[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.]