Five tribunals and a dress code

Coming up this summer; a two-week General Medical Council (GMC) tribunal for the consultant psychiatrist to be held in Manchester in August, and four Nursing and Midwifery (NMC) tribunals.

  • Four years after LB drowned, alone, in an NHS bath.
  • Over three years after an independent report found he died a preventable death through neglect.
  • Nearly two years after an inquest jury determined he died through neglect and serious failings.

It’s all going on this summer. The pipers are suddenly calling the tunes.

The NMC sent me (Rich has dropped off these communications without explanation) four identical letters last week which open with a cheery:

On behalf of the NMC, thank you for your time and commitment in helping us to investigate this case; your help is greatly appreciated. Without the evidence provided by witnesses we would not be able to safeguard the health and wellbeing of the public. We recognise the valuable contribution you have made to this investigation.

‘This case’? ‘My help’? ‘The valuable contribution…‘ Really?

Is humanity bypass a criteria for a job at the NMC?  I’m all for change but spare me the vacuous Dambuster shite. LB died.

The letter continues by ‘asking me’ to provide my unavoidable (in bold) commitments in June, July and August. There is no reflection of the enormity of demanding these dates (after years of crap all action) so breezily, four times over, with a response deadline of ten days. No. The reverse. If those pesky bereaved parents don’t get their act together to respond, there is a simple fallback position:

If we do not hear from you we will assume you are available and proceed to schedule the hearings.

I’m then directed to a lengthy weblink which I have to retype from the letter to find out more (there is so much so wrong here but seriously, if you ain’t sending a letter electronically, a URL is as good as fucking useless).

It gets worse.

At each of these tribunals, the staff member is represented by a barrister who can ‘cross-examine’ the witness.

Giving your evidence in person also allows the opposing side, if present at the hearing, to ask you questions and test your evidence. This is vital to ensure a fair and thorough hearing.

The opposing side? I don’t think that the staff who should have been looking after LB are on an ‘opposing side’. What a terrible way to frame the process. But if there are opposing sides, surely both (or none) have recourse to legal representation? (Witnesses are not allowed representation). How can this possibly be a fair or thorough process?

The concerns and focus of these regulatory bodies should be on the integrity, professionalism and abilities of the people they register, not putting (bereaved) members of the public through trial and examination. There’s a shedload of evidence to draw upon to do this, including two weeks of inquest recordings, staff and other witness statements.

James Titcombe described his and his partner’s experiences earlier:

I have spent days giving evidence to both regulatory bodies, checking this evidence, finding supporting documentation and waiting for action. In the next few months, I’m expected to travel to Manchester and wherever in the UK the four NMC tribunals are held (using annual leave and making sure I’m available at all times), to be cross examined by five different barristers.

You can fuck your denim, sportswear and trainers ban.

A whistle stop catch up…

l1026830

Been writing like a batshit from hell since Christmas. Weekends and evenings, just thundering away on the keyboard in the back room. Bess often keeping me company on a cushion by my feet. Sometimes not. The book contract is being thrashed out. I’ve pretty much reached the proposed word count; it’s a question of trying to make a tale that doesn’t typically float many boats, into a page turner that grabs attention and makes the likes of LB (Danny Tozer, Nico Reed, Thomas Rawnsley, and many more) human.

I’m on it, with remarkable support.

Other stuff that has been happening (in random/(reverse) order…)

  • The NMC only communicate gibberish so fuck knows.
  • The GMC tribunal date for Dr M has been set for two weeks in August.
  • The HSE are hoping to share further information in the next few weeks.
  • We’re getting an update from the police on Friday evening.
  • David Harling is in the final stages of his fourth animation… this one will include voices… [howl].
  • Caiolfhionn Gallagher was sworn in as a QC this week. Something so unusually right, something so deserved, and so blooming reassuring in terms of the ways in which she will, undoubtedly, continue to use her ferocious intellect, human rights expertise and extraordinary empathy to fight/right as many wrongs as she can in her waking hours.

cg

The solicitor, the student nurse and scholar activism

On Tuesday Katherine Runswick-Cole gave her inaugural  lecture which touched upon numerous highlights of her work over the past 10 years or so. Well worth a catch up if you missed it. One of the things she talked about was #JusticeforLB and the responsibility of academics to be scholar activists.

krc1

The disability studies assemblage certainly did, as she highlighted:

krc3

I particularly loved this comment.

krc2

I remain chilled by the obscene focus of Sloven and Oxfordshire County Council on reputation immediately after LB’s death. And the eight months or so it took before his death made it into national news. That ‘random’ people now know what happened can only be a good thing.

