Still unable to make much meaningful sense of LB’s inquest but moments are surfacing. A few here. Again in no order. Toilet moments. The toilets were back from the courtroom, through the cafe towards the exit. A block of three cubicles for women. Despite strategically timed efforts (roughly aiming for the middle of break times) I always seemed to collide with a jury or Sloven staff member. So blinking awkward.There was only one woman advocate across the other seven legal teams so this was less of an issue [sigh]. I kind of went for a ‘make do and definitely don’t mend’ approach with jury members. This involved eyes firmly on the floor and the usual ‘thank you’ type acknowledgements around holding doors firmly parked.
The kids were upset and angry by the various interactional exchanges that occurred in the courtroom. Smirks, hints of excitement and puff and schmuff between various Sloven bods at the front of the courtroom. A ‘screw face’ technique was tried and tested across the two weeks to manage this.
Rosie also stepped up and explained what it was like to experience this behaviour to a senior Sloven staff member. Love her. Hopefully this has been passed to the Sloven senior team/board and will be incorporated into their inquest policy/engagement. Our and other families’ experiences suggest an over emphasis on staff coaching rather than any thought to what it must be like for family/friends in this setting.
Moments involving Dr M, the consultant psychiatrist, and her barrister, AJ, are sadly hard to forget. For so many reasons. Not least the efforts AJ made to work to a script seemingly derived from the various Disney/Pixar films LB both loved and got so upset about. Depicting me, ‘The mother’ [with extended dramatic pause], as a Cruella de vil type character. Skinning puppies for fur coats.
At one point Paul Bowen, QC, asked Dr M who was the best person to know what LB meant when he said something. This generated avoidance strategies reminiscent of childhood banter hanging out in the car outside pubs with my sisters. Coke, crisps and bickering/discussion with a backdrop of the Grease soundtrack. Dr M, not a child, prevaricated and twisted a knife that should have been removed over two years ago.
That is a very general question. It depends what being said and when it is being said, I cannot ask that question. It would have to be more specific.
[Howl]. There was worse to come. Almost luckily via video link as I’m not sure what I would have done if she was present after this exchange.
Mr F: You heard Winnie Betsva admit that she had failed Connor, SR and the family, is there any matter relating to failures from your part?
Dr M: It was an act of tragedy. In hindsight, we could have made some different decisions but with the information we had at the time and balancing of pros and cons we made right decision at the time.
Mr F: I asked ‘you’ not we.
Dr M: I made the decision at the time with others weighing information we had at the time and no, I don’t believe there was a failure of care from my part.
An act of tragedy? No failure? Can you even begin to imagine? And this woman is a practicing psychiatrist in Cork having given up her licence here. The GMC still investigating her conduct… There is too much too wrong here. And our beautiful, funny, loving boy is dead.
mydaftlife 
Heart and Soul go out to all and Total Empathy re “too much too wrong” AGREE! Our sons are dead they must not hide any more!
Reblogged this on Bernie Mayall and commented:
Please, just read this. Our systems are broken and fail the people they are supposed to support and protect, and that extends into the CJS and courts. Brave Blogging.
Brave indeed! But maybe “they” cant scare us anymore!
I do believe there is a big F for failing his care, a failure to listen, a failure to respond to his needs.Where ? was the supervision while he used the bathroom, if less time was spent on trying to blame his mother and love ones, and more time caring for the patient a lovely young man would be living his life to the full in a caring family!
Couldnt agree more! My lovely son died under “Enhanced observations” in a bathroom on the wards!10 years on I have certainly learnt many lessons!!! Still waiting for truth! But I wont let go!!
So sorry to hear that is already one two many.Why? are lessons not learned! My heart goes out Sara and her family,to you and your family. I hope this great war this brave lady and friends lovely family have championed stops it happening to others in the future.
Thank you….Sara is a very brave woman! Lessons are not learnt because nobody oversees them. Cheap labour and too few of them! For nurses there is a line manager….oh and a Nursing Director in charge of all. What are they doing?
Worse still its happening all over the country, as I write.
And, more are dying, as this is systemic.
Huge amounts of money, is made ticking boxes, and chasing meaningless pieces of paper, to ossify, protect a system, which aims to make as much money as possible, for an army of pen pushing, bureaucratic experts, managers, consultants, whilst the actual care, is by itinerant, prescribed, over managed, unable to do anything, minimum wage oppressed workers.
And moving it all down, to a local level, of private Adult Treatment and assessment Units, and supported living, will only make things worse not better.
Thank you for comment….I totally agree!
So inertia rules eh!….as it seems NOTHING can be done! We can still shout though!
Agree!!
There is a huge difference between nothing CAN be done and nothing WILL be done until people like KP accept the enormity of their failure. A young and precious life lost, and no lessons learned, just legal wriggling off the hook.
For me, this wickedest thing that was said was “The mother didn’t want him home.” The failure of imagination behind that statement, the cynical savagery of it, beggars belief.
My dead sons possessions were sent back to us in a bin liiner marked NHS Household Waste….who on earth finds that acceptable?
There are lots of lovely MH workers put there and thankfully they provide some solace. But there is not enough training, Not enough “Lessons learnt” and definitely not enough supervision! Too many Fat-cats and not enough “cream”.
