One of the various devastating moments during LB’s inquest was the revelation that another patient had died in the same bath in 2006. Can you imagine?
As difficult as it is to believe, the same psychiatrist, Dr J, who rang me at work the morning LB died in a pretty lackadaisical way, signed the patient’s death certificate in June 2006. The two 999 calls made the morning LB died were played in court. (The unit phone wasn’t working). I didn’t listen to the first but the second, by Dr J, was extraordinary in that the operator, after three or four minutes of collecting detail, was completely unaware of the urgency of the situation and was going to tick a ‘within four hours’ response box. Can you imagine?
Dr J meanwhile seems to have remained resolutely unreflective about these two events, not mentioning the earlier death in her statement or live evidence and mouthing to me across the court ‘Are you ok?’
At least two other staff members were working in STATT in 2006. No one mentioned this earlier patient in their statement or evidence. Or during the Verita ‘investigation’. No one saw the bath as a potentially risky space. No one seemed to give a shit.
The bare facts: a patient in his 50s had a seizure in the bath (non epileptic seizure though how this was determined is a mystery to me) with someone present who apparently struggled to get him out of the bath. His cause of death is recorded as 1a. convulsion with asphyxiation due to 1b. malnutrition, and 2a. contributing cause depression. There was no postmortem or inquest. The coroner is now investigating whether an inquest should be reopened into his death.
Sloven, of course, come out of this deeply sad tale coated in crapshite. The more recent back story: Back in March 2014, a CQC inspection of a unit on the Slade House site (next to the now closed STATT unit) criticised a bath ban. Dr M, the consultant psychiatrist (who together with her barrister must qualify for some unaward for the pond scummish smear tactics they repeatedly employed during the inquest) apparently vaguely recalled a patient dying back in the day, that the baths were found to be unsafe as they were too deep and after some ‘leadership mentoring’ (always a dangerous thing for those who shouldn’t be within whiff of leadership) banned baths.
This ban, falling foul of the CQC, caused an on the spot investigation on the instruction of Sloven execs. [NB. The same execs who didn’t go near STATT after LB’s death to check the provision was safe for other patients. Death schmeath*. It takes a CQC inspection and hint of bad publicity to get action. Every time]. Once the earlier death came to light, Sloven management apparently actively discouraged Dr M from raising this issue further. She left Sloven’s employment (on what terms?), relinquished her licence in the UK and went back to Ireland to, erm, ‘practice’ there.There was then an apparent burying of this information until the first week of the inquest when it was disclosed by Dr M’s legal representative. Sloven did their best to re-bury it during the inquest by insisting the patient died of cardiac arrest in very different circumstances. Mmm. (Same) bath, seizure, death… I dunno. Strikes me as pretty fucking relevant, at least to be disclosed in order for any relevance to be properly examined.
What a sad and sleazy little tale. From a public sector body who claim 100% candour compliance in their 2014/5 annual report. The deliberate concealment of a similar death on the part of Sloven (even to their legal representative) revealed in an obscure and disingenuous way during the inquest. Adding even more (I didn’t think it was possible) distress to a harrowing experience.
We’re left wondering what else hasn’t been disclosed? How often does this level of cover up happen within the NHS? And was there any point to the Francis Inquiry?
*As the Mazar’s death review will reveal, in harrowing detail if it’s ever published.
Sometimes…not very often I admit – there are times that I am lost for words, this is one of those times. Just when you think this lot couldn’t get any worse, they manage to sink even lower.
The 4 deaths in St Andrews. in less than 8 months, show a similar ad hoc, bureaucratic unjoined up thinking.
Might be a different attitude, if they knew, that they would be subject to proper investigation, correct causes of death, and inquests.
Considering, the huge salaries, they are receiving, and the huge amount paid for each patient’s care, this is the very least one would expect.
Everything you describe is appalling. I too am lost for words.
the patient in his 50s who drowned in 2006, he may well have been without next of kin, no PM or inquest . Did the LA organize the nine o’clock trot for him I wonder ? nothing to see or feel here. Shameful shameful concealment.
Sloven said the family said they didn’t want a postmortem. Not sure if this is true or if family can choose typically.
The 2006 death was sudden and could have been as a result of violence if only one other person was present, the coroner should have been informed and there should have been a PM that the family would not be able to object to. How anything other than that series of events occurred is beyond baffling. Family can refuse a GP request to PM and may themselves request a PM. Our circumstances were that following our daughter’s death in our home ( family present only ) a certificate was issued with haste by our family GP. A second GP was at the funeral parlor to countersign at the same hour as my husband and myself, he told the director that he didn’t feel able to make himself known to us ! of course he was a stranger to us and although we met face to face in the building we were not introduced at his request.
He rang after we had returned home and asked whether we would like to say anything about our thoughts concerning our daughter’s death from a catastrophic infection( not the cause of death given ) and posed the question as to whether we felt he should agree with GP 1. I could not think straight at the time but I can see now that he was offering us an opportunity ( without actually saying so ) to request a PM. It was surreal that our opinion was sought at the precise time we were least able to communicate and in the throes of funeral arrangements, our eldest daughter took the phone because of my distress , he repeated the question stating that she could offer him guidance as she was her sister’s carer (which she was not ). I sincerely hope the coroner investigates the death disclosed from 2006, what are the details regarding malnutrition? horror upon horrors. Did the family decline a consented PM? who requested it ? which family members were approached and WHEN in relation to them being informed of their loss?
a question if that patient did not suffer from seizures/epilepsy why was there someone with him but there was no one with LB?
I thing I find the hardest to bear is that the professionals who we rely on to care for our loved ones are often the very people who have a problem with accepting them as human beings. It is the utter disregard of their feelings. Talking over their heads as if they were not in the room. Ignoring them. Leaving them to sit for hours with no stimulation. These practices would be unacceptable in any other walks of life, but seems perfectly okay when looking after people with a learning disability.
The fact that Sloven have got form when it comes to people dying in their care and in almost the same way as LB, seems to indicate that they really do not give a shit when it comes to providing good safe and professional care to people with a learning disability This ‘could not care less’ attitude is worrying. However, the lack of candour and the arse covering, and the awful way they went about trying to discredit LB’s mother is scandalous. They should have all been shown the door.
It is the stuff of nightmares for carers looking into the future for when they can no longer cope. It terrifies me. I am not expecting health and care professionals to love my son the way I do, but I do expect some compassion shown towards his vulnerability.
Another new failed cqc report at slade hospital this week.
I don’t remember the gentleman who died in 2006, but I remember working at STATT a few years later & we had a clear guideline/protocol in place that stated at no point could we leave anyone with epilepsy alone in the bath. There were no obs levels, 15 minutes or otherwise as you stayed in that bathroom every second someone remained in the bath. One of the bathrooms had a dignity screen that care workers could either stand behind or sit behind and remain in the bathroom at all times. The safety of the people we supported used to be the overriding factor in all descision making. Sloven are a money grabbing soulless organisation, but the service had become rotten before they took over.
Maybe the coroner just took the doctor’s word as gospel. Deference to one high status professional from another. And the death of a human being who was not regarded as fully human.
‘The coroner is required by law to carry out a post-mortem when a death is suspicious, sudden or unnatural.’ NHS Choices. What is natural about malnutrition on a hospital in-patient unit, or a death by seizure that is contributed to by ‘depression’? How can depression cause a seizure? None of this makes sense.
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