‘Second victims’ and calling a boat a boat

I’ve lost count of the number of scratchy NHS related tweet exchanges I’ve had with certain human factor fanatics over the past three years. Blooming tedious and always brings in the flying monkey types who don’t engage or discuss but just retweet the too often cultish, Stepford Wifey, non speak.


On a vaguely related note, there has been ongoing discussion over the past two days around ‘no blame’ cultures and accountability. I’ve kind of tried not to get involved but every now and again words like ‘witch hunts’, ‘equal parties’ and the like make me chip in. Earlier today the concept of ‘second victims’ cropped up. Second what…?

Blimey. Turns out there is a body of research around health professionals being ‘second victims’ when a patient is harmed. A concept introduced 16 years ago in the BMJ by AW Wu and apparently uncritically accepted as a ‘thing’. The US based paper shared earlier has the following findings and conclusion around the impact of ‘adverse patient events’:


Six stages that conveniently sidestep any engagement with responsibility or accountability. What is astonishing – in this paper, I’m sure in the broader ‘second victim’ literature and in the twitter discussions I’ve been involved in or followed as a lurker – is the cosy, untouchable, (sadly too often smug) portrayal of healthcare professionals’ working practice being beyond scrutiny. No accountability (or heaven forbid, criminal prosecutions), here thank you. Move along now. We’re doing our holier than thou, extra special work. If anything goes wrong, we need help to start to enjoy our work again.

And zip all reflection about those  left brutalised by the death of their child, parent, grandparent, family member or friend…

The fakery and indulgence around this second victim nonsense is laid bare in the conclusion of the article where the authors state:

Regardless of sex, professional background or years of experience, all participants in our study easily recalled the immediate and ongoing impact of their specific career jolting event.

A career jolting event is nothing like experiencing the preventable death of a loved one. Please don’t ever pretend it is.


Tama on vene [translation from Finnish: this is the boat].

Postscript: I’m not ignoring or denying that healthcare staff may/must be devastated by the death or serious harm of a patient here. It simply ain’t comparable to the experiences of families.

The GMC investigation (Part 2)


Memorial bench lichen at Wolvercote Cemetery. August 2016

Delved back in time to trace the steps of this investigation and it’s worse than I remember. Part 1 covered how, after sending a lengthy and detailed letter of referral, I had to return the consent form to the GMC within 8 days or risk delaying the investigation. Back in June 2014.

So how have the intervening 26 months been filled? 26 months…? Good question.

We started with six weekly updates by letter (good) which tailed off towards the end of year 1.


Blimey. Another tight deadline for us. Waiting on Sloven as ever. 10 months to get an expert report, get the referred doc to respond and, er, think about what to do next. But at least it looks like the investigation is pretty much finished.

In May 2015 I replied to an email from a journalist saying among other stuff the “GMC should really be any day now (they started last June) and it was at the final decision stage the last I heard, a few weeks ago”.

I look back on these exchanges now and wonder at the utter naivety they reveal on our part. And the (at best) indulgence demonstrated by the – no urgency here, fuck off and wait for as long as it takes, you bereaved families, you – General Medical Council.

The next communication was a letter from a GMC in-house legal person, sent by email on July 15 2015, with this vaguely hilarious subject heading:


Please respond. That’s all we do. Like obedient (through regular beatings) puppies. Grateful for any crumb of progress. Though this particular crumb was a surprise. Fifteen months after our initial referral:


What the actual fuck? Why/how does the need for ‘confidentiality’ erase the need for effective and sensitive communication? Is there a collective historical amnesia in operation within these regulatory bodies that means everything that came before is just tossed out with the rubbish? Did no one involved really not pipe up and say something like:

Er, this is a teensy bit awkward given the referral was made over a year ago now. And we’ve led this family to believe that the investigation is pretty much finished. We really should contact them to explain exactly why we are only now collecting statements*.



To be continued.

*We still don’t know.


The GMC investigation (Part 1)

Starting a series of posts about our experience of a GMC investigation. I don’t suppose it will be a big surprise to hear that this is utterly shite. I don’t  know what to call it. Journey? Process? Piss take? Shambles? I dunno. You decide. I’ve kind of held off from unpacking this [fill in from above] in case it somehow influences or ‘biases’ the outcome of the ‘investigation’ but have reached a point at which I sadly realise that there is no outcome to muddy, bias or de-rail. Just an inept, unwieldy, careless, brutal, inhumane (no)thing

Back to 2014. When I first referred Dr X after Sloven repeatedly refused to let us know anything about possible staff disciplinary procedures. We got wind that Dr X had relinquished her licence and gone to practice outside the UK.

The referral was harrowing. Having to lay out the reasons why we thought Dr X failed LB (it wasn’t (and isn’t) our job to do so) was deeply painful. Luckily our fab solicitor helped us.

