Crown Court

When we were kids, off school with a bug, flu or other illness, we’d snooze in front of the big old (tiny) TV. ‘School programmes’ (shudder) in the morning followed by a less dull but still dull drama (was it a drama? I dunno… maybe it was based on actual cases) called Crown Court at lunchtime.

Crown Court. A kind of ritual endurance, marking the mid point to the crawl to the end of school time and delights like Little House on the Prairie. Time for lunch if not already scoffed. A soft, non medical drug to easily bring on slumber if you felt like shite.

I dug out the theme tune on Youtube earlier. Rich, in another room, unexpectedly shouted “Is that Coronation Street?”

Off sick to the same tune/drama. Capturing the ennui, traffic free streets, all male advocates, a dose of beige and a baby Zoe Wanamaker.

 

On 18 September Sloven pleaded guilty to the Health and Safety Executive (HSE) prosecution of LB’s death at Banbury Magistrates court. The magistrate referred the ‘case’ to the Crown Court. The next hearing was held in Oxford Crown court on October 13*. The judge then set a date – 27 November – to decide a sentencing date. [I know.]

A second HSE prosecution for the death of Teresa Colvin was raised during this hearing. Teresa died a year before LB. Months after Mike Holder, a health and safety expert, meticulously documented patient safety risks which Katrina Percy and the Sloven board ignored.

[Edward Hartley, in turn, died months after LB’s death flagged up issues around epilepsy training and understanding, risk assessment and observation levels. Edward’s death, like so many others, has yet to edge or inch towards proper scrutiny and answers.]

On 20 November the HSE prosecution relating to Teresa Colvin’s death was held at the Oxford Magistrates court. [Sorry. It’s complicated].

Tomorrow (Monday) a hearing at Oxford Crown Court will pin down the timetable for the sentencing date.

The judge will be asked to sentence both HSE prosecutions together. Or formally agree to do so.

This is for various reasons, not least the importance of joining the dots between what happened to Teresa and LB and for the judge to understand the extent of (repeated) failings. Other considerations are the importance of consistent sentencing and costs.

Breathe.

Crown Court. Childhood memories. The never ever. The never colliding.

LB. Teresa Colvin. Shades of Edward Hartley. And so many others.

The sentencing hearing

The sentencing hearing is, we’ve been warned, likely to last for up to two days and will probably happen between next February and June. Time has lost any meaning as next year becomes dusted with various dates or anticipated dates. I can’t imagine what life without the stench and stain of NHS related processes looks or feels like.

The HSE barrister will present the two ‘cases’ in turn and the Sloven barrister will present a set of mitigating circumstances to try to reduce or contain the punishment (fine). They have a statutory duty apparently, as a public sector body to do this.

There is no such statutory duty to prevent a failing Chief Executive disappearing with a year off and around a £200k pay off. There is no statutory duty to stop a public sector body from recording a preventable death as one of natural causes. From openly and publicly withholding information that is in the public interest. From wasting public money on dubious training programmes. And the rest.

One grotesque rule for the bloatedly powerful and another for the rest of us herbs.

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*I had at the time, and have had since, visions of Richard Partridge telling me to turn to page 908 in a massive legal bundle to confirm that, yes I was not present at this hearing. And then scuttle back to page 26, para 4…

I was in the US. I wasn’t supposed to be there.

 

 

Prof Ted the Gut Man and the travelling suitcase

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Exhausted. A terrible, terrible day following George Julian’s live tweeting of the General Medical Council (GMC) tribunal examining the conduct of LB’s ‘responsible’ clinician, Valerie Murphy. A tribunal that began back in August and is now spread across the next weekend or so.

Todays offering included a tangential figure – Prof Ted (a gut expert) on the phone to provide a character reference for Murphy – and an account of a travelling suitcase full of patient records. Murphy apparently asked Prof Ted to pluck records out of her suitcase, like drawing raffle numbers, to comment on her record writing skills. These are apparently top notch now. She’s learned not to keep them in her head.

Twitter commentators went into free fall. Eh? Audit? What records? With patient consent? Were they redacted? What price ethics?  Murphy was unable to attend for undisclosed health reasons. She seemed to be following the @JusticeforLBgmc twitter feed as, late afternoon when her barrister phoned to ask how this ‘audit’ was conducted, she tried to re-shape the suitcase story into something slightly more robust. Apparently she selected the first fourteen patient records (whose?) alphabetically and stuffed them in her travelling suitcase. Prof Ted randomly selected eight records from these 14.

