Category Archives: Inquest stuff

The mothership, blunt instruments and telling again

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I had a phone interview earlier with an investigator investigating Sloven nursing staff on behalf of the Nursing and Midwifery Council (NMC). This has taken so long to happen because Sloven spent an age and a day doing their internal disciplinary investigations [of course] and consistently refusing to say who they were investigating [of course]. We referred a consultant to the General Medical Council (GMC) back in May 2014 after being told by ‘a source’ she’d done a bunk. The nurses weren’t so clear cut.

So today I found out the names of the six referred nurses. Six. And no medics. The Sloven sloven industry as always delivering pure shite. Take over (land lucrative) provision from afar, leave it to sink into a hellhole of discontent, malaise and fear and, when the inevitable shitola happens, make sure no one within a fifty mile radius of the mothership catches any of the fall out. Particularly anyone approaching board or CEO level.

In her opening spiel, the investigator offered me the services of a liaison officer to ‘provide support during this process’. Bit late in the day for that really. It reminded me of the Health and Safety Executive leaving us a booklet about what to do after the unexpected death of a family member. About 18 months after LB died. Learning point 1,345,987 If you come into contact with families some while down the grief and bereavement road to nowhere, perhaps think about the standard bells you typically offer and frame them appropriately…

Next stop was the blog.

‘You, er, write a blog. Could you not write about this, it may disrupt the process…’

Mmm. There wouldn’t be a process if I didn’t write a blog. And despite the ludicrous shrieks of the Dr Crapshite brigade, I’ve not been a name shamer on these pages. (Well not below leadership level… the likes of KP, Petter, Jacko and Hudspeth who I reckon get paid to swallow the pill of possible publicity). I agreed to not mention the content of the interview.

Then we were off.

It was so blinking distressing to go over everything again. Even more distressing, if that’s possible, after experiencing LB’s inquest and hearing the (still not quite) full story of what happened. Layers and layers and layers of wrong that simply scream out. While crap all happens.

‘Can’t you use the context I provided to the GMC?’ I asked after the first question.

‘No, we need to have what happened in your words.’

‘They were my words‘, my brain screamed… like they were for the police. For the coroner… for Verita. Learning point 1,345,988 There is no justification for repeated telling when the telling has already been done in an official capacity unless people want to. Otherwise, agreement with the person/family that they are happy for a cut and paste version to be used from another official telling should do. There is always the option to add or delete bits at the next stage.. [Howl].  

Such disconnect among the various arms of the (non) accountability dance. A fresh beating with a blunt instrument on each iteration (I now suspect with even more nails as the futility of the telling becomes more and more apparent). Perhaps 1,345,989 should be a brief note, early on, stating:

Now you’ve experienced the worst thing you could ever (not dare to) imagine, we’re going to spent the next few years or more (well as long as it takes) torturing you in a combination of bureaucratic, thoughtless, deliberate, ignorant and incompetent ways…

Yours,

The State

‘Do you want a break?’ asked the investigator several times during the interview.

My brain seemed to be hosting a particularly absurd but unavoidable horror show that made it difficult to speak. Sitting at work, I drilled the phone into my ear and sort of strangely gargled, cried, caterwauled and clawed my way through the following hour. I didn’t want a break. I just wanted it over.

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[Final reflection: I had the odd moment while writing this post that I haven’t had before. Would I somehow jeopardise the NMC investigation. Not by disrupting the process but by simply pissing them off? I don’t know. But we’ll never know anything if things remain secret.]

Useless eaters, human ballast and empty husks…

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Bit of a convoluted ramble tonight. Sorry, but hopefully it makes some sense.

James Titcombe found out this week that Morecambe Bay hospital paid £42,123 in legal representation and attendance of communication staff at his son, Joshua’s, inquest. Early this year, My Life My Choice (and Michael Buchanan) found out that Sloven spent £318,121.20 on legal representation at LB’s inquest. It’s not clear if this figure includes preparation for the four pre-inquest review hearings. It doesn’t include the costs of Sloven staff attending the inquest. [It became a daily activity to spot Sloven (and Oxfordshire County Council, NHS England and Oxford Clinical Commissioning Group) bods loitering around the public gallery. Lacking the lanyards typically worn, they were identified by furtive awkwardness.]

