‘A terrible confusion…’

We were away last week and missed the Panorama programme about the death of Jack Adcock and the erasure and then reinstatement of Dr Bawa-Garba from the medical register. There’s a lengthy piece written by Deb Cohen, a medical journalist, here. I wasn’t surprised it’s biased because a previous article by Cohen demonstrates her support for Bawa-Garba. I am surprised it’s being touted as a balanced piece of journalism by (some) medics.

As usual, raising this on twitter generates some pretty low level insults/attack.

“…suggest Sara contacts or shuts up”.

Or this:

There’s also no dot joining with sense offered by other twitter peeps.

Ho hum. Here are some reasons why I think it’s not a balanced piece of journalism.

A poor start…

The article starts with a sweeping statement;

When a junior doctor was convicted of manslaughter and struck off the medical register for her role in the death of six-year-old Jack Adcock, shockwaves reverberated through the medical profession.

There were no shockwaves reverberating through the medical profession when Bawa-Garba was found guilty of gross criminal negligence nearly three years ago. The #IamHadiza hashtag probably emerged some time late last year as medics started to realise there may be implications for their own practice.

Differential treatment

Bawa-Garba is treated differently to other people referred to within the article. She’s presented as a devoted mother, daughter and doctor with elaborate descriptions like “writing till her pen ran out of ink…”

In contrast, mention of the Adcock family is perfunctory and largely brief other than a few paragraphs capturing some of the family trauma and Jack’s character.

This difference is clear from the first mention of Jack and Bawa-Garba in which additional context is offered about the latter.

Jack Adcock wasn’t himself when he returned home from school. He later started vomiting and had diarrhoea, which continued through the night.

Trainee doctor Hadiza Bawa-Garba arrived at work expecting to be on the general paediatric ward – the ward she’d been on all week. She had only recently returned to work after having her first baby.

When Jack or his mum are mentioned sentences are typically short and factual without much or any additional commentary or explanation.

The boy’s hands and feet were cold and had a blue-grey tinge. He also had a cough.

But they [parents] say they heard very little from the hospital. They were sent a copy of the Leicester Royal Infirmary investigation and invited to discuss it, but they didn’t want to.

Cohen repeatedly fudges and fills in the gaps for Bawa-Garba. She doesn’t do this for Jack or his family. They are left with a careless ‘didn’t want to’.

‘But…’

Liberal use of ‘but’ is sprinkled throughout the article in relation to Bawa-Garba. There are few ‘buts’ about the Adcocks.

Fewer ‘buts’ are arguably better in terms of journalistic (or broader writing practice) but the ‘but’ differential suggests Cohen falling off the balanced and informed journalistic perch. (The old ‘mistake’ creeps into the first example here with a dramatic, unevidenced statement.)

But she didn’t consider that Jack might have had a more serious condition. It was a mistake she regrets to this day.

Dr Bawa-Garba looked for Jack’s blood results from the lab. She had fast-tracked them an hour-and-a-half earlier. But when she went to view them on the computer system, it had gone down.

But Dr Bawa-Garba says she wishes she had given him antibiotics sooner.

Bawa-Garba is quoted in full throughout the piece. She isn’t paraphrased, a practice which introduces doubt over authenticity and validity. The Adcocks (and others) are paraphrased.

It was only then, the Adcocks say, they heard the “true facts” and “listened to the detail” about the errors that Dr Bawa-Garba had made.

The use of minutes taken by a family friend during a meeting with the Trust as evidence also suggests questions around the validity of the family evidence. Bawa-Garba however is given space within the article to explain, account for and/or have the accounting/explaining done for her by Cohen:

“I knew that I had to get a line in him quickly to get some bloods and also give him some fluids to rehydrate him,” says Dr Bawa-Garba. He didn’t flinch when she put his cannula in.

Dr Bawa-Garba tried a number of extensions before managing to speak to someone. They read out Jack’s results and she noted them down. She says she was looking out for one particular test result called CRP, which would confirm whether Jack’s illness had been caused by bacteria or a virus. She noted it was 97, far higher than it should have been, so she circled it. But she says she was concentrating so much on the CRP that she failed to register that his creatinine and urea were also high – signalling possible kidney failure.”

Inexcusable failings like missing the significance of blood results are buried in words. Unsubstantiated words that offer flimsy excuses or explanations. Bawa-Garba was concentrating so hard on something else... Cohen almost trips over herself with excuses, explanations, ‘buts’ and the downgrading of what is basically shite practice to ‘mistakes’.

Dr Bawa-Garba had been on call for more than 12 hours when an emergency call went out for a patient who had suffered a cardiac arrest on ward 28 and doctors and nurses rushed to help. In the morning, Dr Bawa-Garba had had to intervene to stop doctors from trying to resuscitate a terminally ill boy who had a “do not resuscitate” order. She assumed it was the same boy. What she didn’t know was that Jack had subsequently been moved to the same ward as the boy who had crashed in the morning – ward 28.

