Long lines…

I’ve been off work since November with ‘mixed depression and anxiety complicated by grief and trauma’. The thoughtful and consistent support I’ve received has involved focusing on doing very little in order to regroup and recover before the General Medical Council (GMC) decision on the fitness to practice of LB’s responsible clinician (Feb) and the judgement in the Health and Safety Executive (HSE) prosecution of Southern Health NHS Foundation Trust (March). 

Doing very little has been a revelation. After early days of intense agitation and wondering ‘What the actual fuck…?’ I’m getting good at it. I can wash a pan or sort out a small pile of crap (untouched since 2013) with unprecedented attention and a (non) speed that would beat the slowest of slow lorises. Disrupted/nightmare-filled sleep is more manageable when you can decant from bed to settee with a blanket during the daytime. Reducing panic attacks to moments of breathlessness/fear is something else.

I’m shocked now that Rich and I returned to work so soon after LB’s death in 2013 (with no pressure from either of our employers). But of course back in the day we had no idea of what lay ahead. 

“Who supported you after LB’s death?” asked the mental health team a few weeks ago.

Supported us? In the wake of LB’s sudden, brutal, unexpected and utterly preventable death? Like a police liaison officer? Ah. No. LB died in the NHS. There’s none of that stuff. Respond offered us telephone counselling via social media. 

We didn’t know…

I think we probably thought at the time that work would be a distraction from intense pain while the wheels of justice and accountability turned in the background. With the odd nudge from our newly appointed legal representatives.

We returned to work in the early days of the dirty tricks game the Trust and local authority were playing. All we knew at the time was that the Trust pegged LB’s death a ‘natural cause’ death in online board papers in late August. We didn’t know about the behind scenes activity; the briefings and secret reviews; the twists and turns, lies and obstruction. We didn’t know these processes would drag on for years or how much of an enormous collective effort would be necessary to gain accountability.  

This was and is our ordinary. In the extraordinary space of public sector related preventable death.

As it is for so many other families. Many of whom have endured more than the 4.5 years we have, while others regularly join this liminal space. There’s little change. There’s little support for young people who struggle and teeter on the brink of admission to inappropriate settings while their loved ones do everything they humanly can to pick their way through the paucity of appropriate care. It simply ain’t good enough.

A new National Director…

Ray James, the newly appointed NHS England National Director for Learning Disability tweeted earlier today.

James is, of course, one in a long line of people charged with the task of reducing the scandalous number of people incarcerated in assessment and treatment units. We’ve witnessed a series of awkward and sometimes embarrassing failures in trying to do this, not least the Winterbourne View Joint Improvement Programme/Concordat and Stephen Bubb’s big breakfast. I don’t doubt James’ determination and commitment to the task he faces. What is concerning is the disappearing of everything that came before. A snapping of lines.

Another day, another face, another resolution. While people continue to live heartrendingly miserable existences.

No #Learningfromdeaths

Rich was appointed as one of two family representatives on NHS England’s Programme Board last summer for the Learning from Deaths programme (work commissioned as an outcome of the Mazars review). He received an email from a family advocate who said that families would be reassured by his involvement in the work. The first event he attended was a two day gig at the Oval in November. He walked out after two hours. The meeting opened with two apologies from NHS England – not for the fact that 75 bereaved families had to be in the room in the first place – but that no work had been done for last ten months and for the shoddy organisation of the original meeting. As the meeting unfolded, Rich felt he could not validate the process.

In December a further event was held in London with Jeremy Hunt and the great and the good. The unofficial erasure of any focus on the premature mortality of learning disabled people was completed during this meeting. Two years pretty much to the day from publication of the Mazars review. Hunt ploughing ahead with his misplaced belief that improving the process of investigation for patients more generally would improve the investigation of the deaths of marginalised patients. 

What about the work relating to learning disability related deaths? I and one other family member tweeted during this event.

“Ask NHS Improvement or NHS England” replied the Care Quality Commission. “They’re tasked with taking forward the recommendation relating to learning disabled people.”

We did. Neither responded. 

Certain people don’t count. Or worse.

They never have.