Totally agree!!. The wriggling has to stop! ACCOUNTABILITY is only way!
We have the EU Parliament, particularly, the Petitions Committee.
The MCA, which is worse than then the MHA, which in any event is being at present used illegally, ie indeterminable treatment, and, continued sections.
But MCA. is illegal under EU directive, as it removes decisions from the disabled.
If we just concentrate on the NHS move to local, all will be worse, as the MCA gags all parents, all services are in secret, and at any time, in any event, without even our knowledge, our children can be sectioned under MHA, and removed to a locally owned private hospital or ATU.
And the MCA is for life.
Only a few, monopoly, private venture capital backed health and care services exist, and eventually, will take over both medical NHS and Social services Adult care ie like Cambian, who own both Woodleigh Care Home, and the ATU, where Thomas Rawnsley was abused in Bradford and then sectioned to. They are backed by Rothschild. Their boss earns 450,000.
Then in Sheffield, we have Life ways, a Canadian Pension Fund investment group, who owned the Kingdom House, where Thomas, was taken from, to a privately owned ATU, but paid for by NHS, where he died, not sure, but probably owned by same COMPANY.
Lifeways, the name says it all, also own, all the Autism Care UK holding, and, supported living units..
These venture capital cabals, employ all their own experts, psychiatrists so huge cabal, and conflict of interests, as if they don’t do, as employer all for profit want, they will lose their contracts.
So there cannot be, an independent voice, or check. That is why so many are dying.
This would not happen in US, as insurance based, and the companies, would sue to regain their loses.
Finola we know we know, BUT WHAT CAN WE DO/
A lot more.
I have just been reading, the National Autistic Society Accounts, in the Charity Commission website
And, all interested, should read these, and, the major epileptic charities ones.
And then wonder, what has been done, over the past 20 years, with all those billions.
And, why our autistic/LD/ epileptic, are worse off ,than they have ever been, with 3 a day dying needlessly, and, the MCA removing parents, and, the disabled decisions for life.
Particularly, when more than ever, is spent by the government on autism, and, more than any other condition.
A £ 4500 min per week is paid for their ‘treatment’, £3,500 for their enforced supported living, and, residential education.
By a plethora of companies feeding into all this money, as well as the National Autistic Society- LIfeways, Autism Care UK, building new units and assessment centres.
All this money available, and increasing, yet the outcomes for the autistic/LD, and their families ever worsening.
As they are removed from the community, medication enforced for life in private increasingly venture capital backed modern day institutions.
The idea of our charges being driven to extremes of distress, then sanctioned and restrained because they are distressed, then left to rot because there is no-one with the wit to comfort and calm them is the stuff of nightmares.
Think I would become “dangerous” if treated that way!
How can these terrible things go on happening?
A big factor in this situation is LB asked to go home on more than one occasion. ,Where was the support and why as in so many cases were the family seen as the enemy. Who and why did someone want to make a statement and use power over sense, the facts of what was in his best interests. Families do more on a shoestring and get it so right just with love and instinct,please start listening to them and stop trying to break them apart.
Because all learning disabled/autistic, have been made commodities, for a huge private NHS, and social care industry.
They can make, at least £3,500, in supported living, hand in hand with the private Adult Treatment Units paid £4,500 per week to drug. Some are owned by the same venture capitalist companies.
These are self regulating, and unaccountable, even for the drugs they administer, and the amount they charge.
One mother tells how an ATU charges now 12,500 for her child per week.
LA Cost cutting is just an excuse, to forced by MCA COP, all 18 years olds, into this lucrative industry, which is in secret, and boosting our economy, but hugely increasing the deficit.
This money is what we as parents, and the disabled, have a statutory right to, under the Chronically Sick and Disabled Act 1970,which has been hijacked by the state, to make private profit out of the removal of parents and childrens EU and Human rights, abuse, torture, neglect and, even death.
So much sense being spoken!Thank you all.
Hmm, ‘an ACT of tragedy’? People often use the word ‘tragedy’ to imply it was ‘just one of those sad things that happen, nothing we could do’. But using that word ‘act’ is significant. Tragedies in the dramatic sense involve ACTION and INACTION (or, if you’re of a religious bent, sins of commission and sins of omission). Tragedies don’t just happen; they are a chain of events set in motion by wrong choices, fatal flaws, misplaced confidence, poor information. Classifying something as tragedy does not absolve you, Dr M.
Hear hear! SPOT ON!
GMC are toothless, they acknowledge ” regrettable decisions ” and concede that ” if such actions had taken place it would have been good practice “. No pinning an investigation on compliance with their own guidelines and as they are only too willing to accept ” no real prospect of challenging registration “. We observed for ourselves ” failed encounter ” set against an urgent fax sent to the specialist monitoring and supervising from the GP, a response was made by letter 18 days after death had occurred and 30 days after the original urgent contact. No referral for the specialist nurse who admitted ” degrees of confusion “. There are capable and competent health care professionals, but you have no guarantee that those assigned to your loved ones are among their numbers. Catastrophic poor practice appears to fall within a wide margin of acceptable failure.
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