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.

 

‘I want to ask you a little about your blog…’

This blog has again loomed large. It did at LB’s inquest and again this week at the ongoing GMC tribunal. Dr Murphy’s respective barristers both presented it as a transgressive space/action that somehow underpinned or fed into what unfolded. It was a malign catalyst for something (I’m not sure what either barrister was trying to argue other than the blog damaged the relationship between some consultant psychiatrists and a patient’s mother).

How social media ‘feedback’ is ‘used’ by health and social care is the subject of considerable research, some of which is happening in our research group. A colleague has been interviewing people who document their health experiences online to explore why they do so.

When I started writing the blog back in May 2011 ‘online patient feedback’ was not a twinkle in my eye and possibly wasn’t even a thing. I wanted to capture the funny stuff that happened in an online diary. I didn’t expect it would be read beyond close family and friends (or even by them). In fact it became quite widely read and a few hundred people started to follow it. The fun focus sadly disappeared towards the end of 2012 and it became an account of trying and failing to get support for LB and subsequently the 107 days he spent in the unit.

This week the blog questions unfolded like this [RP is Dr Murphy’s barrister] :

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This was ground already thrashed out during LB’s inquest nearly two years ago now [VM is Dr Murphy talking about a community psychiatrist].

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A different view was presented by the Band 6 nurse during his evidence:

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I was told a few years ago that a STATT staff member was warned about LB’s imminent admittance four days before he was admitted. I thought this must somehow be wrong. I mean we didn’t know the unit existed until the day we took him there. It was almost in the realm of Mulder and Scully terrain to think that discussions were going on, without us, about a specialist unit we were to find out about from a mate on March 19th.

This week it became apparent that Dr Murphy and other consultant psychiatrists had discussed LB’s potential admittance to STATT (unrecorded discussion) in the weeks before it happened. I spoke with one of the consultants from back in the day earlier today and it turns out that my blog was known about before LB was admitted to STATT. My blog (and my aggression or forthright communication depending on where you sit) generated strong emotions, anxiety, irritation and distrust. There was, as JC said ‘an irrational fear of the blog’.

Social media activity like this was unprecedented and no one who was bothered about it knew how to deal with it. Appeals were made to senior Oxfordshire County Council (OCC) levels to somehow close it down. These were robustly rebutted by a redacted person who, like JC above, suggested that it created an opportunity for engagement.

I appreciate the frank discussion which happened with no notice today. I was also shocked that consultants could be so discommoded by the blogging of a parent, that none of them were able to read, discuss or engage with what was being written in a constructive way. I’d been carefully documenting the complete lack of health and social care support for an increasingly anxious and unwell young man for three or four months by then, or possibly longer.  This is remarkably similar to the Blog Briefing Sloven circulated the day after LB died in which concern focused solely on reputation and professional pride.

I wonder if my writing style somehow added to the fear and distrust. The irreverence and liberal swearing. If I had written a more conventional and ‘polite’ account would it have been better received? I suspect not given the consultant I spoke with denied actually reading it. This was irrational fear.

I’m baffled that not one of these consultants was able to speak to me about their concerns. (Interesting we could have an open discussion today… I assume the toxic mother label is finally shifting as Sloven failings are finally recognised.) I’m deeply horrified we were oblivious to this consternation about the blog when we admitted LB. As the GMC argued this morning, it was Dr Murphy’s responsibility to talk to me about LB’s treatment. It was also the duty of these consultants, surely, to share their concerns with me about my blog?

I suggested to the consultant that the extreme response at the time was generated by the lack of actual challenge to medics by patients or families who are too easily silenced in different ways. The blog created a space of challenge but instead of being used to improve practice, or even engage with and consider the limitations of practice, it was despised and I suspect had an impact on how LB was treated. The veneer of professionalism can be shown to be very thin when ‘transgressional’ activity takes place.

There is some irony that #JusticeforLB is now used in health and social care learning and teaching. The blog also created an unusual contemporaneous record of what happened. The power of the posts that reviled or worried staff before LB died formed part of the evidence at his inquest. The typically disempowered position family members occupy when their testimony is dismissed as ‘anecdote’ differed here. Lowly families aren’t allowed the defence of ‘I did it in my head’ like Dr Murphy has used this week at the tribunal but I had written it down.