A full circle…

We woke this new year morning to the news that Toby Young has been appointed to ‘help lead’ the Office for Students (OfS). 

There is so much so wrong with his appointment… a quick search on twitter will reveal his appalling views, ill-informed commentary and actions while he tries to (ironically and pointlessly) disinfect his own timeline through a heavy handed programme of deletion. Relevant here is his apparent distaste for disabled children and associated flag waving for ‘progressive eugenics’.  (Improving the ‘genetic stock of the least well off’ in an attempt to improve the overall national stock…) 

Eugenics is, of course, eugenics as @Education720 points out: 

Woolf’s diary entry was written in 1915:

… we met & had to pass a long line of imbeciles. The first was a very tall young man, just queer enough to look at twice, but no more; the second shuffled, & looked aside; and then one realised that everyone in that long line was a miserable ineffective shuffling idiotic creature, with no forehead, or no chin, & an imbecile grin, or a wild suspicious stare.  It was perfectly horrible.  They should certainly be killed.

There are long, long lines that can be traced here. Plentiful dot joining between the desire for the ‘improvement of the British breed’ (Churchill, 1899) and the eugenics movement. The continuously poor treatment, neglect, bullying or abuse of learning disabled people in whatever setting – long stay institutions, the community, inpatient hospitals, home – by a range of individuals and professionals over the last century. And Young’s support for ‘progressive eugenics’.

Complex and complicated strands are interwoven into and between these lines; ignorance, maliciousness, systemic and structural processes, cronyism, fear, power, gender, economics, culture, power, politics, stupidity, greed, elitism, narcissism… the list goes on and on.

‘Progressive eugenics’ is a deeply flawed and harmful ideology that denies any recognition of the humanity, creativity, compassion, love, diversity, joy and brilliance people bring to society. I miss LB with an ache that hasn’t diminished in over four years. My heart contracts and eyes well up in a split second whenever I think about his gentleness, humour, generosity, curiosity and straightforwardness. Contrasting his obvious qualities with the bile that Young (and others like him) spew, with nonsensical reward and little censure, is unspeakably grotesque.

How is it possible that not one person, in a long, long line of influential people who can and should speak up and call this for what it is, ever does?

 

Crown Court

When we were kids, off school with a bug, flu or other illness, we’d snooze in front of the big old (tiny) TV. ‘School programmes’ (shudder) in the morning followed by a less dull but still dull drama (was it a drama? I dunno… maybe it was based on actual cases) called Crown Court at lunchtime.

Crown Court. A kind of ritual endurance, marking the mid point to the crawl to the end of school time and delights like Little House on the Prairie. Time for lunch if not already scoffed. A soft, non medical drug to easily bring on slumber if you felt like shite.

I dug out the theme tune on Youtube earlier. Rich, in another room, unexpectedly shouted “Is that Coronation Street?”

Off sick to the same tune/drama. Capturing the ennui, traffic free streets, all male advocates, a dose of beige and a baby Zoe Wanamaker.

 

On 18 September Sloven pleaded guilty to the Health and Safety Executive (HSE) prosecution of LB’s death at Banbury Magistrates court. The magistrate referred the ‘case’ to the Crown Court. The next hearing was held in Oxford Crown court on October 13*. The judge then set a date – 27 November – to decide a sentencing date. [I know.]

A second HSE prosecution for the death of Teresa Colvin was raised during this hearing. Teresa died a year before LB. Months after Mike Holder, a health and safety expert, meticulously documented patient safety risks which Katrina Percy and the Sloven board ignored.

[Edward Hartley, in turn, died months after LB’s death flagged up issues around epilepsy training and understanding, risk assessment and observation levels. Edward’s death, like so many others, has yet to edge or inch towards proper scrutiny and answers.]

On 20 November the HSE prosecution relating to Teresa Colvin’s death was held at the Oxford Magistrates court. [Sorry. It’s complicated].

Tomorrow (Monday) a hearing at Oxford Crown Court will pin down the timetable for the sentencing date.

The judge will be asked to sentence both HSE prosecutions together. Or formally agree to do so.

