Been at a Broken Narratives conference this week in Prato, Italy. Fascinating papers and people, good company, sunshine and piazzas. What a privilege. Now I’m thinking about Verita and the two ‘independent’ reviews they did about LB [howl]. For which they must have been paid a costa del fortune.
We were naffed off with the second review pretty much from the start really. And the finished version made no sense. Having read the transcripts from the staff interviews for the first review, shared with us before LB’s inquest, our confidence dropped to the level of ‘What the Verita?‘ Flimsy interviews, heavy on the interviewer blather and little or no probing.
Mmm. What the Verita indeedy?
The second paragraph on their website blurb is a bit peculiar. It seems to be a veiled way of reassuring organisations [the NHS] that might want a bit of shonky, that they do a good enough job without doing a thorough, robust and warts and all investigation. Stating our approach is always measured, appropriate and focused on improvement pretty much says ‘we do superficial, skeletons remain buried and we’ll come up with a few suggestions’. And this is exactly what they did.
The first review, focusing on the immediacy of what happened to LB, failed to uncover that a patient died in the same bath as LB several years before. Despite two of the staff Verita interviewed being present on both occasions. [No words]. Despite the original terms of reference (a) including direct reference to the earlier patient and the slightly revised terms of reference (b) alluding to it:
(a) ‘to review how learning out of concerns from a previous similar incident has been embedded in practice and informed care practice and safety’
(b) ‘to review how learning out of concerns from any previous similar incidents/external reports has been embedded in practice and informed care practice and safety.’
Verita just ignored this in their first review. Their methods simply failed to uncover what was clearly a very well known about earlier incident. I suspect it’s hard to ‘forget’ being present when someone dies whatever the circumstances…
In an NHS hospital.
In a bath.
And a second person dies in the same bath
Nah. It really shouldn’t take a police investigation, an unfinished HSE investigation, two ‘independent’ reviews and almost an inquest to not unearth this.
Moving onto the baffling and serious pile of crap, second review (Verita2). We declined to comment on the draft we received last summer. George Julian who represented us on the expert review panel similarly withdrew from the process. She details her 10 reasons why here. I wouldn’t recommend wasting time reading the review. It is truly nonsensical.
Sloven’s legal team clamoured to get Verita2 admitted as evidence to LB’s inquest while spending £42,000 [of public money] in legal fees to try to sink publication of the Mazars review. [This underlines how non independent Verita really are]. It was eventually published, to silence at the end of October 2015.
Last week (was it really only last week?) we were leaked a Quality and Safety Review written by a Sloven employee in August 2012. This clearly documents numerous failures at STATT where LB died and the next door unit, John Sharich House a few months before Sloven took over the provision. In Verita 2, Finding 5 states:
The trust undertook appropriate, adequate and reasonable due diligence into the quality and safety of the services prior to acquisition. The due diligence reviews did not identify any acute concerns about the safety of services in STATT. The more acute concerns were focused on the non-Oxfordshire services.
Mmm. Awkward. Gut wrenchingly, howlingly, awkward.
I emailed a Verita partner to say, erm.. little bit of a cock up here, matey. Twice. He emailed back, very sharpish, to say they’d seen the review I mentioned [clearly they hadn’t or they couldn’t possibly produce Finding 5] and there was no mention of the earlier death in the staff interviews. He finished by saying Verita ‘obviously investigated in detail the processes and practices within the unit – these underpinned the conclusions reached in the report’.
I think, in this inhumanely long, tortuous and consistently distressing journey we’ve learned there is nothing obvious on the part of the actions of any of the state, or state appointed representatives, other than deny, deceive, batter and deflect. Verita did (can’t even call it conducted) two, very well paid, reviews. Neither hold up to scrutiny.
I thought my email would lead to them seizing the opportunity to defend their independent, robust and experienced reputation. And turn a lens on their practices; retract, respond, revise and openly talk about what they will do in future to make sure NHS Trusts disclose all the relevant documentation. But that was before I read their website blurb.
[Fill in your own words here. I have none. And feel free to swear your fucking socks off].
I listened to a diverse set of papers in the last few days. Thoughtful, engaged reflections about listening to the experiences of people who may not be able to articulate their experiences in ‘recognisable’ ways. People who are too often silenced by the actions of others (including researchers).
About trying to open up, challenge and change academic practices (it was an academic conference..) We heard narratives about dementia, cancer, trauma, brain injury, hearing voices, autism, sexuality, child sexual abuse
I’m now thinking that there are some truly broken narratives in spaces you wouldn’t think to look.
Common flaw; in obtaining the ‘truth’ you don’t upset the paying customer or word gets round and you don’t get new or return business. Ask any honest consultant in or of anything, and they will admit this?
The HR director who was assessed by a consultancy I worked for was the most incompetent of the assessed Execs of a struggling Public Organisation, and he/she held the consultancy budget. ‘What to do, what to do…consultancy partners wrestled with ‘tell them the truth…then …..’ probably not’??
Painful advice is not a good move where big ego’s live. Pragmatism rules with a long term head .
Many canny consultants are experts at keeping a red hot investigation running on till it cools a bit, and the fees coming in, and then delaying a report for ages till all the very bad stuff is hopefully forgotten; then burying all unavoidable facts in pages of empty text wrapped round a very well sugared pill.
No idea if any of this has happened here.