There is much to think about, discuss and chew over here in some ways. In other ways there ain’t. Health and social care professionals should be engaging with patients and families in different ways, at different times and in different spaces. They should be encouraging comment and feedback. I hope our experience is already historical and within the ivory tower of unassailable medical practice medics are learning to be more humble and take public accounts of patient experiences as opportunities to better understand the consequences of their actions, or non-actions, and the interaction between the various individuals involved. These accounts should be treasured not vilified.

 

 

 

Writing trauma

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I want to write this post as close as possible to giving evidence at the General Medical Council (GMC) tribunal investigating Dr Murphy’s fitness to practice. To capture the essence and rawness of the experience.

The unnecessary and unchecked brutality. And destruction.

It’s a pretty and long detailed account. That is writing trauma.

[I also acknowledge our GMC solicitor and colleagues who have done what they can to try to ease this journey.]

Weeks of dread led to Rich and I setting off to Manchester (earlier than planned) by train on Monday. Summer holiday travel. Young kids and families. Excitement and crisps.

Our summer has been blighted by the timing of this tribunal.

Rosie decided to come too after I was unable to speak to her on the phone on Sunday evening (after writing this post). I simply couldn’t speak.

Stirring up the horror of what happened four years ago now is, as you’d expect, deeply distressing. LB died. He died. The shite we accepted or were made to endure back in the day is harrowing. And increasingly baffling as we grow further from the cosh of typical learning disability offerings.

Following the @JusticeforLBGMC twitter feed on the train we were surprised when Dr Murphy accepted 28-30 of the allegations raised. Not the Dr Murphy we’d so far come across. With so few allegations left to deal with our thoughts turned to the apology I would probably receive when giving evidence the next day. An apology four years in the making. But an apology.

The next morning, we gathered in the hotel minutes from where the tribunal was being held. George and Charlotte left for the tribunal just before 9.30am. I switched my internet off. Witnesses are not allowed to hear witness evidence and LB’s neurologist was due to give evidence before me. Rich, Rosie and I sat around. Anxious and agitated. Rosie followed the twitter feed passing her phone to Rich every so often. It’s fine, they said. Looking grim. The GMC solicitor called to say the 10.30am start for my evidence was looking on time.

Rich answered the phone. I was on the toilet. Again.

We walked up the road. A couple of men with television cameras at their feet were outside the building chatting. On the 7th floor, we were shown to an inevitably bleak witness room. The GMC solicitor and barrister came in and described what to expect.

We waited. There was an unexpected delay of about 45 minutes as the tribunal panel questioned the first witness.

We flicked through photos of LB on Rosie’s phone.

 

“So cute…”

“Look at that baguette he’s holding!” [sob]

IMG_2810Then it was time. The clerk took us into the tribunal room (left). Rich and Rosie sat in the public bit at the back while I was taken to a large desk facing the tribunal panel. It had a white arch level file with over 1000 pages of documentation, glass of water and microphone.  Before sitting I had to read an oath from a laminated coloured sheet. I couldn’t read it without crying. I couldn’t at LB’s inquest. I don’t know why. Maybe it’s such a stark reminder of the horror that is this (public sector generated) experience and the layers of utter shite that have been woven through it since.

The panel chair introduced the people around the table. The GMC barrister checked I’d signed and re-read my two statements which were in the front of the white file. Then it was over to Dr Murphy’s barrister, Mr P.

There was no apology. Our naive optimism was instantly crushed. Mr P asked me to turn to page x in the file and began a meticulous questioning that involved turning backwards and forwards between my two statements in the front of the file and medical records 700 or so pages towards the back of it.

He had a skimpy pile of the relevant pages laid out in front of him. He didn’t have to lob wedges of 1000+ pages backwards and forwards over a metal lever arch file bridge and leaf through numerous pages to find the relevant page, and section of text.

Briefly scanning through pages of painful words about LB’s horrific last few months.

His lightness of documentation and organisation of the ‘cross-examination’ meant he effortlessly lined up question after question after question. I felt I was being repeatedly sliced open with such a sharp knife there was no trace left on the blade.