This cost could only have been spent in an attempt to limit damage to Sloven’s reputation. What happened to LB is undisputed. Sloven said back in February 2014 they accepted the findings of the first Verita report which found that his death was preventable. Why would they need (external) legal representation at an inquest which is supposed to establish what happened rather than attribute blame?

How did we move from this (clearly fake) position in Feb 2014 to a space in which eight barristers (and accompanying solicitors) jostled for table space at the front of the courtroom? Sloven were culling staff (or ex-staff) from their legal umbrella pretty much up to the start of the inquest. But bizarrely included in the dosh spent is £90,000 on legal fees for staff they didn’t represent. Eh?

Total absurdity.

Sloven’s response was clearly to chuck unlimited dosh at trying to grab a genie that had well and truly left the bottle. A social media related genie.  Mike Petter, board chair and member of the Sloven leadership trinity, told My Life My Choice:

petter shite

Jaw dropping duplicity. Like most (all?) Foundation Trusts Sloven have an in house legal team. Unlike families who are catapulted into a space of abject horror and distress, usually with little or no legal knowledge or support. Petter doesn’t explain why Sloven brought in an external solicitor and barrister. Or why they contributed to the costs of staff members they didn’t represent. (Or why they didn’t make this clear at the beginning of the inquest when we were led to believe that there were six other independently represented Interested Persons…)

I bumped into a lovely neighbour earlier. She’s been a teaching assistant for over 30 years at the junior school Rosie and Tom went to and follows the campaign.

“All those hundreds of people”, she said. “And they didn’t know…”

I think ‘they’ did know. How could they not know? They knew but didn’t think it was important that (certain) people were dying prematurely. I’m reading Neurotribes at the mo. The go to book about autism by Steve Silberman. Earlier today I read this;

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Life unworthy of life... Nearly a 100 years ago Hoche and Binding produced a simple and effective framework for understanding contemporary provision of health and social care for learning disabled people in the UK.

Wow.

Just got to make sense of how a public body could squander over £300,000 on LB’s inquest now…

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What the foodles?

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Rich sent me a link to this story this afternoon. The Star Wars production company, Foodles, is being prosecuted on four criminal charges by the HSE for an incident in which Harrison Ford broke his leg. A year after LB died. He died.

[Howl].

What if Sloven actually learned lessons?

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News today of another inquest in which the coroner identified failings in the ‘care’ provided to Louise Locke by Sloven. This inquest was delayed a few months ago after the documentation provided by Sloven was incomplete. Classic Sloven incompetence (or worse) that generates more pain. Nothing like having your mum’s inquest bumped to the new year because the Trust who couldn’t look after her in life continue to fail her in death. Nope. Nothing like it.

Anyway, Lesley Stevens was back on inquest duty. I can’t imagine how she gets out of bed of a morning given the awfulness she must sit through and defend on such a regular basis. Still, she gave the typical Sloven corporate speak end of inquest statement about lesson learning and yadiya blah bleurghdy bleurgh stuff. I’ve pulled together a table detailing a selection of these post inquest statements taken from newspaper coverage over the past two years or so. (And it’s probably worth another butchers (and a weep) at Rich Watt’s post about lesson learning from two years ago now.)

Learning lessons

What’s interesting here is both the emphatic insistence that lessons are learned and the immediacy with which Sloven claim to act; Immediately after her death; We have already undertaken a number of actions. Bearing in mind it takes months or typically years for inquests to take place these are strong claims indeedy. I remember Lesley Stevens talking the coroner and jury through the Sloven (apparently already) implemented improvements off the back of LB’s death at the end of his inquest. Fran was sitting at the back of the public gallery gently prevented by loving mates from repeatedly shouting out ‘That ain’t true. That’s not happening…’

What have they learned?

So what have they learned? Clearly very little. You can distill down the various shiny lists produced for the various coroners to a small number of categories; family involvement (red), staff training/risk assessments (blue), record keeping (mauve), care coordination and communication (green), clinical leadership (orange) and better decision making processes (brown). There are no new and dramatic lessons being learned here. Quite the opposite. Tired old non lessons that limply lie next to the dominant and empty vital and immediate action claims.

What will this achieve?

