Ok. This is hugely important. And devastating. I’m going to go through it in some detail because it is so fucking important. And devastating.
Here’s the rub. In November 2015, the CQC inspect Loring Hall, a care home for up to 16 learning disabled adults, run by Oakfields Care. ‘Good’, ‘good’, ‘good’, ‘good’ and ‘good’ on all five domains inspected. A clean bill of health.
The CQC then received concerns around the management of risk to people living at Loring Hall.
On April 28 2016 they reinspect the home focusing on how safe and effective the service was. This produced a remarkably different picture to the November inspection. The re-inspection was conducted by an inspector and specialist advisor with epilepsy expertise. The key findings:
The inspection report reads eerily like the September 2013 inspection report of the unit LB died in. Medicines not stored properly, untrained staff and inadequate risk assessments…
Despite the list of failings identified during this new inspection (including a striking lack of training)…
… the CQC decided not issue any enforcement action:
A last bit of detail on the process of the April 2016 inspection:
On April 13 2016 Elric Eiffert drowned in the bath in Loring Hall. He was 34 and diagnosed with epilepsy and autism.
His family were told about his death on April 30 2016.
Just a few scrambled questions and comments (I can’t make much sense of any of this) largely for the CQC:
Our son drowned in a bath in a craphole unit, six years after another patient drowned in the same bath.
The first patient’s death was covered up until October 2015 when it was used as a nasty little ‘weapon’ at LB’s inquest.
Nearly three years after LB’s death (and after a Prevention of Future Deaths report was issued by the Coroner), Elric Eiffert drowned in a bath in a craphole ‘care’ home that five months earlier had received a ‘good’ CQC rating.
No one should drown in a hospital or care home bath in the 21st century. Or die unsupervised of a seizure in a ‘care’ setting. LB, Elric, Edward Hartley, Danny Tozer and countless other people, would all be alive if they had received appropriate care.
This is beginning to look a tiny bit like state supported eugenics. And no one who should appears to give a fucking shit. Still.
mydaftlife 
Oh, God help us.
17 days of not telling his family is adding insult to death (injury).
Where was his body in all of that time?
Again. CQC needs the same deep clean Southern Health had. Can’t understand how people can care so little. 😢
“The same deep clean Southern Health had”? I question use of the past tense – the clean-up has hardly started.
Exactly. The number of deaths is shocking
Wales doesn’t even have the CQC – the CSSIW reports are not worth the paper they are written on. My son has Lennox Gastaut syndrome epilepsy – the most complex of the epilepsies. No care plan, no protocols, no safeguards. The DOLS diagnoses him as autistic, and learning disability – no mention of epilepsy. No one is listening.
I remember my neighbour’s son died in a bath in what I think was a specialist home for severe epilepsy 40 years ago. Until I read your blog I would have said no way could that happen now. Why aren’t management charged with manslaughter?
When Danny was 3 we were told that he would have a normal life expectancy by Tony Attwood an international autism expert. We had not worried about this at the time as he was a lively preschooler but he died following a seizure aged just 36 having developed epilepsy 12 yrs earlier just after the death of his younger brother who had severe epilepsy.
Would this have happened at home with us? No because we were aware of him at all times – if there was a thump we were there immediately but managed to keep a close eye on him without intrusion. We also knew this was required because of our knowlege developed over the years. A few weeks before his death at a meeting with house manager, care manager and some of the support staff we were alarmed to find out that they were shutting Danny’s door when he was awake in case a young woman who had moved into the house in the previous 6 months might look in his room and see him naked/masturbating/ any other ‘undesirable’ activity. On the morning that the seizure occurred he was left in his room with the door shut for 30 minutes – the support plan said he should be encouraged to get up in the morning every 10 minutes and we had been told he would be checked every 5 minutes when out of sight/sound but suspected this did not happen. What were they doing – we’d love to know but have a few ideas.
He was ambulanced to hospital and his heart was restarted but he was brain dead by the following afternoon. We had been told by house staff ‘you’d better get here quick – he’s had a cardiac arrest’. We were shocked but not surprised. We thought ‘what have they done now?’
At the time the ICU consultant told us and our daughter that if he had been found sooner and put in the recovery position he would probably have recovered. Unfortunately now 21 months later he apparently cannot recall our conversation.
What did the house manager do before she went to the hospital to support Danny on the previous morning? She checked the alarm under his mattress to see if it was switched on. This was for when he was asleep – he was awake. We were driving back to York from Oxford which took 4.5 hrs that day and had asked her to keep us informed. Did anyone ring us on that journey? No.
Any guesses why we think Danny died? Because staff did not want to listen to a word we said and thought they knew best how to support him and any advice was seen as criticism. Lots of incidents/issues seemed designed to provoke and worry us – they certainly suceeded this time and also managed to get rid of us and Danny of course.
What happened after his death? The safeguarding team, police and coroner interacted in some way and decided there was nothing to investigate. Noone spoke to us. It took City of York Council 9 months to commission a management review – they refused to do an Adult Safeguarding Review /SCR in breach of the Care Act Sect 44 without an understandable explanation. The independent review reported in March 2017 and found serious failings in CYC and Mencap eg not complying with the Mental Capacity Act ( no DOLS in place)not understanding person centredness, not following up our concerns about safety and wellbeing, not following support plans etc When I asked the house manager at the hospital if they had a defibrillator she said ‘what for?’
Over the past 18months we have engaged inquest solicitors who have made several attempts with 2 coroners to persuade them to open a section 2( right to life) inquest. This has so far been refused as he was not under a DOLS but should have been – Danny could not speak and could only make simple choices. In the light of the review report and support from our MP we are still waiting for a further response.
