pillow talk and going viral

So the latest Sloven shitfest hit the fan yesterday. Michael Buchanan continuing to shine a light on the murkiest of murky practices in the dank and musty corridors of Sloven towers. Reading the latest unfolding in a sneaky preview, we thought (again) game over. Stupidly. [LB died, CQC failings, Verita, repeatedly negative coronial determinations, CQC failings, Mazars and further CQC failings…] As the day unfolded, it was back to now familiar and stale feelings of incredulity, disbelief and despair.

Background

Basically (thanks to George Julian for spotting this gem) Katrina Percy apparently set up a programme of leadership development in 2009 which she later ‘follows on’ from as CEO of Sloven. [Note how she switches to ‘I’ when it comes to claiming a bit of glory. Elbowing staff and the ubiquitous ‘we’ out of the way when it comes to relentless and shallow self promotion…]

kp..

The story today exposed how this ‘investment’ (a cracking misnomer) spiralled 2000% over the original tender amount (from around £300k to £5.365m). For a naff old programme called, er, Going Viral. Oh, and the tender went to an associate of KP; Chris Martin and Talent Works. Cosy. (Apparently, by the end of the current contract CM/Talent Works will receive £9m… £9million). A second associate, Paul Gray, who used to work with KP in pre-Sloven times has earned £602,000 since 2011 without bidding for a contract. Over half a million pounds… Without bidding for a contract.

What is Going Viral?

Good question. We don’t know because Sloven has removed the link to the programme on their website. Shifty move given the weight of the public gaze on what £5m buys. But, in true viral fashion, it has mutated into other cash cows; Senior Viral, Viral Essentials and Gone Viral. [I know].

Handily there are a few vimeos (not) explaining what Senior Viral is. For example:


<p><a href=”https://vimeo.com/171538199″>Senior Viral: What is the biggest priority for leaders in our system right now?</a> from <a href=”https://vimeo.com/southernhealth”>Southern Health</a> on <a href=”https://vimeo.com”>Vimeo</a&gt;.</p>

This includes gems like One of the biggest priorities has to be the number of complex priorities that staff are having to work with” (unknown woman) and, as baffling, So Sloven is big enough almost to be a system its own but I guess we probably need to think about the wider system… (Chris Gordon). It’s taken me about 20 minutes to transcribe two sentences as I kept being overcome with hysterical laughter. £5.365m…

Are.these.really.executive.board.members?

What a painfully awkward situation. £millions spent on a ‘leadership programme’ run by mates so publicly exposed, four (seven) years after inception. In an organisation that continues to fail…

Rest and recuperation

Not surprisingly twitter nearly collapsed under the weight of people tweeting the link to the BBC story throughout the day. Spending cuts, a buckling NHS, ‘post-truth’ politics, etc, etc, make the continuing utter wrongness of Sloven practices sharper and clearer to us herbs.

Later in the afternoon chat (rage) rightly returned to how such sums of money could possibly be necessary for individual trusts to spend (remember there is in existence an NHS Leadership Academy), and what the £5.365 (£9m) could have funded…

pillows 2

Asda pillows. £6 a pop.

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If nothing else, that money could have bought 894,167 pillows. Nearly a million pillows.

Apparently NHS Improvement are saying that Sloven have done nothing wrong. Procurement processes have been followed. (Mackey and his bunch of yes bods on fire as ever). I think [hope has long gone] this is the touch paper to finally bring this foul, toxic and beyond brutal charade to a close.

Those who have refused to listen for whatever reasons. Those who have refused to act for whatever reasons. Those who so readily discounted the life of our beautiful, beautiful boy, along with so many others [howl] for whatever reasons. Those who watch and read what is happening and do fuck all for whatever reason…

There must come a tipping point.  A point at which those who have taken the chunky salary, who pretend they are ‘doing their job’, who kid themselves the bigger picture is more important than the odd (numerous) casualties along the way, are forced to admit something is seriously off. A point at which even the family, friends and colleagues of those who can, start to shake them, or more vigorously shake them, to the point at which the tinted specs finally fall off.