A terrible confusion was about to follow.

She is seemingly oblivious to a doctor basing her medical practice on assumption and guesswork and ignoring the evidence in front of her. Ironically, Cohen seems to be doing a similar job in this article.

A terrible ‘confusion’…

Only one of the numerous failings Jack experienced that day is prefaced with a fanfare ‘failure’ statement:

It was at this point that another failing in Jack’s care occurred.

Any guesses which failing? Yep. The administration of enalapril by Jack’s mum. Cohen includes the inquest evidence that Jack’s mum acted responsibly doing this and that the impact of this drug on Jack’s condition is inconclusive. Despite this evidence she still positions this failing differently.

The inclusion of micro detail at times speaks to a determination to funnel out any whiff that Bawa-Garba did a poor job.

She asked one of the doctors in her team to chase up the results for her patients, and took on some of that doctor’s tasks.

Within this reification of Bawa-Garba’s medical ability, the work of medics is kind of lost. Work is work. Bawa-Garba was doing her job like other staff present were doing their jobs. The guilty manslaughter charge was based on the layers of exceptionally poor care Jack received. Bawa-Garba remains guilty of this charge. A vague statement about taking on some tasks does not mitigate this.

And the unsaid…

There’s so much unsaid within the article I can almost hear tumbleweed blowing through it. While I understand constraints on what can be written in terms of length/word count what is left unsaid is deeply problematic.

Cohen mentions the crowdsourced legal fees by medics which raised over £300k. She doesn’t mention the Adcocks remortgaged their house to cover their legal fees.

She refers to the negative commentary Bawa-Garba has received from members of the public on and offline without mentioning the negative commentary Nicola Adcock has experienced (blaming her for the death of her son).

She speaks to various medics and includes tweets from medics in the article. She doesn’t include interviews with, or commentary from, the wider public. She doesn’t include tweets by non-medics. Presenting ‘us’ and ‘them’ is clear in intent and execution. This is about a ‘wronged’ medic and her rattled peers. A medical guild. There is no ‘public and patient involvement’.

Cohen ignores various inconsistencies; medics belatedly joining Bawa-Garba’s fight, denouncing scapegoating while scapegoating, talking about a ‘no blame’ culture while blaming, ignoring the proceedings of a lengthy trial and appeal process, ignoring the nursing staff.

She doesn’t comment on unchecked inappropriate commentary from some medics circulating on social media.

Or how public confidence must be dented by this demonstration of arrogance, refusal to engage with evidence and self-preservation.

She doesn’t make the link to evidence around the premature deaths of learning disabled people or ask why Jack was the recipient of such exceptionally poor care

In short, Cohen has decanted and deliberately funnelled a particular version of events. In doing so, she’s captured the (medical) sediment and lost the oxygen, the life, the flavour and basic humanity. Cohen had an opportunity to demonstrate skilled, balanced and informed journalism. To explore what happened to Jack with his family, Bawa-Garba, Theresa Taylor and Isabel Amaro and relevant others. She chose instead a route of overly-sensationalising what happened or didn’t happen and erasing other parts. Perhaps feeding on or being being fed by the agitation of a group of medics who appear to have lost sight of what constitutes evidence in their determination to protect themselves.

The NMC and the fact free determination

This is going to be a detailed post as it’s important to highlight just how shite the NMC panel ‘fact determination’ about the STATT nurses is. This is about the hearing process rather than what the nurses did and didn’t do.

As background context feast your eyes on this:

Maintaining public confidence and proper professional standards is a bit of a stretch given the almost fact free determination. Instead, the 66 page document contains unsubstantiated assertions, conjecture and an erasing of evidence from previous hearings. I’ll present a few examples here to give a mcwhiffy flavour of the whole thing. The six nurses are referred to as Colleagues A-F.

Batting for the nurses

The bias throughout the document is quite simply breathtaking. Here’s the description of one nurse. The same nurse who refused to answer a question at LB’s inquest on the basis of self-incrimination (evoking Rule 22).

The panel fall over themselves in a smorgasbord of judgement and conjecture which makes ‘the dog ate my homework’ seem a reasonable excuse. The extent of this bias is beautifully captured in the following extract.

The expert witness clearly states a risk assessment should have been done and patients with epilepsy should be within physical reach at all times. This reiterates the expert witness evidence from LB’s inquest and the GMC hearing. The panel attempt to bury this unassailable evidence in a set of absurd and discrediting sentences. Under some pressure… declined to express a view… She could not say…

How can she say what the outcome of an assessment might have been when it wasn’t done? Putting her ‘under some pressure’ is also a chilling comment.

A very partial engagement with ‘evidence’

The pesky facts that get in the way of the chosen panel narrative are ignored or buried as we saw above. They argue at length that the nurses could not have known LB was having seizures in the unit. That I told them LB had a seizure in May is erased. The fact [this is a fact] that I emailed the unit three days before LB died to say I was concerned he had been drowsy at the weekend is dismissed using evidence from the CTM notes.

