News today of another inquest in which the coroner identified failings in the ‘care’ provided to Louise Locke by Sloven. This inquest was delayed a few months ago after the documentation provided by Sloven was incomplete. Classic Sloven incompetence (or worse) that generates more pain. Nothing like having your mum’s inquest bumped to the new year because the Trust who couldn’t look after her in life continue to fail her in death. Nope. Nothing like it.

Anyway, Lesley Stevens was back on inquest duty. I can’t imagine how she gets out of bed of a morning given the awfulness she must sit through and defend on such a regular basis. Still, she gave the typical Sloven corporate speak end of inquest statement about lesson learning and yadiya blah bleurghdy bleurgh stuff. I’ve pulled together a table detailing a selection of these post inquest statements taken from newspaper coverage over the past two years or so. (And it’s probably worth another butchers (and a weep) at Rich Watt’s post about lesson learning from two years ago now.)

Learning lessons

What’s interesting here is both the emphatic insistence that lessons are learned and the immediacy with which Sloven claim to act; Immediately after her death; We have already undertaken a number of actions. Bearing in mind it takes months or typically years for inquests to take place these are strong claims indeedy. I remember Lesley Stevens talking the coroner and jury through the Sloven (apparently already) implemented improvements off the back of LB’s death at the end of his inquest. Fran was sitting at the back of the public gallery gently prevented by loving mates from repeatedly shouting out ‘That ain’t true. That’s not happening…’

What have they learned?

So what have they learned? Clearly very little. You can distill down the various shiny lists produced for the various coroners to a small number of categories; family involvement (red), staff training/risk assessments (blue), record keeping (mauve), care coordination and communication (green), clinical leadership (orange) and better decision making processes (brown). There are no new and dramatic lessons being learned here. Quite the opposite. Tired old non lessons that limply lie next to the dominant and empty vital and immediate action claims.

What will this achieve?

Then finally. The transformation claims. Less evident in the media coverage (thank goodness). If Sloven want a quick win from this brief analysis it’s ditch the big claims of improvement. Awkward. Embarrassing and fallacious.

What does all this mean? A few thoughts:

• Sloven’s readiness to use loose phrases and recycled statements that bear no resemblance to proper action and accountability demonstrates their complete insincerity in actually learning or changing stuff.

• The rote mechanical reaction and vacuous use of language needs to be challenged by the Department of Health, Monitor, the CQC, NHS England, the Clinical Commissioning Groups and the media, and held up to repeated and close scrutiny.

• The fact they clearly are learning nothing from these preventable deaths demands urgent and effective attention. Hannah Groves died over three years ago and Sloven are still learning that they need to involve families and carers. Louise Locke’s inquest found that care coordination across agencies was still failing patients. Despite learning this at various points over the years.

• And finally the space none of us really want to enter but has to be confronted. If Sloven had actually learned lessons, how many people would still be alive? Fuckers.

We’ve started to regularly discuss the futility of repeatedly making this shite visible only for it to be ignored. Busker John called round earlier and Rich said two or three times ‘Hey, tell John about the latest this, that and the other..’ Each strand of telling was worse and worse. Mencap gate. Louise Locke’s inquest.The latest (not yet public) whistleblowing detail. Harrowing stuff.

‘Blimey’, I said. ‘Imagine coming round and us just saying something like ‘Wow. Lovely sunshine outside…’

‘But it never stops,’ replied Busker J. ‘There’s always something new…’

Yep. And nothing ever happens.