Category Archives: Death

The GMC investigation (Part 2)

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Memorial bench lichen at Wolvercote Cemetery. August 2016

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

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

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

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

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

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

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

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

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

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

Nope.

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To be continued.

*We still don’t know.

 

The GMC investigation (Part 1)

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

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

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

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

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

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

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

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

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

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

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

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

Kissing bare feet…

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

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

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

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

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His mum kissed his bare feet.

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

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

When trusts go bad

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

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

Sloven who:

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

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

Truly, truly extraordinary.

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

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

Surely…

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

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My incredulity monitor has finally broken.

I start walking…

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

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

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

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

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George Street, Oxford. August 2 2012

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

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

And wait. Still.

Updating LB

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Hello matey,

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

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

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

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

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

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

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

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

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

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

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

Connor

Connor

xxx

State sanctioned cruelty

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L1020557Rich and I were back on the bus to London at lunchtime to meet with Norman Lamb and the Health and Safety Executive (HSE). Brilliant sunshine on the walk from Victoria to Westminster. People going about their daily biz. Three years and three days after LB died a preventable death in the care of Sloven Health. 266 days after a jury determined LB died through neglect. And still no accountability.

The meeting, at Portcullis House, largely involved discussion around the length of time the HSE investigation has taken so far as detail couldn’t be discussed.

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Our love for Norman Lamb has been a constant since the curry night when we first met him. He was instrumental in getting the HSE to investigate LB’s death. Writing to the CEO after the HSE originally decided not to investigate. I’ve not seen him in action up close before today. He was deeply impressive, carefully questioning the HSE trio throughout the meeting.  Sense, clarity, knowledge and sensitivity. Pinning down timings, process and progress.

Why did the HSE decide not to investigate originally?

I assumed when I was informed there would be an investigation it would happen straightaway.

Why is it taking so long?

Why did you not work in tandem with the police?

This is not being given the seriousness it deserves. I can only conclude it’s an indication of how learning disabled people are seen as less than human…

It amounts to cruelty to take this long. It isn’t complicated what happened.

I don’t understand why it is taking so long. 

Where does the failure lie?

There were mixed answers, some contradiction and non answers. The back story is that the HSE originally decided not to investigate because they decided (no idea why) that LB died as an outcome of a clinical decision. [Howl]. After Norman Lamb’s intervention five HSE people reviewed the decision and, with particular focus on the Verita report, decided to investigate. Apparently there was some blurring over investigative responsibility while the police were still involved and the HSE took primacy for the investigation after LB’s inquest in October 2015.

The HSE inspector finished her report in February and it then got stuck in some interminably slow process of internal checking for around five months until this week. It’s now been sent to legal advisors and next steps are expected to be announced at the end of October…

It’s taking so long because these things can do, it depends on the complexity of the particular case, because there was a lack of clarity over responsibility. It most definitely is not related to LB being learning disabled or (slightly less emphatically) because an NHS Foundation Trust is involved.

On the bus home, I had a look through recent HSE press releases. Three bath related investigations since December 2015.

Joseph Hobbin died in June 2013. Ark Housing Association pleaded guilty and were fined £75,000. [December 2015]

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A patient died in April 2008. NHS Kent and Medway Social Care NHS Partnership Trust pleaded guilty and were fined £107,000 plus £25,000 costs. [January 2016]

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

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Blimey. Should never have happened. Well documented risks. Legal duties…

Same old same old. An alternative re-run of Sloven related inquests over the past five years. Lesley Steven, Medical Director, popping up to say lessons learned/changes made and the CEO in hiding. A grotesque and macabre dance around death. Dripping in (meaningless) and lengthy bureaucratic processes. A fine and a non rap over the knuckles. Disconnecting and siloing. No linking between instances of shit care. To enable the wheels to keep turning.

Meanwhile families continue to be brutalised.

We know LB should never have died. We knew before we walked out of the John Radcliffe A&E into blistering sunshine that July morning. He was completely failed by the state who had a duty to care for him. Since then, evidence of Sloven failings have been unprecedented. Both in volume and the extent to which they have led to no action.