He unwittingly generated criteria for what to look for when choosing a character witness who doesn’t really know you. Not a big demand for such a role possibly but useful to a few maybe:

  • Choose someone who barely knows you but is prepared to stick their hand into a dodgy travelling suitcase of patient records and describe this process under oath.
  • Make sure they are so tangential in your life that you spend around 14 hours a year in situations in which your paths could cross.
  • Make sure they are prepared to make outlandish statements about how good you are. For example, that you’re in the top 10% of consultants they’ve ever come across.
  • And when pushed on this claim, they’re willing to state rubbish like having a PhD and ‘being helpful and willing to offer an opinion’ is evidence of being brilliant at your job.

Around late morning the GMC presented their submission. We were suddenly thrown into a space of rare sense. Suitcases and gut stuff ditched. The GMC arguments can be read on the @JusticeforLBgmc twitter feed. The statements that made me weep were around how it was not unreasonable for us to expect LB would be looked after in the unit. Chloe Fairley, the GMC barrister, made the point that Partridge’s cross-examination of me in August was an example of Murphy’s more general blame-casting which included nurses and support workers.

Rich and I broke off to eat our weight in takeaway nosh. Returning to twitter an hour later Partridge was presenting his submission. Right back to Gut Man and the suitcase. And Murphy’s ‘brainchild’ the ‘yellow card’.  A shameless rip off of a well known government scheme on a pilot scale. The ‘yellow card’ was presented as Murphy’s contribution ‘to the profession’ to make sure no one ever died again.

Her entry back…

The fakery, sham and offensiveness of this redemption narrative, generated once the  tribunal process was put in motion and not as an outcome of LB’s death, was difficult to sit through. The dripping of ‘madam’, ‘in my respectful submission’ and ‘very painful for her’ statements by Partridge were grotesque.

Tears and more tears.

The day ended around 5pm. It starts again tomorrow at 9.30am with a private hearing.

Writing about an ongoing tribunal (or inquest) process is something we’ve thought about. We concluded today the process is so flawed and stacked in favour of the ‘professionals’ it can’t matter.

The deep sadness I feel. For LB. For the callous and continued disregard of his life (and so many other lives) – presented today as a ‘single patient episode in 2013’ – is matched by the obscene acceptance of the clearly wrong by tribunal panels. By senior NHS officials, by Jeremy Hunt and so many others.

We’ll keep writing justice. As simple as. And not be bullied by the processes seem to be designed to silence. That’s all we can do.

[Thanks to @RoseAnnieFlo for the title of this post.]

The Percy Problem?

Oh my. A piece in the Mail on Sunday* today about Katrina Percy, former Sloven CEO, touting leadership expertise on LinkedIn.  During twitter exchanges across the day I was bounced back to exchanges around our referral of Percy to the Care Quality Commission (CQC) for investigation under the Fit and Proper Person Regulation (FPPR) back in the day.

A right old dogs dinner that spanned more than 18 months. Littered with a remarkable number of non-responses. Demonstration of the disregard and disrespect bereaved families can expect from the NHS and wider bodies. Brutal non-responses…

2015
17 March 15 We refer Katrina Percy for investigation.
[No response.] Please reply even if only to say you’ve received the email. Families are in a terrible, brutalised position. To ignore is to simply add a size 10 Doc Marten kick in the gut to the experience.
27 May 15 I tweet about this non-response. Andrea Sutcliffe steps in to mediate. Good for Andrea but it shouldn’t take a tweet and the potential for reputational damage to generate action.
29 May 15 An apology from Mike Richards, then Head of Inspection, for the delay in response.
1 June 15 A letter from Richards with the panel decision:
Richards bollox

No words.

