More intense reading this week. The CQC inspection. Back in September. More evidence that LB’s death [howl] had the impact of slightly sour milk being poured down the sink. The Oxon Commissioning Group at a meeting in County Hall (less than 100 metres from where I’d just returned to work in September last year) minuted that STATT had been given a green light in January 2013 (due to the “positive engagement” with Sloven). Wow.

And then, a planned visit to the unit in the summer didn’t happen because of ‘the death of a service user in the unit’.

Wow.

A dead donkey.

The visit didn’t happen? After someone died there? Am I missing something?

The content of the CQC inspection of STATT needs no revisiting. Assessment and treatment had long gone (if ever present). It was a site of malaise and perceived bullying/overly process driven and ignorant/detached management. The spread of this toxic mixture was apparent in the observations of the inspection team. A damning and shameful account.

LB was kind of caught up in this. His death wasn’t a focus of the inspection. But he’s there. Part of the space, the story, the life (and death) of the unit. Epilepsy non-management, family non-involvement, non-choices and flaky capacity decisions. Hideous.

Sloven had waded in to bid for the Oxfordshire contract with a campaign worthy of whatever it cost. They talked the talk impressively enough to win the gig. KP filmed her message for Ridgeway. Then did little else and got caught out. Big time. Three failed CQC inspections in Oxfordshire in a matter of months. A complacency born of ‘too big to fail’ syndrome. A focus driven by sponds rather than patients.

Bizarrely, nothing has happened to the Sloves. They seem to be able to act without sanction (nonsensical redactions, undisclosed medical records, ongoing (into infinity) staff disciplinary procedures, letters sent to wrong recipients or dead patients, sacking advocates, veiled accusations of me trolling and hacking into their staff twitter accounts, blocking JusticeforLB supporters, etc etc etc).

In another set of heavily redacted emails I was sent yesterday, someone (redacted) emailed KP;

This is clearly a very painful period and one that is not made any easier by Sara Ryan’s unwillingness to engage with you. I feel you and your colleagues are continuing to deal with this in as sensitive and professional way as you possibly can

Are we living in a parallel universe? Here is a copy of the briefing they produced for Monitor. The world according to Sloven; 20140515094441957. It contains this note at the end:

Accurately my arse. It seems impossible to understand how such high level professionals could mistake two completely different phrases which have completely different meaning. When did the police start deciding cause of death? And the police were conducting an investigation at that point (and still are) so the whole statement is a fabrication to try to wriggle out of such a damning response to LB’s death. In an official briefing document?

It should be a concern to everyone that something as serious as death [he died?] can be treated so carelessly or worse. Not to the Slovens though. In their May board minutes (page 16, item 7.7)  they proposed for closure the independent review, commissioned by NHS England, that is being undertaken into the deaths in their mental health/learning disability services since 2011. We asked for this review because we were concerned that the ‘natural cause’ label had been slapped on other patients in the past. And appreciated David Nicholson actioning it so straightforwardly.

It’s not Sloven’s review to close, as they then report in their June board minutes (and it certainly ain’t complete) but they are arrogant enough and, apparently, untouchable enough, to do and say what they like.

Astonishing. Are they living in an imaginary world? Is the Board complicit in this or completely in the dark? Are Monitor/the CQC/NHS England/Jezza Hunt/Norman Lamb, etc etc not concerned about their actions?

Why is any of this?