3 October 2013 John Stagg
24 February 2014 Katrina Percy
28 September 2015 Jennifer Dolman (by courier)
2 October 2013 Jennifer Dolman (by courier)
More records not scanned onto RiO due to human error. Deeply sorry and will review processes… Can’t be arsed to photograph.
Blimey. Six months ago now that Oxfordshire County Council’s (OCC) secret ‘independent’, ‘internal’, ‘review’ arrived in my inbox first thing one Monday morning. Without warning. Six months ?? I’ve written about this a lot because we’ve been so distressed, incensed, baffled and depressed that a local authority could act in this way. Without apparent remorse. LB died. In ‘care’ they commissioned…
It turns out they can’t behave like this.
We’re fortunate. Lucky? [I don’t know what the right word is here…] Just bloody grateful to have pro bono support from someone I can only describe as a tornado of human rights expertise, action, commitment and sense. A remarkably detailed 27 page letter was sent to the Legal Officers at OCC. Carefully documenting the wrongness of their actions and why.
Some lowlights from this letter [my flaky lay interpretation]:
You can’t conduct a review into support offered to a family without involving the family in the review. You can’t treat local authority records as a definitive record of what happened when they are clearly flawed. Inadequate record keeping and inappropriate records (describing people disparagingly) is wrong. You can’t offer contradictory explanations why a review is commissioned and proceeded. You can’t circulate an internal report to external people. You can’t deny pre-publication right of reply to one individual/family. You shouldn’t share people’s personal data without requesting consent or informing them. You shouldn’t spring a review on people without warning. Meaningless apologies are meaningless. You can’t make vague reference to stuff (like changing practices in the future) and not follow it up. You can’t defame people and present them in a particular light that is offensive and untrue. Circulating such a review is a breach of a person’s (human) right to a private and family life…
And so it goes on. Issues raised around maladministration, defamation, data sharing and the processing of personal data.
I sent the letter to Agent T (big sis) earlier. She replied; “Just realised my jaw has been really clenched for the last half an hour just throughout rereading that letter…”
I’ve given this post a bit of a flippant title. I don’t know why. Maybe I’m sick of being such a consistent harbinger of public sector related misery. Sadly there seems to be no end to this position.
We’re expecting a response from OCC by 4pm tomorrow.
LB died.
These last few weeks have been (particularly) battering. Sloven have revealed ‘their hand’ as documentation is circulated in advance of LB’s inquest. Despite glossy (meaningless) words in the Independent on Sunday, they continue to hold their (battle) ground.
Six members of staff now have separate legal representation. Six? Four of these are currently ‘properly interested parties’ along with Sloven and us. Interested parties can ask questions during the inquest. There will be eight sets of legal bods present. Wow. How will the tiny, wooden courtroom, described by John Lish, accommodate everyone?
I pretty much stopped working today. Sadly. It’s impossible to read the reports/interviews/documentation and continue to ‘work’. The emotional distress is too intense. We’ve been catapulted back to that space between LB’s death and his do. A space that defies words. This afternoon I slept. This morning we talked with a journalist. Re-living horror. And hearing further horror. Learning disabled people are simply treated with unchallenged (and accepted) contempt. Over and over again.
Our experience over the past two years can be summarised as harrowing grief, devastation, disbelief and destruction with repeated, unremitting and remorseless (hobnailed) booting by Sloven/OCC. Neither body has expressed a drop of positive action, candour or transparency. Fake apologies and dirty actions. Remarkable really.
In contrast, people have collectively recognised, rallied, raged and stepped up. A sort of maelstrom of creativity, colour, brightness, spontaneity, humour, life and humanity. Even more remarkable. [Thank goodness]
I hope we manage to retain some ‘sanity’ during the unfolding of this long awaited and deeply dreaded process. We’ve nothing to gain in many ways. LB is dead. That ain’t going to change. Answers? Within the boxes of documentation/reviews stacking up it’s pretty clear what happened and why. There’s no need for the inquest to be adversarial. With eight legal teams and the rows of ducks lined up, I can’t see it being anything else.
We received two weighty boxes of inquest bundles on Friday. (Bundles are lever arch files of well organised, numbered documents.) The ‘medical records’ bundle contains records we ain’t seen before. Despite requesting all of LB’s records in July 2013.