Then finally. The transformation claims. Less evident in the media coverage (thank goodness). If Sloven want a quick win from this brief analysis it’s ditch the big claims of improvement. Awkward. Embarrassing and fallacious.

sloven inquest commentary

 

What does all this mean? A few thoughts:

  • Sloven’s readiness to use loose phrases and recycled statements that bear no resemblance to proper action and accountability demonstrates their complete insincerity in actually learning or changing stuff.
  • The rote mechanical reaction and vacuous use of language needs to be challenged by the Department of Health, Monitor, the CQC, NHS England, the Clinical Commissioning Groups and the media, and held up to repeated and close scrutiny.
  • The fact they clearly are learning nothing from these preventable deaths demands urgent and effective attention. Hannah Groves died over three years ago and Sloven are still learning that they need to involve families and carers. Louise Locke’s inquest found that care coordination across agencies was still failing patients. Despite learning this at various points over the years.
  • And finally the space none of us really want to enter but has to be confronted. If Sloven had actually learned lessons, how many people would still be alive? Fuckers.

We’ve started to regularly discuss the futility of repeatedly making this shite visible only for it to be ignored. Busker John called round earlier and Rich said two or three times ‘Hey, tell John about the latest this, that and the other..’ Each strand of telling was worse and worse. Mencap gate. Louise Locke’s inquest.The latest (not yet public) whistleblowing detail. Harrowing stuff.

‘Blimey’, I said. ‘Imagine coming round and us just saying something like ‘Wow. Lovely sunshine outside…’

‘But it never stops,’ replied Busker J. ‘There’s always something new…’

Yep. And nothing ever happens.

Post-mortem stuff

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Warning: upsetting content…

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A coroner concluded that 24 year old Sarah Davies died of natural causes due to unknown origin this week. She was found dead in the Tarry Hill ‘care’ ‘home‘. The pathologist originally said she died of SUDEP (sudden death through epilepsy) but changed his mind during the inquest and said her death was unexplained. He admitted he hadn’t sent samples of Sarah’s brain for further analysis as he should have done. Sarah’s family are understandably distraught to not get any answers from her inquest. [Matt O’Donoghue live-tweeted the whole hearing. It’s harrowing reading. And uncannily similar to LB’s inquest.]

When it emerged there were serious omissions on the part of the pathologist at Sarah’s inquest I was pitched straight back to the week after LB’s death. That baking, baking, long, hot summer when our lives were shoved into a black hole of insensible grief, horror, anger and incomprehension.

Charlotte, our newly appointed solicitor, working with INQUEST, advised us to make sure the pathologist followed the guidelines for patients with epilepsy. Unimaginable phone calls. A house full of people. Flowers. Tears. And terrible decisions to be made. He hadn’t. He hadn’t? They were ‘just guidelines’. I still can’t write much about this episode.

Some emails from this time …

The reason I mentioned a second post-mortem is because the current cause of Connor’s death is unascertained and it may be that a different pathologist could assist in providing further clarification, or it could be that Connor’s case is one in which the post-mortem examination itself cannot provide clear answers. I am sorry to be so blunt but I want to be sure that you can make an informed decision. (received 10.7.13)

In terms of a second autopsy, Connor has been moved to the funeral directors and we’re reluctant (though would if it would make a difference) to have a second postmortem. (sent 11.7.13)

I did say to the coroner that the guidelines are written with a view to persuading family members who may be resistant for whatever reasons to the sampling of the brain tissue and we weren’t consulted. (sent 12.7.13)

After a bit of a battle with the coroners office because they were reluctant to do anything, they’ve taken the brain tissue sample and Connor is now back at the funeral directors, thank goodness (my levels of what is ‘good’ are so low after this latest mess up). (sent 12.7.13)

[Howl].

When LB died I’d been blogging about him and we were given advice via twitter about what steps needed to be taken. I’ve not revisited the failed post-mortem thing since. I can’t imagine how Sarah’s family must feel. No answers because essential tests weren’t conducted.

Just because.

Because Sarah and LB’s (and many other) lives simply don’t count. And in death they aren’t worthy of the typical and expected scrutiny applied to others.

It’s inhumane families have to fight to get answers in these circumstances. And, if they ain’t armed with the relevant info, the space to get answers or accountability is severely compromised by (further) crap actions by professionals. We  shouldn’t be policing whether post-mortems are conducted properly. Or be consigned to a netherworld of no answers when this well documented process is cocked up by professionals on inflated salaries and no whiff of accountability.