A month later we receive an acknowledgement from our newly appointed GMC investigation officer. Kicking off with a breezy opening:

Thank you for your letter of 22 May 2014 about Dr X.

I will be investigating your complaint and will be your main point of investigation during the investigation.

Note to GMC. We really ain’t complaining about the actions of Dr X. Our son died. Something you seem to erase from this exchange. LB isn’t mentioned until the fifth paragraph. Halfway through the letter:


This is the grist of the letter. The consent form. Five out of the 10 paragraphs focus on the urgency of returning the consent form. No acknowledgement that someone died. There is no empathy, understanding that we may be in a pretty crap space. The only vague mention of this is towards the end of the letter (before a final demand for the consent letter):

Some people find making a complaint to us a stressful experience… [link to Victim Support]

The irony in this sentence speaks for itself. I think I’ll leave Part 1 here. I returned that consent form before the 27 June 2014 deadline. The only deadline met in this brutal process.

The GMC (are they actually medics?) gave us 8 days. We’re now at 2 years and 3 months with no idea of the end date. Yet another classy bunch.

PS. Hoping I don’t need to spell out the ‘learning’ here but will in a summary post at the end.

The lost day… Helsinki way


Up at 5am today to catch the 8am flight back to Gatwick after a wonderful weekend in Helsinki. My supersaver flight. £30. Such a blinking bargain. The airport bus was full of sleepyheads.

“Ah, I’ve found what I’ve been looking for…!” announced the driver after 20 minutes or so. “The airport. I stop at Terminal 1 first and then Terminal 2.”

The bus emptied out at Terminal 1. I waited on board wondering what all the fun was at 1.
“Er, excuse me,” said comedy driver getting back on board. “Where are you going?”
“Terminal 2”, I said.
“This is Terminal 2. You’d better get off or I’ll take you back to Helsinki…”
Blimey. Where was Terminal 1? The check in machine spat my booking reference out and told me to go to the help desk. I queued for ages with a few other people who had also fallen foul of the machine. When it was my turn, the woman looked completely perplexed and called for help.

“Is there a problem?” I asked.
“No, no. Not at all. The system is very slow, that’s all.”

The second woman called for a third woman as the queue behind me got longer. I turned round at one point and did a ‘Sorry guys, some sort of system error’ shrug to the grumpy looking passengers. They blanked me.

After a few more minutes and a lot of heated chatter and jabbing the screen, the third woman cracked the problem.

“This ticket is for yesterday” she said, triumphantly.
“OMG. No way. What date is it today..?” I yelped, looking around for a floating calendar. She flourished the ticket at me.


November. Not yesterday. Not even close.

The three women, clearly relieved their system wasn’t faulty, pointed me in the direction of the Norwegian Air hidden service for losers who can’t book flights properly, two floors below ground level. In the dark space I found two guys with Norwegian Air logos on their t-shirts playing Pokemon (don’t) Go. They politely told me to get lost. There is no standby on Norwegian Air.

Back above ground I had to suck it up and buy a single ticket home. Flying with SAS. Leaving nine hours later via Copenhagen. A five hour trip.

From Terminal 1.

L1022310 (1)

A brighter moment from yesterday: the Sibelius monument.

Postscript: It turns out the cheapest flight back was business class. Luckily an eagle eyed SAS guy noticed some marking on my boarding pass and told me. I’ve now been in the SAS lounge for 8 hours and 20 minutes now. With cheeky white wine on tap. Funny times.

Puff the Mackey Dragon…

It sounds like there’s a dose of musical chairs going on with the Sloven executive. Sigh. Word in the shed is that Sandra Grant, who does summat and goes back to the olden days with Katrina Percy, is off for a six month secondment while Chris Gordon, Chief Operating Officer  (COO) and Director of Patient Safety, is apparently heading to NHS Improvement for 12 months as an improvement director. [I know…]

He, Lesley Stevens and Katrina Percy, are holders of the obscene salary and pension pots exposed a few weeks ago.

In the NHS (unlike much of the commercial sector) it appears when you fail at exec level you simply get moved around in a never ending chess like game. Only one in which the board is so worn the squares are no longer visible and the grubby pieces have been handled so often they’re unrecognisable. And there are no ‘rules’. Just fakery and nonsense played by overly paid, under qualified (in real terms) bods who share a common language, code and cloak of protective armour invisible to the rest of us (who pay their over inflated salaries).

I can remember Tim Smart, the newly, NHS Improvement, appointed interim Sloven chair (the Flash of yesteryear) at the My Life My Choice meeting. Tapping his nose and saying with much gravitas:

Just remember Sharon Shoesmith…

Effectively stopping any discussion about anything.

So, two or three months on from the “action” taken by NHS Improvement in response to repeated evidence of Sloven board failings, where are we exactly? And what did “Remember Sharon Shoesmith…” mean?