Yesterday, a second year learning disability nursing student left a message on the #JusticeforLB facebook page. He wanted us to know how much of an impact LB’s story was having on his, and other students’, education.

comment1

He went on to say:

Nothing could ever make what happened ok. It will always be a tragedy. But LB is shaping the education nurses receive. He is changing the way people work who have been nurses for years, and most important of all, LB is making the lives of other people safer but ensuring they get the care and support they need.

[Sob]. Spot on. Nothing can make it ok. And I so agree about the impact and change. I’m not surprised in some ways. I mean, remarkable campaign magic has included walking a cardboard bus 100 miles along the Camino de Santiago in memory of LB, Danny Tozer, Thomas Rawnsley and others. In the past few years, we’ve collectively managed to prise open a [new?] space for the scrutiny of, and engagement with, preventable deaths (and, hopefully, non lives) of learning disabled people. l1025096Sadly, this focus is not replicated among relevant health and social care bods. We need no more evidence to know that it’s time to properly address and act on the barbaric and inhumane treatment of certain people in the UK. The CQC swerved from this opportunity with their recent deaths review. There seems little effective action from other parts of the NHS (or social care). Just the inevitable, systemic compromise as always. With nothing inevitable about it.

Anyway, here’s to Prof Runswick-Cole, scholar activism and a new generation of brilliantly enlightened nurses. We salute you.

l1019209

Johnny Rotten and the legitimacy of anger

Rich met me at the bus stop after work yesterday. I was feeling a bit low. We wandered home across the London Road.

“You seem a bit despondent…”
“Yeah. I am. Fed up with raging. And the continued shite that just doesn’t change. Not sure I can bear another year of being so angry... I’m weary of being constantly angry.”
“That’s what happens.”
“What?”
“People get worn out. They stop being angry. But it’s right to be angry. Anger drives a refusal to accept the low bar, the unacceptable. It drives action and critical engagement. Without it, issues are reduced to vague problems too easily dismissed.”
“Hmm…”
“Like Johnny Rotten said, anger is an energy…”

Minutes after getting in, an old mate turned unexpectedly. Her son a year or so older than LB. We had a catch up over mugs of tea and a chunk of Christmas cake. She filled me in on the horror that has been her family’s recent experiences of adult services. Not a pretty story. But it so rarely is. We reflected on the way in which 18+ years of loving and bringing up our kids (along with their sisters/brothers) can be summarily dismissed or problematised by health and social care (with the eye watering irony they offer nothing in its place). The misuse of power and erasure of love and more (the right words don’t exist) too often, just extraordinary.

Before she left, she said;

Do you remember when N and LB were young? And we were so optimistic about the future…

Blimey. I’d forgotten. We were. There was a group of us parents. A right old bunch of budding agitators/activists [just mums really…] All with kids the same sort of age. So utterly convinced we could change what we thought was an already changing world to create rightful space for our kids. To live the lives other people lived. I was shocked to remember this, and that I’d forgotten.

Later, one of LB’s school mates posted two photos on Facebook from years ago. LB was sitting among the small group of kids. He looked so chilled in one and smiling, as he saw the camera, in the other. It was clearly before the fake, fixed cheesy Wallace grin period which lasted a good year or so. Until my relentless photo taking became commonplace again.

Rich is right. Anger is necessary. Or you get sucked into the malaise that is the myriad words/excuses/bullshit/reviews and recommendations that health and social care bods endlessly come up with. Non existent change… what’s about to happen. And never does. At best, a kind of hope soup. That never leaves the kitchen. And feeds no one but the cook.

So 2017. Another year. With anger. And focus on brilliance. The remarkable. And humour. That rightful space is still there, somewhere. We just have to collectively, and persistently, nudge the crap out of the way. And never stop saying this is simply unacceptable.

bindmans

Bindman’s published their first ever annual review today.

