More tales of dismal practice and bullying at senior Sloven levels are arriving in the shed. [Thank you for speaking up]. Apparently Mark Morgan, the Director for Mental Health and Learning Disability has a bit of a tawdry background. A serial interim manager, he was reported to be earning £28,000 a month back in 2014 at the Medway Foundation Trust. His director blurb on the Sloven page states:

Bit of a funny statement about ‘pending a recruitment process’ but it turns out that Morgan (allegedly) wasn’t appointed when he was first interviewed for the post. Not very confidence inspiring and means he was an interim for longer than necessary [yes, my fingers can barely type these words, the level of absurdity is so extreme.] Prof Hatton was keeping a careful watch on the data and tweeted:

Mark Morgan was paid just under £300,000 for 8 months work.

[Fill in your expletives here:_________________________________  I’m out]

This afternoon, a 38 page investigation report into the care of a patient at the Ridgeway Trust. This is the assessment and treatment unit that takes Oxon patients now the STATT unit is shut. The harrowing complaint, made by the patient’s mum (terribly difficult woman I’ve heard, and no doubt has “hostile” written all over her son’s files) has 29 items relating to the unit in 2014-15.

The covering letter is from Julie (scores on the) Dawes who must be wondering what she’s wandered into but I’m assuming Mark Interim Morgan must have signed it off. It’s under his remit. A tiny bit of context here for any new blog readers:

In 2013 the CQC failed an inspection of the STATT unit where LB died. It found a hideous set of failings including a lack of therapeutic environment [howl], poor record keeping, no involvement from people using the ‘service’ and so on. 

Today’s report upheld complaints in 13 different categories of complaint:

access to services, communication, discharge, nursing care, failure to follow procedures, record keeping, attitude, clinical care,funding, medication and prescribing, aids and appliances, code of openness and equipment

Some low lights:

• A lack of active engagement with the patient’s mum.
• Failure to record incidents on RiO or Ulysses or inform families
• No therapeutic engagement with patients
• Little access to the community because of low staff levels
• A distant and unhelpful psychiatrist at the team meetings
• Misreporting of the patient’s activities at the team meeting
• Inconsistent communication
• Failure to effectively minute meetings or act on action points
• Trust and NICE guidelines were not followed around medication use
• No specific care plans or risk assessments around observation levels* and their purpose.
• No discharge report received ‘because of an administrative error’.

LB didn’t get to the discharge bit. Otherwise this is pretty much a repeat of the failings identified three years ago. Sloven clearly are clueless and have no learning disability and mental health expertise at senior level. They don’t get it and they don’t give a shit they don’t get it. While Dawes is cognisant of the failings the report identifies how can any patient/member of the public have any confidence that the recommendations (listed below) will actually happen? We have been told over and over and over again that lessons have been learned and improvements made.

I’ve nothing else to say about Jeremy Hunt, NHS Improvement, NHS England, Oxfordshire County Council and the Oxon CCG. It’s all been said repeatedly.

The system is clearly broken.

* This reminds me of LB’s psychiatrist (currently missing in Ireland) who when asked by Paul Bowen to explain the difference between an observation and a ‘check’ at LB’s inquest, said “Ah, now I’d have to really drill down to do this”. These are people’s lives.