Category Archives: Inquest stuff

History of a GMC investigation

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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 info. A 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

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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?

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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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The Shaw Report

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Start writing a book with determination. A new evening activity. This means digging out all the FOI stuff, documents, reports and paperwork. It feels like the right timing given LB’s inquest started a year ago today. Two harrowing weeks, a jury determination of neglect and no action. Still.

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Revisiting these documents (post LB’s death, I can’t bear to return to the earlier stuff yet), in the light of what has unfolded is pretty revelatory. I just wanted to single out one of the many individuals who have stuck with the campaign from the start here. Graham Shaw. Graham, the CEO of the DIPEx Charity until a couple of years ago, has consistently written letters about what’s happened. To all those implicated. Incredibly sharp and dripping in sense, his letters generate responses.

This one, written to Jeremy Hunt in April 2014 was prophetic really.

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The Sloven Head of External Communications responded in a tawdry and deeply inappropriate way asking [redacted] to “support the drafting of any response to Mr Shaw” [16.4.4 13:46]. Extraordinary evidence of the blurring of boundaries and positioning of NHS trusts as above questioning.

Here is the unfolding exchange. About as Stinky McStink as you get really, particularly given the timing of the responses and redactions. Emails 3 and 4 probably hold some significant clues to the continued lack of action against Percy and the board.

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Two and a half years ago.

A year and a half before LB’s inquest.

No words really. Other than Graham Shaw, we salute you. Keep writing the letters matey.

Of mice and (NHS) monstrousness

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A story ‘broke’ yesterday about extortionate NHS interim director costs. Sickening figures of waste, greed and mismanagement. At senior levels. Again.

In another of those ‘you couldn’t make it up’ NHS moments, the highest paid interim Improvement Director named in the report, Steve Leivers, was helicoptered into the trust Tim Smart, now Sloven interim Board Chair, previously ran. Yes. Really. Not Smart in non action. Again.

I read this latest news having been unable to move beyond Chris Hatton’s recent analysis of Sloven’s annual report. Cut and paste Katrina. And extraordinary senior exec salary figures. With Lesley Stevens, Medical Director at the top of the ‘leader’ board. A cool £365-70k per annum including jaw dropping pension contributions. How can she possibly ‘earn’ this sort of dosh? Let’s have a look at her performance during LB’s inquest last October.

Lesley Stevens and LB’s inquest

Reasonably confident while reading out her evidence and then being (sleep) walked through clearly rehearsed questions by the Sloven barrister, she floundered big time when questioned by the six remaining barristers. Her answers so deeply insubstantial (a generous interpretation) it was as if the courtroom had switched to watching CBeebies.

£365-70k per annum…

Some examples:

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LB died in July 2013. The (post Mazars review) CQC inspection in January 2016 found the Sloven epilepsy policy had yet to be signed off. Paul Bowen, QC, carefully questioned each Sloven staff member about their knowledge of epilepsy during LB’s inquest. No one answered in other than the vaguest ‘ain’t got a clue’ terms. There was no up-skilling staff over two years after LB’s death.

[Howl].

LS3Here Paul Bowen seeks clarification of Stevens outlandish statement that all learning disabled patients with epilepsy were reviewed before the CQC inspection in September 2013. At that point, Sloven were still spinning the line that LB died of natural causes. They did nothing to check the provision in STATT (it failed on all 10 domains inspected 6-8 weeks after he died) let alone review patients with epilepsy in their wider provision/outposts.

A blatant and contemptible lie. Perjury to us herbs outside of senior NHS circles.

LS2Paul Bowen tries to drawn Stevens on the failure of the RiO system. A failure that persists to this day. She resorts to her default response. A murmur/mutter noise reminiscent of the dog ate my homework type responses from school. Not the sharp, authoritative, informed, engaged response you’d expect from a senior exec at an inquest over two years in preparation, with nearly £300k squandered on ‘defence’ costs.

When questioned by Adam Samuels, another barrister, about the reduction in Band 6 and 7 staffing reductions in STATT (and the next door John Sharich House), Stevens says:

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‘We make savings where we have to make them…’ On frontline staff. While you continue to draw an obscene salary

Monstrous. And remorseless. Just one, among so many.

When did the NHS we grew up with, took for granted and loved, become so riddled with greed and rot… with complacency and arrogance, with inaction and protection. At senior levels?