2016
3 Jan 16 After publication of the Mazars review we ask the CQC to reconsider their decision.
[No response.] As above. I tweet and Andrea Sutcliffe again steps in to mediate This flags up some communication type issues that really need addressing.
1 Mar 16 Email from Mike Richards’ executive PA to say our referral is tabled for the FPPR management review meeting on 11 Mar 16 and we’ll hear after that.
‘Thank you’ I reply. The differential in power laid starkly by the ‘thank you’ emails.
31 Mar 16  Hello, I email… Again.  Is there any news? As above.
1 Apr 16  Email from Paul Lelliot (Deputy Chief Inspector for Mental Health) to say the Chair, PA and Mike Richards are on annual leave. We should hear soon. A holding email takes about 1 minute to write and send. There is no excuse to piss off on leave and not reply. 
4 Apr 16 The Chair replies:

The panel concluded that any further action should be considered once CQC had concluded our most recent review and have an understanding of the position of NHS Improvement in relation to the trust.

6 Apr 16 A warning notice (and no action) from the CQC is announced.
7 Apr 16 I email to ask what the CQC are going to do about Katrina Percy.
14 May 16 I chase up my email.
15 May 16 Apologies for not updating I’m told. We will provide an update shortly.
29 July 16 I email for an update. [Note we’re leaving gaps of 5/6 weeks before recontacting. The spectre of the vexatious family/mother ever present. This consideration is not even a whiff among CQC business. Kind of reminding me of a paper we wrote about the ringside seat autistic people can have to mainstream life with little or no reciprocated thought from mainstream society.]
29 July 16 An email response: they are waiting for Tim Smart’s review of board capability and governance.
22 Aug 16 I email to ask if there is any decision about FPPR.

No reply. They didn’t bother to reply. As above. With bells on.

Katrina Percy ‘stepped down’ at the end of September 2016.

2017

There are three criminal prosecutions against the Trust in 2017. All cover Percy’s period of ‘leadership’. The Health Service Journal awarded her a ‘CEO of the Year Award’ back in the day which features on her LinkedIn profile. This was, according to a HSJ journalist, awarded by an independent (non-HSJ) panel, nothing to do with the HSJ and ‘before the issues were known‘.

We all know the issues now. Many of us recognised them before weighty (bloated, worn out and toxic seeped and steeped) senior NHS (Improvement/England/CQC/Dept of Health figures) eventually stopped slumbering. We all now know.

There is no more pretence. No more shonky little (and big) practices covering up, denying, bullying, bouncing and battering blame onto bereaved families.

The questions that whizzle around our brains/discussion relentlessly (raised by all sorts of people we meet, bump into or who even pull over to talk to us on the street)… Questions any sensible, non-NHS befuddled (at best) person asks and continues to ask remain unanswered. Not least how the hell could any of this happen? 

I don’t know if I want to ever know the answer/s to this. I just hope that those senior bods who were, and continue to be implicated, take a long hard look at themselves. That they start to polish their murky and corrupt stained goggles. Set aside the lure of the rewards for not seeing, not listening and denying and breath in some fresh air.

You’ve been arsewipes of fuckwhattery proportions. There’s no doubt about this. There is also time to change.

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*Our experience of sensitive and thoughtful exchanges with journalists continued with Jonathan Bucks. Thank you.

They put their cameras down

On Monday Sloven pleaded guilty to the HSE (Health and Safety Executive) charges. It was a short hearing. The district judge referred the ‘case’ to Oxford Crown Court for sentencing. He stressed it was important that time was factored in for the crown court judge to carefully read the papers and for a full day to be scheduled for the hearing. He was deeply kind and sensitive, recognising how awful and serious it was that LB died. He made a point of acknowledging our family (my mum, sister Agent T and Tom attended).

We met with the HSE and their barrister, Bernard Thorogood, before and after the hearing. They explained the process and answered questions carefully and thoroughly. At the end they went to let the various press (including the BBC and ITV) outside know we didn’t want to be interviewed. We’d been filmed walking into the building.

They’re still outside. I’m sorry but we can’t do much about it. If you’re prepared to stay till 5pm or so they may have given up and gone… A bit of advice is to try and keep a fixed expression on your faces when you leave.

We grimly walked out of the Banbury Magistrates Court and passed the gaggle of journalists and camera people.

They put their cameras down.

And more…

It was an unexpectedly moving day. With the kindness and respect shown by the judge, the HSE and Bernard T, the media. Julie Dawes, Sloven CEO, attended.

The hearing date has yet to be set but will be in the next few months, possibly early January. Bryan, the My Life My Choice coordinator, emailed this afternoon:

The trustees want to attend on mass (probably 12-15 people) Oxford Crown Court for the SH sentencing.  They wanted to know how you might feel about this rather than them just turning up unannounced.