I’ve not got a typical punchy demand some action end bit here. With a hefty swear or two.There doesn’t seem any point. I’ll just end with another email extract from that week.

I think this search for answers/campaign or whatever it is or becomes, is important. (sent 12.7.13)

Explaining #JusticeforLB to a child

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IMG_0112-2Well LB was a bit older than you. He was very funny, loving and loved buses and Eddie Stobart lorries. He got upset and a bit low when he was 18 and ended up in hospital. It was a special sort of hospital. It cost more money each week for LB to stay in that hospital than most people earn in a month. It was run by a bit of the NHS called Sloven. The NHS is supposed to look after everyone in this country when they are unwell.

It turned out that Sloven didn’t really care about patients like LB. Or care about some of their staff.  Staff became fed up and some became pretty rubbish at their jobs because of this. They stopped looking after patients properly. LB had a thing called epilepsy which meant he could suddenly pass out. Staff knew this but the doctor in charge told them it wasn’t a problem.

One day LB was in the bath alone (which he shouldn’t have been) and passed out. He went under the water and died. We felt our world had ended. Sloven pretended LB would have died anyway. They said he died of natural causes. But people don’t usually die in the bath (or when they are 18).  Instead of being able to feel sad and think about our beautiful boy we had to fight to get Sloven to admit LB died because they didn’t look after him properly.

Sloven refused to do this and the people, like NHS England or Monitor, who were supposed to make sure Sloven did the right thing didn’t. Nobody who should have sorted this out, did anything. Usually when you work you have a boss who makes sure you do your job properly. And your boss has a boss. It turns out, in the NHS, the bosses of bits of it can do whatever they want. The Sloven boss, called Katrina Percy, and her senior team just carried on behaving badly.

We were worried some other people might have died because they weren’t cared for properly like LB. The boss of NHS England agreed to pay for a review into other deaths that happened in Sloven’s care.

Meanwhile, a lot of other people, all sorts of people, joined in the fight to try and get Sloven to take responsibility for LB’s death. They did all sorts of brilliant stuff. Sports stuff, music stuff, they made films, animations, held cake sales, did embroidery, gardening, drew pictures of buses, flew flags, put LB’s name on buses and trucks and all sorts. Lots of people began to know who LB is. There was lots of fun, love and happiness about LB and people like him.

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The trouble is, all this fab stuff didn’t stop Sloven behaving badly. They lied to us (and others) and tried to stop us finding out what happened to LB. They spent more money than some people earn in a lifetime on lawyers to do this. Money paid for from people’s taxes. Luckily, some brilliant human rights lawyers and barristers helped us. The inquiry into LB’s death, run by someone called a coroner, found that LB died because he wasn’t looked after properly. He should still be alive.

The report into the other deaths also found that Sloven didn’t care about lots of people like LB. When they died suddenly Sloven said they died of natural causes and didn’t try to find out why they’d died. Sloven were furious about this report. They said it was rubbish and tried to stop people reading it. Then they argued that other bits of the NHS were just the same. Allowing certain people to die early and then say it was natural causes.

We think Sloven don’t really think that LB and people like him are proper people. That’s why they didn’t do anything when they died early. Like a lot of things, they’ve got this completely wrong. We just need to work out what to do about it. Because LB’s death has shown us just how badly some people are treated in this country. And how those people whose job it is to actually do something about this, don’t really care either.

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2016. Starting as we mean to go on.

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I don’t know. I don’t know if it was Chunky Stan’s death this week which was so blinking sad but immensely peaceful. Or the start of a new year. But the Justice shed is cranking up the volume. Enough is enough.

First. A letter to the Southern Health NHS Foundation Trust Council of Governors:gov 1

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gov 3

gov 4gov 5

Shiny new policies, ducks and ‘learning lessons’

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The ‘learning lessons’ tripe regularly spouted by NHS Trust representatives in the wake of a negative report, inquest or otherwise (typically not in response to the harm caused to a person and their families) really naffs me off. We learn all the time. LB’s death wasn’t a ‘lesson’ to be learned from. He shouldn’t have died. Simple as. A point brilliantly made by AnneMarie Cunningham yesterday in a talk to a group of psychiatrists. To use ‘lessons learned’ in this context trivialises and further dehumanises LB (and everyone else who has died or experienced serious harm). Particularly when crap all is actually learned.

