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.
So sorry to hear your Mum has shingles. It was good to meet her. Please give her my best wishes and hope she feels better soon.
Have long thought there has been a need to find ways of making commissioners accountable for the rubbish they commission. It is not good enough to dump on, sack and prosecute only lowly paid care staff. Currently the only accountability/measuring – the ability of commissioners, seems to be whether they have driven down ‘point of care costs’ – through a process of a ‘modernising and transforming care agenda’ – or other such rollocks. Until commissioners have to take personal responsibility all care models will continue to fail large numbers of people. All our loved ones remain vulnerable. Everyday some of our loved ones will be damaged, maybe like Connor die. Tears shed and families broken.
Didn’t I read that Oxfordshire have extended
SHFT’s contract in the past few days? Or did I imagine that? I really hope I did imagine it, it is beyond awful given the inquest verdict if it is true
It’s true. Extended to the end of 2017. Just seems incredible that the commissioners are completely off the scrutiny radar. Do they even exist? Are they a Wizard of Oz of the social care world?
How that bloody woman (Katrina Percy) can sleep at night is beyond me!
Several times whilst reading the stream from @lb_inquest I thought about the sinking of the Herald of the Free https://en.wikipedia.org/wiki/Herald_of_Free_Enterprise_disaster and the subsequent inquest and legal proceedings. Obviously there are differences but there are many similarities – failure to learn from previous incidents, blaming junior, poorly managed, overworked staff. What has changed in nearly 30 years, except that self-protective and tacky management practices are rife in the public sector too,
all talk and crap all action sums up my LA and local NHS Trusts. The Atos assessor genuinely grimaced at the high jinks of the community mental health team during a PIP assessment today, an unlikely but very human response and some timely and thoughtful advice given. Sara keep watch on you/yours physical and emotional health, for our family the aftermath of years of truly worthless investigations has resulted in the total collapse of my husbands health ( shingles closely followed by severe eczema ) new consultant appointments with the same hateful Trust that failed to monitor or supervise our youngest daughter’s treatment. My eldest suffering severe croup for the first time in years, take time for yourselves as a priority.
The Mazars review delay
I have known many patients and ex patients of sloven who have died in the last five years.
A mixture of suicide and the physical effects of medication not being taken seriously or physical illness ignored.
The ten years prior were not as bad.
The cuts in social care and NHS closed day centres, drop in centres and access to health care support workers who could act on issues before they escalated or advocate or role play to enable access to stuff.
Many of those who have died had been discharged back to GP as no longer acutely unwell enough to receive sloven services. Abandoned no day services where support and not forgetting informal PEER SUPPORT no longer there.
Peers often spotted first signs of mania, psychosis, depression, depersonalisation etc and mention to support workers.
I’m wondering if sloven are arguing over how long since discharge is a person still a patient.
If this is not the case, then the mazzars review is the tip of the iceberg.
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When I wrote the above yesterday, I had no idea this letter by another person would be published in Southampton paper.
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