Monthly Archives: May 2015

Cluedo. And the OCC report

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Today has been spent going through the OCC independent investigation. I ended up identifying 61 factual inaccuracies, comments and questions across the 23 pages. A foul, foul way to spend a sunday. For the diehard among you, the full list can be read here. Some summary thoughts (produced with George Julian) here:

ONE. How is it possible to review what happened to LB and the service provided to him without family input? How could this possibly produce any useful suggestions. And why weren’t we told about this review? If OCC were being transparent, seeking to learn, had nothing to hide, why not be upfront about it?
TWO. Given the obsessive focus both Sloven and OCC have demonstrated around my blog, wouldn’t the reviewer think about reading some of what I’d written? Both Verita and the Mazars have done so. It’s an information source after all. I’m not saying it’s an absolute truth but it presents our experiences and our thoughts and feelings about what happened. This knowledge could have made staff interviews more robust and led to a more coherent, accurate and useful report.
THREE. If a complaint is made about not being listened to and, in the process of making that complaint this point has to be stated more than once for accuracy, and then is inaccurately responded to, what hope is there? A reliance on ‘official’ documentation leaves this OCC investigation riddled with holes. Key things may not form part of documentation (deliberately or through incompetence). It’s naive and foolish to treat such documents as infallible.
FOUR. Who has a duty of care in this context? If, as OCC seem to be claiming here, I wasn’t coping why did they not demonstrate any concern for LB’s wellbeing? He barely features in the report.
FIVE. The report is littered with erroneous ‘althoughs’ and ‘howevers’. This isn’t a comment on the writing style and accuracy for its own sake; but these seem to be used to deliberately mislead the reader, to lead them to biased conclusions, even when evidence doesn’t stack up to support it.

Funnily enough (not funny really), the defence letter we received from OCC’s legal department presents spurious arguments like “this would seem to be an entirely reasonable response given the Council’s very high expectations…” throughout. This makes my internal organs fold in on themselves and turn to liquid.

SIX. Why does everything take so long, and need to be so bad before anyone steps up? It feels like the report paints a picture of failing parent, challenging son, and dedicated and compassionate staff who are constantly rebutted. Why is there no recognition or understanding of what we were experiencing? And why? And why the apparent surprise that we suddenly had LB admitted to STATT? Why did no one involved at the time listen to what we were saying?

SEVEN. What relevance is A4e support to this review? The focus on this in the report  either indicates the independent reviewer’s (mis)understanding of Direct Payments and/or is another attempt to pass the buck away from OCC and paint me in a negative light. My refusal to use their ‘service’ is mentioned in at least three places in the report. In some detail. Why? I’m left wondering if my  refusal to use their ‘service’ was a financial? political? problem. An additional bit of card marking. Adding to the rest.

EIGHT. Verita 1 was clear that discharge planning was not advanced (by any reasonable person’s standards) and yet this review suggests it was almost complete (largely through the efforts of the Care Manager who, as we are told in two places, came back off annual leave in April and got straight on with organising the professionals meeting). Well she didn’t. And I’d probably have felt more disposed towards her if she’d seen LB more than once while he was in the unit and attended more than two of the weekly meetings across the 107 days he was there really. Again, whose truth counts?

NINE. Perhaps the most disturbing element of this report is the undercurrent of parent blame. Implicitly and explicitly blame permeates the report. Well it’s drenched in it. It reads less as an investigation of OCC’s processes and involvement in what happened to LB and more an attempt to paint a picture of a flaky parent who  repeatedly refused countless offers of support and help and forged a resolutely independent (and flawed) path down direct payment alley. In the vein of “there’s always something or other with Mr Neary”.

George commented; “The reference to Direct Payments and choices, pretty much could have been written as ‘Inspector shrugs shoulders and says in a loud disgruntled voice: “Well, they wanted a Direct Payment, they made their bed so let them lie in it”; OCC 1 and OCC 2 hug and all three leave stage right’.”

Possibly (though it’s impossible to really judge given the number of contenders) the most damning statement in the review comes towards the end;

I consider it important to note that this [families choosing to use direct payments] also means that those families then have responsibility for the choices they make.

Ah. It was the mother what done it. In the kitchen. With the direct payment and a full time job.

Classy.

Dealing with this report, from the moment I received it with no warning by email a few weeks ago, to the lengthy and tortuous work today, has been intensely harrowing, time consuming and distressing. How OCC, like Sloven, can continue to extract more from the fragments of our crushed lives, in seedy and self serving attempts to cover their own backs is just barbaric.
He died.

I wasn’t listened to.

