The making of a serious incident

Under a Freedom of Information (FOI) request, we received the full file yesterday of the CQC inspection into Slade House last September. A delight to receive (largely) unredacted documents, unlike the pages of black received from Sloven. At the same time, a harrowing and distressing read. The published inspection report necessarily providing a precis of the appalling provision found there. How could they?

Among the 39 documents received, was a letter from Sloven to the CQC (Sept 24th) saying, amongst other shite, that they had “agreed with commissioners and the Local Areas Teams (NHS England) to upgrade the incident involving the death of a patient at STATT in July to a Level 2 SIRI“. (Becoming a bit of a dab translator of Sloven speak, I suspect this means they were told to change this grading.)

NHS guidelines around serious incidents can be found here. On p.23 it states;

    • Initial incident grading should err on the side of caution, categorising and treating an incident as a serious incident if there is any possibility that it is.

Classy old Slovens went for the natural cause grading initially. Chucking err on the side of caution out with the defibrillator battery (and giving it a tick on the matron walkround sheet). Astonishing. They didn’t even deign to properly investigate the context of his death and the services being provided in STATT in July. Stating in the same minutes (23.7.23) that due processes were followed. Tick. (Bit like the local authority/commissioner visit to STATT in June last year where senior staff were asked about restraint; “Face down restraint Guv? Us? Nah. Never”. Tick.)

Level 1 investigations (p.37) are;

incidents involving No Harm and Low Harm and/or where circumstances are very similar to other previous incidents.

Now as LB died, the first two criteria don’t apply, and unless Sloven have a habit of letting patients drown in the bath in their provision, the latter isn’t relevant. So it seems extraordinary his death wasn’t judged to be worthy of a Level 2 investigation. I can only think, that, under a Sloven lens, any death of a learning disabled person is.. well a death of a learning disabled person. Kinda irrelevant really. Very similar to all those other deaths (4 in 10 learning disabled people die prematurely).

LB’s death finally became the serious incident it always was after a regulatory body found the unit he was in a shit hole and the commissioners/local authority stepped in. If this isn’t evidence enough that no NHS Trust should conduct an internal investigation into the unexpected death of a patient in their learning disability/mental health provision, I don’t know what is.

Footnote: I don’t know how much I have to spell out that not only was LB’s preventable death scandalous, but it is also completely unacceptable that we are having to nip at the heels of a sloppy, careless (or worse) and completely disregarding Trust (and other relevant bodies) to make all this shite visible and demand accountability. Every interaction with the Slovens has involved delay, prevarication and nonsense. And NOTHING has happened yet. Does Katrina Percy/senior management team have someone overseeing their actions or can they do what they like? [And on that note, if someone could bung this under the nose of Simon Waugh, Board Chair, that would be helpful. I don’t have time to write to every fucker who might actually have some influence to do something. Not after a whole year of this nightmare]. 


2 thoughts on “The making of a serious incident

  1. Pingback: Dog the Bounty Hunter, the LBBill and a campaign down under | mydaftlife

  2. If you were not the extraordinarily brave and determined woman you are, what are the chances they would have got away with “natural causes”?

    My daughter had a particularly nasty form of potentially lethal epilepsy which was beyond control for a lot of years. I sometimes felt I was keeping her alive on sheer will power – and lived in constant fear of handing her over to those who felt: people with CP sometimes have epilepsy, epilepsy sometimes kills people, no big deal, what do the “guidelines” say? “Don’t leave them unsupervised in the bath? But we are short staffed…

    Got me labelled “over protective”.

    I don’t think I would have found your determination if our luck had run out I am so glad you did, and wish you hadn’t had to.

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