What do we feel? What a bloody brilliant  idea!

Let’s make it big. Let’s make it colourful and let’s mark this milestone in the lives and deaths of learning disabled people in typical #JusticeforLB chaotic and love coated fashion.

Who knows who may turn up.

 

 

The afternoon before the hearing

 

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I spent the afternoon with Tom trying to get photos from an old mac that’s been gathering dust and more upstairs. Eventually, after exemplary focus and persistence by Tom, and a few chuckles along the way (yep, yep, my computer smarts are shite, I’ve a desktop that demands a cone of shame and I’ve not updated anything since about 1749), 451 pics from the (g)olden days are now on my desktop. (A fair few have an alarming luke white question mark but we can save that battle/puzzle for another day).

Above is LB ploughing his own path up a hillside holding tightly onto to his i-summat music player. The gadget he produced myriad playlists on, back in the day. Each with one song on.

It was our last family holiday in 2010. He did what he typically did; stuff (the day out in the Black Mountains with a makeshift picnic) in his own way, own time while breaking nonsensical and meaningless rules along the way. So what if he was far behind? He got there in the end.

Before we got stuck into this task Rich and I walked into town to get a hard drive. On the bus home Julie Dawes, Sloven CEO, rang in response to my email from Friday. Good for her for calling back. I want to present the gist of our conversation here because I think it contains or flags up important elements/ingredients for the relationship between Trust staff and bereaved or harmed families.

The Sloven board apparently made the decision that no board member would attend the Health and Safety Executive hearing at Banbury Magistrates court tomorrow for ‘various reasons’. This was because they decided it would cause us further distress and it was ‘usual’ to send the communications manager to such hearings.

Julie Dawes rang me out of the blue on Friday because she was worried about the distress their planned press release would cause us. We weren’t asked whether the attendance (or non-attendance) of a senior exec at the hearing would cause us distress. This suggests that baby steps of improvement (concern about press release distress) remain coated in relentlessly longstanding concern about Trust reputation. And an accompanying lack of really understanding what is important to families.

You can’t assume distress in one area (attendance at the hearing) while checking it in another (press release content) without raising questions about what is actually ‘important’ here. Our feelings as a family or Sloven comms/reputation.

And when you’ve endured the extraordinary through Trust actions like we, and so many other families, have the ‘usual’ is irrelevant and obscene.

It’s really time to start walking up hills using the example of LB (and others) if you mean business around changing practice. Chuck out the grotesque, the turgid, the meaningless, the offensive and step up. Demonstrate the ‘impact’ a patient’s death has had on your organisation with actions. Not talk. [As an aside, and a frankly unapologetic plug for my book, one of the things I learned from early readers was ‘show don’t tell’.]

Think about the thin arguments you’re making and challenge them yourself. Instead of sending the comms manager ‘as usual’ (I struggle here with what ‘usual’ is in such circumstances), make sure a board member pitches up, even if you anticipate a five minute hearing. LB wasn’t given the chance to live. Don’t show further disrespect or worse by thinking it’s only a ‘five minute hearing’, or because you want to downplay the importance of the hearing.

Stand up publicly and show you fully understand and recognise that your organisation is responsible for the preventable death of a patient. Until you do this, no other fucker is going to.

Julie Dawes said on Friday she wanted to offer any personal help she could. It turns out this was distinct from arrangements around the hearing tomorrow and board decisions about attendance. A revealing comment (which is not to knock the offer of help which we appreciate). For families ‘the personal’ is too often the process. And the obliteration of humanity through that process.

By the end of the conversation I think we were sort of on the same page. I appreciate her sticking her neck out by ringing earlier. I hope productive discussion followed our fraught conversation. And I hope some respect will be shown to our beautiful boy who died in the cross hairs of a greedy, arrogant and failing Trust, local authority and CCG, tomorrow.

He deserved so much more.

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Imagining a guilty plea

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The Health and Safety Executive (HSE) prosecution against Sloven is scheduled for 2pm Monday at Banbury Magistrates Court. If the Trust plead guilty it will be a short hearing adjourned until a sentencing date in the next few months. This is a criminal prosecution. A guilty plea is pleading guilty to a crime. A crime that caused LB’s death.

