Experiencing Mazars, fuzzy boundaries and rank closing

I was working through the open docs on my computer yesterday evening and came across a PDF called 2642_001. It was one of the numerous docs we received the week before LB’s inquest began last October last year. At that point (intense stress, distress, fear and anxiety) I skimmed through them.

I couldn’t remember this particular document. Discovered by a Sloven IT bod, buried in the dark and dank basement of the RiO system. RiO, of course, was the focus of many a boring and repetitive moment during LB’s inquest. [I’ve heard on the leak line that Sloven are currently trialling a new version of RiO… How much money, time (and lives) have been lost through such a clunky and craphole piece of software?]

LB was listed as living in Tadley, Hants. In stark contrast to the scrutiny Sloven placed on the Mazars review. Accuracy aint necessary in generating learning disabled patients records. Address? The moon. Diagnosis? Anything and everything to do with early (natural) death inevitable. His discharge date was 4.7.13 and discharge method ‘6-Client deceased’. [Howl].

Someone we’ve not heard of before ‘diagnosed’ LB with various things in this document. The speed of ‘cover up and protect’ activity very apparent here. Like the ‘Mother’s blog briefing‘ circulated within 24 hours of LB’s death.

death diagnosis

Astonishing for so many reasons. But not surprising in light of the Mazars findings. Careless reporting of and burying unexpected deaths. Constructing ‘best case scenarios’ (i.e. nothing to see here). The Sloven way. While raking in vast sums of money to ‘provide’ care on a weekly basis. The cost of LB’s stay in STATT was around £3500 per week. PDF 2642_001 details he received 1 of a possible 40 specialist assessments. The Incident Management Assessment (IMA) we eventually received via the coroner [Sloven have right old sticky paws when it comes to disclosing any information] states that LB’s seizures were rare and nocturnal.

Fabrication. Fabrication. Fabrication.

Reputation. Reputation. Reputation.

The Mazars review

There has been no real action taken in response to the Mazars findings. Publication just before Christmas was cynically timed to facilitate deep burial of bad news. There’s no other explanation. The findings clearly present failure at Board level, a carelessness and disregard for particular lives and an unknown number of deaths which could have been prevented if earlier deaths had been investigated. A breach of human rights on an unprecedented scale in NHS provision. 

According to the Monitor CEO who I met very briefly with this week if the CQC flag up any issues on their unannounced inspection in the next two weeks [I know] they will consider action. In the meantime they will stick an Improvement Director in Sloven towers. There’s no other information about this Improvement Director.

Sloven meanwhile appointed an ex-Monitor Regional Director to their board this month. Fuzzy boundaries and all that. The stench from sordid and sneaky ‘deals’ seemingly conducted behind closed doors so depressing. I think one of the resounding sadnesses in the Justice shed is how much this experience has exposed (for us) the level of collusion, stitch up and corruption that operates (without check) within these publicly funded bodies.

We received a cheeky copy of Slovens internal briefing about the ‘unannounced’ CQC inspection last week [thank you]. This briefing can be summarised as ‘get the posters up, all hands on deck, persuade staff not to take annual leave till Feb and crank up the quality of death reporting which is still rubbish’. Farcical fakery and nonsense.

We’ve now had 2.5 years of Sloven dealings. Setting aside our personal experiences, documented at length on these pages, Sloven are clearly a ship with shite leadership at the helm. Board member performance (apart from some non execs) at the extraordinary board meeting on Monday was truly excruciating. The CEO, whose only connection to leadership seems to be the number of times she mentions the word, repeatedly deferred to the Chief Operating Officer who cooed beside her awkwardly. When asked directly how he felt about being cosied up with the leadership trinity of Percy, Petter and Grant, he broke into an overly long speech which included the word ‘proud’ so many times I expected the Dambusters film score to burst out from some hidden speaker in the cramped and heated room.

You could argue (and I’m sure that the Monitor/CQC/NHS England trinity have) that being faced with a room full of raging members of the public after publication of an incredibly damning report can only be unsettling. But there’s no evidence of effective Sloven leadership in any setting/context. A focus on expensive nonsense like the ‘Going Viral’ programme; an inability to see that they are spending money on crap consultancy;  minutes and quality and annual accounts you can drive an Eddie Stobart truck through;   recorded performances online that are unconvincing... The list is endless.