This is for various reasons, not least the importance of joining the dots between what happened to Teresa and LB and for the judge to understand the extent of (repeated) failings. Other considerations are the importance of consistent sentencing and costs.

Breathe.

Crown Court. Childhood memories. The never ever. The never colliding.

LB. Teresa Colvin. Shades of Edward Hartley. And so many others.

The sentencing hearing

The sentencing hearing is, we’ve been warned, likely to last for up to two days and will probably happen between next February and June. Time has lost any meaning as next year becomes dusted with various dates or anticipated dates. I can’t imagine what life without the stench and stain of NHS related processes looks or feels like.

The HSE barrister will present the two ‘cases’ in turn and the Sloven barrister will present a set of mitigating circumstances to try to reduce or contain the punishment (fine). They have a statutory duty apparently, as a public sector body to do this.

There is no such statutory duty to prevent a failing Chief Executive disappearing with a year off and around a £200k pay off. There is no statutory duty to stop a public sector body from recording a preventable death as one of natural causes. From openly and publicly withholding information that is in the public interest. From wasting public money on dubious training programmes. And the rest.

One grotesque rule for the bloatedly powerful and another for the rest of us herbs.

L1031321-2

*I had at the time, and have had since, visions of Richard Partridge telling me to turn to page 908 in a massive legal bundle to confirm that, yes I was not present at this hearing. And then scuttle back to page 26, para 4…

I was in the US. I wasn’t supposed to be there.

 

 

The sick note with no ‘post’ in sight

I spoke to my GP on the phone on Monday (practice process). A GP really. Not my GP. Or maybe she is my GP but she left the surgery today. I’ve not met her before. My GP dropped our family from his too-busy list a good two years or so ago.

“Would you mind giving me some context as to why you may be experiencing these symptoms…?”
“Er, well our son died four years ago…”
“Oh, I’m sorry. Can I ask how he died?”
“He drowned in a hospital bath.”
“Ah. I’m afraid I can’t hear you properly. The line is terrible.”
“He.drowned.in.an.inpatient.unit.”
“He drowned?”
“Yes. On the Slade House site.”
“Oh. I am so sorry to hear that…”

And so the tale unfolded. Today at a face to face appointment I was diagnosed with post-traumatic stress disorder (PTSD) and signed off work. ‘Treatment’ options are anti-depressants, a mental health intervention of some vague shape (the referral will take up to 6 weeks) or bereavement counselling.

I’m left both unsure and un-reassured how PTSD can be treated when there is no ‘post’ in sight. Is there an ongoing version? The various disciplinary processes are set to stretch well into next year.

Our legal team strongly suggested Rich and I went to see our GPs a good year or so ago, saying how damaging the process is in the long term. No, we both said. This thing ain’t gonna lick us. That was without reckoning on Richard Partridge’s brutal, cruel and unnecessary take down at the GMC tribunal in the summer. Or the Nursing and Midwifery Council being so incompetent they shared our personal details (including my bank details…) with the six nurses and their advocates under investigation around the same time.

I’m writing this in part to underline to other families how the processes involved in gaining accountability in the NHS are lengthy, destructive and deeply harmful. With little in the way of protection of or care about your health and well being. The best you can expect is a support number to ring and start again from scratch. Telling your version of the ‘four years ago our son…’ story to another person. With all that entails, demands and saps. Somewhat ironically, you cease being a patient when you enter the terrain of NHS investigations and become something else. I’m not sure what.

The mental health referral is underway (I think). In early January I have to contact the surgery and speak to a GP (who may or may not be my new GP from today) on the phone. And repeat the above exchange.

There is so much that could be done so differently here it leaps off the page. But it ain’t our job to spell it out. Again. Why don’t some of you – occupying very well paid senior roles to do so – crack on and do it?

Update: Someone from the Mental Health team rang me yesterday evening and asked for symptoms rather than story. [Thank you.] I’m going to have an assessment next week. (Thank you for the messages of support, advice and information which are much appreciated).