This handily ignores the RIO notes where staff reported LB was subdued and red-eyed over that weekend [more facts]. A few paragraphs later the RIO notes are used as (quote) ‘positive evidence’ to show that a nurse made a verruca care plan for LB. The determination (see what I did there) of the panel to rule out any whiff that the nurses should have done anything differently because LB’s epilepsy was ‘well controlled’ is undermined by the fact [yep, another one] that they all knew he had had a seizure in January. Just a few months earlier. This document is more about annihilating actual facts than determining them.

The old language giveaway

There is a littering of language which demonstrates the lack of panel objectivity. I don’t know if this is typical of an NMC panel determination but sweet baby cheesus I hope not. Tom has been an employee at Yellow Submarine for 8 months now and his work involves writing reports. He knows you have to be objective with the language you use. A quick google shows the panel chair has been doing the job for way more than eight months (and I suspect is considerably older than 19) so I can only assume using words like ‘unsurprisingly’ must be commonplace among NMC panel determinations.

A further example can be seen in the following two paragraphs.

The first sentence is again absurd. How could there be evidence of something that didn’t happen? Then there is an emphatic ‘precisely’ underlining apparent good nursing practice. This is followed with a mealy mouthed ‘may have been incorrect’ in the second paragraph which makes me want to gouge my eyes out it’s so deeply offensive. It was incorrect. That’s why LB is fucking dead. [Howl]

Blame, blame and more blame

Blame rears its ugly head again. Particularly hideous given the judgement in the HSE criminal prosecution stated there.was.nothing.more.we.could.have.done. Blaming us again is astonishingly cruel.

Without any apparent reflection the panel say that “the undisputed evidence before the panel is that it could be very difficult to engage with Patient 1″. Undisputed evidence. Just a quick reminder that these nurses are specialist learning disability nurses. All they could get was ‘a grunt and a nod’

‘It would appear’ appears throughout the document in defence of the nurses. In the following extract ‘it would appear there was limited additional information that could otherwise have been sought from the family’. How can they possibly make this judgement? One bit of evidence (that destroyed part of my already savaged heart) underlined how little understanding the panel (and nursing staff) had of LB:

In his oral evidence, Colleague B confirmed Patient 1’s fear of gangs of youths and his reluctance to go out alone.

He didn’t go out alone. He never had. This is a pretty substantial piece of information the nurses were missing.

We though (‘they’ ‘they’ ‘they’) could have/should have done more.

We visited too much (‘virtually every day’) and there is a juicy third hand suggestion that I was so difficult the unit had to introduce a telephone triage system to cope with me.

Venturing further into the realms of the absurd

The final example takes absurdity to a new level. Yep. It is possible.

One charge was that the nurses didn’t make a planned referral to the epilepsy nurse. It turns out the person they all thought was the epilepsy nurse (Miss 12), wasn’t. [I know]. With a palpable flourish, the panel dismiss the charge. There was no epilepsy nurse to refer to. Do you hear me? And this is a fact. A fact I tell you. The over-use of the word ‘fact’ in this paragraph kind of suggests the panel know they are on flaky ground.

I can almost sense weariness from Mr Hoskins (who I assume is the NMC barrister). Such twisted, twisted logic.

I got as far as p18/66 with this analysis. It continues in the same vein. Grim, biased, childish nonsense. I’m sickened that this could be considered to be of ‘proper professional standards’ in any way shape or form. When you add in the fact [yep] this has taken five years and during the interminable process the NMC shared our personal details with all six nurses and their counsels twice, it’s very clear this body ain’t fit for purpose.

Sharks on the rooftops

I went for a wander round Headington late afternoon earlier. In part to practice taking photos with my new camera and because I remain so blooming upset/agitated by the description of LB in the NMC hearing ‘determination of (un)facts’. How dare a fucking ‘panel’ of a nurse and two lay people who never met LB and have done nothing to try to understand anything about him be so callously disrespectful of who he was.

No doubt they will argue their determination is based on evidence but evidence is not statements like so and so ‘seems to suggest that…’

Distressing, unnecessary and cruel.

In the late afternoon sun I wandered past the Co-op where LB smashed doing the shopping back in the day. Still makes me chuckle. On to Posh Fish, a go-to chippy for 20 years though our visits have dropped to rarely as the kids have grown older. My mum and dad took Rosie, Tom and LB there for some nosh on the day of my viva at Warwick in 2006. Rich and I pitched up later to have a celebratory beer with them. Such a joyful day. Posh Fish rocked. Reach for the stars stuff it seemed at the time.

Sharks on the rooftops.

Then round to the other Headington shark. The one we used to go and look at when the kids were tots. Rosie was convinced for years it had been a fish and chip shop. I think maybe as a way of trying to make sense of an enormous shark apparently falling head first from the sky through the roof of a terraced house.