Our solicitor repeatedly requested missing records during those early months. Documents dribbled in. Peppered with ‘Oh yes we have!‘…and then ‘Er, missing docs attached’ type responses. In February 2014 came the extraordinary realisation that none of the unit records we had were complete. We’d never received full copies of unit meeting minutes before or after LB died. Leaving us unaware that his seizure activity was disputed and dismissed.
Disputed… Dismissed???
[Howl.] [Can you imagine?]
Katrina Percy wrote to us in Feb 2014 apologising for this evidence of her piss poor leadership. A letter sent the day the first Verita report was published. [She didn’t mention the words piss poor or leadership but that’s what it was. The odd mistake may be ‘explained’ away as an error. When mistakes start stacking, up as they have and continue to do so, it can only be piss poor leadership.]
He died.
LB drowned.
In November 2014 the coroner sent us copies of the Initial Management Assessment (IMA) [I think that’s what it stands for] report and 72 hour SIRI document, neither of which we’d received. Over a year after LB died. More key documents slipping through the flakey Sloven disclosure net.
And yesterday, even more unseen footage…
We simply don’t understand how an NHS Trust can get away with such blatant disregard of candour and transparency. Without censure. We don’t understand how it’s acceptable that families have to, if they can scrape themselves off the floor long enough and have the resources to do so, police this stuff. We have excellent legal representation, costs covered by remarkable fundraising actions of all sorts of people and pro bono support. We’ve also research skills that enable us to wade through this shite and identify omissions, crap and dishonesty. A lot of people don’t.
I’ve lost count of how many times we’ve (repeatedly) said These are public bodies… How can this be? How often we’ve been let down by people who must know the implications and consequences of their actions. They may have particular job titles/authority but they’re still human at the end of the day. Just baffling. With an icey core.
Back to the bundles. No surprise that the biggest bundle in the bundle box is the ‘Sloven Policy bundle’. A remarkable 1030 pages of policies and procedures.
Nothing slipping through the net here of course. Nah. I won’t bother checking.
A full on few weeks. Writing witness statements for the coroner a hideous task. Reliving everything that happened. Again. He died? While having to discard what we now know [unit records/CQC inspections seared into my brain/eyelids]. So blinking painful. Then a week or so later, receiving Sloven witness statements. Piercingly painful, sometimes enraging reading.
More reading as both big reviews commissioned by NHS England around LB’s death pitched up. The broader Verita review building on their original review which found LB’s death preventable. And the Mazars review into deaths in Sloven’s mental health and learning disability provision since 2011. These have been circulated for ‘factual accuracy checking’ (just drips off my tongue these days) and won’t be published now until after LB’s inquest. Around 500 pages that must be generating agitational agitations at top Sloven towers level. As it fucking should.
Yesterday was the fourth pre-inquest review hearing at Oxford County Hall. My Life My Choice turned up in force. It makes a difference to see family/ friends/campaigners in the public gallery. Sort of counteracting the apparent ease with which LB’s life seemed to be treated in a ‘deleted/trash emptied’ way. Like so many other people. George Julian brilliantly tweeted much of what was discussed on a new dedicated campaign account; LB’s inquest.
It was just incredibly sad. I don’t know. Maybe more so than the previous three meetings (if that’s possible). Earlier hearings involved thrashing out issues around whether or not the inquest should be an Article 2 inquest with a jury. This related to LB’s human rights – something he was always so (rightly) hot on – under the European Convention on Human Rights. How the state has a duty to protect life.
Back in the day, these were important points to us and we were worried Sloven would derail them. Yesterday it was confirmed that LB’s inquest will start on October 5th for up to two weeks. Discussion turned to witnesses, jury bundles, floor plans and photos.
Don’t ever tell me this is an inquisitorial process.
[The first of a (maybe one, a few or too many) detailed, dull, note heavy, contextual posts leading up to LB’s inquest. Sorry. It’s too important not to document...]
I’m pretty sure I’ve previously mentioned the original Verita investigation (V2008) into the beyond crap services provided at Fordingbridge Hospital in 2007/8 (rehabilitation and palliative care services). Fordingbridge Hospital was run by the Hampshire Primary Care Trust which eventually became Southern Health NHS Foundation Trust (Sloven), absorbing Hampshire Community Health Care services (HCHC). [I know. Layers of tedious detail. Stick with it if you can bear too? to? to eurgh.]