Reflecting on the GMC hearing

Spent the day, exhausted, dozing on the settee and trying to make sense of the GMC tribunal*. The full determination can be read here. Having waited since August 7 when the tribunal began (and the dread leading up to that date) and limping over the past two weekends of part hearing, hearing that the panel found that Valerie Murphy’s fitness to practice was impaired was both a relief and beyond distressing. I’ve no coherent thoughts, just a set of (overlapping) questions and reflections. Hopefully the process of writing will help.

1. Is Murphy’s ‘medical practice’ common?
The damning determination (worth reading in full to get some idea of the medical ‘care’ learning disabled people can expect to receive) misses some points that made my stomach curdle during the August hearing. Is specialist learning disability health provision so impoverished that it’s OK to prescribe medication before meeting patients? What does this mean and suggest about the treatment of certain patients?

Can it ever be acceptable, knowing you’re going on a two week holiday at the weekend, to not see an 18 year old young man you’ve agreed to be admitted on the previous Tuesday evening? A young man brutally restrained and sectioned that first night [Howl].

Is it common for medical consultants to tout a travelling suitcase with patient records for a colleague to rummage through?

Have these points dropped off the determination because there are bigger issues to pursue or because they aren’t seen as unusual?

2. Was Partridge’s ‘defence’ appropriate? 
A pre-meeting with the GMC earlier this year to go through my evidence left me reeling. It wasn’t a patch on the cross-examination I was subjected to in August by Murphy’s barrister, Richard Partridge. The pre-meeting preparation suggests that the cross-examination I endured wasn’t unusual.

Partridge repeated similar lines to his colleague, Alan Jenkins, who represented Murphy at LB’s inquest. Both focused on my ‘failings’ and the ‘Dr Crapshite’ post. On what they both seemed to view as unacceptable, unreasonable and discrediting action by a feckless mother. Ignoring what that post (and so many others) revealed about the lack of available support. This focus says so much more about them. And/or their client.

3. Ted why? 
Twitter discussion has focused on Murphy still practicing in Cork. Earlier, a minor bombshell from Stuart who lives in/near Cork. Murphy’s appointment (which is still unclear) was heralded as a ‘turning point’ in CAMHS service provision. An expert from Britain, leaving her investigation cloud behind her.

Prof Ted Dinan, the Gut Man, was prepared to offer a character witness to a colleague he seemingly barely knew. What were you thinking Ted? Boldly pegging Murphy in the top 10% of Irish psychiatrists [shudder]. He told the travelling suitcase story without faltering. While twitter groaned and buckled with disbelief, a few sharp questions reduced his story to a handful of contact hours – “in an academic year she gave two lectures and approximately 14 hours of tutorials” – and help with 5 patients across two years.

He stated that he regarded Dr Murphy as “extremely competent” and marked her apart from other consultants he had worked with, particularly in respect of her willingness to come in and give her assistance.

In contrast to her apparent unwillingness to see LB for 19 days.

4. What price power and insight?
Power. On April 24 2014 Murphy received a letter from the Sloven Chief Medical Officer stating ‘it was not considered that any further action is required in this matter‘. A clean bill of medical health from the Sloven exec. The various CQC inspections, Verita report, inquest and Mazars review processes led to no further scrutiny of her medical practice. We made the GMC referral (with Charlotte Haworth Hird) in May 2014.

Without this referral Murphy would, I assume, be continuing her practice of ‘implicit risk assessments’ (in her head) and remote prescribing in Oxfordshire, Cork or somewhere else. How can this possibly be?

Insight. Reflexivity or reflectivity is a central task for sociologists. Constantly reflecting on stuff; who we are in terms of our identity and experiences, our assumptions, what we bring to our research, how we interact with research participants and the data generated, and our analysis. I’ve always thought of it as a sound task for life. Like I’ve long thought that ‘easy read’ texts should be the stuff of everyday life, not an added extra when funds or thought permit. Adjustments that make life better for everyone.

Murphy failed on insight. She failed over and over again. Her barrister arguably added to this with his own apparent lack of insight. 

We’ve been brutalised by this process. At the mercy of timescales decided by others, cross-examination, forced to revisit what happened, rehashing blame lines… our lives on hold. John Lish captured the experience of the tribunal perfectly in a tweet.

There must be a better way.