At the end of the shark road is the funeral home LB was in before his funeral. Well in and out of because of the balls up over his post mortem. Behind the side window is the ‘viewing room’ or chapel of rest. It’s just a room really but a room completely and devastatingly not like any other room.

[For geography nerds, the John Radcliffe Hospital is up the road there on the left.]

As I waited to cross the road directly opposite a coach went passed blocking my view. Oh my…

Angel Executive Travel. No.fucking.way.

This coach passed me on the day of LB’s funeral. Walking in distress and agitation in the park across the road (the same road). A different type/flavour/density? of distress and agitation.

I didn’t know whether to laugh, cry or punch the air.

I’m taking air punching.

At the end of a week in which professional sharks (not our local fun and quirky ones) have once again been circling for blood and behaving like fucking spunktrumpetweeblewarblers we’re not going to let LB’s memory be sullied in a crass, ill-informed and deeply biased report.

On Friday we’re back to London to fight the fucking fight that never, ever seems to end; to try to establish the humanity of our fun, quirky and beautiful children.

‘A grunt and a nod…’

The Nursing and Midwifery Council produced its determination of facts yesterday. Six nurses referred by Southern Health who also decided the psychiatrist had done no wrong. (We referred her. She was eventually suspended for 12 months by the Medical Practitioner Tribunal Service panel last November, saved in part from being struck off because she worked in ‘the difficult field of learning disabilities’.)

The difficult field of learning disabilities

The NMC hearings have been going on for a few months now. We boycotted them. We didn’t think the nurses should have been referred (and the NMC sploshed our personal details to them and others). It turns out the NMC panel is as unenlightened as the MPTS panel.

The determination is 66 pages long and deeply repetitive as charges and evidence overlap. I seriously hope a dedicated and brilliant doctoral student will one day meticulously analyse the content of these disciplinary hearing documents which are laden with assumptions, snide judgements, some pontification and ignorance.

The most distressing part (these documents always rip your heart out, punch it repeatedly and intricately slice it with a Stanley knife seasoned with chilli and lime) is the callous dismissal of LB as someone ‘too difficult to make a care plan with’.

No one is too difficult to make a care plan with.

A sort of peripheral (that is, never engaged with him because he wasn’t ‘assigned to her’) learning disability nurse giving evidence said LB ‘didn’t verbally communicate a lot, he’d sit and listen and you’d get a grunt and a nod but you wouldn’t get much to go on’.

You fucking what? [Howl]

The panel accepted this statement without question and thought it important enough to regurgitate in the determination. It will be on public record, ironically demonstrating where serious nursing issues lie. With no comment or reflection.

How can an NMC panel be so complicit in denying LB’s humanity?

Why are these panels so fucking ignorant?

Why? As LB would ask, repeatedly.

The determination goes on to consider the charge that we were unjustifiably restricted from visiting LB by having to ring and ask permission to visit him in the unit. [There were advertised visiting times.]

I dunno.

Phoning to ask permission to visit a patient? Within visiting hours. Daily. For 106 days….

Ahhh. Difficult mum stuff again. They really can’t help themselves. Dismissed at LB’s inquest, publicly retracted by Southern Health in June 2016, and summarily dismissed at the Health and Safety Executive hearing in March 2018 (below), mother blame is back again. And again…

Tsk, said the panel, oblivious to this history. Oblivious to LB dying. [He died.] Oblivious to any understanding of what this experience must be like. Oblivious to anything. Including an almost complete lack of off site visits and therapeutic sessions that family visits could ‘clash with’.

The charge was unproved. (“difficult”) Relative A clearly misunderstood the point of having to phone and ask. This was no (quote) “unjustified” restriction. It was justified given the frequency of the family visits.

We visited too much.

A new coating of mother-blame assimilated into these disciplinary hearings without reflection. Do panel members ever venture out into daylight? Christ. Are these panels linked to the anonymous ‘panels’ that make decisions around budgets and other stuff when our kids turn 18? Who are these panel people? How do you become one? Are they middle class (typically white) people with exclusive life experiences?

Does anyone scrutinise panel membership?

There’s no logic, sensitivity or apparent thought underpinning this latest determination. And no dot joining between the evidence from other hearings (or around the deaths of Edward, Richard, Danny, Thomas, Oliver, etc etc etc). Each person is singled out as an atomised being, subjected to different, unfathomable, barbaric rules, actions and judgements. Without any apparent recognition or awareness by ‘panels’, coroners, ‘independent investigators’…

Why are these dots so hard to join?

Ordinary people (and juries) get it.

Don’t poke the beast…

The footies on. Somewhere. Everywhere, it’s so damn quiet. Home alone with Bess. Listening to music. Head spinning from so much happening and not happening. LB’s five year death anniversary speedily approaching. The day before NHS 70th birthday celebrations. I feel queasy already. Hunt and NHS England remain silent about the leder review. Bouncing back FOI requests as too expensive. Refusing to comment.

An extraordinary level of engineered wilful disinterest.