Humanity, value, love and sunshine…

Today, as part of the International Day of Persons with DisabilitiesLearning Disability England and Spanish friends held an event in Aviles, Northern Spain, celebrating #JusticeforLB and all those who have died through neglect and indifference. Stitching, artwork, music, dancing, fun and so much more.

Just brilliance…

I felt a right old pang seeing the #JusticeforLB bus/quilt in twitter pics. And reading the shock, outrage, sense and warmth expressed by local kids, self advocacy groups and others…

Valued members of society. Blimey. ‘Reach for the stars’ type aspirations that seem to firmly remain the stuff of dreams here. Despite the continued and brilliant efforts of some/many.

Still. We gotta recognise steps made and there have been some. First, the General Medical Council (GMC). Having proceeded at a snails pace (over 2.5 years so far) in the investigation of Dr M, we were told we’d hear the case examiner decision this week. Sitting at my desk earlier [grey sky, gloominess and an all to0 familiar feeling of delay dread] I steeled myself for another weekend without news.

Then an early afternoon email. Dr M is being referred to a tribunal hearing.

A few hours later, a comprehensive (and spontaneous) update from the Health and Safety Executive (HSE) beautifully headed ‘Connor’.

If you’re embroiled in a serious investigation involving a preventable death [howl], your priorities may well be on the meticulous steps involved in evidence collation/examination. Keeping families informed may seem a less relevant, smaller, almost inconsequential part of the process.

It ain’t.

Keeping families informed demonstrates:

that beyond loved children/sisters/brothers/grandchildren/nephews/nieces/friends are valued.

serious consideration and scrutiny of what’s happened, allowing/enabling slightly easier rest in a harrowing (possibly lifelong) space.

a basic, deeply warming, and too often missed, humanity.

Thank you. To the GMC, HSE and ongoing Spanish based magic. For shining light and sunshine on the way forward.

l1025606-3

You can join, contribute to and keep up with Learning Disability England for £12 a year.  

 

 

The curious incident of the earlier death in the bath

In June 2006, HC, 57, died unexpectedly in the same bath that LB died in. Days after two ECT treatments he was unable to consent to. This emerged during LB’s inquest in October 2015. The coroner, who was clearly surprised to hear about the earlier death requested statements from the key three people involved in HC’s death.

  • The student nurse present in the bathroom

Once I had H supported I managed to pull my alarm, whilst at the same time shouting for assistance. At that point a member of nursing staff entered the bathroom, it was a female member of staff but I cannot recall who it was, simply due to how long ago this incident occurred. I can however recall that [nursing manager] followed that female in to the bathroom. It was approximately 10-15 seconds from H starting to have a seizure to other staff members joining me in the bathroom. By the time they arrived the water was drained and H was still in the bath and [nursing manager] told me to leave the room, which I promptly did. I understand that he did this purely because of my age and experience and he felt it was best to be away from what was happening to H. I did not see what happened next and never saw H again.

  • The nursing manager 

At the time of the incident I know I was not on the Unit.

Later in his statement he says:

I am not sure if I arrived there before Dr J or after but she went into the bathroom and assisted in trying to revive patient. I also cannot recall whether paramedics were already present when I arrived at the ward or whether they arrived after.

  • 3. Dr J (who phoned me the day LB died)

As the attending doctor, I pronounced HC dead.

Later in her statement she says:

On 29 June 2006, I received a phone call from the HM Coroner’s Office asking me if I was prepared to complete and signed the Part 1 of HC’s Death Certificate as I was the attending doctor at the time of his death. They called me again after 15 minutes and informed me that the HM Coroner was not going to ask for a postmortem examination and open an inquest. They informed me that HM Coroner would sign the Part II of the Death Certificate.

The 2014 Sloven ‘investigation’

Another Sloven psychiatrist was tasked with finding out more about HC’s death in 2014. He wrote to the Sloven Clinical Director on March 25 stating:

[Dr J] confirmed that there had been a death some years before Dr M’s appointment. [Dr J] relayed that the circumstances were different in some respects to the epilepsy related death last summer, but similar in that an inpatient on STATT had a seizure in the bath. An attempt at resus followed but it was complicated by the difficulty staff had extricating the man from the bath. He died soon after.