*Am now off ‘sick’ for the week. Wary of the extreme spaces we now inhabit and what these mean. It’s only two weeks until the @HSE hearing to set the date for the HSE hearing…

Prof Ted the Gut Man and the travelling suitcase

L1031093-4

Exhausted. A terrible, terrible day following George Julian’s live tweeting of the General Medical Council (GMC) tribunal examining the conduct of LB’s ‘responsible’ clinician, Valerie Murphy. A tribunal that began back in August and is now spread across the next weekend or so.

Todays offering included a tangential figure – Prof Ted (a gut expert) on the phone to provide a character reference for Murphy – and an account of a travelling suitcase full of patient records. Murphy apparently asked Prof Ted to pluck records out of her suitcase, like drawing raffle numbers, to comment on her record writing skills. These are apparently top notch now. She’s learned not to keep them in her head.

Twitter commentators went into free fall. Eh? Audit? What records? With patient consent? Were they redacted? What price ethics?  Murphy was unable to attend for undisclosed health reasons. She seemed to be following the @JusticeforLBgmc twitter feed as, late afternoon when her barrister phoned to ask how this ‘audit’ was conducted, she tried to re-shape the suitcase story into something slightly more robust. Apparently she selected the first fourteen patient records (whose?) alphabetically and stuffed them in her travelling suitcase. Prof Ted randomly selected eight records from these 14.

He unwittingly generated criteria for what to look for when choosing a character witness who doesn’t really know you. Not a big demand for such a role possibly but useful to a few maybe:

  • Choose someone who barely knows you but is prepared to stick their hand into a dodgy travelling suitcase of patient records and describe this process under oath.
  • Make sure they are so tangential in your life that you spend around 14 hours a year in situations in which your paths could cross.
  • Make sure they are prepared to make outlandish statements about how good you are. For example, that you’re in the top 10% of consultants they’ve ever come across.
  • And when pushed on this claim, they’re willing to state rubbish like having a PhD and ‘being helpful and willing to offer an opinion’ is evidence of being brilliant at your job.

Around late morning the GMC presented their submission. We were suddenly thrown into a space of rare sense. Suitcases and gut stuff ditched. The GMC arguments can be read on the @JusticeforLBgmc twitter feed. The statements that made me weep were around how it was not unreasonable for us to expect LB would be looked after in the unit. Chloe Fairley, the GMC barrister, made the point that Partridge’s cross-examination of me in August was an example of Murphy’s more general blame-casting which included nurses and support workers.

Rich and I broke off to eat our weight in takeaway nosh. Returning to twitter an hour later Partridge was presenting his submission. Right back to Gut Man and the suitcase. And Murphy’s ‘brainchild’ the ‘yellow card’.  A shameless rip off of a well known government scheme on a pilot scale. The ‘yellow card’ was presented as Murphy’s contribution ‘to the profession’ to make sure no one ever died again.

Her entry back…

The fakery, sham and offensiveness of this redemption narrative, generated once the  tribunal process was put in motion and not as an outcome of LB’s death, was difficult to sit through. The dripping of ‘madam’, ‘in my respectful submission’ and ‘very painful for her’ statements by Partridge were grotesque.

Tears and more tears.

The day ended around 5pm. It starts again tomorrow at 9.30am with a private hearing.

Writing about an ongoing tribunal (or inquest) process is something we’ve thought about. We concluded today the process is so flawed and stacked in favour of the ‘professionals’ it can’t matter.

The deep sadness I feel. For LB. For the callous and continued disregard of his life (and so many other lives) – presented today as a ‘single patient episode in 2013’ – is matched by the obscene acceptance of the clearly wrong by tribunal panels. By senior NHS officials, by Jeremy Hunt and so many others.

We’ll keep writing justice. As simple as. And not be bullied by the processes seem to be designed to silence. That’s all we can do.

[Thanks to @RoseAnnieFlo for the title of this post.]

A missing ‘apology’ in five parts

L1028123-2

Part I.

Michael Buchanan (who I suspect bereaved families across the country are developing serious love for) continues to fight the good fight of uncovering and shedding light on brutal NHS practices. He did a piece about the decision of the Health and Safety Executive (HSE) to prosecute Sloven for BBC News on Tuesday.