Non-disclosure

I put in a Subject Access Request a month ago asking to see Valerie Murphy’s statement for the MPTS hearing. She read my statement. Her barrister commented on it during his illness inducing cross-examination.

The answer came back today:

“I do not believe there is information that is disclosable under the DPA”. Oh. The GMC will however disclose extracts relating to LB if I sign a confidentiality agreement.

Murphy had no such restrictions. She can say whatever she wants about my statement. To whoever she chooses.

And so it continues..

A week ago a bizarre comment was posted on justiceforLB.org:

The answer to George’s question was this:

Spencer and Murphy studied at the same university at the same time.

Oh my.

[Howl].

We know snarky (or worse) and largely unchallenged discussions go on behind the password protected doctors.net (and I’m sure other forums). These started within weeks of LB’s death. Mother (and other) blame has had a remarkably unremitting purchase in health, social care, education circles for decades now. Noted and discussed at length by families. A steely silence (apart from the odd dissenter) from professionals who must recognise this shite for what it is.

These random, unexpected and typically incoherent attacks are pretty hard to endure. Our boy died. He died. You just don’t seem to understand this. He was 18. Can you imagine your child dying a preventable death in the ‘care’ of the NHS?

A beloved and beautiful child. Dying. A preventable death.

Can you begin to imagine?

Why don’t you fucking try to imagine?

 

 

 

 

 

 

 

Housecoats, aprons and mucky labour

Captivated by the women of Galicia along the last section of #CaminoLB.

“Can I take your photo?” I asked pointing at my camera. A few said no. Others stood tall. Looking me in the eye with quiet confidence. There was no artifice or prevarication.

Incredible, beautiful faces.

Lines. Life carvings. Contours of determination, humour, dignity. Resilience. Well earned, authentic resilience.

Glimpses of triumph and more. So many stories.

Housecoats, aprons and mucky labour.

Back to work tomorrow.  It’s been a long five years.


Smashing it

FullSizeRender 51

We did it. A historic judgement by Mr Justice Stuart-Smith on Monday morning which involved a £2m fine for Sloven Health. LB and TJ Colvin were treated with the respect they deserve. Justice was served. We had been prepared that the sum of money was not as important as the Judge’s comments would carry more weight. As it was Mr Justice smashed both. He carefully read out a judgement so drenched in sense and fairness it was extraordinary to listen to. In a court again packed with JusticeforLB campaigners including several members of My Life My Choice.

The sensitivity and commitment of the Judge, Bernard, the HSE team and the media who attended (many of whom have followed the campaign over the years) were also extraordinary. Kindnesses that will stay with us.

Our statement about the prosecution can be read here.

Michael Buchanan’s news film with beautiful video clips of LB is here.

A few thoughts and outstanding questions

We were surprised (and pleased) to hear Jeremy Corbyn raise LB, TJ and the campaign in Prime Minister’s Questions yesterday. May also praised the efforts of the families. This is good but serious questions remain about the failure of the various regulators/bodies to act on what the Judge described as ‘the dark years‘ of Sloven. Jeremy Hunt is captured in the Commons looking slightly uncomfortable. So he should. It’s not the job of bereaved families to ‘uncover the serious systemic problems‘ in health and social care.

Mr Justice describes ‘very grave concern‘ that endemic failures were allowed to arise at all and to persist for so long. I mean why was this? Do senior people leave sense on a middle rung of the ladder to success? Are critical scrutiny and self reflection dirty words in senior circles? Is the culture so dire that no one can offer challenge to unspeakable actions?

Many of the mountains of email exchanges we have through Freedom of Information requests include abysmal statements and the complete absence of challenge to these statements by numerous people. Norman Lamb stands out as someone who stood firm, recognised how wrong it was and acted. And made sure action happened.

We have in the Justice shed a long standing plan to hold an exhibition plastering this documentation around a cavernous space to allow people to wander around and read the levels of shite and what families are forced to endure. What is said and not said. Replicated in too many other cases.

Looking back across the five years there was a wilful refusal by NHS Improvement, NHS England, the CQC and Jeremy Hunt to act. One example. Two referrals (yes two) of Katrina Percy to the CQC’s Fitness to Practice panel in 2015 and 2016.

1. Mike Richards sent  a ‘fuck off she’s fine’ letter months later (the referral had got lost). 2. After chasing we were told the fitness panel would wait for NHS Improvement’s trouble-shooting Chair Tim Smart’s exec board capability review. Smart bafflingly concluded the board were all fine. Percy again exonerated.

NHS Improvement and the rest continued to slumber.

Point 4 of the judgment states: ‘When the systemic problems were finally recognised, a welcome realism entered the Trust’s appreciation of what happened‘. This interpretation glosses over the crucial point that it was the replacement of ‘pay off Percy’ which enabled the (slow) recognition of failings. She and her turgid, complacent and arrogant board have got off scot free.

