Imagine that pretty much straight after LB died, Southern Health deftly kick away the stale, overused ‘learning disability=natural causes’ cloak lying, as ever, in the lobby of Southern Health Towers. With a yellowing ‘use me’ sign attached. Commonly found in most Trusts/social care HQs.
They instead turn turn a critical lens on how a fit and healthy 18 year old young man could die in their care. They contact the family and say how desperately sorry they are that this has happened. They’ll do everything they possibly can to find out how it happened and make sure it will never happen again. They will work with the family and keep them informed of all developments.
A key person is designated to make sure this happens (the Southern Caped Crusader in this instance). S/he knocks up a newly designated work station (with clear plastic ER type ‘white’ boards and brightly coloured whiteboard pens) and knuckles down. With resources. The police are investigating but that doesn’t stop the planning and organising of the investigation team. The caped one pulls together a robust investigation team and provides them with the records to start doing meticulous preparatory work. An external advisory set of experts, including an epilepsy expert, is created.
As soon as the police pass the baton, the investigation team are off. Leaving no stone unturned in their quest to establish how such a catastrophic incident could have happened. At the centre of their investigation, always, is LB. The dude. Not a hollow set of initials. Disconnected from anything other than NHS speak. The team regularly update the family with their progress (checking, of course, in advance how regularly they want to be updated). The investigation is timetabled to take 60 days.
There are some confounders along the way. The CQC do an unannounced investigation and the unit fails on everything. Really? That adds fuel to the fire for our team. The caped one contacts the family to say how deeply sorry s/he is that this will clearly compound to the distress they must be experiencing. Adding further reassurances that the Trust are committed to making sure that this could never happen again. S/he underlines this by outlining radical and innovative steps the Trust are already taking to make sure their learning disability provision is as good as it could be. Steps that draw in learning disabled people and family members as core movers in the creation of good care.
Monitor step in. And start to examine whether Southern Health should hold a licence. Whoah. Cripesy. Serious stuff. But no. Bring it on. Southern Health are determined to make sure any failings on their watch are identified, made accountable, transparent and act on changes identified.
Sixty days later the report is finished (bang on time). It doesn’t look good for Southern Health (obviously). But that’s cool. They’re willing to hold their hands up, admit appalling practice, operate the shiny, new duty of candour and spell out how they are going to change. Slamming and locking the door on the traditional/historic ‘sweep it under the carpet brigade’ is a bit niggling/challenging but no, the Caped Crusader is firm. It’s time to face the public. And the family.
“We got it so completely wrong. We are so sorry. LB should never have died.”