Katrina Percy, then CEO, consistently distanced herself from the dire happenings she presided over between 2011-2016 with the apparent blessing of those who should know better.  Even after the jury at LB’s inquest found serious failings:

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An ‘absolutely tragic failure’. I don’t know what these words mean. Other than it was nothing to do with me guv. But no one (no one) who should have, challenged them. For Percy, the unit and not her leadership was to blame. Before and during LB’s inquest, the argument was LB died of natural causes and it was my fault. The difficult mother and the pesky blog.

Sloven smeared here and they smeared there. Across the years. Embarrassing briefings outlining the wrongdoing of #JusticeforLB campaigners. Hacking, trolling and persecuting hapless staff members. And more. Blaming staff. Blaming everyone but themselves. There was no looking glass among the Sloven senior exec. Or Oxfordshire County Council and the Clinical Commissioning Group. No reflection whatsoever.

A tawdry soup of typically self-serving, smug, arrogant and sometimes nasty individuals. With inflated salaries and no understanding of what it is to be human.

Percy took her massive pay off, disappearing in to the early winter sunset last October. Waiting in the wings to re-launch herself as a leadership consultant on Linkedin.

Meanwhile, the new and remaining board members took it upon themselves to exonerate her in the recently published (and now suddenly removed from their website) 2016/7 annual review. She displayed neither “negligence or incompetence” apparently “during her time with the Trust to the extent that would warrant her dismissal”.  Despite two prosecutions underway.

Psst… board members – past and present – do you really not understand that patients have experienced serious harm or died under Percy’s leaky leadership?

Really?

Imagining a guilty plea

Just imagine. A guilty plea from a Trust who have forced us to fight every step of the beyond distressing way for accountability. Full pages of black redacted pages while other people leaked key quality reviews, briefings and more. Lies, more damn lies and non-disclosure across 51 months to us, to the coroner, and I assume to the police… Smears, delay and prevarication. Desperate attempts to prevent an Article 2 inquest and jury.

Valerie Murphy recently sharply shifted from a four year blanket denial of failings to partial admittance at her tribunal. Will Sloven, having steadfastly trawled through the darkest of dark practices, suddenly shift to a guilty plea?

If they plead guilty what does it mean? Can we can expect an apology for everything we’ve endured since LB died? The mother-blame shite. The staff witness statements with their ‘my relationship with Dr Ryan’ sections. The #fuckingpest commentary from the Berryman board member’s son. Will the abusive caller acknowledge I wasn’t a vindictive cow…?

Will there be recognition that we were collectively trying to get accountability for LB’s death?

Will Oxfordshire County Council and the Oxfordshire Clinical Commissioning Group hold up their hands and finally admit their role in commissioning and enabling crap care on their watch?

Will people/organisations actually take responsibility for LB’s death and their subsequent actions?

An unexpected call

On the bus to work this morning, my phone rang. It rarely rings. Sloven CEO, Julie Dawes. Ringing to update me about Monday. She wanted to run her statement by me, given we’ve been upset about earlier Sloven statements. Reflecting on our upset over previous statements is good. The statement she read out was an improvement on previous Sloven statements. More heartfelt and human.

It was missing any reference to the impact of Sloven’s actions on us since LB died though. What they forced us to endure. Walking through Cornmarket I tried to explain to Julie what it was like to listen to the Sloven barrister argue that drowning was a natural cause of death during LB’s inquest. Just one example of the slippery dishonesty the Trust demonstrated. I tried to explain how damaging this process has been.

Julie listened and said she’d try to reflect this in the statement. She said she wouldn’t attend the hearing on Monday ‘for various reasons’, she recognised how distressing Monday will be be and said if there was anything she could do to help I should get in touch. She reiterated this a couple of times. She asked if I was going to read out my witness impact statement on Monday. No, I said.

I thanked her, hung up and an hour or so later wondered why she, or the board chair, weren’t going to attend the hearing. It’s a criminal prosecution and most people don’t get to not attend ‘for various reasons’. If nothing else, it’s a simple sign of respect.

Given the earlier offer of ‘anything she could do…’ I thought I’d call her back to ask her. Number withheld. She could phone me, generating distress, but I couldn’t call her back.

I’m left wondering how much of the call this morning was driven by an underlying concern about reputation and managing comms. I mean if the Trust seriously wanted to demonstrate evidence of change the CEO or Board Chair would attend the hearing on Monday. And I wouldn’t be asked if I’m going to read out our victim impact statement.