Unlike the MPTS panel which decided to include the ‘difficult field of learning disability’ as two mitigating factors in deciding to suspend Valerie Murphy, Mr Justice states ‘the fact that the Trust’s breaches were most likely to affect vulnerable patients is an aggravating factor‘. Of course it is. That he simply saw LB and TJ as human is at the heart of his narrative and judgement. And what has been largely lacking from the broader NHS related responses.

The sentence is here. The biggest Health and Safety related prosecution fine in the history of the NHS.

FullSizeRender 52

There has been some unsurprising meithering on social media about this fine. Yesterday we found out that Sloven quietly sold the Ridgeway Centre in High Wycombe last November. This was one of the spoils they took with them having lost the Oxford contract because they were so shite. A sale that netted them a tawdry sum of £2.3m. Dosh taken from Oxfordshire provision.

It’s a shame the £2m can’t be channelled  into providing groundbreaking provision for LB’s peers some of whom continue to flounder without appropriate support in county.  ‘A TJ and Connor centre of life, love, fun and brilliance’. But that’s out of our hands.

Mr Justice was spot on with his ‘just and proportionate outcome‘.

Finally

We’re pretty much done now. We did what we set out to do and whilst none of it will bring back our beautiful boy we collectively did a bloody good job. As Mark Neary reflected yesterday we may have changed the way campaigns are run.

One of the central features of the campaign has been the extraordinary live tweeting of the various hearings by George Julian. She is now looking into a more sustainable way of doing this for other families. Making dirty practices by public sector funded and instructed counsels visible in real time is priceless. If you can spare £1 a month (or more) please fill in the form on the post and let George know.

I hope a light will be shone on the persistent cover up of the ‘dark years’, the culpability of Percy and the board and that those more widely implicated will absorb some of Mr J’s sense, fairness and integrity and now speak out. Critical scrutiny, transparency and honesty is essential for safe, effective and inclusive health and social care.

I’m off to Spain tomorrow with various #JusticeforLB campaigners to walk the LB bus the last 170 miles to Santiago de Compostela*.

After that it’s back to work. And life.

Thanks, thanks and many more thanks – so many thanks – to everyone who did and kept doing what they could and so much more. We seriously smashed it.

old-pics-2-4

*UK walks are also taking place. Rumour has it, in another magical twist, Mr Fortune, Winnie Betsva’s barrister from the inquest is doing the Devon walk.

 

 

 

Light and the fatberg ingredients

L1031904-2

Crumbs. I’m feeling brighter. I’d anticipated a plummet to rock bottom land in the lead up to the Health and Safety Executive (HSE) sentencing hearing next Monday and Tuesday. A month after the MPTS sanction decision for Valerie Murphy. Two years after LB’s two week inquest. Five years to the day we took him to the STATT unit that cold, dark Tuesday evening on March 19 2013 [howl].

Other than the odd trip to London or Oxford I’ve been hanging out in the Justice shed for weeks. Crocheting.

A recognisable blanket of brightly coloured granny squares has emerged (will add a picture in the morning when it’s daylight). Griefcast has become my (late to the party) go to soundtrack. The (sometimes) humorous reflections of death and grief by comedians has been a gentle and soothing backdrop to the wool action.

I feel brighter.

Tom and I did a news interview this morning in advance of next weeks hearing. In our kitchen. The setting for numerous recordings over the last five years.

Doors have since fallen off cupboards and and half arsed drawer fronts carefully propped up. In preparation for the visit I did a bit of cleaning this morning.

“Mum! It smells really funny down here!” shouted Tom while I was upstairs getting out of my crochet uniform of grey tracky bottoms and a worn out old woolly red jumper.

“Ah I chucked a load of bleach down the sink. It might be that!” I replied. Visions of some right old ripe and until now undisturbed fatberg ingredients fighting back in the u-bend.

We ended up talking about five years of campaigning. Five years. Five of Tom’s seven teenage years. Pretty much the first five of Rosie, Will and Owen’s adult years. Half a decade. Half a decade of repeatedly poring over the hideous and distressing details surrounding LB’s death. Over and over and over again.

Of being blamed and vilified. Of persistent fat berg ingredients.

The interview was unexpectedly positive. There are no more nasties to come. No more bundle pages to turn over and ‘go to’.  No more oaths to swear. No more vicious counsels to face. We’re part of the audience for the hearing next week. And Sloven have pleaded guilty.

Tom made a comment at the end of the interview about the style of the campaign; the humour, creativity and fun. He was spot on.We’ve collectively written, blogged, spoken, tweeted, live-tweeted, presented, met, challenged, shouted, scrutinised, counted, drawn, produced, filmed, sung, shared, kayaked, run, walked, danced, travelled, stitched, photographed, baked, drunk, laughed, cried, wept, hugged, raged and laughed more.

Whatever happens next week we’ve done LB and all the other dudes proud.

Light.