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

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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Leadership and contact traces…

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L1019565-2[…or chandelier and glitziness]

John Sutherland, police commander, has written a cracking post  identifying 10 things he’s learned about leadership. Sloven CEO, Katrina Percy (KP), wrote a piece for the NHS Leadership Academy in August 2014. In this brief (under 400 word) piece she flags up her maternity leave and the problems she returned to. [No mention that these problems were an outcome of the (non) actions she took before maternity leave]. In the same month she wrote a letter to me in which she further elaborates on her “leadership” style.

Here I meander through Sutherland’s 10 points (summarised in italics below) and the Sloven approach to “leadership”. It ain’t a pretty read.

I.     It’s people stupid

Leaders who don’t care about people aren’t leaders at all. They might be bad managers, but that’s really not the same thing. People are precious and rare and extraordinary and brilliant and brave and creative and resourceful and kind. They are also thinking, breathing, feeling, bleeding, sometimes flawed souls who, every now and then, need a helping hand. Great leaders understand these things. They understand people.

KP doesn’t understand people. Though she talks a good ‘staff’ game. Notably the ‘thousands of staff I lead’ [shudder…]. These are the people she is ‘keen to support and promote wherever and whenever they do’ things brilliantly. Services and families are below staff ‘and partners’. Patients don’t feature. Tim Smart, interim Board Chair, clearly gets the people bit. He was open about this during the meeting with My Life My Choice.

II.     Every contact leaves a trace

Every time two objects come into contact with one another, an exchange takes place – fingerprints found at house that’s been burgled; microscopic fragments of broken glass found on the clothes of the burglar. Every time two people come into contact with one another, an exchange takes place. Spoken or unspoken, for better or for worse. Great leaders understand not only that what they do is important – but that how they do it is equally so. Because every contact leaves a trace.

Since the Holder report (2012) there has been more contact trace in Sloven dealings than in an entire box set of CSI. The Sloven CEO and board have consistently failed to recognise this. Contact trace is even more important (in a non criminal context) where this trace can be circulated and re-circulated on social media. Since Smart’s appointment there have been some traces of fresh air through Sloven corridors. Not least the mediation agreement, statement and subsequent inclusion of LB’s pic on the Sloven front page for four weeks.

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III.        Leadership is service

The first responsibility of a leader is to serve. Before anything else, to serve. If the pursuit of my own ambitions has become more important than the cause we all serve, then I have lost my way. If my promotion matters more than your progression, then I am in danger of losing myself.

The words ‘serve’ and ‘service’ were clearly replaced by reputation, dosh, ruthless ambition some time ago. Down Sloven way.

IV.     Everything can’t be a priority

If everything is a priority, then nothing is. Leaders have to decide what matters more. Leaders need to be absolutely clear about what’s most important – particularly in a world of limited resources. And they have to be consistent about it. 

In her letter to me, KP argues

good leadership is founded on a determination and deep commitment to do what is right for all parties concerned, not necessarily what might be either easiest or most popular at any particular moment in time or demanded most loudly or persistently by one group or interest than another.

This self defeating and clumsily constructed statement is yet another attempt to stick the boot in. In fact Sloven do prioritise. Their reputation. They always have. Sutherland should perhaps revise this point to capture effective and reflective prioritising.

V.     Two ears, one mouth

Great leaders are great listeners. And they understand that there is a difference between listening and hearing – and between hearing and actually doing something about what’s been said.

KP’s letter is an exemplar in not listening. A bombastic exercise in ‘me, me, me…’, brutal in callous delivery. Statements like it was ‘absolutely right’ for us to (4 mentions), ‘I believe/strongly believe’ (8 mentions), ‘deeply proud’ (1 mention) and ‘absolutely confident’ (1 mention) are breathtaking in both number and emphasis in a two page letter. Ally Roger’s analysis of KP’s communication further explores her use of language and what it reveals. Contempt and disregard basically.

VI.     Leadership requires bravery

Having courage doesn’t mean that you never feel afraid. It means feeling afraid and doing the right thing anyway. It is both physical and moral. Great leaders stand for what is right, even if it comes at personal cost. Great leaders stand against what is wrong, even if it comes at personal risk. Great leaders have difficult conversations (with people, not about people). And they do these things constructively and positively and professionally – because bravery and bullying have nothing whatsoever in common with one another.

I suspect KP thinks she’s brave. She’s refusing to step down, insisting she needs to steer the flotilla out of the darkness. This ain’t bravery (see IX below). It’s a combination of arrogance and complacency (and stupidity?) She’s not having difficult conversations with people. Audio recordings of Sloven board minutes make it clear there’s little ‘standing against what is wrong’. Little of anything at all.

