Category Archives: Inquest stuff

Dead times and fuzzy felt versions

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LB’s inquest is scheduled to take place from October 5th for up to two weeks. This date will be confirmed at the next (4th) pre-inquest meeting (Sept 9th) and seems to depend partly on whether the police decide to pass evidence to the Crown Prosecution Service for a possible prosecution or close ‘the case’. And whether additional ‘interested parties’ need more time to consider ‘evidence’. [Some staff members are now ‘interested parties’ and may have their own legal representation.]

Attending an inquest isn’t a common experience for a lot of people. The thought of what lies ahead reminds me a bit of the days leading up to LB’s funeral. His do. An inevitable, unavoidable ‘thing’ drenched in horror. Unimaginable horror.

But funerals are typically organised within days or a few weeks. The unspeakable is, necessarily, whipped through really. Mates stepped up and worked magic, generating celebration. A red double decker bus, Charlie’s Angels were pall bearers, “Here Comes the Sun” strumming out from a baking hot woodland corner, hundreds of used bus tickets scattered over LB’s Routemaster coffin. A party. (Almost) fun, food and footy.

When the NHS (or other public bodies) are involved in unexpected deaths, delay is introduced. For no apparent reason. Weeks, months, years added to routine processes. Dead times. Torturing devastated families while generating distance from memory. Effectively producing fuzzy felt versions of ‘what happened’. Pieces moved about, dropped, lost and ultimately discounted. The delay also allows an ‘it was ages ago now..‘ tired feel to the process [howl] and facilitates a ‘things have moved on now.. We’ve learned so many lessons and implemented more changes you can shake a worn out old stick at…’ type outcome. Effective wrapping up and diffusing atrocity/obscenity in faux (shiny) processes and made up ‘learning’.

This strategy is losing its punch a bit now because of social media. Patients/family members and others can record stuff as it happens, return to emails and publicly available accounts, producing ‘evidence’ to challenge or refute. People can hook up with other people who have similar experiences or are simply outraged by what they see or read. Mobilising support, strength and resources. Relevant historical and contemporary context is accessible online or via FOI requests. It’s now easier to convincingly say ‘Eh? Whaddaya mean? This happened before. And continues to happen...’

This is good (though we still ain’t got anywhere in our fight for justice). Why patients, families and others should be doing this work though remains utterly baffling.

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Thanks (it was his tongue btw), Sara

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We went on holiday last week. Starting from the battered position of getting the ‘updated’ version of the OCC ree (I refuse to call this a report as it bears no resemblance to anything I’d call a report) at 5pm, the day before we left. The issue of records cropped up again when we were away. Relating to whether LB bit his tongue or his lip in the unit.

This is a nonsensical question that underlines the importance of families documenting interactions with health and social care professionals meticulously. And even then, how their records are not really records.

In a complete panic, back in May 2013, I emailed the STATT manager to say that LB had had a seizure and accidentally typed lip instead of tongue. This typo has become part of the official record and has seeped into both the original Verita report (extract below) and the documents for the coroner.

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It was a typo. One I realised and corrected the following morning, first thing, in a follow up email to the manager who’d replied to say he had contacted the consultant.

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This email didn’t make it to the ‘official record’.

The lip/tongue question remains an issue. A confounder in getting accountability for LB’s death. [Yes, he died. He drowned. You fuckers].

This raises so many questions about what families can do to make sure their records, their version of events, are treated with respect and fully engaged with. To avoid being dismissed, misrepresented or ignored.

I typed lip instead of tongue that evening because I was so intensely distressed by the thought LB had an unwitnessed (unwitnessed??) seizure in that place. It was a simple typo.

Back from holiday. Sitting at the computer on a sunny Sunday afternoon to gather more evidence that fell outside the official Sloven/OCC record, I can’t help asking;

Really? Are you really making us go through these hoops?

Why?

Updating the update. Of the update.

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We’re fast approaching the second anniversary (hate, hate, hate using this word for this) of LB’s death [Howl]. 16 months after an independent report was published stating LB’s death was preventable.

Here’s an update of the latest update (March 2015). As always (and clearly forever) in no particular order:

1. The inquest: A fourth pre-inquest review meeting is being held at 2pm, September 9th, Oxford County Hall. All welcome. It’s a very public affair. The full inquest is scheduled to start on October 5th. Sloven have “unreservedly apologised” for LB’s death (as the curious Tory template (repeatedly) reminds us) but this hasn’t stopped them pulling all sorts of tricks along the pre-inquest journey. Including a bit of desperate back pedalling from that unreserved apology to argue that drowning is a natural cause of death.