[Note 1. Mike Petter, Hampshire PCT Non Exec Director during V2008, constant non exec board member across the years, is now Sloven board chair (announced August 2015).]
The V2008 report can be read, heavily redacted, here (courtesy of the Daily Echo). Sue Harriman, then Director of Clinical Excellence, originally produced a summary document – the Fordingbridge public paper – in lieu of publication of the full report. [Note 2. Sue Harriman was acting Sloven CEO when LB died.] The full report couldn’t be published apparently because it included names of patients and staff. The Fordingbridge public paper, which reduced V2008 from 84 pages to 7, largely summarises the sterling work Hampshire PCT had conducted to improve the Fordingbridge service in the wake of the (almost) scandal. Recommendations from V2008 were included as an appendix. The paper concludes;
A full review of all HCHC/Care Services inpatient facilities across Hampshire was conducted based on the findings from this investigation. The HCHC /Care Services Board was assured that the issues identified at Fordingbridge were not replicated elsewhere.
However, a Director-led strategic ‘Community Hospitals Action Plan’ was established to ensure our patients received the best possible experience with optimal outcomes.”
So the Hampshire Community Health Care services were all good apart from Fordingbridge and a strategic plan covered all other bases. A sort of Cillit Bang type approach to the emergence of failing services. An approach involving the following steps: i) Neutralise criticism by focusing on actions taken. ii) Isolate ‘germs’ and make it clear they are contained. iii) Add a layer of something wordy/fanciful to oil the ‘moving on’
[Note 3. iii) can often involve bringing in outside agencies at considerable expense (to the taxpayer) adding more oil/speed to ‘moving on’ talk.]
There are 29 recommendations in V2008. [Note 4. The Fordingbridge Public Paper lists 28. 5. At the time of V2008, Katrina Percy, current Sloven CEO, was managing director of providing organisations. Not sure what this means. 6. Sandra Grant, current Sloven director of people and communications, was human resources director.]
Of the 28 or 29 recommendations in V2008 over half – R5 (staff training), R6 (patient information/involvement), R8-10 (care planning), R11 (environment), R14-16 (dignity and respect), R17 (staffing levels/continuity of care), R22-25/29 (leadership) – easily ticked fail boxes in the subsequent series of CQC inspections across Sloven’s Oxfordshire provision that took place in 2013/14.
This stuff just wasn’t new to them.
Acquiring a whole new set of services in Oxfordshire in their (potentially lucrative) takeover of Ridgeway services four years after their Fordingbridge experience and no learning was drawn on to make sure these services were run properly. Despite the continuity of senior staff involved. Maybe NHS reorganisation give (senior) staff ‘get out of jail free cards’? Allowing them to toss aside existing knowledge while holding onto inflated salaries, status and sturdy, award holding, shelves.
Verita pinged up again in Sloven history, investigating crap provision after LB’s death in 2013. An investigation focusing on the unit LB died in; the Short Term Assessment and Treatment Unit (STATT) based at Slade House in Oxford. Sloven tried to avoid publication of V2014 using the same tactics they’d used with V2008. They don’t forget some things. Three weeks before V2014 was due to be published, they announced they’d publish a summary of the report on their website. To protect staff, protect LB’s confidentiality, stop the identification of staff and ensure the continuing ‘free and frank’ accounts of staff in such investigations. More trumped up rubbish.
V2014 was eventually published with the names and job titles of staff redacted.
Research funding is dependent on demonstrating that you understand and are able to evaluate and summarise what is already known about a particular topic. That you will draw on this knowledge throughout the ensuing research. And that this research will have impact. Academic research isn’t without criticism. Quite the opposite. But I’m struck by how limited the lack dot joining is in health and social care reviews/investigations. Rich Watts here details another (stark) example of this.
[Note 7. Rich regularly took the kids camping in the New Forest when they were young. One trip I remember, we went to Fordingbridge and the kids chose a book each in a small, local bookshop. It was the first time LB (still in junior school) surprised us with his book choice. It was something like a detailed log of types of Land Rovers in southern England. In black and white. With a lot of technical specification tables, chassis numbers and little else. It turned out to be the first in a series of nonfiction book choices that included David Bowie’s London spaces, the Red Cross First Aid manual, concurrent editions of the Yellow Pages (a cheap gig), the Eddie Stobart Story and much historical bus and London stuff. LB was never one for fiction.]
mydaftlife 