On May 13, the Sloven ‘inquiry’ concluded:

As this was an unexpected death of an NHS inpatient it was reported as a SIRI. There is no evidence of an RCA being undertaken. The Coroner had pronounced the death as natural causes.

This is how you erase a life and a death in full view. Particular lives and deaths. Those that don’t count.

History of a GMC investigation

How long does it take to investigate a doctor? Good question. We referred Dr M to the General Medical Council (GMC) in May 2014. And were asked to respond promptish in a letter dated 19 June 2014.fullsizerender-7

I did so. Because we bereaved families do. There was a second request for information, again with a short deadline.

fullsizerender-8

Jumping ahead to March 2015. March 2015. By this point, the GMC had got careless in their updates. I was chasing them up for infoA letter in response to a frosty phone call from me. [Hostile… toxic… you know the drill].fullsizerender-9

Nearly two years after LB’s death [he died] and 10 months into the investigation. What does ‘regret’ mean? Where is the attention, the urgency, the respect, the humanity?

In July 2015, thirteen months after making the referral. I was asked to provide a statement. And then sign and return the statement sharpish.

This is your statement and so please ensure you are fully satisfied with its contents before returning a signed and dated copy to me. I would be grateful if you could amend and return at your earliest convenience, so that the GMC may progress its investigation as promptly as possible.

I did as I was asked.

Fast (well very slowly) forward to December 2015.

fullsizerender-10

A change of staff.  And another expert report (the third by that stage). No explanation why.

15 February 2016. I chase them up again. What is happening? Ah. They’d just received the inquest files from the coroner. [LB’s inquest finished four months earlier. I paid a fiver and got a copy of the files within a week.] Four months…  Another expert opinion was now necessary to consider the inquest evidence (taking 5-6 weeks apparently). Then Dr M would be written to formally and have 28 days to respond. So wrapping up in the spring then by my reckoning.

3 May 2016. I chased them up again. What is happening? The supplementary expert report was now expected by May 30th. The spring wrap up was not going to happen. I replied saying that it would be good if families were proactively updated because it was such a drawn out, painful process. I was told my comments would be passed “to our investigations enhancement team who are always looking for ideas and feedback about our investigations and the effect it has on the relatives of patients whilst we investigate”.

Clearly a bunch of comedians in the GMC. Still. Spontaneous updating kicked in at this point.

7 June 2016. The supplementary expert report was received, investigation complete and the legal team would draft the allegations to be put to Dr M who has 28 days to respond. More spontaneous contact a week or so later to let me know Dr M’s clock was ticking. 28 days to respond.

But Dr M doesn’t do obedience. We all saw that during her inquest performance. She asked for an extension and was granted an extra week.

14 September 2016. The Case Examiners want further expert opinion before they make their decision.

6 October 2016. The supplementary expert report is now with Dr M who has two weeks to comment before the case is referred back to the Case Examiners.

I called my friendly ‘caseowner’ today. The report is now in the hands of the Case Examiners (again) (a lay person and a medic). He was very apologetic for the delay. It’s not good enough I said. He said he’d do everything he can to make sure we get a decision as soon as possible. It shouldn’t take this long, I said. How can it take 30 months to investigate the conduct of one individual? No real answer. And no idea when we can expect a decision.

I’m a researcher. When we apply for funding we produce a gantt chart to show how the research process is broken down and the various milestones and end date. If something happens that means the end date can’t be reached (very rarely) we have to apply to the founder for an extension. And provide a clear rationale/explanation.

It strikes me, the GMC could up their investigation smarts in a similar way:

  • Keep families regularly updated and provide contextual information (e.g., why supplementary expert reports have been requested.)
  • Produce a gantt chart and give experts and other players clear deadlines.
  • Share these timings with families and the doctor under investigation.
  • Make sure the expert commits to the timings or find another expert who can.
  • If an investigation takes more than a year, the exec should be informed and a full explanation for the delay provided.

It really ain’t rocket science.