A favourite in the Justice shed – Woman on all Fours – is just one example of this:

Humour aside. It’s clear that people are dying early and unexpectedly in this organisation. Denied the opportunity to lead everyday lives. Doing stuff that other people just do.


Sloven routinely ignore and cover up the deaths of certain people. We know this. And this is apparently acceptable across NHS England, Monitor and the CQC.  Perhaps it’s time for some honesty (candour and transparency) across these publicly funded bodies. Either have the guts to say that some lives aren’t important and if these people die early, that’s fine.

Or fucking do something about it.

16 thoughts on “Experiencing Mazars, fuzzy boundaries and rank closing

  1. Dear Sara

    I hope you don’t mind me posting a comment anonymously.

    I work in a hospital, but not in mental health.

    This department has been the subject of two recent external reviews. Both identified one of the managers as ( a significant part of ) the problem, as black and white as any of these reports could, eg: “ a culture of dysfunctional management, at the top”. It didn’t name her, but everyone knew who was being written about. A couple of months later, the findings of these reviews watered down by the hospital board, I learn that this manager is leaving. She’s going to be working in mental health now, in another hospital. There’s a memo to staff announcing her departure, praising her for all the wonderful work she has done. She sends a letter to staff herself, she’s enjoyed working with the fabulous team so much, etc etc. It is all a pack of lies.
    Our department paid bucket loads of money that could have been given to care, for fancy logos “Transforming Our Service”, expensive consulting teams to “manage the risk” from these external reviews. There is almost a recipe for this. It is a recipe that Sloven seems to be following too. Sara, they are never going to change. They don’t want to. They want to give the illusion that care is being provided without actually providing care. They want their performance bonuses, their perks, their nice comfortable salaries, and so, they pay their buddies to maintain that part of the status quo. There are people like Katrina Percy all the way down and all the way up and all the way sideways.

    What’s the solution? I don’t really know. It is unfair the ways that ordinary people pay for all of this. They pay the salaries of these people, they pay for the fancy external reviews and for the slick responses to these reviews. They of course pay with their health and their loved ones lives.
    Those ones, like yourselves, the only thing to do it to leave the abusive relationship and to try to warn others from entering into it. I don’t see any other solution at the moment, but believe me, I am trying.

    • If only we could leave this abusive relationship – emigrate? No-one will take on a care package that costs millions. Finola Moss says it all

    • The one thing we can;t do is give up an accept it. Indivdually we are powerless and vulnerable but Sara has shown that refusing to shut up can have SOME effect. These things are, and should be, a scandal – the sheer wicked waste of public money. The fellah who got sent down for blatant stealing probably believed he was fireproof. No-one is.

      • It is difficult not be depressed at the way SHFT/KP et al, and neds and govs appear to have just walked off holding hands and smirking.

        But, things rarely happen quite that way in NHS at Board level. There will be execs and neds that have little respect for each other; who distrust and dislike each other. And who are increasingly concerned about the lack of respect shown to Sara and family, plus shoddy care, weak governance and incompetent leadership etc, This will simmer. Relationships at Board level in NHS are rarely all that chummy. I have seen better behaved playground brawls than the open dislike expressed between some execs.

        A big brick of integrity, honesty and openess has been dropped into SHFT …and the ripples will be rippling……

    • Spot on.

      This is exactly the position.

      And anon, you are so right.

      The first thing we must all do, is stop pretending the situation, is not as corrupt, as you describe, and so dire.

      And stop making excuses for this corruption and horror.

      This is, all about making as much money as possible, out of our most vulnerable, for the worse service, self preserving and covering up.

      Why, because they are allowed to, by a government that is now exposing all this, to privatise mental health, and make the service even worse.

      As, mental health services, with its Emperors Clothes treatment, that consists of drugs and cages is the most lucrative part of the NHS.

      Thank you for telling the truth.

