Hind, foresight and the two Phils

Nico Reed’s inquest concluded yesterday. With the coroner making what appears (to a completely lay law person) an important statement. He overturned two of his own rulings to rule (re-rule?) that Article 2 of the European Convention on Human Rights was engaged on facts of Nico’s case. I’ll leave it to Lucy Series to kick off early thoughts about this and focus instead on what I do know something about.

The legendary Phil Gayle (and team) who had Sloven’s director of social care on their show today. Another Phil. Phil Aubrey Harris. A brief summary/set of notes/important points here from the discussion.

Money, morality and humanity

Apparently 20 minute checks written in a care plan are a guide. Not something that must happen. With a few people to be looked after by one member of staff “there is an inevitability that those checks are unlikely to be maintained“.


There is (considerable) jiggery pokery in Sloven practice around hindsight and foresight. The necessity of frequent checking only apparently recognised ‘in hindsight’ (ie. after someone dies) despite being clearly stated in a care plan.


Care plans therefore characterise ‘ideal type’ situations. The 20 minute check is something that should happen if resources weren’t a consideration. Because resources clearly are, this foresight/hindsight distinction leaves a pretty murky area around regulation/inspection. It’s difficult to observe the acting out of a care plan. Especially in the early hours of the morning.

Just help me out here, as a lay person, as someone who might one day have to use a unit like this, for someone I love...” said the wondrous PG wrestling with this gulf between care plan and practice.

It’s a guide“, says other Phil. “Based on individual needs, blah blah de blah…”

Was one member of staff to those four patients sufficient?” PG returned to, with a hint of impatience.

I think it probably was“, said other Phil.

Eh? The coroner rules that Nico’s death was possibly preventable because he should have been checked more regularly, but the staffing ratio was sufficient?

And there were other risks associated with Nico’s care.. said the Gman, without missing a beat.

Oh yes. These were known about. “There were plans in place within Nico’s support plans to acknowledge those risks and to mitigate them”.

Pah. You lost me. Is a support plan different to a care plan? Is a support plan actually acted on? Does anyone know what they’re talking about here?

The Gman moves on to ask whether things are going to change in response to what happened to Nico.

There follows a remarkable but largely unintelligible statement that seems to suggest (on the third listening) that Sloven are now determined that if they ain’t properly resourced by commissioners/local authorities to provide the level of care necessary “we wouldn’t take those [packages of support] on without some sort of challenge with the assessment teams or some sort of local authority or local authorities or whoever it is who is funding those packages”. 

My half arsed interpretation: Don’t blame us for the crap care we provide on the pennies you’re willing to spend. Or, we’re happy to rake in the spondoonies to provide ‘care’ on a shoestring until something catastrophic happens. And then, ex-cer-use-me. Don’t come banging on our door…

Overloading the person to staff ratio at  minimum cost (thereby erasing any consideration of a life that has a sniff of fulfilment, contentment, enjoyment, achievement or productivity) as common practice until an NHS or private provider is dragged under the spotlight. And then offering a half arsed ‘you should have coughed up more’ defence.

What a sordid, sad and shameful situation.

In the final minutes of the interview, the Gman asks why Nico’s family were not told about the circumstances of his death for over a year. More bluster. The Gman, clearly affected by what he’s hearing says;

With respect, other Phil, you use the phrase ‘with the benefit of hindsight a lot and you use it about decisions that anyone else would regard as common sense..'”

He nails it here. Common sense engagement with an extraordinary situation. Stripping away ‘learning disability’ and engaging with what has happened at a human level. Drawing on common sense. On everyday stuff. That we can all relate to.The Gman called it today. As his show has consistently done in relation to LB.

Until people can chuck away their blinkering lenses of learning disability, ‘challenging behaviour’ and other labels, we ain’t going to get anywhere. We are talking about people, experiencing situations that if they weren’t labelled as ‘learning disabled’ would be called out in a multitude of ways.

And Sloven. As ever, you are fucking shit.



17 thoughts on “Hind, foresight and the two Phils

  1. This nay be a really stupid question but if there are situations where they know the necessary checks can not be made are there not some kind of alarm systems on breathing that can be used? I had to use these for my baby when he came home because I could not check him every 5 minutes during the night?

    By the way I thought phil gayle was brilliant

  2. But how much was being charged for this care, I should imagine a considerable sum,and yet they are pleading lack of resources ???.

    In any event the staffing was 3 to 5 patients, ? So this allows for better supervision.

    And this standard 20 minute checking, would not in any event apply, to a vulnerable person in the bath, by any crude risk assessment estimation.

    This is the usual nonsense, that only serves for sense ,if you have the power,as they do and all establishment do, to make 2+2=5.