Well. Crap all to the Shoesmith question. That was probably part of Smart’s briefing from NHS Improvement… “Just mention Shoesmith when anyone asks a dodgy Q“.

The board got the all clear from (the previously failing) Smart on the basis of fuck knows what. The consistently underwhelming (at best) CEO was removed of operational duties and told to focus on strategy. The COO has gone to NHS Improvement and will only work 2 days a month on Sloven operations. And Grant who, after a quick google, is Director of People and Communications, is off for six months. Blimey. Who is keeping this leaky boat afloat in the land of Solent Lee?

Meanwhile, in addition to the salary/pension scandal, financial irregularities are blasted across the news. Failing, upon failing.

NHS Improvement… I can’t help thinking the question Shaun Picken from My Life My Choice put to Katrina Percy at the January board meeting is relevant here:

Katrina, why didn’t you ask for help? You clearly need it.

L1022311 (1)

Kissing bare feet…

Flew to Helsinki this evening. On a flight with free wifi (Norwegian Air) and a lot of kids. Three little kids just in front. Two younger boys with a slightly older sister who kind of policed them. With a good dose of pummelling, cuddling and arguing. Carefully watched over by their mum across the aisle. Tablets, snacks, learning the Koran (via headphones) and cheeky computer games as the flight went on.

A little girl on the right across the aisle with her mum. And a super cute babe with his mum and dad next to me. Seats 8A, B and C.

A three hour flight. The three kids in front were pretty self sufficient other than the odd headphone war. The little girl to the right slept for most of the flight. She woke when her mum went to toilet, howled briefly, was pacified by her mum who lost her place in the loo queue. Beaten by a man who disappeared for a record amount of time only matched by the smells that emerged with him.

The couple I sat next to operated a pretty much three hour work station between them. Food, cuddles, big white soft toy, love, food, singing, blanket, books, big white soft toy, food, dummy, love, more food. He chuckled, played with the seat table, looked out of the window with excitement, studied the menu, looked at a London guidebook, had a whine, chucked his dummy on the floor, batted the books away, cried, chucked his dummy away again, rocked with frustration, howled and fell asleep.


His mum kissed his bare feet.

I thought about the kids when they were tots. About that constant space of love, devotion, work, despair, public service, frustration, absorption, protection and completeness.  In between, I read a book about experiences of social change over time (stories from disabled people born in the 1940s, 1960s and 1980s).


I wondered (again) how the hell we got into a situation in which we took, and left, LB in that hell hole.

A justice ‘pilgrimage’…

It’s confirmed. A celebration – Of Rights and Colour – organised by Learning Disability England will be held on December 2 in Aviles, Northern Spain.

Truly, truly spectacular…

It wasn’t long before talk in the Justice shed turned to walking the #JusticeforLB bus and flag to Aviles from Santander in readiness for the event. A bus made from cardboard boxes by the Boumelha family for 107days of action. And a flag that has graced two Glastonbury festivals and travelled as far as New Zealand via Sydney (meeting People First, Dunedin and the NZ Disability Rights Commissioner among others) thanks to Katherine Runswick-Cole, Rebecca Lawthom, Dan Goodley and families.

Along the Northern way of the Camino de Santiago. We’re planning to set off on October 25 and cover the 150 miles in around 12 days. George Julian, Agent T (my sis) and me so far [anyone is very welcome to join us on part or all of the route]. I think it’s fair to say we ain’t brilliantly fit. And our vague convos so far around how to get the bus from A to B are along the lines of the odd “Maybe we should strap it to a backpack” to “Pull it along on a trolley?” type exchanges on twitter…

But whatever. It will be a remarkable and deeply powerful experience. A time to reflect. To laugh, cry and rage. And maybe make some sense of what has happened over the past three years or so.

Of rights and colour. And love.


A written version of Winterbourne View

Here we are. Late summer 2016. Another day and another failing CQC inspection of support for autistic people. This time the much feted National Autistic Society (NAS). A harrowing read. The NAS have simply shut the provision, Mendip House, down (‘home’ to 6 people who were unable to say if they were being harmed), belatedly issued a half arsed press release after a bit of twitter agitation and carried on trousering the readies from their other provision. Same craphole activities as, er, Mencrap. Another glossy charity losing its way big time…


A summary of the obscene inspection findings (in non CQC speak):