“If you could turn to page x… Dr J is summarising his thoughts here, in this paragraph. Did he share them with you?”

“He made a phone call to Dr M. Can you remember how long that call lasted?”

“Turning back to page y. Do you recall Dr Murphy introducing herself in this meeting? In your statement on page j, you said…”

“If you could turn to page z of your statement. CTM meetings were held every Monday, you describe them as 10min meetings. Dr Murphy recalls the meetings being much longer…”

“Turning to page a, another meeting you did not attend, the notes state…”

A masterclass in something.

Over time, photos can become defining memories of particular events as the broader context fades away. Under Mr P’s questioning, on the 7th floor of that imposing building on Oxford Street, Manchester, LB’s medical notes became photo-like. It became impossible to think about and answer the questions that kept coming. To think beyond the words I was being directed to on different pages at different ends of the lever arch file. My heart started to thud so hard and erratically I thought it would knock me off the chair. Black edges creeping around my vision made it harder to find or read the notes. I became fearful of fainting and began to doubt my ability to answer questions truthfully.

“I don’t remember.” “I’m not sure.” “I just don’t know…”

Mr P continued asking questions. Apparently at ease with an approach that unsettles,  distracts and confuses. Seemingly oblivious to my distress. No one intervened. I had no representation.

“On page j of your statement you describe Dr M as dismissive, arrogant and distant. Do you think that’s a fair assessment of Dr M’s conduct or is it coloured by what happened?”

“It might be coloured by what happened but I was expecting a knight in shining armour from a lead consultant who would do something.”

“It’s very upsetting for Dr Murphy to hear any patients’ relative describe her as such…”

Something stopped. An almost powerpoint presentation (and I fucking hate powerpoint) started to run through my mind. LB holding a giant piece of baguette on holiday. The indescribable pain of his death. What we’ve endured over the past four years. Dr Murphy suddenly admitting 30 odd failures in LB’s care a day earlier. Rich and Rosie sitting behind me listening to this inhumane and barbaric form of questioning with no recourse to action.

I gripped the edge of the table and asked the panel chair for a break.

The clerk took me to a room on the other side of the building. By this time, I was sobbing and repeatedly asking “How could they do this?” without expecting an answer. She was very kind but couldn’t ‘talk’ to me. I was left on my own with a glass of water and tissues for five minutes. There are no words for how I felt. They don’t exist.

Walking back towards the tribunal room with the clerk the blackness came back and I briefly stumbled. ‘Do not pass out’ I steeled myself. The thought of delaying this foul process was too awful to imagine. There was a delay before going back into the room as the tribunal were deliberating something. I stood in a section of the corridor with Dr Murphy and her legal team. Rich, Rosie and other members of the public were waiting in a different section of the corridor. I stared out of the window. Half seeing the Manchester skyline, Oxford Road rail station. The clock tower. Grey and threatening skies.

We were allowed back in the room.

Mr P started:

“I was asking about personality side of things and dynamics and wanted to ask you a little about your blog…”

And so it went on. The same questions that had been asked, answered and dismissed during LB’s inquest. Pages to manoeuvre. Notes to look at. Mr P didn’t miss a beat.

After two hours it was finally over. We left the building ignoring the television cameras outside and walked back to the hotel.

I can’t make any sense of experiencing harm in a medical tribunal. One held to explore the fitness to practice of our son’s responsible clinician. How on earth can this be possible and apparently acceptable?

And Mr P? You have taken crapshite to a new low.

Postscript: After Valerie Murphy spent the entire day giving evidence (well worth a catch up at @JusticeforLBGMC with a blood pressure warning for being chillingly shit) it became clear my evidence contributed nothing to the defence case. Nothing whatsoever. It was the equivalent of a kicking down a dark alley by a gang of thugs.

Grotesque.

 

 

Five tribunals and a dress code

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

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

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

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

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

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

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

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

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

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

It gets worse.

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

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

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

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

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

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

You can fuck your denim, sportswear and trainers ban.