The spotlight has been on Sloven for the last few years now. It is obvious to pretty much everyone there are serious failings and a toxic culture at board level. These are reflected in these financial irregularities and the use of the CEO’s mates (over half a £million without bidding for a contract?). (As Roy Lilley said on the Today programme, despite what Sloven say, these aren’t ‘specialist’ tasks that only a small number of organisations can deliver.) The Sloven board are failing patients and bringing Sloven and the various NHS organisations around them into disrepute.

It’s time for action.

Seeing and doing different things…

Caught up with a mate’s son earlier who used to take LB out on a Saturday when he was at college and LB was about 11/12. He was a quiet guy, thoughtful and kind. They used to go down to town on the bus and typically wander about a bit then sit in a cafe on the High Street, eating cake and watching the buses go past. One day he went with LB to London for the day. Lashing rain, the Science Museum and a much loved trip on the Oxford Tube. They had an easiness in each other’s company.

Now, aged 32, and living in Oz for the last five years, he chatted about some of those outings. Bit of a blub moment. Especially when he said he’d seen things he wouldn’t have seen and done things he wouldn’t have done. Yep. That.

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When trusts go bad

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Walked into Oxford earlier with Rich. One of those days when there were no end of brilliant photos to take. Including a cheeky bee.

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Got home to find out one of the rebel governors, Peter Bell is under formal investigation by Sloven. Yep. Sloven are formally investigating the actions of a (rare) governor.

Sloven who:

  • initially said LB died of natural causes and all due process was followed.
  • tried to stop the publication of the first Verita investigation which found LB’s death was preventable.
  • spent nearly £300,000 on legal expenses at LB’s inquest to try to avoid accountability.
  • spent nearly £50,000 to try to sink the Mazars review into their death reporting.
  • have been found to be failing by numerous coroners over the past five years
  • etc, etc, etc…

Blimey. A formal investigation…
peter bell

‘Seriously derogatory remarks’…. Not sure where, in the guvs’ code of practice, it states ‘thou shalt not say owt negative against the hallowed trust’. What a load of bullying bullshite. Those of you following this deeply harrowing tale of a trust gone bad will know that an extraordinary meeting to discuss a vote of no confidence in the Sloven leadership was stopped on May 17 by interim chair, Tim Smart. He got the Capstick heavies involved. The discussion remains to be had. Now this.

Truly, truly extraordinary.

Extraordinary timescales too. An ‘investigation’ into the actions of a governor with such priority it can be sorted in a month. We’re into the fourth year of investigations into LB’s death. GMC, NMC, HSE.. Every one of them drawn out because of Sloven slovenliness. Delay and obfuscation.

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LB died. He died. Without any accountability. But the investigation into the actions of a governor is racing on. Interviews, evidence collecting and all. By an organisation who failed to investigate 100s of unexpected deaths in their care. I almost think I’ll wake up in a mo. Surely this can’t be happening in full view of NHS Improvement, NHS England, the CQC and Jeremy Hunt?

Surely…

In a final piece of [no words left] the Sloven annual report has been signed off.

smart and percy

My incredulity monitor has finally broken.

Another sordid little tale of failure

Sloven have shut the psychiatric intensive care unit at Antelope House for 8 months. Reported in the media last week. The board papers published yesterday provide more detail (around p72).

The closing of these beds mean patients who really should not be, will be shipped to a unit in London. To a unit that ‘needs improvement’ according to the latest CQC inspection. Yep. Closing shite provision and shipping seriously unwell patients to sub-standard provision. Extraordinary.

The board papers describe how a ‘tipping point’ was reached:

tipping

To the extent the Deanery raised concerns about the quality of Antelope House as a training place for Junior Doctors…. Deep breath. Hold on to something solid.

Sloven run a unit that isn’t a fit space to train doctors.

How can any NHS Foundation Trust run a unit that is not considered a fit space to train doctors?

What about the safety and wellbeing of the patients?

I suspect Deanery concerns led to the sudden closure of the ward at Antelope House. The CEO/Board could clearly ignore the 4/5 year of failings publicly documented over the past 3/4 years. Lives lost. Non lessons learned. Inquest after inquest after inquest, failed CQC inspection after failed inspection and the Mazars review.