2. Disciplinary councils: We referred one clinician to the GMC in May 2014. This investigation continues, slowed by some additional stuff that has cropped up. Apparently Sloven disciplinary processes led to an undisclosed number of undisclosed staff members referred to the (undisclosed) NMC. Who knows?

3. Police: The investigation continues. Staff interviews are underway.

4. Health and Safety Executive: The investigation (apparently) continues in line with 3. above.

5. Oxfordshire County Council: We’ve received legal advice on the “independent” report OCC commissioned into LB’s death without our knowledge. It seems that it is defamatory so there is ongoing legal action relating to this. OCC are sticking to the ‘We did nothing wrong’ line. Chilling really. The consultant is apparently working through the list comments/issues I was forced to identify a few weeks ago to revise the original report. I still say chuck it in the nearest bin but what power do we have? [I’m dreading receiving another version given the methodological approach].

6. Verita 2: This second, broader investigation into what happened to LB remains ongoing.

Mazars death review: The review into deaths in Sloven learning disability and mental health provision since 2011 has been extended by NHS England to allow additional work to be done. Given the announcement this week of a national review into the premature deaths of learning disabled people, this extended work makes sense.

So. That’s it really. When we sadly started #107days again this year, we naively thought some of these investigations would be completed during this time. It’s now clear that this ain’t going to happen.

It’s all a pile of cock rot really.

I’ll leave you with this pic from a holiday we had in July 2010. When life still had colour, beauty and the extraordinary (in a good way).

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The expert witness report

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Blimey. In the topsy turvy world we’ve been pitched into, I found out today I’m in Manchester tomorrow and not not Birmingham. The Birmingham confounder was the Community Care Live gig last month. When I wrote and forgot about this post. About the expert witness report:

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I received the epilepsy expert witness report this lunchtime, ahead of the pre-inquest review meeting next Tuesday. I was in the Speakers Lounge at the ICC (dunno what ICC stands for but something Conference related), Birmingham, at the Community Care Live event. It sounds pretty posh and not something I’ve sat in before. But it was just a space. A bit scruffy. With lukewarm tea, coffee and biscuits.

Various people I ‘know’ through twitter were around though. Which was kind of cool.

I vaguely grazed the report, half thinking about my talk, half listening to/joining in conversations around the table. The emotions involved in reading such a report are indescribable really. Deeply, sadly intense with no space to go. Certainly not at the ICC. In the Speakers Lounge.

On the train home, a few hours later, a woman was on the platform with her young daughter and a big case. She coached her daughter carefully and repeatedly about the steps they would take when the train arrived.

“You get on first and I’ll be right behind you because I want to make sure you’re safe”, she kept saying.

I got home this evening and read through the report again. Properly. With a flickering home movie stream in my mind. Constant moments of watching, coaching and doing the extreme safety parent thing. Interspersed with silent howls.

And bizarrely (or maybe not) I thought ‘Thank you for calling him by his name’.

Thunderbirds, the scullery, care plan and the candlestick

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Justicequilt-201Third pre-inquest review meeting yesterday. Pretty buoyed by the wondrousness of the Sparrowhawk Art/LiveatLICA event on Monday – captured in its deliciousness in a Guardian online gallery – we headed to County Hall. To be confronted by this screen in the foyer. The colourful and textured fabric of LB’s life reduced to an outdated, clunky and unnecessary statement. ‘The Late’… [Howl].

It really is a number sitting on a bench in a county courtroom. Listening while details relating to your child’s death are thrashed out in front of a Coroner. Sloven and their legal team sitting to the right. Family and journalists sitting behind. Given it’s supposed to be an inquisitorial process, Sloven attendees had a couple of chewy exchanges with their legal team. But we all know it ain’t really inquisitorial. That’s just fakery. A pretence signed up to by many.

The twists and turns of these pre-inquest meetings have been pretty extraordinary. Sloven have (so far) argued drowning is a natural cause of death, argued against a jury, argued that the reviews into LB’s death meant an Article 2 inquest wasn’t necessary and then, once the Coroner ruled that it would be an Article 2 inquest, tried to get the inquest moved to the High Court because the reviews made it very complex. They now seem to be circling in a new direction. One with a hint of clinician.

