I’m beginning to think about the inquest with a bit of coherence after a shaky week in which Rich and I repeatedly started sentences “I still can’t believe that…” Some mysteries remain and we have a lot of questions still. Like how the fuck can learning disabled people continue to be treated so badly in 2015?? This is probably the first of a few rambling posts reflecting on this stuff.

My mum has post-inquest shingles which is seriously crap. Can you imagine? Someone needs to look urgently at the enormous emotional, physical and financial cost this system imposes on families. NHS Trusts should not be allowed to inflict such damage with their shitty actions and practices. [Have a look at the similarly awful action dished out by Humber NHS Foundation Trust to Sally Mays and her family.]

This week Verita 2 was published. The broader review into what happened to LB, moving beyond what happened in the unit. Slightly controversial really. It details a stream of failures by Sloven in their takeover activity of the Ridgeway Partnership in November 2012 but concludes LB died as an outcome of clinical staff actions rather than failings on the part of commissioner/Sloven managers. Wow. I’ve tried to read the final version twice and can’t get past p30 (the executive summary). It actually makes my eyeballs ache.

Chris Hatton has provided excellent commentary on this review, ‘Verita, a little less than the truth‘, which concludes;

I cannot reconcile in my head the evidence contained in this report and the conclusions it reaches – short of finding video evidence of Katrina Percy stalking the corridors of STATT with a piece of lead piping I doubt that any evidence would have been sufficient to make Verita reach a different conclusion.

George Julian has also documented why she can’t support the conclusions, looking at both process and content. Within moments of publication of Verita 2, ongoing disgruntlement around Verita’s relationship with NHS England and their ‘independence’ appeared on twitter. Just one example here which is pretty astonishing. Ho hum… This leaves an even bigger question mark for us over the independence of ‘independent reviews’ generally. Having read interview transcripts for Verita 1 and listened to evidence across the two weeks of the inquest, it’s hard to reconcile some of the findings (or unfindings) from the original review.

The secret Oxfordshire County Council review also continues to baffles me. Not just because of the secrecy with which it was conducted and circulated to various organisations a week or so before we got sniff of it, but also because it seems to be an exemplar of a non-independent ‘independent’ review. What’s going on here? Pretence? Delusion? Denial? I dunno. Any explanation is chilling.

All this underlines our concern about the newly introduced Independent Patient Safety Investigations Service (IPSIS) which seems to be headed by Mike Durkin of, er, NHS England. Membership of the expert advisory group is beyond depressing. Nothing like embracing a multicultural, diverse society. Nope. Nothing like it. It seems to be another Winterbourne View Joint Improvement/Bubb type endeavour. All talk and crap all action.

There shouldn’t be layers of ‘independence’. As simple as. Until this is recognised, there’s no point in puffery.

Oh, and for those of you wondering why the Mazars death review hasn’t seen the light of day yet (originally due to be published last summer), Sloven have challenged the review methodology. So it’s being independently validated. Another cracking example of the differing power families and NHS bods have. Despite the latter being responsible for death and the ongoing destruction of families.

It also hints at a level of independence rare in NHS related independent reviews. Here’s hoping Mazars will break the mould. Something needs to happen.