At one point, Huw Edwards, introducing the story, said:

“The Trust earlier apologised to the family…”

I nearly dropped my glass of cheeky and chilled vino.

“Eh? Did you hear from Sloven today, Rich?”
“No.”
“Neither did I. What apology?

The next morning, a local journalist rang and mentioned the apology.

We ain’t received an apology, mate.

I looked on the Sloven website. Maybe they’d issued a statement. [Putting an apology in a statement is not the way to apologise to a family, mind. I was curious about where this ‘apology’ was].

Nothing.

I continued to hear about ‘the apology’ as the day wore on. With no sign of it. Then bingo. This, on twitter:

carding

Ah. The apology was part of a statement the Trust were sending to journalists. A fake apology extraordinaire.

Part II.

In the same way that the Trust response to LB’s death was to write and circulate a briefing document about my blog to protect their reputation, their response (and this needs to be read within the context that three board chairs, a CEO and a complete set of non-executive directors have now been replaced)  to the HSE decision was to tell the British public, via the press, that they have, once again, offered their ‘unreserved apologies’ to us.

Now Julie Dawes, and your merry band of (shit and/or remaining) executives, here’s the rub:  this is no apology. It is nothing resembling an apology. It is so much worse.

What you have done is:

  • compound the barbaric treatment you have relentlessly dished out to us (and many other families).
  • Make visible the insincere, formulaic and performative ingredients of an NHS ‘apology’.
  • demonstrate you have learned nothing despite saying you have.
  • treat us with further contempt and disrespect I didn’t think possible.
  • show us you remain incapable, either wilfully or otherwise, of understanding basic humanity and decency.

Part III.

The statement is pure spin. A closer look at the wording:

carding2

The HSE has “informed the Trust of its intention to prosecute in relation…” [Prosecute who?] “Connor’s death whilst in our care…” [It could have happened to anyone, we just happened to be holding the parcel when the music stopped.] “Could have been prevented…” [Introducing uncertainty into the findings of the independent investigation and the inquest.] “We would like to…” [But we ain’t going to.] “Once again…” [We have apologised to this vexatious mother relentlessly.] “Offer our unreserved apologies…” [A prize for us to take with grateful hands.]  “To his family.” [Family for PR purposes, ‘the Mother’ for every strategic opportunity to stick the boot in.] “Continues to do everything it can…” [Apart from actually say sorry].

Part IV.

You didn’t get in touch with us to say sorry. You got in touch with the press.

Minutes after finding the ‘apology’ on twitter, I received an email from your administrator. On behalf of you and the Board Chair, Alan Yates, about meeting up with the group of families you have treated like utter crap.

dawes

You can email me about a meeting (to benefit you) but you can’t say sorry.

You didn’t get in touch with us to say sorry. You got in touch with the press.

I find this unforgivable.

Part V.

Rich and I have felt pretty low since the HSE news. People have been saying it’s remarkable that the campaign has achieved so much. It is. Bryan, from My Life My Choice, earlier reminded me of the time I sat in his office a year or so ago, dejectedly saying we didn’t have a craphole chance of achieving our aims… particularly around making sure Sloven didn’t profit from the sale of the Slade House site and a prosecution against the Trust.

The trouble is, of course, LB remains dead; our beautiful son, brother, grandson, nephew, cousin and friend, is forever absent and, within a shifting family landscape, newer family members will never meet their quirky uncle LB, brother in law, second cousin or potential godfather. We know this. Any bereaved family knows this.

What your latest ‘unreserved’ non-apology beyond shiteness this week has shown, is that you have zip all understanding of this, and that you couldn’t give a flying fuck. You have been beaten into a corner by a remarkable, and unprecedented, collective brilliance, and you’ve learned nothing.

Still.

L1027974-2

Branch, burial or crematorium…

“Darling, I’m sorry but the undertaker wants to know if we want a burial or the crematorium…”

“I’m just filling in a HSIB Patient Safety Awareness form.”

“A what? What’s HSIB?”