Deanery rumblings and concerns around junior doctor training (with implications for Vanguard membership) generates ‘action’.

As my brain, again, slowly, slowly melts, I (easily) stumble upon a news report about Antelope House from September 2011. Yep. Really.

A report on failings identified during the inquest of a patient in 2008 and a recent (2011) failing CQC inspection report. Risk assessments not updated,                                                                                                                                                inadequate records, lack of training, etc etc. The same old same old failings. Identified over and over and over again. The then Medical Director, Huw Stone, long gone (sensible guy), did the old learning lessons spiel:

huw

Mr Stone, back in the day, 14 months before Sloven took over the STATT unit LB died in, said all care plans and risk assessments were now reviewed. Extra checks were conducted on standards of care. And further made up blarney. How any NHS exec can stand in front of the press/coroner and say these empty words when the lives of patients are at stake is beyond me.

No other words really.

I just wonder.

  1. How those who should be doing something about this continue to look the other way/slumber despite documented failings.
  2. How those around those who should be doing something about this, allow their colleagues, family or friends, to continue look the other way/slumber despite documented failings.
  3. How those directly implicated look the other way/slumber.
  4. When any of the the above will realise that we will continue to document this shite for as long as it takes.

 

 

I start walking…

Started walking to work this week. Prompted by consistently destructive levels of rage generated by the continued non action around the Sloven senior team.  (Despite an extraordinary evidence base of failings.) About 3-4 miles depending on the route. Monday was day 1. Bit spooky walking along a long, isolated stretch of footpath by the river to University Parks. Rich came with me the next day, love him. We found a spooked dog. Pippa. I got to work later than planned. I changed my route to High Street/George Street/St Giles…

Then went to Staffordshire, via Birmingham New Street, on Wednesday so walking was shelved. London on Thursday. Watching walking instead.

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Yesterday we walked to town. Raging slightly muted by pounding the streets. Absorbed by watching/snapping everyday life. Back on the High Street, a vaguely familiar couple were snugged up on the bench by the bus stop.

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I photographed them before. Four long years ago. In the life that was. As snug. Just mobile.

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George Street, Oxford. August 2 2012

Today I didn’t leave the house. Among working and hoovering I started reading Victim and Victimhood by Trudy Govier. Unpacking what and who a ‘victim’ is, what being a victim means and different ways of making sense of victim and victimhood. Silence, blame, deference and restoration. Hmm. I’ll keep reading. And walking.

And get a print of the photo to drop off to the couple who apparently sit on the same bench most days. And, I suspect, have a story or two to tell.

And wait. Still.

Updating LB

Hello matey,

Three years now. Well we’re into the fourth year really. I thought I’d update you on where we’re at in terms of justice and accountability. Not far really. [Sorry]. Various investigations limp on. The General Medical Council (GMC) has spent over two years collecting evidence about the clinician who was kind of in charge of you. You know. That woman who spoke to you for about 15 minutes across your whole time in STATT from what I can tell from the records. And gave you Bonjela after you had that seizure. She’s got about a week left to respond to the allegations the GMC have put to her. We’ve no idea what these allegations are because it’s all secret squirrel stuff. She’s working in the Emerald Isle now. Still responsible for patients.

She pitched up at your inquest in October with a barrister who was like the worst of worst baddies in a Simon Pegg film. He, like Sloven peeps, questioned whether we wanted you home. We did. I’m so sorry if that got lost over those hideous weeks in the unit. We stupidly, stupidly thought you were in a safe space while support was being sorted. Turns out all the failings in the unit were written in a report the summer before you went there. But nothing was done. [Howl…]

Your inquest went as it should have done. Superb legal representation (as you’d have expected) and a jury of nine members of the public who listened and understood how deeply you were failed by Sloven.

Other investigations are going on. Still. We met three people from the Health and Safety Executive (HSE) on Thursday with Norman Lamb. The meeting was in Portcullis House which you’d have loved. Heavy weaponery, police presence and security… The meeting was disappointing. Not the objective, razor sharp, robust, investigative scrutiny I imagined. Mind you, the writing was on the wall given the speed in which they slapped a charge against a production company for Harrison Ford’s leg injury in June 2014. 