  3. This very current issue, of poor to nil monitoring of care by providers and commissioners, is also very relevant in ‘supported or ‘independent” living. I asked our LA repeatedly for information on how the private agencies being commissioned post the redundancies of their own staff, were to be monitored. I asked how this would happen: eg. clear quality measures of how often care and people would be monitored, and who would be accountable for this. I got increasingly irritated responses from LA. None gave me more than ‘of course we monitor’. Then a final ‘end of matter letter’. I took this to CQC who replied that the LA probably did not have this information. I have had to monitor my son’s increasingly dreadful care from crises to crises. I have had to monitor the poor, disrespectful and at times illegal and dangerous ‘care’ by one worker, continuously. Without my doing this my son could be dead from this nil/zero/zilch monitoring by LA or agency. I have found since, care is not monitored, only cost and contracted hours is monitored – annually. The worker who repeatedly put my son’s life at risk and routinely failed to turn up and/or respect him, is still employed by the agency, still ‘supporting’ other vulnerable people. The LA (commissioners) say they have no power to influence this.

    • Did the Slovens chant the usual mantra of how they respect and value all the people under their care? Did they say they have learnt lessons?

      Well I do not believe my loved one or any person with a learning disability should be a test case in any hospital/carehome/social service learning curve. They should not be dismissed with the throw away excuse that ‘we wll do better. This sort of response to the relatives of the people who have lost their loved ones is insulting. More than that it is unbelievably cruel.

    • As the LA policy, is to remove all mentally disabled, to independent care by court order, on rendering them, most times illegally, incapable, under the MCA, and then exclude family to aid poor secret care, this is a huge issue. Which no one is doing anything about.

      The MCA allows the LA and GPs, who will benefit hugely from independent living, to the tune of 4,000 per week, under Chronically Sick and Disabled Act alone, up to 82,000 per annum can be claimed from NHS alone, allow with education to 25 ,and all the disabled’s benefits including housing.

      Drug trails are allowed under MCA, and any enforced drugs , so independent living is a laboratory for big pharma and researches.

      So there is a huge conflict of interest, and a state cabal which systemically cannot be fought.

      This is the appalling hell ,that I might be forced to surrender my daughter to , as we can get no support, to join thousands of others who are living in such hell, unseen, unchecked but making billions. Read my blog finolamoss

    • This is the biggest scandal, which is not dealt with by LAMB’s Green Paper, nor LB Bill.

      Firstly, why are all forced at 18, away from family, illegally under MCA, by COP see my blog posts by googling finolamoss

      We know it is to make huge profits, on backs of cheap, zero hour labour.

      Our Adult Services social worker, on completing the assessment for adult services, for our autistic daughter, declared, we do not provide specialist care , this despite the provisions of the Autism Act 09, saying they should, but, these are merely guidelines, and cannot be enforced except, by us on judicial review, which would cost, and is effectively impossible,

      Therefore, adult service provision is not autistic/learning disabled specific.

      In fact, the only adult service provision is ‘ independent living’, or, if at home, which would be difficult to maintain, due to possible intervention by court under MCA, is a day centre provision, and/or support by their chosen carers. There is now no overnight away from home respite for 16 and over in our LA.

      But, in independent living, the providers are in fact allowed, to claim for specialist autistic provision and do, HENCE the profit margin, so the autistics are a gold mine, and on top NHS care, and ‘education’ till 25, so all legislation has been drafted, to allow the maximum to be claimed for private profit. And the LA pay it , so this is certainly, not, about cutting LA budgets.

      Yet despite on average £3,500 per week, being thus paid by LAs to independent living providers, there is no apparent accountability for their services, except CQC, and parents are given limited access, often cut out , and dare not complain . And can only complain internally which goes no where, not to CQC.

      We have already experienced, the lack of an effective complaints system, when we tried to alert the abuse in my daughters residential NAS school, and lack of medical care, see blog pages, and this was to her independent reviewing officer, social worker, and even safe guarding board. So this is a huge whitewashing cabal.

      Whilst ,non existent safe guarding issues, are made up against parents.

      Whilst the system remains ‘us and them’, our children will never be happy, let alone safe, and we will be never have peace of mind, and the autistic/learning disabled , will continue to be used as lucrative commodities, for private, unaccountable profit.

  4. With the benefit of hindsight maybe if we’d have followed the care plans, the young man that we were paid to “care” for might be alive. We knew what he needed…it was written in black and white and we just didn’t do it. But it’s not our fault…we couldn’t have done anything more. But we’re happy to “learn” (whatever that means) Blah blah blah. I’m fed up of this empty rhetoric.

    Why can’t they just say “we messed up…and we’re so so sorry…and we will do everything in our power to change how we work for the benefit of other dudes so that Nico didn’t die for nothing”.

    How are people with Learning Disabilities supposed to be safeguarded if non-adherence to care plans has no consequences? If it can be so easily shrugged off as though it is inconsequential?!