  2. Thank you for being honest if only their were more people that would be this open. ,Yes we are paying for slogans and offices when we want to see the money go into care and staffing levels. Please the price of losing loved ones is too high.

  3. So they’d had LB in their (couldn’t) care (less) for three and a half months, and only arrived at/wrote up ‘diagnoses’ after he died? How is that not fraud? I hear noises suggesting that NHSE is a lot hotter on fraud than it is on preventable deaths…

  4. Lots to do but had to find time to comment – I’ve been struggling with Sloven’s ‘sticky paws’ not for 2.5 years but for 4.5 years (since September 2011) and now have prima facie proof of a concerted, deliberate violation of The Data Protection Act 1998 and The Medical Act 1983 by two current and two ex-Sloven Directors since September 2013. The effect is that Sloven was successful in perverting the course of a GMC inquiry and are attempting to pervert a GMC Rule 12 Review and inquiries by two Ombudsman.

    I won’t make myself popular with the next comment but credit where credit is due – I only started to make real progress on after a clandestine meeting at home with Mike Petter on 28 October 2015: the executive directors were so unprepared that, by the time I receive a full bundle (promised by 27 January 2016) another three months will have passed. This despite interventions in 2014 and 2015 by the Information Commissioner, the Department of Health and the National Audit Office, whose interventions Sloven defied. Looking forward to seeing what’s lost (known to Sloven as accidental shredding – usually blaming RiO) and what’s inaccurate.

    One final point relating to the CQC’s perversely named “unannounced” inspection in the next two weeks. This suggests they will have inspectors in the area when the next ‘Bored’ and Governors Meetings take place in Lyndhurst on 26 January 2016. It will be interesting to see if they bother to send an observer – there they can talk to a number of survivors and families of the deceased all in one place on the same day.

    Will they have the balls to attend? Any bets?

  5. Just read the gruelling heartrending report on investigation into Ely Hospital, (a must read for Board of SHFT?) where the lengthy recommendations include:

    ‘More attention must be paid to unexpected deaths’
    ‘Found a casual approach to unexpected deaths’. etc etc etc

    Investigation report of 60years ago, and still no change……. But ‘lessons have been learned’…KP, SHFT, January 2016

  6. See (damning) Ely hospital abuses investigation report, 1969:

    ‘Recommendations’; from 560 to end. All could have been copied from the damning Mazars report on SHFT, Dec 2015

    ‘lessons have been learned’. KP Jan 2016

  7. Ely 1969 cont: Conclusions and Recommendations chapter 13.

    ‘Medical care and amenities’
    595. ‘cases of sudden death must be more thoroughly investigated’

    ‘Quality of medical care’
    510. lack of energy and sophistication in record keeping

    ‘Nursing standards’
    ‘an unusually casual attitude taken towards sudden death …….
    (para 237-239)

    lots and lots of more………………………..of the same. ?

    and of lessons not learned ?

  8. Sara and Trudy
    Awake for most of night, I have read the whole of the Ely 1969 report. Heart, bone and gut wrenching. Kept asking, how could this have been permitted for so long? And is still happening. So f’ing little learned.

    1. lack of relationship/integration between Ely and Local Authorities. Nil monitoring of care.
    2016, SHFT LA commissioners keeping very quiet?
    ( 2016 we have ‘care’ delivered by anyone without criminal record, (in community unseen) and not monitored at all by LA’s ?) What is happening out there – who knows, only families? Whose concerns and complaints are still treated with disrespect

    Report 1969 includes:
    2. Families and staff concerns dismissed /intimidation of
    3. Staff who complained forced out
    4. Appalling deaf leadership
    5. Managers, senior clinicians and professionals blocked complaints

    This report has to be revisited in the context of current leadership,attitudes, values, beliefs and behaviour today?

  9. Sarah British medical journal 23/1 letters page. Letter of the week is a Dr calling for a Royal College of learning disabilities. Points out that learning disability is NOT an education pathway for Dr’s or allied health and that there is a lack of training and inadequate services.
    Connor’s photo illustrates it. I wondered if you had seen the letter?

  10. Pingback: Of mice and (NHS) monstrousness | mydaftlife

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