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Justicequilt-187 Just back from attending the 13th NNDR conference in Bergen, I’ve  picked up the OCC investigation into LB’s death (that came like a hammer blow a few weeks ago).  This is something I naively hoped we could just say ‘Er, please bin it. It’s a pile of (harrowing) shite.’ It turns out we need to detail the inaccuracies in it. An awful, time consuming and beyond unacceptable task.

Tonight the tears started on p5. A summary of the complaint I made to Sloven after LB was admitted to the unit in March 2013. A summary of five of the points that the complaint made and the shonky responses to it. 0cc4 But there weren’t five points. There were six.

12.4.13 My email to the social care director: image On 15.4.13, the Sloven complaints person sent me this email and I responded, the same day, again flagging up the sixth point. image 0cc20 Prophetic words and dripping irony. I wasn’t listened to. The seriousness of the situation was not appreciated. I wasn’t listened to in making the complaint either. Clearly. And OCC deliberately didn’t listen in writing this craphole ‘report’ based on half truths and inaccuracies.

Which bit of ‘our beautiful son is dead because you arrogant, bullying, dismissive bastards refused to listen’ don’t you get? And why the fuck am I having to endure this soul destroying task?

Power, prejudice and indifference

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This weekend involves work. ‘Proper’ and campaign work. Part of the latter involved sifting through events of the past 21 months on my blog. I came across this post from a year ago in which I document the seeds of including a request that all deaths in Sloven’s learning disability and mental health provision are investigated in the Connor Manifesto. Our concern was the ease with which Sloven slapped a ‘natural cause death’ on what happened to LB and how it probably wasn’t the first time they’d done this. We met the Real David Nicholson, then CEO, NHS England, a few days later who agreed to commission this review. Days before retiring.

I suspect a few people involved at that point and later probably wrote this commitment off as a tick box exercise to be sorted with a bit of (superficial) number crunching and benchmarking with other Trust data.  A final fling. Or flout on the Real DN’s part. But the Mazars got the gig and ran with it. And gave the task the commitment it both demanded and deserved. The report will be published in the next few months.

At the opposite end to the spectrum of investigation, it turns out that the Sloven staff disciplinary processes led to (certain) staff being disciplined in a robust process (which is good). Clinical staff were, in an apparently equally thorough process with similar external validation, found to be doing all they could be expected to do. No action taken.

This is odd given the referral we made to the GMC last spring remains under investigation.

Power and prejudice. Death by indifference. Dead with indifference. Though I’m beginning to wonder if indifference is the right word.

Justicequilt-169

 

Oxfordshire Conty Concil.

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Having been a cheerful swearer with vague, unarticulated boundaries (that have raised some eyebrows among some family, friends and colleagues) over the years I’m being pushed into (almost) using language I never dreamed I’d use.

Oxfordshire County Council’s legal department have replied to our concerns about the ‘independent’ investigation into LB’s death that emerged a few weeks ago. (We had no idea this report was being conducted, it’s full of inaccuracies and LB’s health and social care records shouldn’t have been shared with a third party without our knowledge).

The response begins with a rehash of the terms of reference of the ‘investigation’. In a howling example of irony these include; ‘to review the contact between adult social care, LB’s family and school’.

There follows a shedload of rubbish statements. For example:

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What a peculiar statement. An all powerful ‘Council’ doing stuff rather than individuals. OCC senior staff should probably have a quick read of Chris Hatton’s latest post about bureaucracy. OCC (and their ‘independent’ consultant) have a habit of stating what wasn’t the case. Like stating in the report that I wasn’t present at a meeting after detailing who was. Detailing what wasn’t strikes me as a bit of a warning flag in terms of trying to understand what’s going on in both the construction of the report and the subsequent defence of it.

The letter states that the OCC report was commissioned by the Director of Social and Community Services in July 2014 (and then was delayed by the police investigation) before the Verita report was commissioned.  As the tender process for the NHS England review was underway in June 2014 and Verita awarded the contract in July this is simply inaccurate. Post-hoc rationalisation. Wrongness upon wrongness.

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Wow. OCC taking ‘the dog ate my homework’ to new levels. This is just nonsense. Almost laughable but of course it ain’t. In some sort of unacknowledged hinterland (a space occupied by many families I’m sure) we now have two choices. Leave this ‘report’ as a public document inaccurately detailing events, to be potentially used in LB’s inquest and other arenas. Or suck up the emotional distress (and time) of carefully picking through the lengthy document to edit and correct seedy, inaccurate and self serving statements. That seems fair.

The final statement in the letter responds to the confidential status of the report. It sends my brain into a spin, given the context.

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I’m left raging. As always. Well and wondering if OCC really have a legal department or does someone like the independent consultant do a bit of moonlighting.

We are seeking legal advice.