Jeff Vader and getting it right

The day after posting LB ain’t no Han Solo, I received an email update from the Health and Safety Executive (HSE). There’s a pattern here that wouldn’t take the brightest social science analyst to identify. That is, being called out on social media for crapness can* be an effective mechanism to generate some action. This is a good thing. I mean let’s face it, us public ain’t typically served well by ‘official’, pigeon post type PALS and PHSO processes. (These organisations shouldn’t need calling out, of course. That we’ve consistently had to ask for updates over the past 3 years of so is an indication of how poorly families are typically treated.)

The action or response these blog posts or tweets generate varies. We’ve typically had stilted and clipped non updates that I read as woven with “vexatious” whisperings and stabbing needles. Them pesky parent-type stuff.

The latest communication from the HSE included acknowledgement and recognition that we shouldn’t have had to ask for an update. Good. A straightforward sorry, an explanation for the delay in updating and an update. Including notice that the investigation will be continuing beyond the expected end of October deadline. Not so good. But when you get an explanation for this delay it’s slightly easier to suck up. I replied with a brief, Han Solo, related question.

1

Today I received a detailed explanation of the complexity of different investigations and differing time frames. This was followed by a second email again acknowledging a failure to keep us updated and some reflection on what the experience must be like for families. These emails have reduced my intense rage about the length of time this investigation is taking. No mean feat. I feel reassured and relieved.

This respect and decency stuff isn’t complicated. Treating people who have been battered into unspeakable spaces by the actions of  health or social care organisations as human, with honesty, care and thoughtfulness shouldn’t be so difficult. Hopefully the other involved strands of the NHS can learn summat from this.

1. Update families regularly (even if there is no news).
2. Try and put yourselves in their shoes. Imagine what it must be like.
 

LB funnily enough wasn’t a Star Wars fan. But he laughed until he cried each time he watched this clip. Which was a lot.

*The effectiveness of this mechanism needs scrutiny. There’s a social media campaign type ‘labour’ that needs unpacking to identify what works and what doesn’t. To help families and campaigners [and NHS and social bods] be more effective.

LB ain’t no Han Solo…

The makers of Star Wars: The Force Awakens have been sentenced after failing to protect the actors and workers while on set during filming at Pinewood Studio, Slough, Buckinghamshire. Harrison Ford suffered a broken leg and deep lacerations when he was knocked off his feet and pinned to the floor of the Millennium Falcon set, as a prop door closed on him. HSE’s investigation found that there was no automatic emergency cut off, to protect those on set, instead relying on the reactions of the prop operator(s) to bring the door to a stop. Aylesbury Crown Court heard how a combination of preventable events, starting with how the door was designed, led to the incident.

In 2013, Southern Health NHS Foundation Trust (Sloven) failed to protect patients in the Short Term Assessment and Treatment Unit, Headington, Oxford. Connor Sparrowhawk lost his life when he was left to bath alone despite a diagnosis of epilepsy. 

During dress rehearsals on the 12 June 2014 Harrison Ford walked back towards the entrance ramp of the Millennium Falcon and pressed the prop door button to ‘close’ the door. As the cameras were not rolling he did not expect it to close. The production crew member who was operating the prop believed they were in full rehearsal and closed the door. The door’s steel frame was overlaid with sheets of metal and had a tapered edge. It’s operation moved from ceiling to floor in a sharp downward motion. It did not have any automated safety mechanisms to cut out if a person was unexpectedly under the door.

On 4 July 2013, Connor went to have a bath. He didn’t expect to drown. Staff on duty didn’t think about his safety. There was no leadership from Sloven, both locally and at executive level, which meant the recently taken over unit was unsafe.

The risk of the door causing a serious injury or death had been highlighted by one of the health and safety officers for the production company. Foodles Production (UK) Ltd should have put a system in place to ensure the actors and production workers were protected. A different design with inbuilt safety features or using a different material could have guarded against any possible miscommunication on a busy film set.

The risk of seizure activity had been highlighted by Connor’s mother and wider longstanding health and safety failures by Mike Holder. Sloven should have put systems in place to ensure patients were protected. A different system with robust safety procedures would have guarded against any possible miscommuncation in a small unit.

Foodles Production (UK) Ltd, who had pleaded guilty at a previous hearing to Section 2 and Section 3 (1) of the Health and Safety at Work etc. Act 1974, were today fined £1.6 million and ordered to pay costs of £20,861.22 at Aylesbury Crown Court. 