Oh dear Mike

Oh dear. Mike Durkins, National Director for Patient Safety at NHS Improvement (my arse), made this statement about the CQC deaths review;

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There is so much so wrong with this statement, not least Durkin’s apparent indifference or obliviousness, to what are, often, preventable deaths. What really makes my jaw ache though is his bizarre reference to families of learning disabled and mental health patients. Mike, all families should be properly treated and supported when a loved on has died unexpectedly. Just like all unexpected deaths should be properly investigated. Singling out these families suggests a complete misunderstanding of this latest scandalous unfolding.

As Patient Safety Director you really need to be focusing on why certain patients are dying (consistently) in the first place. [And, if you need herbs off the street to point this out to you, you should probably have a long, hard think about whether you are in the right job.]

Also, before you make a leap to global standards of excellence, you might want to see what’s going on in Spain and their response to the way in which the NHS treat certain members of society. Strikes me, you could learn a thing or two.

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The curious incident of the earlier death in the bath

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

  • The student nurse present in the bathroom

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

  • The nursing manager 

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

Later in his statement he says:

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

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

As the attending doctor, I pronounced HC dead.

Later in her statement she says:

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

The 2014 Sloven ‘investigation’

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

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

On May 13, the Sloven ‘inquiry’ concluded:

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

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

LB’s Fighting Fund. The postscript.

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Been a bit tardy with this, sorry. A few days before leaving for the #CaminoLB, we received a chunk of our legal fees back from Sloven. This means we are able to donate £20,023 of the funds raised to charity. We originally said any recovered dosh would be split between Oxfordshire Family Support Network and INQUEST but feel that the My Life My Choice champs have flown (and walked) the #JusticeforLB flag brilliantly so there will be a three way split. £6,674 to each charity.

Thank you to everyone who donated dosh, sold cakes, chocolates, jewellery, plants, ate cakes, did sponsored runs, head shaves, bus rides, cycle rides and more, bought cards, made pencil cases, bought pencil cases, made notebooks, bought notebooks, held work parties, discos, party nights, donated christening presents, the takings from comedy shows, recorded an EP, made Jack’s cats, bought Jack’s cats, photos and all the other magical efforts people made to ensure that LB was beyond brilliantly and effectively represented at his inquest.

We should never have had to do this [and shame on the Ministry of Justice for relentlessly misguided faith in the coronial system] but given we did, we couldn’t have done it better. Dipping into the remarkable #107days of action collection is a much needed tonic and continues to astonish me. A colourful, random, joyful, diverse, spontaneous and collective effort to get on and do stuff.

LB would have expected nothing less, love him.

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History of a GMC investigation

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

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

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

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

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

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

I did as I was asked.

Fast (well very slowly) forward to December 2015.

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

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

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

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

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

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

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

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

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

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

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

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

It really ain’t rocket science.

Jeremy ‘witch Hunt’ and the mother blame

Was reminded all week about the terrible mother blame that went on across LB’s inquest which was held a year ago. Just a few tasters:

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Unspeakably awful. Again my brain weeps This is the NHS…

Sadly, blaming us has been a consistent theme since LB died. Sloven have sent extraordinary briefing reports to all and sundry blaming us for hacking into staff twitter accounts and trolling. Oxfordshire County did a corporate number with their sordid secret review of me, while one of their commissioners wrote a terrible letter tearing me to shreds (I’ve never met the woman who is apparently deeply christian).

Jeremy Hunt seems to have joined the blame brigade now. He was interviewed by David Fenton in a bizarre piece on BBC South last night. Between them, pushing a ‘witch hunt’ version of events. Fenton even described how Sloven staff are too scared to go out with their Sloven lanyards on for fear of reprisal.

Wow. A witch hunt. An unfounded persecution?

For the record.

  1. There was no ‘witch hunt’ after Percy. 
  2. She didn’t form part of our Connor Manifesto.
  3. We have consistently called for the resignation of several exec/non exec members (Gordon, Spires, Grant, Berryman, Stevens…)
  4. Percy, and the above, should have gone a long time ago.
  5. Our campaign has always focused on the executive board (and LB’s responsible clinician) and not the 9000 or so staff members, many of whom I’m sure do a brilliant job.

