For anyone managing to keep up with this dense (and often tediously frustrating and jargon laden) tale of trying to get accountability when your child dies a death in NHS ‘care’ (involving a dereliction of such basic care that defies understanding) well done.
To recap. A week or so ago, a second Verita review (V2) was published. This was commissioned in July 2014 to explore broader issues around why LB was admitted to the unit in which he died. A third review, the Mazars death review (M1), examining how Sloven responded to deaths in their learning disability and mental health provision since 2011, was commissioned on our request by David Nicholson shortly before he stepped down as NHS England CEO in March 2014. We thought this needed urgent investigation because of the ease with which Sloven dismissed LB’s death as natural causes. [Weep]. The contract was given to Mazars in November 2014. Another six month contract.
We fully expected both reviews to be published by June/July 2015. With the pesky general election as the big delay factor. But nah, they dragged on. M1 because the findings inevitably generated the need for further investigation. V2 because, er, it could. V2 was eventually circulated for factual accuracy on Aug 21th, M1 a couple of weeks later on Sept 9th.
During LB’s inquest the status of these two reports were continually contested. Sloven were determined to get V2 in front of the jury while chucking M1 into oblivion. We thought the coroner should have sight of M1 because the findings were relevant to a prevention of future deaths report. We found out, during this nasty piece of game playing in open court that V2 was complete. Nothing like being kept informed, sensitively. And then we were informed it wasn’t. What a mess. In a space that you’d kind of hope that the wellbeing of the family would be uppermost in the actions and thoughts of the NHS Trust involved and all related organisations. Family wellbeing? Eh? Nope. It’s all about reputation, reputation, reputation.
In the end, neither report was disclosed to the jury.
A week later, V2 was published. No further delay. Despite both lay reps (George Julian and Bill Love) disputing the findings. M1 continued to be challenged by the Sloves. NHS England took the criticisms of M1 seriously and commissioned an academic review of the methods used. [I know.]
Seems to be that an extra level of rigour is needed because the findings are so controversial. Yep. Make of that what you will. The NHS England plan for moving people out of of Assessment and Treatment Units was published last Friday. This was the subject of some criticism around resources, reach and expectation. To me it seemed to be well thought out, sensible plan particularly given the failures of everything that had gone before in the last 3/4 years (as long as the money followed the patients into the community and remained with them). It strikes me that the delay in the publication of M1 is a strategic move partly relating to last weeks news. We can’t have a report that drips death and darkness casting a shadow over shiny new plans.
The latest M1 delay news (the report of the methodology will take up to Nov 13th) came with the usual teeth jarring statement that NHS England know this will be ‘particularly disappointing for the family’. I don’t think NHS England know what this experience is like for us. I think it’s almost impossible for anyone to understand what it is like to have a child left to drown, alone, in an NHS hospital bath and then be forced to fight for over two years for accountability for his death. Please ditch the trite and meaningless statements.
Here’s a radical thought.You don’t need to wait for a written review on the methodology (you are choosing to). A telephone call with written confirmation to follow would do. Why not put this ‘grieving family’ at the centre of this vile and harrowing process for once and just publish the fucking report?