The big shocker (and there were were several) during LB’s inquest was the revelation on Day 4 that a patient died in the same bath as LB in 2006. The Responsible Clinician let it be known, through her counsel, that she had been actively discouraged by members of Sloven senior management from raising the issue of this earlier death. In the same bath…

Ground spinning stuff. Sloven revealing new depths of odious deceitfulness and an astonishingly relentless determination to not be open, honest or transparent.

It transpired that two staff members were on site and involved in the response to LB and the earlier patient’s death. And (at least) two other staff members worked at the unit in 2006. I wrote about this a while back.

[Howl].

How this patient’s death was not mentioned to the police, the coroner, the HSE, Verita, to us, until this reveal on October 9 2015, is just, I dunno. I’m running out of words.

He died of natural causes apparently. Though this was simply guesswork. There was no postmortem or inquest despite him being only 57 and fully expected to come out of the bathroom alive that day…

At points like this I almost expect (hope) my keyboard will spontaneously combust. The utter wrongness of what I jab out on the keys, over and over again… Wrongness and repeated wrongness. With no glimpse of right or just ever happening.

Today we got a letter from the coroner. I’ve been a bit of a champion of the coroner but my champ tokens are running out now. He said at the end of LB’s inquest he would ask Sloven to explain why the first death wasn’t disclosed earlier. I chased him up about this a few weeks ago. [Note: You have to chase up everything. No one in authority volunteers anything.]

He replied:

I received an apology from the trust in December and an explanation that there was no active decision to withhold the information and that it was simply the case that the matters known to the trust did not suggest that there was a real link to LB’s death and therefore it did not occur to the trust to inform me. As I say, this is the explanation received from the trust. It should have been raised earlier.

Wow. Simply just wow.

‘Simply the case’… ‘No active decision’? Matters did not suggest there was a real link? The same bath. A seizure. The same staff present? No real link? Oh, and active discouragement from raising it…

Southern Health NHS Foundation Trust are arrogant/deluded/I don’t know what enough to defend the indefensible even after the Mazars review findings are public. How could this person’s death not be relevant? And who are they to decide whether it is or not?

What sort of monstrousness are we dealing with here?

The coroner finishes with the statement:

I am afraid that I am unable to assist or comment any further due to the fact that I no longer have any legal jurisdiction once a case is concluded.

So Sloven should have raised it but they didn’t. Hey ho. Nothing like a bit of one way wriggle room to the moon. Cards stacked clearly in favour of the system. Against people/families. A simple siloing which enables every official to pass the buck. My bit is fine. I’m ticking the boxes involved in my role. And I don’t have to look at the bigger picture.

Until the various players/actors involved in or associated with this almighty mess are prepared to step up and act, we may as well chuck in the towel.

Here’s a thought. Why not give stepping up a go?