Meanwhile, without telling us or the CYC, the CQC looked into whether the Mencap management should be prosecuted. This followed an inspection of the house and others not long after Danny’s death – ‘requires improvement in all areas’. They decided there was insufficient evidence and wrote a letter supporting the staff in being ‘flexible’ in following the support plans, closing the case. They told us this some time later, having only spoken in their inquiry to the Mencap management who were implicated( not making this up). So Mencap has now said in writing that the inquiry report, the Coroner and the CQC all agreed that Mencap did not cause Danny’s death and will no doubt use all that in the future. As my sister said, the support Danny got when he needed it, he might as well have been living in a B&B.
7 months after Danny died we had a visit from the CEO of Mencap ( only the suggestion of the NVFF soon to be disbanded )who said the staff in the house must have been ‘crap’ and the atmosphere ‘toxic’ – but we know it’s the same hostile staff and ineffective manager still there, still commissioned by CYC.
But the reinspection by the CQC of Mencap houses( definitely not homes)found all was now good apart from leadership and staff were being ‘kind’ to tenants.Our view is now that there is a closed shop between all these officials who seem to cosy up to each other and are prepared to listen to and believe other preofessionals but not families who know most about their relative – are probably seen us unable to accept their child has died, unrealistic about what should have happened and move on.
We have kept quiet and been reasonable for all this time under huge stress adding to our grief. We rather wish if Danny had to die that he’d fallen off his horse – he would have been enjoying himself and would at least have got an inquest! But we have to fight on to achieve accountability and justice for our beloved boy and believe unless bad practice is sanctioned nothing will change for all the vulnerable people at risk now and in the future.
Dear Rosie,
I’m so sorry to hear about the sad death of your son Danny.
I do remember you and your family from York. My daughter used to go to (SNAPPY) and she used to live in a supported living service in Cheadle with the Seashell Trust. Unfortunately, my daughter had a fall and she refused to go back to Cheadle, and she ended up in an emergency placement in a Mencap supported living service in York a few years ago.
We have also have a bad experience with the Mencap management in York, and they were not family friendly and did not listen to or value our views regarding our daughter’s care. Also, the CQC gave a “requires improvement” on the Mencap service she was in. She has just recently moved and It has taken nearly four years of hard work to move her to place that meets all her needs including (BSL).
I hope you get this message.
I wish al the best to you..
Take care,
Thanks for your message Jane and I’m pleased to hear Samantha is now in a better place. We’d planned to move Danny again but were too late. Mencap are a dreadful organiasation from top to bottom, certainly in this area – complacent, arogant and incompetent and we’re still hoping CYC will withdraw contacts but with the current staff at Systems House and managers at West Offices we don’t see that happening.
All the best,
Rosie and family ( my daughter remembers yours from Snappy!)
Hello Rosie,
I’m glad you have received my message.
Yes, Mencap are a disgrace especially in York.
We have had years of stress with York Council, it feels like they are only interested in saving money. It is a shame because York is such a beautiful city.
Take care.
Best wishes,
Jane and family.
And thank you Jane for your contribution to Danny’s sunflower tribute fund – your kindness is much appreciated. Do hope Sam is having a good life now!
Rosie x
Thank you Rosie, I wish I could do more.
It has been a horrible fews years for Sam but things are starting to improve now. At least she is now in a service where they provide British Sign Language to meet her needs. I just wish she could live a bit nearer to York.
Take care,
Jane.
Hi Jane,
Would you be interested in attending a meeting with me and Ali Cowen ( ansd possibly one or two others) with Kate Helme and her boss who are leading on the Future Focus project at CYC to transform commissioning and support. Ali ( mother of Tom ) and I are extremely sceptical as they seem to have little idea how to engage with families of people with LD and autism etc but think the odd survey suffices, rather than buildng collaboration into into their practice, but Ali thinks this is a rare chance to get them to see things differently. They claim this is partly in reponse to Danny’s death so I want anything they claim to be doing in response as worthwhile!
The meeting is 1 to 3pm at West offices on Tuesday september 12th. If not convenient for you or not your thing do you want to be consulted in another way by them and how?
You can reply using my e mail if easier – rosietozer@aol.com – or we could meet for a coffee sometime before then if you would like.
All the best,
Rosie
Hi Rosie,
I hope you are keeping well.
Thank you for your message.
I sent you a couple of emails through your email above. Is the meeting still on for tomorow?
Kind regards,
Jane.
Yes it is – sorry not received your e mails.
We’re meeting in the foyer of West Offices at 12.30 so it would be great if you can make it.
hope to see you later,
Rosie
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So devastating. When had family in mental health units, on 15 minutes obs hourly obs etc. The thing is at home you know where everyone is all the time, If you hear a bang or too much silence you go and check straightaway, not wait for 15 minutes or an hour………. ,
State sponsored eugenics? Quite a plausible reality. The sheer number of people with a learning disability whose deaths were never investigated over the last fifty years for instance added to the statistics of deaths we know were victims of gross negligence in recent years, in the very place where there is every expectation by society they will be kept safe is too shocking. We’re now aware that the number of victims is ongoing and too frequent. Not surprising the unthinkable becomes a real possibility.
Hi Jane,
I’ve not received your e mails though seem to have an old e mail address. Not sure how this messaging works! Meeting on tomorrow- we’re meeting at 12.30 in the foyer of West offices if you can still make it. Hope to see you then.
Rosie
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