Monthly Archives: March 2016

‘Did you tell them LB had epilepsy?’

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imageThe other week I had another interview to do with ‘LB’s case’. He ain’t a case but he’s become ‘a case’. Nearly three years on. Not to us but to officials around us. I don’t think he even qualified as ‘a case’ for Sloven initially. He was less than human. Less than a case. Like the other 330 odd people who died in their ‘learning disability care’ between 2011-15. Tossed aside without consideration. A two bit non human service user with a pain in the arse mother who blogged about her son’s experiences.

The interviewer at one point asked me

‘Did you tell them LB had epilepsy?’
Eh?
‘Did you tell the staff in STATT LB had epilepsy?’

I eventually managed to breathe again, stop the tumbling tears and say, without swearing, that LB took daily medication for his epilepsy which we handed over to staff on his admission. Of course we fucking told them.

[I didn’t bother saying about the time we were phoned to ask if we had additional medication because they had run out, or that day in May when I told them, phoned them and emailed them to say he’d had a seizure they hadn’t recognised. Or that unknown to us, the psychiatrist went on to insist LB wasn’t having seizures…]

So. Yes. We told them… why the fuck are you asking me this?

I was embroiled in twitter exchange yesterday with Human Factor (HF) protagonists. An approach that focuses on learning not blame. I don’t know. I find the HF bunch a bit evangelical. And the whole idea that preventable deaths are ‘golden learning opportunities’ makes me feel ill. Unfortunately our ‘meeting Jezza Hunt’ experience was pretty depressing as he insisted a HF approach would lead to safety improvements across the board. Thereby improving the currently dire mortality rates for learning disabled people. No Jezza. Stop it. Just stop it. But he wouldn’t.

What is astonishing is the focus on protecting staff. Creating a safe space so staff feel they can tell the truth about what happened, about what went wrong. So that ‘golden learning’ can happen to prevent people dying in the future. Meanwhile, parents/families can be implicitly, or explicitly, blamed and crushed by the process.

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Talking of which, 12 Angry Women premiered on Friday night at the Brighton Dome, packing a punch or ten. Edana Minghella, one of the writers, wrote a short piece about LB and composed a song; ‘The Mother’s Song’. Just astonishing. In a 10 minute piece, she wove together a combination of blog extracts capturing LB as a quirky, funny and much loved dude and ‘official’ commentary contrasting the brutality of what happened and what followed. It included the mermaids, Afghanistan, slavery, wanking, social media and toxic mothers.

There were three characters each of whom were performed brilliantly by Gem Bennington-Poulter (LB), Leann O’Kasi (me – bit odd saying that) and Richard Attlee (Generic Official Person). The latter was a mix of the coroner, Sloven, NHS England, the CQC, Monitor and Jezza rolled into one. You could hear a pin drop in the packed and boiling auditorium as the story unfolded. Tears. And more tears. And the song is simply beautiful.

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Light in the shed

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I wrote an ‘opinion’ piece for the Guardian about the latest Bubb stuff this week. Loftier heights than this blog without the swears really. I’m flagging it up here because I’m chuffed they asked and beyond delighted it’s had so many shares and brilliant comments. Learning disability hitting a mainstream groove. About bloody time.

Today we’ve an extended family trip to Brighton. To watch 12 Angry Women at the Brighton Dome. Edana Minghella, one of the 12 commissioned writers/artists, has written a short play and composed a song about LB. Her script and song are simply spine chillingly brilliant. And devastating.

Yesterday, Edana was on BBC Radio Oxford talking about the play. [From 10.48 mins here]. Having walked past an Eddie Stobart lorry on the way to the studio…

eddie stobartTurns out Mark Attlee who plays Kenton in the Archers is the Generic Official Person (GOP). I don’t listen to the Archers. But Edana nails the contrast between the chilling interjections by the GOP (a lukewarm brew of Sloven, NHS England, CQC, Monitor, Oxfordshire County Council, Department of Health, coroner) and the love and humour that is part of many families’ everyday lives.

A photo from rehearsals yesterday.

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So LB will be on the stage tonight. Nearly three years to the day he was admitted into the unit. A big old hanky moment. But how blinking cool?

A sordid little fail tale

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

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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.