State sanctioned cruelty

L1020557Rich and I were back on the bus to London at lunchtime to meet with Norman Lamb and the Health and Safety Executive (HSE). Brilliant sunshine on the walk from Victoria to Westminster. People going about their daily biz. Three years and three days after LB died a preventable death in the care of Sloven Health. 266 days after a jury determined LB died through neglect. And still no accountability.

The meeting, at Portcullis House, largely involved discussion around the length of time the HSE investigation has taken so far as detail couldn’t be discussed.


Our love for Norman Lamb has been a constant since the curry night when we first met him. He was instrumental in getting the HSE to investigate LB’s death. Writing to the CEO after the HSE originally decided not to investigate. I’ve not seen him in action up close before today. He was deeply impressive, carefully questioning the HSE trio throughout the meeting.  Sense, clarity, knowledge and sensitivity. Pinning down timings, process and progress.

Why did the HSE decide not to investigate originally?

I assumed when I was informed there would be an investigation it would happen straightaway.

Why is it taking so long?

Why did you not work in tandem with the police?

This is not being given the seriousness it deserves. I can only conclude it’s an indication of how learning disabled people are seen as less than human…

It amounts to cruelty to take this long. It isn’t complicated what happened.

I don’t understand why it is taking so long

Where does the failure lie?

There were mixed answers, some contradiction and non answers. The back story is that the HSE originally decided not to investigate because they decided (no idea why) that LB died as an outcome of a clinical decision. [Howl]. After Norman Lamb’s intervention five HSE people reviewed the decision and, with particular focus on the Verita report, decided to investigate. Apparently there was some blurring over investigative responsibility while the police were still involved and the HSE took primacy for the investigation after LB’s inquest in October 2015.

The HSE inspector finished her report in February and it then got stuck in some interminably slow process of internal checking for around five months until this week. It’s now been sent to legal advisors and next steps are expected to be announced at the end of October…

It’s taking so long because these things can do, it depends on the complexity of the particular case, because there was a lack of clarity over responsibility. It most definitely is not related to LB being learning disabled or (slightly less emphatically) because an NHS Foundation Trust is involved.

On the bus home, I had a look through recent HSE press releases. Three bath related investigations since December 2015.

Joseph Hobbin died in June 2013. Ark Housing Association pleaded guilty and were fined £75,000. [December 2015]


A patient died in April 2008. NHS Kent and Medway Social Care NHS Partnership Trust pleaded guilty and were fined £107,000 plus £25,000 costs. [January 2016]


A patient died in August 2011. The European Healthcare Group pleaded guilty and were fined £100,000 plus £50,000 costs. [June 2016].


Blimey. Should never have happened. Well documented risks. Legal duties…

Same old same old. An alternative re-run of Sloven related inquests over the past five years. Lesley Steven, Medical Director, popping up to say lessons learned/changes made and the CEO in hiding. A grotesque and macabre dance around death. Dripping in (meaningless) and lengthy bureaucratic processes. A fine and a non rap over the knuckles. Disconnecting and siloing. No linking between instances of shit care. To enable the wheels to keep turning.

Meanwhile families continue to be brutalised.

We know LB should never have died. We knew before we walked out of the John Radcliffe A&E into blistering sunshine that July morning. He was completely failed by the state who had a duty to care for him. Since then, evidence of Sloven failings have been unprecedented. Both in volume and the extent to which they have led to no action.

Norman was spot on when he said this is a form of cruelty. State sanctioned cruelty. With no end in sight.


5 thoughts on “State sanctioned cruelty

  1. From Dee Speers: Brutalization of a family.
    I completely agree Sara and am pleased you are finding some support from Norman Lamb…………agree totally with your final sentence…..’ Norman was spot on when he said this is a form of cruelty. State sanctioned cruelty. With no end in sight.’

    ‘Meanwhile families continue to be brutalised’………the evidence!!
    My son was also found in a bath at West London Mental Health Trust (WLMHT) where after a complete MH Breakdown he was placed under section 2 & observation ‘for his own safety’ (ironic eh!)
    Anyway he was found and operated on and moved (l believe if transferred you need paperwork as Duty of Care changes) to life support at St Thomas’ Hosp in London (as no life support beds were available. There we discussed Organ donation but was advised as he had been failed ‘NOT to let them touch the body’ I didn’t! The language around organ donation also needs addressing as words like ‘Harvesting’ only made me feel my son was only saved for this purpose?
    WLMHT continue to change their ‘story’ and won’t learn any lessons. Who says its acceptable to send possessions back to families in a bin liner marked “NHS Household Waste” …….WHY?
    An “unremedied injustice” flag was removed from my PHSO complaint file…..WHY?
    The Parliamentary Health Service Ombudsman (PHSO) delayed the investigation …WHY? seems because its now ‘historic’ it will never be investigated …WHY?
    The PHSO has resigned but staying on indefinitely (she covered up her deputies cover up of a sexual harassment case )….WHY?
    The Parliamentary Public Administration Select Committee supposed to scrutinize PHSO said OK…..WHY? (I expect because their Chair appointed PHSO!)
    Yep (unlike our sons sadly) State sanctioned cruelty is alive and flourishing!

  2. Oi Sara! Watch what you say about “Telegraph Readers”: there are Telegraph Readers amongst your supporters and other complainants about Sloven. They use “Guardian Readers” as a derogatory term.

    The rest of you: we know Sara: she will take this comment in the light-hearted manner in which it is intended. Please do the same – let’s not start a fight over what newspapers we read! We know of a person sectioned under the Mental Health Act inter alia for reading the ‘Daily Mail’ too much – to quote a Sloven Consultant Psychiatrist!

  3. Corporate Manslaughter and Homicide Act 2007,

    A Corporation cannot form an intention to commit a crime and therefore the “Identification Doctrine” is used to overcome it. The court must be able to identify the acts or omissions onto those people who have control within the company, which means sufficient seniority in the company. This is often called the directing/controlling mind of the company. There must also be evidence to establish the link.
    This attribution doctrine means that the gross negligence which caused the death can be linked to a person(s) carrying sufficient responsibility.
    An organisation will be guilty of an offence under s1 if the way in which its activities are managed and organised causes a person’s death (and this must be a substantial part of the breach, s1(3)) and amounts to a gross breach of a relevant duty of care owed by the organisation to the deceased.
    The relevant duty of care is defined in s2 as including the duties owed by organisations under the law of negligence
    The breach of this duty of care must be gross which means the conduct must fall far below what can reasonably be expected of the organisation in the circumstances.

  4. And meanwhile, Sloven patients’ loved-ones have to travel 80 miles to visit them.
    Everyone in the South of England could work out why Sloven has staff recruitment problems (or ‘challenges’ in NHS-speak) – any volunteers to work for an organisation like that? I thought not. And so it will go on until Percy and Stevens get the boot.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.