After the first review into LB’s death (Verita 1) was published, back in the day it made several recommendations around epilepsy care. 18 months later, during LB’s inquest, it was clear that Sloven staff members giving evidence had learned little about epilepsy. This didn’t stop Sloven’s Medical Director talking the talk about shiny new epilepsy policies and toolkits at the end of two weeks of harrowing evidence.

Similarly, when Sloven (eventually) realised that they were in a teensy bit of trouble around their response to deaths in their learning disability/mental health provision (a good 16 months after they knew an independent investigation was commissioned by NHS England), they started talking the talk about their mortality policies and processes. The Sept and Oct 2015 board papers include 65 and 70 mentions of SIRIs (Serious Investigations Requiring Investigation) and mortality respectively. There were 8 mentions in the June and July papers.

‘Wow. That’s good. They are taking the Mazars review seriously,’ you may be thinking.

Mmm. They are clearly taking it seriously. But I suspect the it is an unprecedented threat to their reputation. Evidenced by remarkable challenges to the content/publication of this review which remains under wraps somewhere in NHS England. If Sloven can’t bury or somehow influence the review, they will want to line their ducks up to try to distract attention from the brutality of their practice up to now.

Various changes – a central investigation team will now oversee investigation and learning, training and implementation of a new electronic investigation system continues, 50 investigators attended a 2 day investigation training course in November, so on and so on – must be in place and operational by the time the shit hits the fan. [On my more cynical days I can’t help thinking this delay is enabling these ducks to be better placed for buffing and final shiny distraction attempts. Easing the inevitable discomfort felt by pretty much every organisation involved in this scandalous and inhumane tale].

But hey ho. Sloven remain all talk and little real action. The December Board papers record that an inquest into a patient who used their mental health services was adjourned on Nov 11th until January 26th 2016. The quality of the SIRI reports provided by Sloven and Hampshire County Council were [still] not good enough. Another family facing the torture of further delay – across Christmas – caused by Sloven (and local authority) disregard and carelessness.

Their shiny new focus on SIRIs, candour and involving families can be tossed in the nearest skip. It doesn’t translate into action and they don’t give a shit about what really matters.

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Nearly turning 21, magic and mopping up crapshite

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Not a good time. LB’s 21st birthday on November 17th. Against a backdrop of global senselessness and horror. MargoJMilne posted a link to a wonderful version of Faure’s Cantique de Jean Racine yesterday. This sort of worked/distracted me for a bit.

Originally Rosie and I were going to be around on Tuesday and started to plan a ‘treat’ outing with some cracking suggestions via twitter (fab suggestions that will be squirrelled away for future enjoyment). Rich reorganised his work. It turns out Tom finishes lessons at noon that day. Will is coming home tomorrow for the week. Owen pitched up yesterday for the night, rearranged his university work and is staying till Tuesday. And the wondrous Molly and gang are coming round in the evening. Wow. We’ll muddle through with visits to the cemetery and Mansfield College to see the quilt, nosh, drink, memories and hopefully laughter.

I’m on leave tomorrow as well. After the dentist, another visit to the quilt, followed by lunch with big sis Tracey (Agent T) and our parents. It’s randomly spectacular that the quilt is in Oxford at this time and that Kevin the porter is so blinking helpful. [I think it will be on display till at least the weekend and will post the end date when it’s decided].

Several people have asked if things are pretty much sorted now the inquest is over. Here’s a brief summary of where we’re at (in no particular order):

  • The coroner has written a Prevention of Future Deaths report which Sloven have 56 days to respond to.
  • The Verita 2 report was published at some point in the last few weeks (tumbleweed).
  • The Mazars (draft) death review has undergone and survived severe challenge from Sloven (very long story). This should be published this week some time.
  • The Health and Safety Executive (HSE) continue to investigate LB’s death and should be drawing on evidence from the inquest. Of which there was plenty.
  • The General Medical Council (GMC) and Nursing and Midwifery Council (NMC) are investigating referred staff.
  • The Oxfordshire County Council maladministration/secret review shite is ongoing.
  • Norman Lamb’s Green Paper – No voice unheard, no right ignored – has shamefully been buried by the government (non) response published last week. The #LBBill is an ongoing endeavour.