  • The formal communication system (pics) used by two people had been stopped.
  • Concerns about abuse were raised and no action taken.
  • Staff regularly stole money from the people they were supporting.
  • Lack of staff training.
  • Mismanagement of medication and no record of medication reviews.
  • Hot water temperatures were too high so risk of scalding.
  • Using saucepans on the door to raise the alarm if someone slipped out failed.
  • No attention was paid to changes in people’s behaviour to understand how they felt.
  • Accidents and incident reporting was crap and records went missing.
  • Some staff had no CRB clearance or employment references.
  • Staff played on the playstation, ignored people and came and went without record.
  • Dodgy or no induction processes/records or ongoing supervision.
  • Poor or no health plans, health checks or recording of any GP appointment.
  • Care plans were out of date.
  • Rubbish epilepsy plans/assessment [howl].
  • People ate crap nosh (little fruit and veg) and were dehydrated.
  • The Mental Capacity Act wasn’t followed and people’s rights were trashed.
  • The decor was worse than rubbish and worn out.
  • The house was dirty and appliances needed replacing.
  • No one was supported to be independent or have relationships with family/friends.
  • Complaints by family members were ignored.
  • There were few opportunities to go out spontaneously because of staffing issues.
  • A gang of male staff arranged to work on the same shifts and ignored people.
  • A “laddish” and “gang culture” developed through lack of effective senior leadership.
  • The NAS identified “culture issues” in 2014.
  • That “Senior Management Team were concerned with Mendip” was minuted in 2015.
  • Issues identified by the NAS in January 2015 hadn’t been acted on 18 months later.

Given we don’t know what went on in Mendip House with this laddish gang culture ruling the roost for over two years, this is as bad, if not worse, than the abuse captured on film in about 5 minutes by the Panorama team back in 2011.

In Mendip House, run by the National Autistic Society, the senior team were aware of serious problems for two years. They did fuck all.

Of mice and (NHS) monstrousness

A story ‘broke’ yesterday about extortionate NHS interim director costs. Sickening figures of waste, greed and mismanagement. At senior levels. Again.

In another of those ‘you couldn’t make it up’ NHS moments, the highest paid interim Improvement Director named in the report, Steve Leivers, was helicoptered into the trust Tim Smart, now Sloven interim Board Chair, previously ran. Yes. Really. Not Smart in non action. Again.

I read this latest news having been unable to move beyond Chris Hatton’s recent analysis of Sloven’s annual report. Cut and paste Katrina. And extraordinary senior exec salary figures. With Lesley Stevens, Medical Director at the top of the ‘leader’ board. A cool £365-70k per annum including jaw dropping pension contributionsHow can she possibly ‘earn’ this sort of dosh? Let’s have a look at her performance during LB’s inquest last October.

Lesley Stevens and LB’s inquest

Reasonably confident while reading out her evidence and then being (sleep) walked through clearly rehearsed questions by the Sloven barrister, she floundered big time when questioned by the six remaining barristers. Her answers so deeply insubstantial (a generous interpretation) it was as if the courtroom had switched to watching CBeebies.

£365-70k per annum…

Some examples:


LB died in July 2013. The (post Mazars review) CQC inspection in January 2016 found the Sloven epilepsy policy had yet to be signed off. Paul Bowen, QC, carefully questioned each Sloven staff member about their knowledge of epilepsy during LB’s inquest. No one answered in other than the vaguest ‘ain’t got a clue’ terms. There was no up-skilling staff over two years after LB’s death.


LS3Here Paul Bowen seeks clarification of Stevens outlandish statement that all learning disabled patients with epilepsy were reviewed before the CQC inspection in September 2013. At that point, Sloven were still spinning the line that LB died of natural causes. They did nothing to check the provision in STATT (it failed on all 10 domains inspected 6-8 weeks after he died) let alone review patients with epilepsy in their wider provision/outposts.

A blatant and contemptible lie. Perjury to us herbs outside of senior NHS circles.

LS2Paul Bowen tries to drawn Stevens on the failure of the RiO system. A failure that persists to this day. She resorts to her default response. A murmur/mutter noise reminiscent of the dog ate my homework type responses from school. Not the sharp, authoritative, informed, engaged response you’d expect from a senior exec at an inquest over two years in preparation, with nearly £300k squandered on ‘defence’ costs.

When questioned by Adam Samuels, another barrister, about the reduction in Band 6 and 7 staffing reductions in STATT (and the next door John Sharich House), Stevens says:


‘We make savings where we have to make them…’ On frontline staff. While you continue to draw an obscene salary

Monstrous. And remorseless. Just one, among so many.

When did the NHS we grew up with, took for granted and loved, become so riddled with greed and rot… with complacency and arrogance, with inaction and protection. At senior levels?

In search of rights and colour…

Came across some serious craftivism this evening. Mind and the Drunken Knitwits (among others) set too on the Radcliffe Camera. A welcome distraction from the continuing non action by those who should.

Left me thinking about plans for a bit of a #JusticeforLB shindig later this year (not quite confirmed) called In Search of Rights and Colour. Involving people, human rights, commitment, explosions of colour, love, brilliance, enthusiasm, stitching, passion, double decker buses and a pilgrim path.


Drops of brilliance.