Bit of a lengthy summary post capturing our interaction with Sloven Health up to the publication of the independent report into LB’s death, but maybe useful for new readers. I’ve included a set of tips in the text to try and inject a bit of positivity into what has been experienced as a form of torture for us. These tips are largely summarised in this post where I daydream about how it could have been (at pretty much no cost).
So, our beautiful dude died on July 4.
Sloven apparently sent in an investigation team immediately. No idea what they did given that the CQC found a complete fail when inspecting the unit eight weeks later. There was some communication between my mum and Sloven in the next few days. She was told the investigation would take around 4 weeks and the Divisional Director was willing to meet with us.
July 11 Acting CEO wrote us a condolence letter stating “I also wanted to offer any support you may feel you need during this time”. [Tip 1: Our child had just died. Completely unexpectedly. We had also just found out we would need legal representation to avoid a potential cover up. And that representation would cost us £1000s. This offer,”of any support” framed so carelessly, was received as a bit of a kick in the teeth. If you’re going to make such a statement maybe give it some legs; indicate what sort of support you are thinking of, based on an understanding of what has helped other families in the past.]
The Slovens sat back at this point and did fuck all. The internal investigation (this time with a 60 day time limit) started on Oct 1 after the police finished their investigation. Nothing was in place to do this investigation. [Tip 2: Sort the investigation panel straightaway. It doesn’t interfere with the police work. And start preparatory work, like reading notes. It makes the whole process quicker and less distressing for the family.]
A Serious Incident Panel was booked for Dec 6.*
Oct 10: We’re told we can have an advocate on the panel. Sloven present this as a gift to us but it turns out (personal communication) the CCG insisted we should have one.
Oct 17: It was confirmed our advocate (Fran) can attend all meetings and staff interviews.
Oct 21: Fran is sacked. Sloven are to choose a replacement advocate from an advocacy organisation of our choice. S/he will no longer be able to sit on the staff interviews, and will have to sign a confidentiality agreement.
Oct 25: Fran is reinstated. And she can sit in on the staff interviews. Sloven continue to try and find an independent chair for the investigator. [Day 24/60] [Tip 3: Don’t mess about. Chopping and changing like this is not only hugely stressful but also whacks up the legal costs.]
Oct 30: Fran met with the investigation panel (still no independent chair). Only 2 of the 4 members turned up. She was asked to sign a lifelong confidentiality agreement and took it away to read. Later that evening and the following morning she received several calls on her mobile. A bullying message from a panel member was left [and remains] on her mobile saying she was not under any circumstances to share the confidentiality agreement with anyone (including us or a solicitor). Could she confirm this asap? Tip 4: Sorry. No tip. No words.
Into November and still no independent chair.
Nov 6: The Slovens ask
(agree to) Verita taking on the investigation independently.
Nov 15: Verita start the investigation. [Day 36/60]
A welcome period of peace for us at this point in some ways. The investigation is clearly in capable hands. Verita engage with us sensitively, keep us informed and get on with the job with the minimum fuss. Tip 5: Hugely important to be kept informed of what is happening and why.
A new year. Sigh.
The Sloves want a meeting with us and Verita on Jan 23 to discuss the draft report.
Jan 18: We receive the draft report and, given the content, want our solicitor present at the meeting. The meeting is postponed to Jan 30 so she can attend.
Jan 23: Brain melt email received from the Sloves asking who we want present at the meeting because it’s “our meeting” and they want to offer us an apology in light of the findings of the report. [Tip 6: Try to put yourself in our shoes and imagine what we are going through. Announcing an apology will be forthcoming because a report ‘proves’ that you are to blame for our dude’s death is pretty inappropriate.]
Jan 24: Our solicitor lets the Sloves know we only want to discuss the content of the report at the meeting and not do the whole ‘apology’ business.
Jan 27: The Sloves decide Verita are not to attend the meeting. Instead, we’re to share our comments about the report with the Sloves who will pass em on to Verita. We are to put our concerns in writing in advance. [Tip 3 again, Tip 7: Pretty onerous suggestion really. Four days before the meeting.]
Jan 28: Verita are allowed to attend the meeting again. [Tip 3 again.]
We arrange to meet Verita on our own to discuss our concerns about the report. At this point, we don’t want to meet anyone from the Sloven family. The final version of the report is due on Feb 4.