There seems to be a fog engulfing and dispersing any critical challenge by public bodies of public bodies. And when you stupidly ain’t considered to be fully human, that fog just thickens. 

We managed to get a review commissioned by NHS England into deaths in Sloven ‘care’. This found a scandalous lack of interest or engagement in investigating unexpected deaths. We thought this report would lead to sharp and immediate action. But nah. Seems like this is ok.There’s a bit of tweaking going on round the edges but no commitment to really looking at these deaths or to act with any conviction. You’ve been mentioned a few times in the House of Commons though which would make you smile. 

Meanwhile, Sloven failings continue to pile up. They are seriously shite. NHS Improvement sent in a troubled shooter, Tim Smart, to look at leadership failings. He spent a few weeks there, avoided speaking with families, got some psychometric testing organised and decided there were no leadership probs.

I can hear you saying ‘Mum? Why mum?’ into infinity and beyond.

I dunno. I was waiting for the Scooby Doo gang to pitch up and unmask him as Mr Crawls or one of the other villains in the end. Such a nonsensical, cartoonish judgement. Apparently Alistair Burt, the social care minister, is still looking into it but for some reason, that rag bag bunch of muppets remain in post. 

These systems we loosely brought you up thinking were good, right and just, simply and sadly ain’t fit for purpose. While the public have stepped up and created an explosion of brilliance around you, your life and the lives of so many other people, you were and continue to be well and truly fucked over by those you always firmly believed in. 

There was a story in the Guardian mag about you a few months ago. A very funny journalist, Simon, came round and later a photographer. You’d have liked them both. Joel souped up some of our old photos. Like this one. No orange binoculars but the old shower cap and goggles. Rocking life as you always did. Your way.

Connor

Connor

xxx

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.

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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]

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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]

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

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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.

 

4.7.16

Approaching the third anniversary of LB’s death…

Death anniversaries involve different layers of sadness to the everyday living with unexpected bereavement. More frequent gut punching, breath stealing moments. Additional anxiety and irrational irritation/rage. Intense sadness. A constant thinking back (to three years ago). An almost compulsive recounting and counting down of last times:

Seeing, hanging out with, talking with, going to [London, the Aziz for Sunday buffet lunch, the farm, Trax…], photographing…

Trying to quash the horror of those last few months.

It’s odd how this date is so important. More significant than the day LB was born. More important than Christmas, Easter, birthdays, holidays. And the days in between…

I’m beginning to think 4.7.13 dominates on the date stakes because it holds a key thread. Between life and death. Between what was and what is. At 10.18am on that boiling hot July day LB’s life officially ended. Our lives changed irrevocably. I (still) find it impossible to make sense of this. Up to that moment LB was. We were what we were.  A few words, spoken by a kind A&E consultant, and we were no longer. 

The lives of family, friends, colleagues, acquaintances and layers of people we didn’t know changed in different ways and intensities.

Maybe we just don’t know what to do with this thread.

I dunno.

4.7.16

Nearly 9pm. Feeling dog tired. Relieved the day is nearly over. Good to hang out with family and friends over the last few days. Too much food, drink. Late nights. Tears, music and laughter.

We waited at the bus stop earlier this afternoon. To catch the 700 to the cemetery.

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Close to where I took this pic of LB on the way to his interview at Helen House in February 2013. When life had a different shape, colour and texture. And a sort of assumed certainty it turned out not to have.

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The challenge (still) is trying to work out what life after LB’s death is and what it means.

With the constant and unrelenting shit storm of Sloven related crap this is almost impossible.

Final thoughts:

Thank you for the messages, tweets, thoughts, best wishes and love today. These are remarkably comforting.

Please read Chris Hatton’s reflections about Tim Smart’s judgement. [With a colourful and insightful illustration from Ben Hatton…]

A powerful piece here by Rachel Hepworth for ITV Meridian in memory of LB. A refreshing focus on My Life My Choice champs who cut through the crap. As always. 

I’d forgotten LB asking why a friend from Springfield, Illinois, wasn’t yellow back in the day.