The day after LB died Sloven wrote ‘Mother’s blog may cause a risk to the reputation of the organisation’. Over four long years later the only risk to this organisation remains themselves. And their actions.

 

A levels, love and waiting for the tribunal

A ‘day off’ from the GMC tribunal which continued in private today. Day three of deliberations to determine the facts.

A level day.  Early morning jitters (and humour) from Tom:
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He stormed it. We could not be prouder.

Funnily enough, a photo of Tom and Owen from 2012 popped up on Facebook. A day out in London months before Tom’s childhood was to change irrevocably. Owen, then 17, turned turned 18 the day before LB died. [I know].

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A friend messaged earlier saying congratulations and Tom has ‘done his part in saying ‘fuck you’ to the system and not allowing it to control’. Rosie, Will and Owen have also done their part in doing this. They have, in addition to the death of their beyond loved brother, endured home becoming a site of activism, anger, rage, despair, distraction, tears and more tears.

About a year ago now, at some particularly low point, Rich and I decided during an unusual weekend home alone that we would chuck in the towel on the fighting front. It was too much. It wasn’t fair on the kids. We were trying to climb a super smooth glass NHS mountain coated with a combo of pig grease, melted butter and olive oil.

We told Tom on his return expecting relief. A levels looming and all. He was shocked we’d even consider it. The love, concern, steadfast and unquestioning support and humour they have demonstrated over the last four years, mirrored in the actions and support of their partners and friends, is something we treasure beyond words.

These last few weeks have been particularly unpleasant. We’ve been shoehorned into even more extreme spaces by the careless fuckwaddery actions of the Nursing and Midwifery Council sharing our personal details and Mr P’s brutal and unnecessary cross-examination last Tuesday.

Wilful attempts to discredit without any relevance to the allegations under examination.

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On Wednesday we waited for the tribunal to begin again in public. A inhumane waiting even without the unchecked, salacious and unnecessary savaging. I lay on the settee, under my Routemaster blanket, refreshing twitter repeatedly. Bess dozed on the chair opposite. I took a pic of her on my ipad and tweeted it.

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#Waitingforthetribunal

This generated an unexpected and hilariously heartwarming set of photos; the pets of twitter. Waiting in solidarity for the tribunal. Including a plant (a groot?) which I can’t find now (sorry).

Names, spaces, commentary and love.

I’ve written about pets and health, we’re currently putting together a funding proposal with vet colleagues to further explore this area and yet I didn’t expect to find such solace in the sharing of photos of much loved animals on twitter. It made me chuckle. It was grounding. It was kind of reassuring.

Yep, I thought. These non humans could teach us a lesson or ten. If we would only start listening.

Late morning tomorrow (Friday) the panel are due to announce their determination on the facts (whether the doctor is guilty of the remaining charges she has not admitted to). The tribunal will then be rescheduled to continue at some point in the future.

We will continue waiting. Four years and six weeks on.

Being (in)sane in insane places… in four parts

Part I

Waiting for the GMC tribunal to come back from ‘in camera’ (secret) discussion today. It’s impossible to do anything constructive. Wait. Mope about in bed. Play Candycrush. Clean the floor badly. Answer a few work emails. Pace around the house. Play Candycrush. Poke at weeds for a bit. Mope. Back to bed. Wait.

Agitate.

Part II

We’ve waited four years. But the events of last week make it impossible to concentrate. The cross-examination brutality, the revelation that this blog was causing anxiety among consultants before LB was admitted to the unit and other outlandish arguments by the doctor’s barrister, RP.

Including his bizarre claim he had no computer access to produce submissions for the Friday morning. In central Manchester… sitting next to a colleague with a laptop.

There was incredulity and practical info on twitter.

The next morning RP circulated a set of handwritten bullet points ‘not in narrative form’:

He later argued:

Not all of us are au fait with narrative… You have to find a computer first and then go into free text…

Oh my. Did he handwrite a set of bullet points (a day or so after deftly destroying me as a reliable witness) to demonstrate the point that computers aren’t necessary to do a good job as a consultant?

The day ended with this comment:

Part III

The GMC are keeping us informed about the timetable and process of this hideous process with thoughtfulness and sensitivity.

This is where we are at:

The panel are currently reviewing and considering the evidence given last week and need to agree the position on each charge that has not already been admitted and draft a full decision referring to the evidence, setting out their reasoning for each of the charges.  
 