Feb 6: We find out from Verita that the final version is delayed because Sloven have decided that staff can comment on the draft after all. Final version is now due Feb 21. [Tip 3 and 5 again.]
In the meantime we’re confused because the report has some findings that are not apparent from the documentation we received from the Slovens back in July. We also seem to have a different set of minutes to those quoted in the report. Verita follow this up and it turns out that there is a load of previously undisclosed documentation. This is given to Verita on Feb 19 two days before the final report due. [Tip 4 again.]
We receive the final report on Feb 21 [day 144 of the 60 days allowed to complete the report].
232 days since LB died.
*We have no idea if a Serious Incident Panel was ever held.
Ahh geesh. Been aware of LB, and the awfulness of what you have been through for a month or two now. Your experience is truly heartbreaking. I will continue to spread the word about this awful failure of care for LB, and for you, his loving family. So so sorry that you have suffered such an awful loss.
Sara this is simply terrifying
When (it’d better not be ‘if’) the ‘duty of candour’ comes in, some folk are in for one hell of a shock. Good.
Tips for surviving this:
1. People will say or do anything to get you to give up & go away. Expect this and it stops hurting so much.
2. Institutions including charities are full of people who are just doing whatever gets them through the day without too much hassle. Accept this and it comes as a wonderful bonus when somebody actually helps and cares.
3. Institutions will always play on your weak points ie “The parents are angry and grieving” . Always turn this to your advantage by admitting the truth of what is true ” Yes we are angry and grieving but this is irrelevant to the central issue, which is that a young man died due to negligence.” Focus on the key point always.
4. Keep things impersonal. Not YOUR negligence, just negligence.
The moment you make it personal you encourage them, because you show you are upset.
4. You need powerful allies and to network with successful campaigners. Avoid oddballs who are just looking for a bandwagon or to feel/share your pain. They drag you down personally with their own hang-ups.
5. Lots of sympathizers help, but you need money and a voice. Identify and target the influential people who might help. Make it easy for your sympathizers use their contacts, lobby their MPs etc. For example – model letter on website to send.
6. You are very fragile because newly bereaved. The institutions you are up against know this and are banking on it. Most people get ill and/or sink into depression/despair. This makes them go away & stop being a nuisance.
You must look after yourself and your family. You must eat rest and sleep heathily.
7. You are in this for the long haul. Any battle for justice is a war of attrition. Be practical. Yourself and your family will only survive this if you have ordinary happy times ahead as well as campaigning.
Thank you Jean What wise words and a lesson I have tried to learn. My beautiful son also died in hospital “for his own safety” and the Strategic Health Authority (SHA) (who reemployed the errant CEO) also “granted me an investigation” six YEARS after my sons death. This of course was whitewashed and failed to deal with the fundamental flaws which impacted on our lives! Such as why did trust withhold key documents from the Inquest hearing? Why was the Deputy Coronor put in charge of the case, just 3 weeks before it took place?Who said its acceptable to send a patients possessions back in a bin liner marked “NHS Household Waste”?Why did the SHA Investigation Manager (a management consultant) lie to PHSO case worker and say I was happy with and had agreed the Terms of Reference (ToR)…..nothing was further from truth but I was grieving and they took advantage! Lesson learned: The ToR is often where the devil hides the detail and MUST be formally agreed by all.
The PHSO refused to investigate even though a departing case worker felt there was an “unremedied injustice” which he placed on my complaint file….its now disappeared but I have written evidence on this! Lesson learned: Seems PHSO process is intended to frustrate, deny and delay. Over 8 years later and I agree “You are in this for the long haul” Be kind to yourself. As Nelson Mandela is reported to have said when leaving prison “I leave all my hatred and torment behind in the cell, because if I dont I will be in jail forever!” More wide words….thank you all for sharing!
Glad if it helps Dee. You often don’t realise when you are grieving just how vulnerable you are. You very much need support + honest advice from a personally uninvolved source.
Never beat yourself up about what you couldn’t do. You did your very best and you were up against tremendous odds.
Oh and I found writing letters in the third person far less emotional! Beware a complaints manager who says “I’m sorry YOU feel like that!”
Gosh, Sara, I’m a regular reader but seeing it set out like this in a timeline just reinforces quite how shocking their behaviour has been since LB died (not to mention beforehand). Their behaviour around Fran, the undisclosed documentation, the lack of insight and messing you around… jaw-hitting-the-floor.
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