Like a kind of Cluedo on speed; there was no wrong doing… no body… no weapon…it was the dog… the cat … Miss Scarlett… Thunderbirds, the scullery, care plan and the candlestick.

We’ve just steered a straight path really. But then this isn’t a game to us.

Managing to meet the Minister

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Justicequilt-92I met Simon Hughes, Minister of Justice, today. Eventually.

I got to the House of Commons with a few mins to spare before the 2.45-3.15pm appointment and found a great (really great) wedgy of lecturers queuing to get through security to lobby their MPs over college cuts.  I watched Big Ben eat up 10 minutes of meeting time in the static queue, took a deep breath and asked the people immediately in front of me if they minded if I pushed in to get to the last 15 minutes of my meeting.

“Go for it”, they chorused and I pinged down to the front of the queue, feeling like one of those bastard cars that refuses to get into one lane early on and barges in at the front. Unfortunately I got a bit off track once inside and ended up standing in the Lobby, greeting the lecturers, as they pitched up, handed over green cards and went. By now it was 3.05pm. I was clearly in the wrong place.

I took a photo of the clock. Feeling stressed/distressed/frustrated at missing my slot.

“Most people take photos of the ‘no photos allowed’ sign,” said a cheerful policeman, who then filled me in on some Lobby history.

Just before 3.15pm, I was ‘found’ and shepherded along to Simon Hughes’ office. We launched straight into a no nonsense discussion about inquests. His aide (?) reminded him he had to leave almost straightaway. They had a quick convo about ringing his next gig and explaining he was slightly delayed but would be there by 3.45pm.

The call was unanswered.

‘The Secretary of State? He’s just upstairs. You could nip up and tell him I’ll be along be along shortly. He’ll understand.’

Oh my blinky blonky blimey, I chuckled to myself. Was that scripted? Was that a genuine exchange? Really??

I don’t care. On the eve of #107steps to justice, the Minister of Justice demonstrated interest, respect and a genuine commitment to improving the experience for families in the coronial process. That’s pretty cool.

Inaccurate submissions

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At that first pre-inquest review meeting, back in the day, Sloven’s legal team tried to narrow the focus of LB’s inquest with their infamous natural death statement. In addition, they argued the various ongoing reviews into what happened meant that broader issues were being investigated.

This list of reviews included (quote):

Investigations by a number of professional regulators, including the GMC and NMC, following referrals from a number of sources.

Wowsers, we thought. Have Sloven souped up the slowest staff disciplinary process on record? (19 months and still waiting…*) A number of sources? Who? We referred one staff member but other sources?

We found out eventually (today, nearly two months later) that, er, it was just the one two professional regulators. And one two staff members. One referred by us and one (a member of staff who had left) referred by Sloven. Blinky blonky blimey. Really? Trusts and their trusty, publicly funded, legal teams can submit made up rubbish to coroners? How the fuck does that work?

Well clearly in direct contradiction to Simon Hughes’ nonsensical argument on Radio 4 last week that inquests are family friendly, cuddly, inquisitorial gigs.  And families most definitely need no legal representation. Tsk. ‘No no no‘ says Mr Hughes. Waggling his finger vigorously at bereaved families.

It turns out that Bevan Brittan, Sloven’s solicitors, openly promote their expertise in ‘inquest management’. They’ve even got a handy little ‘Avoiding a Coroner’s Rule 43 report at an inquest‘** article allegedly aimed at beleaguered Trusts caught on the hop letting pesky patients experience serious harm or worse on their watch.

An extract from their website:

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Inquest management. Managing witnesses. Statement taking. Management at the inquest. 

My brain (what’s left after 19 months of intense and unremitting grief and a full on battering by everything I naively/stupidly held to be ‘good’), kind of melts at this point. How can an inquisitorial process need management by an ‘Interested Party’?

LB died. He drowned in a bath. In a place in which he should, if nothing else (because there was nothing else) have been safe.

As simple as.

That we are being forced, seemingly deliberately slowly through a shite coated, beyond unfair and punitive system, is inhumane. To discover that Sloven’s legal team can apparently trot out lies, in a public hearing, without sanction, is…?

Dunno. We’re out of words.

*For a Trust that has consistently positioned the well being of their staff over us and other patients at the unit, they don’t half treat them like shit too.

**A serious and reputation damaging knuckle rapping report.

[Update 27.1.15 I made an error in that Sloven had referred a member of staff, but not sure this changes much of the above].