VII.      The difference between activity and progress

Being busy and making a difference are not the same thing. I played a game in my younger days that involved placing my forehead on an upright broom handle and spinning round in rapid circles, before affording my  friends the opportunity to have a good laugh at my attempts to walk in a straight line. Plenty of movement. No progress whatsoever. I know a lot of busy, dizzy people.

The Sloven leadership has nailed talking the talk and making no difference. From burying the Holder report, to repeatedly not ‘learning lessons’ at inquests and failing CQC inspections. They must be dizzy at the sounds of their repeated (and meaningless statements).

Chillingly, in the 26.1.16 board minutes (around 3hrs 36 minutes) in response to James Younghusband’s mother asking KP about the Holder report and identified ligature risks, she responds that the Holder report is archived and they’ve only found the process documents not the ligature risk report. Eh? Those old contact traces? What did KP say about this back in 2014…

Firstly, openness and transparency are fundamental when things go wrong…

VIII.     Leaders must be dealers in hope

The more challenging the context, the greater the responsibility that leaders have to deal in hope – to tell the kinds of stories and to paint the kinds of pictures that get people up out of their seats and cause them to come, running. It’s not the critic who counts.

Hope schmope. The Hansard transcript from the recent Westminster House debate details the lack of hope being generated by Sloven leadership. The NHS Staff Survey similarly illustrates increasing staff disillusionment with working there:

staff

Hopeless.

IX.     Leadership is about character

It was the American General, Norman Schwarzkopf, who said:  ‘Leadership is a potent combination of strategy and character. But, if you must be without one, be without the strategy. Who I am matters. What I believe in and what I stand for matters. Great leaders ask you to do as they say. And as they do.

When the latest shedload of contact (CQC) trace hit the fan in May, KP (again) disappeared. Lining up sidekicks to face the barrage of press interest (badly) and without apparent support. Again, the ghost of the Leadership Academy trace (ironically called ‘When the going gets tough’) shows KP arguing:

Visible leadership is crucial, for both staff and patients.

X.     Legacy

Great leaders provide the shoulders for others to stand on. To adapt a quote from the journalist Walter Lippman: ‘The final test of a leader is that they leave behind them in others the conviction and the will to carry on.’

Not sure about number 10 in Sutherland’s list to be honest. I suppose we will hope KP leaves so we can tell what’s left behind.

There it is. Leadership. And nothing like leadership. In a Sloven nutshell.

 

 

 

The magic wand

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11

Friday afternoon I left work mid afternoon and went to the cemetery. The outcome of the ‘settlement’ reached on Wednesday was impossible to make sense of. I just kept crying. On the bus home I received an emailed letter from Lesley Stevens (Sloven Medical Director). About the unethical study they are conducting into families experiences of their death review process. The letter inviting people to take part is being reviewed and revised by three ‘service users’, the Health Research Authority have said no ethics approval (or ethical thought apparently) is necessary and Stevens defends the use of the questions being asked of bereaved families (e.g If the review process had been perfect – if it had been everything that you would want it to be, what would it have looked like for you?) with reference to the “Magic wand” question:

“if you had a magic wand, and could have three wishes granted…” (see Verma, N., (2014) Appreciative Inquiry: Practitioners’ Guide for Generative Change and Development) and the standard Solution Focused “miracle” or “future perfect” question: “Suppose a miracle happened tonight?” (see Jackson & McKergow (2002), The Solutions Focus: The simple way to positive change).”

magic wand

I read the letter. Blinked. Read it again. And bizarrely (after all this time) realised that Lesley Stevens and a sizeable chunk of the Sloven board will simply never understand (or refuse to understand) that LB died. Or engage with what #JusticeforLB has revealed over the past three years. The burying of the agreed public statement in a PDF, off a link from the Sloven news page, demonstrates the same old, same old, contempt and fakery despite an apparent “successfully mediated settlement” reached on Wednesday. A point not lost on others…

mills tweet

This afternoon I sorted out some photos for Open Democracy who are going to publish the public statement as a word document so it’s permanently searchable online. [A PDF is not…]

As I did, I thought again about Steven’s reference to “a magic wand” or “a miracle” happening. And wondered [again]… how can these people possibly be in charge of an NHS trust? Still.

magic wand 2

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