I miss him.

Tears, rage, disbelief, frustration and utter bafflement

Tim Smart made his judgement about the Sloven board on Thursday morning:

smart shite

Graham Shaw managed to summarise this statement in less than 140 characters shortly after it was published.

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Needless to say there have been tears, rage, disbelief, frustration and utter bafflement in the Justice shed. Richard West produced a powerful statement on behalf of families and patients (drafted in the early hours of Thursday after we’d pretty much worked out that KP was not going) summarising key failings and articulating our collective incredulity. [The decision to transfer Oxfordshire provision to Oxford Health was made months ago…]

In a (farcical?) twist, Smart arranged to meet some families with Alistair Burt just before his statement was published on Thursday. Their response (with evidence of contemptuous Sloven behaviour) surprised him and he said he needed to think further/hear more. This explains Alistair Burt’s statement on local news that the issue of Sloven governance wasn’t concluded.

I’ve got a lot of time for Alistair Burt (and never thought I’d say that about a Tory MP). Here he is, a few weeks ago, at the extraordinary Sloven debate at Westminster House:

Burt tweets

On Wednesday, the day before Smart’s announcement, the inquest into the death of another young woman in Sloven’s care was held. The coroner reinforced Alistair Burt’s concerns as lack of communication, ignored care plans and records changed retrospectively were revealed. Again. Lesley Stevens, in her full time role of attending inquests and producing worn out platitudes dropped the ‘lessons learned’ crap this time. That ship has well and truly sailed. Sadly, and incomprehensibly, the Sloven CEO was not on it.

It’s worth revisiting Alistair Burt’s words about Tim Smart and NHS Improvement from the Westminster Hall debate here:

Burt

I think many of us disagree that ‘the right person is (was?) in place’. Smart, for whatever reasons, failed inexorably to cut effectively through Sloven murkiness. Despite the clear evidence trail laid out for him online. An example of the dangers of crusty (and arrogant?) senior bods dismissing social media without having more tech savvy colleagues provide them with a summary of what has gone before. Or perhaps Smart knew and chose to ignore this beyond damning evidence. After all, he pulled me up on the language I use on this blog when I met him.

I can tell you, Mr Burt, (and I know you heard this in the meeting on Thursday morning) the (non) actions taken by Tim Smart have not gained the confidence of people. Quite the opposite. And there seems to be little quality in the actions he’s taken. We’re left asking how and why the person ‘leading’ an organisation that cannot keep certain patients safe (while her focus has apparently been overly focused on operations) remains in post? Despite demonstrating no understanding of patient care, humanity and appallingly little competence stretching back over four years (and possibly longer).

I could pepper this post with swears. My brain has swears careening around it at the speed of sound. Rich and I have become even more randomly sweary since Thursday morning. If that’s possible. But I won’t. Instead I’ll leave you with a photo of a Playmobile figure I dug up in the garden earlier. LB died three years ago on Monday.

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The judgement

Tim Smart makes public his judgement today. Smart was sent in by NHS Improvement, on the back of the findings of the Mazars review, of failing CQC inspections stacking up since 2013. Of clear warnings about safety issues flagged up as far back as 2011. Sent in on the back of (and only because of) the actions of people who have campaigned relentlessly, stepped up and refused to accept typical NHS (public sector) whitewash/cover up.

This has been an almighty battle. It too often is when the NHS fails. With the enduring culture one of deny, bat aside, ignore, obstruct, deny further, smear and obliteration. We have a series of NHS scandals (followed by reviews, well meaning but ultimately empty recommendations and rhetoric) to draw on. So much evidence. So little action.

The Sloven story, like any story, has many versions. The focus and attention of the post apocalyptic reviews conducted by Tim Smart, the improvement director (forgotten his name… Clive summat?) and the independent consultants brought in to review governance will all use different (but I suspect similar) lenses. None of them have engaged with families.

After a late, late night worrying about what is to unfold I’m left thinking If the people who died weren’t learning disabled or didn’t have mental health issues, none of this would have happened. If it had, to non disabled people, the CEO and board would have left Sloven pastures long ago.

A simple and damning as.