Sloven have consistently tried to wriggle out of any accountability, blame Connor’s mother and ride the waves of executive level corruption over £millions wasted on nonsense training by an organisation led by the then CEO’s mate. 

HSE’s Divisional Director Tim Galloway said: “This incident was foreseeable and preventable and could have resulted in more serious injury or even death. The power and speed of the door was such that, had Mr Ford or anyone else had been struck on the head by the door as it closed, they might easily have been killed. It was only the almost instantaneous actions of the prop operator in hitting the emergency stop that prevented the door from continuing to press down on Mr Ford as he lay on the floor. I think everyone would accept that all the people who work in the film industry have a right to know that the risks they take to entertain us, including when making action movies, are properly managed and controlled.

End.

There has been no statement, report or court case about LB’s death. His death. There was no ‘might’ about what happened to him. No over sensationalised, dramatic rehash of what (nearly) happened with photos. He died a year before Harrison Ford’s knee injury.

The HSE, like the GMC and NMC, clearly have no interest in swift, efficient and timely investigations into the death of a young man with his life ahead of him. LB ain’t no Han Solo. Well, he aint human in the eyes of these organisations. But Harrison Ford is more so. As this salacious guff  highlights.

There is no whiff of respect, dignity, care or humanity around the deaths of LB, Danny, Edward, Adam, Thomas, Sarah, Nico and others. Along with complete disregard for their families. We are simply ignored, dismissed, bullied, battered and, I suspect, despised.

I’ve given up asking, pleading, demanding, raging or expecting any action. Here’s a selection of words. Please order them in any way you choose. Or don’t bother.

Bunch. Jot. Among. Fuckers. Sad. You. You. Of. Of. Self serving. Integrity. With. Among. No.

l1023281

Thank you. From Berlin

Back from a weekend in Berlin with two mates, Ulla and Jorun. Special times. We met when we started working together nearly 10 years ago in January 2007. Ten years. Wow. [Howl]. Two beautiful babies, the death of two dads and one child, moving back to Finland and Norway (before any whiff of Brexit), getting a doctorate, a professorship, a new career in the charity field of women’s work in the Global South.

A weekend of talk about families, love, work… Laughter, health, life and shopping.

On Friday afternoon, in a coffee shop in Kreuzberg, my phone started to ring. I didn’t think it worked in Europe. And it rarely rings. I missed the first couple of calls. Unknown numbers. Something kicking off. Clearly.

We headed for the East Side Gallery. Later, standing outside the closed to the public, iconic television tower, the Fernsehturm de Berlín, my phone was still ringing. Katrina Percy had stepped down.

l1023077-2

Earlier, I’d decided to walk from my hotel to Kreuzberg to hook up with them. A 7km walk apparently. Armed with a cheeky tip from George Julian (for no phone or roaming wifi) I screen grabbed the route in my hotel room and set off early. CaminoLB training. It all went brilliantly until this point (screen grab 4):

img_2231

I walked in the direction of the blue dots, post canal, for what seemed like miles. I knew I’d missed screen grabbing one section of the route (because it was all the same road) but couldn’t remember which one, so just kept walking. And walking. And walking. Eventually I stopped at a junction, stared at my next screen grab (again) and a passerby asked if I needed help. He didn’t speak much English, my German is non existent. He looked at screen grab 6, pointed a sharp right turn and we started walking together.

We walked and walked. Managing to share, along the way, that he was Lebanese, living in Berlin and owned an Italian restaurant that did takeaways. And that I lived in Oxford and was going to meet mates. We walked in a comfortable silence after those few exchanges. Eventually, we reached the overhead railway. He pointed to the steps up to it and gesticulated one with his thumb. One stop. One stop…

“Can I take your photo?” I asked. He seemed chuffed.

l1023014-4

 

I caught the train, one stop, and met my mates. We chuckled (I’ve an embarrassing history of travel mishaps) and had a fab weekend.

This experience made me wonder, again, about the utter, utter failure of Sloven, NHS England, NHS Improvement, the General Medical Council, the Health and Safety Executive, the Nursing and Midwifery Council, the Care Quality Commission and the Secretary of State, to help bereaved families in any way whatsoever.

As always, it comes down to being human.

Thank you.