southern Health and the investigation team because, having read the report, we’d like our solicitor to be present. The meeting is re-scheduled for next Thursday. We can’t imagine this meeting. How to even think about bridging the gulf between our grief, heartbreak and intense pain, and the relentless and dogged efforts of Southern Health to protect their reputation and their staff.

The only point to the meeting we can see is to thrash out the ‘confidential’ status of the report. The investigation has pretty much done what it says on the tin. Uncovering how a largely fit and healthy young man with diagnoses of epilepsy and learning disabilities could drown. In a hospital unit with five patients and a minimum of four staff. A hospital that subsequently closed following a damning CQC inspection. It really ain’t rocket science.

The content of this report should be in the public domain. It’s a matter of public interest. How could it not be? The death of a young man in an assessment and treatment unit two years after the uncovering of the  Winterbourne View abuse demands public scrutiny. The death by indifference campaign can’t continually be swatted away. This is off the scale of unacceptable.

Oh, and while we’re on the subject of unacceptable, another Southern Health learning disability/mental health unit has got enforcement notices from the CQC this week.

What is it going to take?