    Nico was presumably placed in that setting because the care provider saw a summary of his needs and confirmed that they could meet them. They took the money and agreed to do the job. They entered a contract and they apparently didn’t stick to it.

    If funding is insufficient, if a person’s support needs are too great, care providers should be jumping up and down and telling social services and/or commissioners that the care plan can’t be adhered to in that budget. Taking the money, doing less than expected, staying quiet about it and hoping for the best is just not acceptable.

    My bro’s care provider seemingly had no knowledge of a care plan that was designed to keep him healthy and he also died. I cannot bear to see this same old story happening over and over with almost nothing in place to stop it happening again.

  5. I whistleblow about a rogue supported living provider linked to organised crime.A vulnerable adult was found dead by his parents.He’d been dead for 12 hours.The staff were at the bingo and failed to give him his medication for epilepsy.
    I was later told by a senior manager that the social services department I worked for would continue to do business with the provider because the young man’s care plan “looked as though it had been written on the back of a fag packet” and as the provider knew of this “achilles heel” the social services department would continue to do business to protect their reputation.
    I whistleblew about this and other matters and was bullied out of my job as a result.I have been unemployed for over 2 years and will never work in social care again.

    • As I have sat in my kitchen with care workers, over now nearly 2 years , I have heard a liturgy of horror stories of unsafe procedures in various care facilities, which are still providing care.

      As you say, this is all about self preservation, cover up, and form filling.

      But most of all about managerialism, power and vested interests. And it comes from the top.

      As much profit, as possible has to be made for the venture capitalists, who own these facilities, they are just another market place.

      In 2012 Norman Lamb, warned in financial media, that the private care home sector, was going to take a hit after Winterbourne.

      The public are just a money making opportunity, the staff the cheapest, preferably migrant tools, and the management widgets.

      Everyone is deliberately left powerless, in the forest looking at the trees.

      The top and bottom of it is, no one is accountable.

      And as here the coroner may have made someone accountable by engaging Art 2, he will have been instructed to, for a politically motivated reason ie NHS mental care at the moment is under the media spot like for 2 reasons, to increase its market, and to strategically move it into a different private sector.

      Laudable reasons are given, but it is all about the money, not the individual, and all will remain unaccountable, and the law deliberately subverted, as and when necessary for government purposes.

      Most of the public don’t care, or know this is happening, and or will not choose to realise it, because the horror is too great, and they are in any event, powerless.

  6. Is it not time to come out onto the streets with our banners and fight for the rights of our loved ones.

    Like Finola states, “Most of the Public don’t know or care”.

    Let us march in our thousands to bring awareness for all disability rights. Let us march with our banners and bring this rotten culture awareness into the Public domain.

    Until the Law and Prosecution becomes the norm for bad practice only then we will see change……

    I have spent 4 years in being educated about a system that is incarcerating people against their wishes tearing them apart from their loved ones and killing them off.

    We must not be powerless.

    • We need to kick off with a few powerful, informative petitions on change. org, to let as many people know as possible know about the outrages.

      One on the MCA and encagement, ie its illegal use as per HL Select Committee Report see my blog. It needs repealing particularly on the definition of capacity.

      LB BILL does not do this. To much vested interest in the concept of the nonsense of independent living, which is just encaging for profit, in secret, worse than Winterbourne View ( love the names they give these hell holes.)

      And one on forced medication on anti psychotics like rispeiridol not now used for old, but for all autistic illegally.

      At moment I am writing an expose of rispiridol use for a blog post, but will have a go at taking out such petitions one to lamb other to Health minister.

      Any other ideas ??

  7. It strikes me they don’t really need care plans, they just need to be told one thing: treat this person as if they were your own child. Mind you, maybe they treat their own children this way?

  8. Pingback: Justice for Nico | The Small Places

  9. When I was a nurse, a 20 minute check was a strict 20 minute check. Not a guideline only to be adhered to given ideal staffing and financial conditions. What has changed legally?

    • Nothing. Except now more difficult to get a lawyer, who knows his onions, and will soon. And if the person, who has died has no dependent’s, you won’t get much in damages..

      And all is commercial awareness, and risk assessed, so this would be taken into account And every move of those doing the job is prescribed, no common sense, and certainly no care.

  10. Oh, maybe that is how our local Trust wormed their way out of corporate manslaughter charges after the death of a patient on suicide watch (who wasn’t watched).

    As nurses we were also obliged to have TWO members of staff whenever we were lifting and handling immobile patients. It was drummed into us from the first day of our training. I don’t understand how the Trust can possibly argue that they had enough staff in place.

    • The only way they can argue it is by invoking the Humpty Dumpty, Through-the-Looking-Glass rule of ‘When I use a word it means just what I choose it to mean — neither more nor less.’ – irrespective of normal rules of vocabulary, grammar, semiotics and truth.

      No-one with a grain of sense is fooled.

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