Norman was spot on when he said this is a form of cruelty. State sanctioned cruelty. With no end in sight.

 

4.7.16

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Approaching the third anniversary of LB’s death…

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

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

Trying to quash the horror of those last few months.

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

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

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

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

I dunno.

4.7.16

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

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

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

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

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

Final thoughts:

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

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

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

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

I miss him.

Tears, rage, disbelief, frustration and utter bafflement

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

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

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

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

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

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

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

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

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

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

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Another dirty day down Sloven way

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Got the background details (via a Freedom of Information request) about the commissioning of the study into families’ experiences of Sloven’s serious investigation process yesterday. I’ve written about being invited to take part in this study. And of Lesley Steven’s defence around the magic wand stuff.

It turns out Sloven decided up front that this study should take the form of an Appreciative Inquiry. David Snowden offers a critique of this approach which includes:

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It ain’t a big surprise Sloven like this approach. They don’t engage with their failings at any level or allow patients or families to express how they feel. Setting aside the criticisms identified by David Snowden, Appreciative Inquiry ain’t an appropriate approach for bereaved families. Unilaterally choosing an approach that only focuses ‘on the bright side‘ when looking at patient deaths is simply wrong. And risks causing more distress to people.

It turns out that the consultant who got the gig was recommended to Lesley Stevens and commissioned on the basis of a couple of emails and meetings:

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Shudder. At the March board meeting, in response to mention of the commissioning of external ‘work’, Mike Petter, then Sloven chair, quipped: This is a company we haven’t worked with before – there is one out there. No joking matter. We know the sizeable chunk of Sloven expenditure over the past few years spent on commissioning ‘consultants’ or legal professionals to help dig them out out hole after hole after hole.

The cost of this latest venture?  £27,000 for 40 days work. Yep. Really.

Sloven have rules (like any public organisation) around the spending of public money on external services. There has to be justification for why there is no competitive process. Any spend of more than £25k has to go to the next Audit Committee for review…

The £27k agreed for this gig includes VAT so I assume the £22.5k (excluding VAT) figure (handily) means it doesn’t make the Audit Committee bar. As for the lack of competitive process… the excuse is presented on the Single Tender Waiver form here:

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Ah. Bloody hilarious. Though it ain’t of course. Recommendation about the supplier is surely the reason procurement rules were implemented. Recommendation by whom? [Handily redacted in the FOI info]. Pace required following Mazars and CQC..? Sloven first got sight of the Mazars review last summer. Not much pace here. Lesley Stevens gifted the job to the consultant in February 2016 after it must have  (eventually) dawned on senior Sloven muppetry that the CQC inspection did not go well. So competitive processes to protect public money are swept aside because of continued Sloven crapness, denial and arrogance… A circularity that makes my brain weep. And for the record, alternative suppliers are plentiful/Appreciative Inquiry philosophy ain’t essential. Quite the opposite.

What’s particularly chilling? (I dunno, running out of words/thoughts here, it’s all so utterly shite) is that Sloven think this ditsy review is an appropriate response to either the Mazars review or CQC inspection.To commission it in such a shoddy, careless and piecemeal way underlines how unfit for purpose the Sloven senior team are.  It’s actually flagged up by Katrina Percy in a letter to NHS Improvement (who she still calls Monitor here) as progress on their enforcement undertakings:

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Further demonstration of how devoid of understanding, ability, empathy, willingness, whatever the senior team are. As if any more is needed. These people simply shouldn’t be running this organisation. There’s a superficiality so obvious, documented so publicly and repeatedly, leading to such serious failings it is extraordinary.

Getting a colleague of a colleague, a mate of a mate or whatever combination to write some nonsense, bypassing processes in place to make sure public money is spent with caution and transparency and demonstrating a complete lack of understanding about bereavement is so wrong it almost defies words.

Work on this ‘review’ is due to be finished in the next week. I don’t suppose for one moment the consultant has been able to do anything approaching what she outlines in communication with Lesley Stevens. I hope Victoria Keilthy reads whatever puff that reaches her with a sharp lens and reflects on the commissioning of this crap. This is a public body.

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