The hearing will reconvene in public and the determination will be read out. Parties may need time to fully consider the determination then the hearing will move to the second stage. Further evidence can be called and submissions will be made on behalf of the GMC and the doctor in relation to whether the doctor is impaired. At this stage, the Tribunal meet alone again and need to make a decision on two matters: 1. whether the facts found proved are serious misconduct (the meaning of which is set out in various case law) and 2. if so, whether the doctor is impaired by reason of her misconduct.  It is not known how long it will take for the Tribunal to make this decision.
 
Depending on the Tribunal’s determination on impairment, the panel will consider the position of sanction. This would involve further submissions by both parties and another determination by the Tribunal.
Apparently the panel are unlikely to give a determination on the facts tomorrow.  The determination (the next step before the next stage) will likely now happen on Thursday. Coinciding with Tom’s A level results.
Part IV
This hearing has dominated the last few months for us. The Nursing and Midwifery Council (NMC) data sharing breach-too-far is bubbling on in the background. We’re less than four weeks from the Health and Safety Executive prosecution. We managed to polish off the personal impact statement yesterday, thank fuck. In less than a page.

You should include the fact you haven’t had a bath since LB died.” said Rosie. “And you loved them. I remember when we were little and we used to come in and chat to you. Sitting on the toilet…”

My definition of crap has taken such a battering I no longer have words for what we’re enduring.

We’ve been pushed into such an extreme space now that daily interaction with people is becoming difficult. Throwaway conversations in the street about the weather, summer holidays, dogs are hard to engage with. You can’t lay the shit storm we’ve been subjected to on any passerby or acquaintance. At the same time, saying, vacuously “Yeah, fine” is harder to say.

This led me to think about another layer to the campaign and social media activity; the sharing of rage, distress, incredulity and bafflement. The discussion and commentary. We know we wouldn’t have got ‘this far’ without social media. I hadn’t thought about how we would have personally been derailed months or years ago if we were experiencing this in isolation.

An hour into Mr P’s interrogation last Tuesday I was doubting myself.

It’s harder to doubt when so many others express sense, offer expertise (in any shape or form) and solidarity. And genuinely care.

 

The bleat action continuum

Over two years ago now I was writing about ground elder and the #LBBill. I’ve moved into the front garden recently, leaving the elder battle in kind of easy truce [I failed]. The front garden has tall ‘weeds’ with yellow tops which grow to middling head height every summer, leaving columns of snappable woody stems in the autumn.

Turns out these fuckers are worse than the ground elder. They have incredibly dense interconnected knotted lumps of a main root with shaggy swathes of stringy roots. Each one involves a hefty dig, more digging and almost full body wrestle to remove it from the ground. I can almost hear the earth breathing as they are lobbed into the brown bin.

Today we were due to hear the outcome of the Nursing and Midwifery Council (NMC) investigation into how they could possibly have shared personal details to the six nurses under investigation and their counsel.

Given the General Medical Council (GMC)* tribunal into Dr M’s fitness to practice starts on Monday in Manchester for two weeks and Rich and I are on extreme stress settings, I naively hoped that the NMC would be in touch early on in the day to limit the stress. We’ve had way too many 5-5.30pm Friday disclosures over the last four years.

The day dragged on. I punctuated work tasks with patches of root wrestling. Still nothing from the NMC. By 4pm I drifted onto twitter. It was impossible to concentrate. There was some discussion around what time we might expect to hear from the NMC and recognition that the Friday afternoon ‘disclosure dump’ is clearly modus operandi for public sector organisations with no heart or feeling. I resorted to tweeting the CEO about the cruelty of this delay.

The email pinged into my inbox. At the very outer edges of the allocated time.

Tip: Because you say an investigation is going to take x amount of days doesn’t mean the investigation has to take x amount of days. Focusing more attention on a complete balls-up to reduce the time the investigation takes and the accompanying stress for the family is the least you can do in a situation like this. Particularly if

  1. you had an additional 15 days between discovering the data breach and bothering to contact one of the four people affected.
  2. you have previously and publicly spent £250k redacting documents requested by another bereaved family in a breathtaking self protective act.

One of the numerous shite practices we’ve noticed over the past four years is the tendency for senior public sector staff to bleat ‘It was not our intention to do x, y or z’ despite doing it. Or ‘On reflection we should have done…’ when they didn’t.