L1032421

L1032418

 

 

 

Battery by bundle and the MPTS transcript

L1032400-3We received copies of the MPTS tribunal hearing transcripts yesterday. I strangely felt some relief reading the finer detail of what unfolded that day last summer. While my brain and heart wept in inept tandem alongside a rage I’m kind of scared of, I could at least better understand why I ended up unwell.  We all knew it was traumatic at the time – Rich and Rosie, Charlotte Haworth Hird, George Julian live tweeting – but my memory was hazy. Now I know.

I’m adding detail here to the post I wrote about the experience; Writing Trauma. Long post warning but this is to give families some idea of what they may face in similar circumstances. And to document how barbaric the (unchecked) processes are.

A few general thoughts:

  1. You don’t typically see medical notes before someone dies. So if for example a psychiatrist jots in medical notes ‘unwitnessed seizure’ the fact you didn’t make it clear the type of seizure you’re ‘pretty sure’ it was is because you’re going through a lot of information and, at that point, it isn’t the most important detail. Once someone dies or experiences serious harm these notes become ‘hard evidence’ despite always being a partial account.
  2. It’s hard to accept Murphy’s new found remorse as genuine given she sat next to Partridge throughout this cross-examination without comment.
  3. I can imagine medics reading this thinking ‘Yep. Well there clearly needs to be robust challenge to the evidence produced. This is a medic with her whole career at stake…’ That’s fine. There’s a process in place here. A process that should not involve trying to destroy someone in an attempt to get a doctor off the hook.
  4. I’m left wondering if the panel allowed the brutality because there’s an assumption of underlying ‘vexatious patient/family’ narratives at these hearings. They seemed oblivious to the trauma being generated in front of them.

 

The transcript

I began by counting the number of questions Partridge asked me. At the time they blurred into a dizziness that I still think about when I wake in the early hours of the morning.

157.

He asked me 157 questions.

157 questions…

Page turning and more

I mentioned page turning in Writing Trauma. It wasn’t only the physical turning of pages in the deep lever arch file but the harrowing glimpses of words, notes and comments about LB across his 107 days in the unit that this generated.

Partridge page turning in action:

‘Can you just turn back to the first statement at page 1?’
‘It is at page 644 it begins.’
‘If you just look at page 645…’
‘If you just go over the page to 646…’
‘If you then go on to page 647 for me…’
‘Can you just have a look in the notes for me at something on page 631?’
‘If you look at 623…’
‘Just look at paragraph 57 of your witness statement.  If it helps, there are some notes at 236.  I hope I have got the right reference.  No. I beg your pardon.  Just pause a moment, Dr Ryan, I do not want to send you on a wild goose chase.  There are some notes at 698 that say CTM meeting, clinical team meeting.’
‘Can we look at the second meeting on page 698?’
‘Just have a look at the document for us, will you?  It is attached to Dr Murphy’s statement.  You have got Dr Murphy’s statement still there just on the side, I think.  There are a number of exhibits to this document.  It is Exhibit VEM/5.’
‘…if you go back to that file at page 692 – sorry, just before you leave that page, Dr Ryan, page 699, can I just ask you about the reference to the seizure monitor?’
‘If we go to page 692…’
‘If you go to 689…’
‘Just go to 685…’
‘If you look at page 673…’
‘If we have a look at 10 June, page 676…’
‘At the end of this at page 679…’
‘At the top of 677…’
‘Can I ask you about the dynamic that was created because if you just look at page 693 for a moment in your bundle there…’
[Break requested by me]
‘… can I ask you to look at page 693…’
‘Just going back to look at your statement, let us go back to paragraph 21′ I think it is at page 70…’
‘Could I ask you just to look at something we looked at slightly earlier at page 647 in the bundle?’
‘I want then to ask you about the incident that you talk about under your heading, “Seizure at the unit”.  It begins at page 32 of your statement.’
‘I think you describe at page 83 that you went to see Patient A on the ward.’
At 84, that you did not discuss with Patient A about how he had bitten his tongue.’
‘Let us just look at that note for a moment.  This is page 541…’
‘On 3 June, this is at page 680…’
‘If we just look at your paragraph 94 – sorry to move you around – back to page 35,
Again we have to go back to the care plan documents at page 676…’
‘It is page 670, 10 June…’

‘Sorry to move you around…’ after nearly two hours of battery by bundle.

Page turning was combined with other tactics:

Just look at paragraph 57 of your witness statement.  Dr Ryan, this is not a memory test any of this.  It is your witness statement at paragraph 57 and it is page 26.  I just want to be clear about this.
Q Therefore you did not hear that conversation.
A No.
Q How long was he gone for, can you recall?  If you cannot remember just say so.
A No idea, it was not long.

Q Again you have no recollection.  I do not want to go through these ad nauseam but you have no independent recollection of these conversations.
Q If we go to page 692, this is 22 April and it is another CTM, at the top there, you will see the people who were present.  Dr Murphy was not present on this occasion.  Do you know if you would have been present?
A No.  If I am not on the list, I would not have been.
Q Can you remember if there was any reason for that; was it work?