I wonder why we are blamed. It’s fucking outrageous. We’ve (collectively) done more to generate awareness of learning disability issues than major charities with enormous budgets. For free. #JusticeforLB has been like a second, full time job over the past 2.5 years. We’ve worked our socks off. We’ve been told we’ve encouraged other families to campaign, and fight for accountability for catastrophic events harming their loved ones. What happened to LB is taught on various undergraduate and post-graduate courses across the UK. School kids have written about him for homework. We’ve generated a shedload of brilliant resources (a justice quilt and other art, blogs, lectures, songs, short films, animations, the LBBill, the first ever inquest tweet archive and loads more… see below). We’ve been consistently reasonable in the circumstances (with liberal swears).

The families and ex-Sloven governors have shown remarkable restraint given everything they’ve endured. Peter Bell is under investigation by the trust (I know) and has declined to sign a gagging order in order to see the draft report of evidence against him (I know). (There was no investigation of Malcolm Berryman’s actions in sharing the Mazars review with his son before publication). John Green has been a model of reasoned, informed, restraint in trying to highlight failures in both Sloven and the wider organisation of the NHS [click here for the abridged version of his report]. Repeated appearances on national and local news by Richard West, Maureen Hickman, the Hartleys, Angie Mote and others have been remarkable for the consistently careful, considered and, again, restrained commentary in the face of such (continued) horror. The behind the scenes email exchanges are reflective and respectful.

It’s a very dangerous precedent if any member of the public who asks questions or seeks lines of accountability from those in power is dismissed as a witch hunter.  Cheap and lazy journalism by the likes of David Fenton, who has failed to have even analysed that which has been put in the public domain by campaigners, is simply wrong. The serial failings that we, and other campaigners and journalists have largely unearthed sit well and truly on the doorsteps of the Sloven board (and some governors), Jim Mackey and the NHS Improvement gang, and, er, Jeremy Hunt.

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An antidote to the above; some #JusticeforLB magic. The middle pouch is an Arabic justice pouch, the bus ipad holder is made from material used to decorate a lorry driver’s cab and the third pouch holds the complete music for Tippett’s ‘A Child of our Time’ to celebrate the performance in memory of LB at Warwick University in June. Brilliance.

Weepage, seepage and who cares?

Dunno why, maybe the anniversary of LB’s inquest, but I’ve been having a weep fest over the past few days. I think about LB all the time. He’s never more than seconds, occasionally minutes and very rarely an hour or so, from my waking mind. I’d got to a state (hate to stage this grief stuff) where I could think about him in different ways. With the occasional, typically left field, gut punching moment. Sparked by a word, a smell, a thought, sound or memory. Moments of near meltdown (I know, the irony), fright, (at the) sheer horror, brutality and worse.

This week I’m back to just crying. Or weeping. Or something else. I don’t know what to call this thing. Maybe weepage. A sheet of tears. There’s no movement. No sort of sobbing and dabbing with a tissue action. No drama. Just moving wetness.

I cried last night re-reading my older sister’s handwritten letter to each Sloven board member. In 2014. Two years ago. Can you imagine?

I cried looking through another pile of photos that have shifted to the surface of home clutter this morning.

I cried sitting at the back of the Oxford to Heathrow coach this afternoon. For pretty much the whole journey. Watching a stream of heavy haulage lorries and coaches. After receiving an update from the General Medical Council. The supplementary expert report is now with Dr M (again). She has two weeks to respond before it goes back to the Case Examiners. Another never ending story.

The Nursing and Midwifery Council investigations? Who knows. Tumbleweed.

We were told, months back, during a meeting with Norman Lamb and the Health and Safety Executive, that some report was with some panel and we would hear something in October. No doubt we will have to chase up any (non) news ourselves.

I think my new tear configuration has (re) emerged because of the utterly shameful banality  of the public sector response to what has happened. A year ago an inquest jury determined that LB died from neglect. He should not have died. He was effectively killed. And nothing has happened. And a recognition that this sustained cruelty can’t continue indefinitely. We (a collective #JusticeforLB we) could not have done more to counter the darkness of the #NHS and social care at its worse, with light. And brilliance. And there is still no accountability.

I wonder where, in the structure of the NHS, effective support and attention exists for brutalised families. Who should know the answer to this. And why the fuck I’m having to ask.

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