What this really means is senior staff act with intent (and speed) when it involves their (organisational or own) reputation/skin and don’t when it doesn’t. The briefing on my blog circulated the day after LB died is an exemplar of this bleat action continuum.

The NMC letter outlined how sorting out the return of our personal data (first shared in November 2016) is shambolic. A mix of returned data, alleged destruction of data and outstanding information about copies made.

About as unreassuring as you could get.

And then, in a move not worthy of being written into a cheesy, made for tv movie, it turns out that after discovering the data breach in July 2017, they re- shared my personal details with three of the nurses. Yes, you read that correctly. Re-shared. Nine months after first carelessly tossing them around. But only [bleat] the same information (minus my bank details) to the same people…

There is nothing like heavy handed, dosh drenched redaction when it ain’t your reputation under threat. Nope. Nothing like it.

Fuckers.

*The GMC have been exemplary in the approach to this: clear, detailed information, communication and organisation.

The victim statement, party and pond re-activity

 

In May, the Health and Safety Executive asked if we wanted to write a Victim Personal Statement that would be shared with the judge in the prosecution against Sloven. They offered support to write it while acknowledging we probably wouldn’t need it. At the time I thought it would be a ‘minor task’. I mean I write, howl and rage on an almost daily basis.

Eight weeks later the statement remains unwritten. Well that’s not strictly true. I circulated a brief draft to Rich, Rosie, Will, Owen and Tom last week. Rosie fed back it was pretty rubbish and contrived (in less brutal words than these).

“Can’t you use an old blog post…?” she asked.

We said we’d talk about it this weekend because we’d all be together for Tom’s 18th party.

The party was on Friday night. It was pretty raucous with a lot of laughter, food and drink. Late evening with the dodgy disco light doing its thing, a Bowie track came on and the room of lively, loud and exuberant 18 year olds became a bit blurry. Rosie was there with a hug. The family grief morse code working as it seems to.

On Saturday morning after a brief party debrief and some groaning about sore heads we talked about the statement and I jotted down notes about what it should contain. This was largely a checklist of Sloven crap actions. We didn’t talk about the impact of Connor’s death on us which is what the statement is supposed to be about.

Later that day, attention turned to the disappeared pond in the front garden. Owen and I dragged the second of two monstrous plants out of the pond and left it sitting upright on the grass overnight. A solid, giant mass of roots, smelly black sludge and detritus with an enormous crown of green fronds that wouldn’t look out of place on a Doctor Who episode.

Rich dug the pond with the kids about 12 years ago now. It was a major operation based on serious pond research. Considerable depth in parts, different levels, shallow shelves for inhabitants to clamber in and out of, grey blankety stuff underneath the rubber sheeting and a couple of plants from an aquatic garden centre in Wheatley. A pond was born.

Life went on. Pond life flourished. We kept the weeds at bay for several years and children from the local primary school visited to see the frog spawn and tadpoles.

The two plants grew. And grew. Life took an unexpected turn. The pond disappeared under the foliage and was largely forgotten about. Apart from a hilarious dog sitting experience a year or so ago when Ned, a husky-cross, went for an unexpected stinky black cool down.

On Sunday morning, I was outside drinking coffee and studying the beached plant which was almost as tall as me and twice as wide. A woman stopped and said primly:

Ah. You’re attacking the jungle. Good! Have you just moved in?
Er, no. We’ve lived here for sixteen years…

She wandered off.

Owen and Tom set up camp in the afternoon for a couple of hours with music, borrowed footwear and gloves, an axe, spade and pair of shears, and the plant eventually disappeared into various bins around the neighbourhood. They later threw themselves into topping up the pond with a hose too short.

It’s incredibly hard to write a ‘personal victim statement’. The impact is unimaginable for each of us in different ways, at different times, in different spaces and with different people.

The fabric of family life continues to be brightly woven with people who didn’t meet LB. Partners, a baby due in November. Life goes on. My camera continues to capture delights. And they are delights.

The moments in between, and occasionally during, remain filled with an unresolvable ache that feels like a rock at the back of my throat or my chest being crushed. I don’t know if people’s hearts actually ache but for me it’s a throat/breathing thing which seems to have a direct line to tear production.

I just miss him.

We all do.