Contemporaneous impact evidence and the death blow

My discomfort at the interrogation was apparent in the transcript.

Q At the end of this at page 679, there is note here whereby attendees of the meeting were invited by mum to brainstorm plans for Patient A’s future.
A Yes.
Q You had a fairly active role.
A Yes, in that meeting.
Q You did not feel in any way cowed, shall we say, to put across your point?
A No, I felt as I feel right now.  I felt deeply uncomfortable and distressed and at a loss really but we went through the process of the meeting.

And I was able to identify the death blow among the raining punches. The point that pushed me beyond endurance. I’d thought it was when Partridge described how upset Murphy was by my description of her. That when I asked the panel for a break. It wasn’t. It was later.

When Partridge too dismissed LB’s seizure.

Q That is 20 May, is it not?
A Yes.
Q That is after the – again let us try and be neutral about this – event with the tongue biting.
A It was a seizure.
Q Yes, I know that you feel it was a seizure.  I understand that.
A It was a seizure.

It was a seizure.

Postscript:

GMC transcript

Giving evidence and the weight of the state

L1032390

Rich and I went to London on Wednesday. This was a big trip in the context of disrupted sleep, nightmares, crochet, Candy Crush and more crocheting. I hauled myself  into the hairdressers for the first time in months on Tuesday. Jack set to on my mop head. He doesn’t talk much which is cool. Lauren a right old talker who used to cut my hair appeared wearing her new carer’s uniform. She’s starting social work training in October.

“I told ’em about what happened to Connor in safety training last week,” she said.

It pissed down when we were on the Oxford Tube but the sun appeared at Marble Arch. First stop was a meeting at Monckton Chambers  with Steve Broach and Charlotte Haworth Hird about the MPTS tribunal sanction decision. We kicked around the content of the planned legal submission to the Professional Standards Authority (PSA). Grim incredulity again at the sanction wording and decision. Charlotte said she’d write to the PSA to let them know a submission was coming.

Rich and I walked to parliament to give evidence to the Joint Committee on Human Rights chaired by Harriet Harman.

L1032378

We were with Louise and Simon Rowland in one of two sessions that afternoon. Louise’s brother Joseph died a terrible death and it became apparent during the session that their experience of gaining accountability was almost as harrowing.  This was to be followed by a panel consisting of Deb Coles INQUEST CEO, Merry Varney lawyer at Leigh Day and Katie Gollop QC at Serjeants Inn. The chambers that spawned both Alan Jenkins and Richard Partridge.

The room was seriously, seriously hot. The committee sat in a horseshoe arrangement  with the four of us on a table facing them. Members of the public sat behind us. It was a similar set up to the MPTS tribunal with less space, more opulence and four family members not one.

Harriet Harman demonstrated an excellent and sensitive grasp of the key issues. Other committee members too were clearly interested and concerned. Some were not up to speed (the recording is here) and appeared not to have read the written submission INQUEST had produced. It became apparent that ‘committee sitting’ is a pastime for some. A quick google revealed one member had spent their adult life trying to stamp on the human rights of certain people. All very odd.

The evidence produced during the first session was harrowing. Other than praise for  coroners (the second coroner in Joseph’s inquest) we presented a situation summed up by Harman as

Where you have lost a loved one and the state is implicated because the loved one was in the care of the state and thereafter the state then weights the system against you because those acting on behalf of the state have full-on legal representation from the word go in order to defend their position and you have nothing unless you happen to find people who are prepared to do it for free.

The state weights the system. Yep. And sets out in the relentlessly protracted process to destroy bereaved family members who dare to try to get answers.

The yellow card

The second session introduced a new layer of bafflement. Gollop had a yellow rather than white name card.  A symbol of the hierarchy that permeated the room I assume. Further reminder of  Valerie Murphy’s yellow card scheme and the Serjeants Inn connection.

The committee began with the same format of question and answer but within minutes Gollop interjected to present the five ‘brief’ (not brief at all) points crowdsourced on twitter she wanted to get across. She painstakingly worked her way through each one without interruption. Her apparent knowledge was privileged in a privileged setting.

The pastime crew were a receptive audience. I suspect they always are to the yellow card holder.

Watching the second session (from 15.57 on the recording) is grimly fascinating offering the viewer a smorgasbord of facial expressions and grimaces. Two women championing the human rights of people and their families catastrophically let down by the state. Oozing knowledge, expertise, experience and humanity. And a third, whose evidence aside from the occasional reflective comment was couched in an alternative (offensive) narrative of compensation, litigation and detachment.

The take home message of both sessions if you strip away the Serjeants Inn white noise is there should be equality of arms between families and the state. As simple as.

Doreen Lawrence came over to speak to us at the end clearly upset by what she’d heard.  We shouldn’t have to fight, she said. This was all wrong. Gollop took the opportunity to slip away. I don’t blame her.

On the coach journey home we received an email from Charlotte. The Professional Standards Authority are going to conduct a detailed case review of the MPTS decision.