Summary of a 4615 word letter about what happened to LB below sent [to anon] by an Oxon Commissioner in 2014, forwarded to our legal team just before LB’s inquest. Beware the wrath of middling/senior public sector figures if you want to publicly document your experience of public sector provision is clearly the message here. An illustration of the toxicity of local authority/CCG practice. [Rage warning.]
A tale of mother blame.
Deference to a bereaved mother means that she has been able to tell a partial story. This is frustrating. I know through inside information that not all that’s written on the blog is accurate. I mean LB’s recent diagnosis of epilepsy was the least of the family’s worries. The children’s team told me this. His mother often rejected support only to come back wanting it immediately. She accused social services of harassment and told the social care manager she should have read her Facebook page to know she wasn’t coping.
It’s my understanding that his mother was the one who pushed for admission. She didn’t want LB home and was pushing for a supported living service that can’t be magicked up in a few weeks. [Christ]. She refused an increase in LB’s direct payment package and never made a complaint which was obviously the sensible thing to do.
It was clearly a difficult time if you read her blog however not everything she reported was accurate. She frequently took lines out of emails people sent her out of context and posted them. And wrote things staff disputed. A colleague was trying to get LB out of STATT but because Sara Ryan didn’t want him home, they didn’t push it. In hindsight, they should have just discharged him.
I’ve read the minutes of the Care Programme Approach meeting where bathing was discussed. There were no minuted objections from the family to the idea that he should be left alone in the bath. He hadn’t had a seizure for a year so although in retrospect, 15 minute checks look unsafe, it may have been a reasonable risk assessment at the time. His mother and her friends tried to make the CPA meeting person centred and this was why vital things could have been missed. You can’t really have person centred planning fitting with clinical health processes. [Tsk].
I know that Sara Ryan doesn’t think this but the majority of STATT staff are very caring. People cried all weekend after LB died and still people are shaken and upset by it. The huge amount of negative publicity that has been generated continues to cause them immense stress. Sara refused to speak to anyone except via her sister and has made it difficult for open honest communication.
Once STATT was closed, and SR was banging on in social media land about stuff, we’ve been unable to do our jobs properly. Patients have nowhere to go and we’re too scared to say anything because of that pesky blog. I still believe that the worst services were always outside of Oxfordshire. The trouble is that SR’s anger is unproductive and her blog is causing problems. She names and shames people and causes illness. One friend was off work sick for two days as a result of one post. I believe her campaigning has done a lot of damage.
I originally thought LB could have died anywhere but I now know [after publication of the original Verita review] that Sloven were responsible for his death. Despite SR refusing to speak to anyone, Sloven did themselves no favours by retreating. We usually do a quality visit after an unexplained death but the police and HSE were investigating. We asked the local NHS England team for the highest level of investigation but it wasn’t until SR spoke to David Nicholson that Verita were appointed. We argued for a family advocate but weren’t listened to. We didn’t visit STATT ourselves because a lot was going on and before we were able to review the unit the [pesky] CQC pitched up. They used a new form of investigation looking at stuff they wouldn’t usually look at (medication storage, clinical waste, batteries in defibrillators and so on). The CQC inspector gave us mixed messages and I certainly felt there were some wider politics going on.
I was really shocked by the Verita findings and had no idea that LB was experiencing increasing seizure activity or that risk assessments weren’t being conducted. I believe we at OCC had no way of knowing that we weren’t being told the truth by STATT staff or that Sloven weren’t checking on things. It’s the STATT team who will have to live with LB’s death for the rest of their lives.
I do think in hindsight we could have perhaps followed up on the blog and done some more checks in recognition of the fact a new organisation was taking over, but we were so stretched, I don’t think we could have done much more than that.
I know LB’s death was horrific and upsetting and I know his mother will never get over it. But you can never guarantee 100% safety and it’s not good for people to be continually checked. I’m fairly confident we’d have picked up STATT’s deterioration at our next visit (we do it all the time) but sadly it was too late.
I feel immensely sorry for Sara Ryan, it is terrible she has lost her son. However, I believe bloggers have a duty to be honest, and accurate; and some of the effect of her campaigning has made things difficult not just for professionals but for other service users and families. My hope is that she can find some kind of peace with this, and that one day, she might be able to move on.
Oh fuck right off.
[I’ve never met this person].