On a slightly separate note, Norman Lamb deserves special mention for his consistent, dedicated and passionate attention to and knowledge about ongoing (howling) gaps and worse in learning disability and mental health provision. George Julian has gone on leave making clear her/our frustrations about the delays that seem be an unremarked upon part of this inhumane process.

It also became clear after an evening with mates on Friday that there was confusion over Dr Crapshite and Dr M. They all thought Dr M was Dr Crapshite. And Mr J, her barrister, made so much about this to defend her. Blimey. No. Sorry if that got lost in translation. Dr Crapshite was the community psychiatrist who saw LB once in Jan 2013 (and, as we heard during the inquest said she wouldn’t see him as a patient post discharge because I was toxic). Dr M was the unit psychiatrist who prescribed bonjela for LB’s bitten tongue post seizure and, erm, insisted (even during the inquest) that LB wasn’t having any seizure activity. Crapshite is as crapshite does but for the sake of clarity ‘Dr Crapshite’ is a different person to Dr M on these pages.

I’ll finish this post with two magical things.

A beautiful photo of LB I’d not seen before.

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And David Harling’s second animation. His first, equally spectacular work (or love), can be watched here.

Gotta keep fighting dark with light/colour. And remarkably (thank fuck) the light keeps coming.

 

A tale of two reviews (and an inquest)

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For anyone managing to keep up with this dense (and often tediously frustrating and jargon laden) tale of trying to get accountability when your child dies a death in NHS ‘care’ (involving a dereliction of such basic care that defies understanding) well done.

To recap. A week or so ago, a second Verita review (V2) was published. This was commissioned in July 2014 to explore broader issues around why LB was admitted to the unit in which he died. A third review, the Mazars death review (M1), examining how Sloven responded to deaths in their learning disability and mental health provision since 2011, was commissioned on our request by David Nicholson shortly before he stepped down as NHS England CEO in March 2014. We thought this needed urgent investigation because of the ease with which Sloven dismissed LB’s death as natural causes. [Weep]. The contract was given to Mazars in November 2014. Another six month contract.

We fully expected both reviews to be published by June/July 2015. With the pesky general election as the big delay factor. But nah, they dragged on. M1 because the findings inevitably generated the need for further investigation. V2 because, er, it could. V2 was eventually circulated for factual accuracy on Aug 21th, M1 a couple of weeks later on Sept 9th.

During LB’s inquest the status of these two reports were continually contested. Sloven were determined to get V2 in front of the jury while chucking M1 into oblivion. We thought the coroner should have sight of M1 because the findings were relevant to a prevention of future deaths report. We found out, during this nasty piece of game playing in open court that V2 was complete. Nothing like being kept informed, sensitively. And then we were informed it wasn’t. What a mess. In a space that you’d kind of hope that the wellbeing of the family would be uppermost in the actions and thoughts of the NHS Trust involved and all related organisations. Family wellbeing? Eh? Nope. It’s all about reputation, reputation, reputation.

In the end, neither report was disclosed to the jury.

A week later, V2 was published. No further delay. Despite both lay reps (George Julian and Bill Love) disputing the findings. M1 continued to be challenged by the Sloves. NHS England took the criticisms of M1 seriously and commissioned an academic review of the methods used. [I know.]

Seems to be that an extra level of rigour is needed because the findings are so controversial. Yep. Make of that what you will. The NHS England plan for moving people out of of Assessment and Treatment Units was published last Friday. This was the subject of some criticism around resources, reach and expectation. To me it seemed to be well thought out, sensible plan particularly given the failures of everything that had gone before in the last 3/4 years (as long as the money followed the patients into the community and remained with them). It strikes me that the delay in the publication of M1 is a strategic move partly relating to last weeks news. We can’t have a report that drips death and darkness casting a shadow over shiny new plans.

The latest M1 delay news (the report of the methodology will take up to Nov 13th) came with the usual teeth jarring statement that NHS England know this will be ‘particularly disappointing for the family’. I don’t think NHS England know what this experience is like for us. I think it’s almost impossible for anyone to understand what it is like to have a child left to drown, alone, in an NHS hospital bath and then be forced to fight for over two years for accountability for his death. Please ditch the trite and meaningless statements.

Here’s a radical thought.You don’t need to wait for a written review on the methodology (you are choosing to). A telephone call with written confirmation to follow would do. Why not put this ‘grieving family’ at the centre of this vile and harrowing process for once and just publish the fucking report?