Oh dear. Reading the 24 page statement Lesley Stevens, Sloven Consultant Psychiatrist and Medical Director, provided at LB’s inquest in October 2015 in the light of the leaked document.
It’s the stuff of many posts but to kick off briefly here…
The report from Verita concluded that Connor’s death was preventable because he should have been subject to “line of sight/sound” observations whilst bathing and would have been had appropriate risk assessments and care plans been in place.
Following the CQC inspection in September 2013, the Trust stopped admitting any further patients to the STATT unit, to enable it to address the failings identified in the CQC’s report.
The same failings identified in the August 2012 review that remained buried until a week or so ago. Steven’s report (drawing on the much used Sloven technique of obliteration through jargon and word length) contains 12 pages about Sloven’s epilepsy map and toolkit. 12 pages. Completely unaware, over two years after LB’s death and all the changes allegedly implemented, that RiO doesn’t allow any recording of epilepsy information, she states:
The health professional undertaking the core assessment must assess the risk using the RIO (a software package) risk assessment form. NICE (2012) guidelines state that the following risks should be assessed as a minimum:
- Bathing and showering
- Preparing food, etc, etc
A failing so serious, the coroner flagged this up in his Prevention of Future Death report:
So blinking awkward. You’d think any organisation would be rigorous both in the changes made after the preventable death of a patient (typed this laborious phrase so many times now, I’m inclined use ‘killing’ as shorthand) and to check, double check, test and review everything that goes into a report to a coroner. Not the Slovens though. Nah. They just make it up.
Just noise. Public noise. White noise. HSJ award winning noise. And it apparently doesn’t matter.