A sordid little fail tale


Back in the day (2011), a staff member wrote a letter to the Sloven CEO raising concerns about various things including safety. She concluded:

Holder docs 1

The CEO bounced the letter to the Associate Director of Governance who wrote back saying that there were concerns and  unfilled vacancies in the governance team including a lack of suitably qualified health and safety leadership. An interim Head of Health, Safety and Security was to be appointed for 4-6 months.

This interim head was Mike Holder. A couple of months later, Holder resigned over concerns about Sloven safety culture. He wrote a report in Feb 2012 detailing these concerns:

At present it is my professional opinion that Health and Safety is considered an adjunct to the Trust’s core business rather and integral element of it.  This assumption is based on my experience with the Trust to date, the lack of resourcing applied to the management of health and safety and information governance with regards to the maintenance of statutory records.

Blimey. Warning lights a go go.

But no. By this time the Sloven headlights were on an NHS organisation, the Ridgeway Partnership, 100 miles away in Oxfordshire which included the STATT unit in which LB died. Ridgeway had some chunky land icing to tempt outside Trusts (including Calderstones) to take it over.

The story can be taken up at this point by the shuddery Verita 2 report*  which found that after Sloven ‘won’ the Ridgeway in November 2012, the roadshow bolted back to Sloven towers, more senior Sloven staff resigned and the Oxfordshire services were left to fester in a slow cooker of discontent, fear, malaise and isolation from the mothership. Extracts from the Verita report state:

6.42 Difficulties arose soon after the acquisition in ensuring the availability of sufficient senior and experienced divisional managers to take forward vital post-acquisition actions. In particular to progress actions arising from the various quality assessments that had taken place before the acquisition.


6.50 A ‘business as usual’ methodology for a newly acquired service may appear appropriate if the service being acquired is mature and relatively problem-free. This was not the case in the Ridgeway services. Contact Consulting had warned of issues in local leadership; governance of serious incidents, along with particular difficulties about care issues in non-Oxfordshire services. There was also a need to begin dealing with the cultural change required of an established learning disability service joining a large mental health and community trust with a small learning disability service.

The writing on the wall. A baguette crumb trail through the NHS forest of cover up, fakery, denial and self interest. From 2011 to the present day. Evidence, evidence, evidence. Death. And evidence and death.

So where are we at? Two months after publication of the Mazars death review.  Almost three years since LB was admitted to what we thought was sharp, specialist unit with a tiny number of patients and a shed load of staff… Five years after the original whistleblowing letter?  Hold on to your hats, folks. We’re waiting for Monitor (NHS snooze hounds) to appoint a temporary, er, Head of Health, Safety and Security Improvement Director.

Yes. Really.



*This report really makes your skin crawl in its tortuous weaving through damning evidence to a conclusion that the Sloven board were not connected to LB’s death. The author left Verita straight after it was published.

13 thoughts on “A sordid little fail tale

  1. It makes me so fearful as I know as you do they don’t change at all
    They don’t see why because they can’t see their systems are wrong in the first place
    Minimum support a to a low priority service in the NHS but throw money at it for greed and best feathering
    They work in these services because they want to and need to
    Nowhere else would anyone so shoddy get a job and survive
    The dead wood of the century paid for and supported by people who loathe and condemn the way people in their non care have been treated

  2. How much exposure of this sickening malpractice within our services does there have to be before someone is made accountable???

  3. they should appoint Tim Bolot aka the grim reaper chances are he is well versed in health and safety besides finance . Perhaps other ‘ personalities ‘ will leave as soon as the improvement director is in post. The staff member that wrote the letter said it all, the CEO is the accountable officer. Reminds me of the harrowing conversation broadcast between the coastguard and the Captain of a sinking ship, ” you will climb the ladder and return to your ship and you will give me details of your passengers “.

  4. If Sloven had put the same amount of time, effort and money into looking after the people in their care as they have in arse covering, families who have lost loved ones would not be living this nightmare today.