British (in)justice and Simon Hughes

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No answer yet to my letter to the Ministry of (or for?) Justice but I remain baffled after this week. A week in which we had a second pre-inquest review (PIR) meeting and Simon Hughes, the Minister of State for Justice and and Civil Liberties was interviewed on You and Yours responding to Nico Reed’s mum, Rosi.

Simon Hughes stuck to the line that families don’t need legal representation at an inquest because it is (simply) an inquisitorial process. Such a blinkingly naive and ill informed response. He swerved the question about why public authorities can (and probably always do) have publicly funded legal representation. Typical slimeball stuff.

Here’s what could have happened if we’d had no legal representation at the PIR this week:

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Coroner: Hello. Any questions from the family?
Family: We would like a jury at LB’s inquest please.
Coroner: I don’t think LB was detained so there is no basis to have a jury.
Family: He was. The unit door was locked.
Coroner: He could have asked for it to be unlocked. He wasn’t detained.
Family: Yes he was.
Coroner: I’m afraid I need more evidence. I remain unconvinced.
Family: He was.
Coroner: That isn’t evidence. It’s opinion.
Family: He just was.
Coroner: There will be no jury. Any other questions?

The British “justice” system clearly on fire when it comes to inquests.

“Yes to a jury…”

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Wow. Not words I ever anticipated writing. Or tweeting. With a hint of triumph. There is no triumph. But then there is, kind of. In a pretty crap and thankless way. In the painstakingly laborious, relentless and distressing process of trying to get some sort of accountability for the preventable death of your child in a hospital bath [crumble].

The coroner agreed to a jury at LB’s inquest yesterday. At the second pre inquest review meeting. An article 2 inquest was already agreed. Whether or not there would be a jury was still to be decided. The decision hinged on whether or not LB was detained. Or not free to leave the unit. The unit with the locked door. And a care plan that stated that he was only to leave accompanied on a one to one basis. The dude who had never stepped outside without someone with him.

The discussion/arguments/submissions highlighted how coroners (and others) don’t necessarily understand how life is for some people. Why would they? With apparent good intentions the coroner tried to make sense of the evidence available to interpret LB’s ability/capacity/wherewithal to simply leave the unit as he chose. A locked door can be opened on request. He asked for evidence, for facts and not legal submissions, to underpin his ruling.

LB wouldn’t ask for a locked door to be opened. Particularly after being restrained face down for over 10 minutes in response to trying to come home on his first night in the unit. [Howl]. After such an inhumane and barbaric experience it kind of becomes irrelevant whether or not the unit door is locked. Simple power rules operate. And if staff had opened the door on LB’s request (which they never did), he would have waited for us to come and collect him.

He was detained. As simple as. Whatever way you want to try and interpret it. The coroner recognised this – after lengthy arguments (both legal and factual) from our legal team- and ruled in favour of a jury.

I was left wondering what would have happened if we hadn’t had legal representation.

The pre-inquest review meeting (2)

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Second pre-inquest review meeting tomorrow afternoon. Here’s where we’re at:

  • The coroner has agreed to an Article 2 inquest which is good but says no to a jury. Astonishingly Sloven have just said they think there should be a jury too. This will be decided tomorrow.
  • The police will update on their investigation.
  • The coroner will rule on whether Oxon County Council are an Interested Party. We think they should be for fairly obvious reasons.
  • There may (or may not be) some discussion about potential witnesses.
  • There may or may not be a date/length of inquest set (depending on the police investigation and number of potential witnesses).
  • The coroner may or may not allow live tweeting.

Sloven (and the Bevan Brittans) have got a different barrister pitching up. Dunno if this was because Gerry Boyle’s photo was bounced around twitter by the wonderful Open Democracy peeps. Or because he looked totally sick to the stomach trying to argue (on either Sloven or Bevan Brittan’s instructions) that drowning is a natural death at the last meeting. Whatever, he’s replaced by Fiona Paterson.

We have the legendary Paul Bowen, QC, representing us (think that’s the right lingo). He, together with the equally legendary Caoilfhionn Gallagher and Charlotte Haworth Hird comprise a trio of human rights deliciousness that LB would have delighted in. Something that not only reassures us hugely but is also an antidote to some of the extremes we’ve experienced in this half world of unremitting uncertainty and unpleasantness.
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Here’s to sense and integrity.