  5. In an earlier post, Sara reported she had found out the names of six nurses referred by Sloven to the NMC. Sara added, “Six. And no medics.” Sloven conveniently forgot to refer the Registered Nurse who, in KP’s absence was (according to one of Sara’s earlier posts) in overall charge of Sloven at the time of LB’s death – one Sue Harriman. I have remedied this today and have an NMC caseworker calling me tomorrow – I chucked in a couple of other Sloven nurses in management positions too. As usual, Sloven is dumping all the blame on junior staff.

    Reporting Sloven Registered Nurses to the NMC is becoming a team sport!

    For more Sloven scandal – KP and SH amending a letter drafted by so-called independent reviewers of quality and governance (Deloitte LLP) – in order to mislead a CCG and the DoH, go to: https://999crash.wordpress.com/blog/ – you will see images of the email exchange with only the names of the patient and the DoH and CCG officials redacted. There will be more scandal there soon – Council officials (Hampshire and Southampton) bullying Councillors to deny patients’ their constitutional and democratic right to meet Councillors. In short, covering up for Sloven rather than fulfilling their duties to Council tax payers.

  6. And if we have a Commissioner, will he read the reports and memos and ignore them as well? I know these organisations are large and complex, and change takes time, but I can;t help feeling it is more likely to come from the bottom up, not the top down, and not until people are seriously in fear of the consequences. I have zero experience of very large organisations, but some of those in charge being far more interested in maintaining their own positions and protecting each other than paying that much attention to the people they are supposed to be responsible for. If even deaths don’t rock their complacent boats, what will? Whole edifices of protection at the top, a lot less at the other end.

  7. I have had a week we would all recognise, part bliss and joy, part utter and total exhaustion.

    I have my son with me for two weeks to ‘slim him and starve him’ or ‘on our fish and broccoli holiday’. He lives with another person in ‘supported living’. Brutal ”care’ years of long neglect very poor, dangerous, nil, and for a too brief darling Rehab officer (made redundant in purge to agency support)……all left him physically disabled, addicted to cola and crap food. Minimal support means always microwaved meals. He is huge. My heart aches.

    He will die too soon unless he loses weight. I care for and advocate for his flat mate also, who has no one. Last year flat mate could/would? have died from social and medical neglect without my dogged desperate intervention. I deal with all crises for both.

    All familiar in life of a family.

    Sara you are achieving a miracle. We have hope now. Because of you Academics are looking up and pushing aside purely esoteric ideas, thinking about implementation, professionals, organisations and journalists etc…too, some out of passion for better, others pragmatic or perhaps seeing a handy band waggon passing by? but who cares if they heft their shoulder alongside us.

    Only you and your family know at what cost to you these hideous long agony years have been? We before you fought till our synapses shut up shop, were treated like irritating fleas

    it is – has always been like trying to halt a brutal mud slide, it kills our lives and takes our sons and daughters. It will be slowed, better will come because of you.

    Back to bliss and the ‘fish and broccoli. XX

  8. Weary Mother I feel for you. There can be nothing more harrowing for a mother than to see her loved one deteriorating before her eyes . It is the stuff of nightmares.

    • Pauline

      True all true, but more joy than desperation.

      I have the advantage of a fairly good knowledge of the system and law and I am still firing on all cylinders – when I raised all (again) with care manager she stated ‘you are getting more than the rest’.

      My son still has, through dogged efforts, his day care place and he benefits hugely from it, they are excellent and his dietary needs are seen as a priority and protected there; all credit and thanks to the staff. Others equally needy, lost their day care service and are, as are their parents, a struggling neglected hidden statistic.

      So much hidden misery.

  9. Weary mother – I just wanted to acknowledge the sterling work you are doing for your son and his flatmate. In a situation that you can’t control or even influence, you are doing very good work and I commend your grit. So much of what we read via #justiceforlb is about the system protecting itself, and coercing frontline employees into serving the system over service to those they should care for. People like you, your son and his flatmate are the casualties of a system that has lost its way, managers who work to preserve the status quo, and a government who wants to outsource accountability to a narrow focus on families and lowest level employees.

  10. Pingback: Sloven and the ligature risks | mydaftlife

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