“The Health Safety Investigation Branch… Some government thing.”

“We need to make  a decision. Apparently  the cemeteries are pretty full around here.”

“Sorry, I’m stuck on this question: Why do you think HSIB should investigate your incident?”

“What incident?”

“Jimmy’s death.”

“Christalmighty. He died for fucks sake.”

HSIB was launched this week. Led by Keith Conradi, an air safety expert and pilot, with over 40 years of experience. The new branch is allegedly independent despite being called a branch, based within NHS Improvement and funded by the Department of Health.

I’m sure Conradi is an ace guy. I’m sure he knows his air safety stuff. Patient deaths and bereaved families?  Not so sure. The ‘its’ and ”relatives of incidents’ on the HSIB website suggest not.

The gig is that HSIB will investigate 30 deaths a year using a Human Factors approach. There is a set of criteria for selecting these deaths; outcome impact, systemic risk and learning potential. Your daughter, father, brother, sister, mother has become a learning tool and the bigger the potential learning from their death, the more chance they have of making the cut.

If you understand the various hoops on the website and get through them, you eventually (after two pages with an identical ‘get started’ button)  reach a link to the Patient Safety Awareness Form. The potential gold ticket. This kicks off by asking:

When did the problem you want to share with us happen?
I kid you not. The problem... The incident. Relatives of the incident. Human Factors bods take the non-pursuit of blame to a level that doesn’t translate well into health care. Reducing death to ‘a problem’ will probably send most bereaved families who have got this far into further pieces. If they limp through to the final page of the form, they are expected to produce a coherent justification as to why the death of their loved one reaches the criteria for investigation.
I don’t know. There is something different about approaches to safety in the airline industry and safety in the NHS. Dragging Human Factors from the former to the latter (without some reflection, understanding, empathy and commitment to adapt the process to the very different context) clearly necessitates an erasure of the human and focus on nothing but systems. But health care is necessarily messy, interactive and drenched in human. It involves patients who die in a many different ways, at different times. In the airline industry I assume (please tell me if I’m wrong) that a plane crash generates an instant grouping of deceased passengers, and their relatives, who have some shared experience of this catastrophic event or happening.
On twitter tonight I was introduced to the concept of “second harm”. This is:
Blimey. Second harm. This is so important (and makes me want to scrowl given the battering we, and so many other families, have experienced because our beyond loved children, parents, sisters or brothers died in the ‘care’ of the NHS).
The information on the new HSIB site is offensively phrased, not accessible and the process of ‘referring incidents’ is exclusionary; it assumes particular levels of understanding, articulation and engagement. And, as importantly, ignores grief and humanity.
It has, in short, considerable potential generate more second harm. Classy stuff.
L1028260

Five tribunals and a dress code

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

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

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

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

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

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

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

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

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

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

It gets worse.

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

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

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

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

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

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

You can fuck your denim, sportswear and trainers ban.

Four deaths, heads and a medical director

Between Oct 2010 and May 2011, four men died unexpectedly in St Andrews, Northampton. All patients in the Grafton Ward; a 20 bed, low secure ward. Bill, one of the four, featured in Under Lock and Key a few weeks ago. You’d imagine that four patients dying unexpectedly within a six month period in the same ward would send shockwaves around St Andrews and wider.

A copy of the investigation into these deaths landed in the Justice Shed yesterday evening. The terms of reference suggest that there was some switched on thinking around these patients’ human rights:

No. The Charity clearly didn’t understand the word ‘independent’ or their obligations arising under Article 2 of the European Convention of Human Rights. The investigation was led by the St Andrew’s Medical Director supported by the Head of Research and Development, Head of Physical Healthcare, Head of Health and Safety Investigations and Head of Pharmacy. About as far from independent as you can get.

Unsurprisingly, there was zero consideration of the four lives that ended, prematurely. The remaining terms of reference were:

The executive summary states:

It was the patients themselves what done it. With their long standing medical problems (clearly untouched by the long term leading specialist care provided by St Andrews at enormous cost to the NHS and other commissioners). One patient had lived there for 18 years. The day before he died, he refused to have his vital signs checked on two occasions.

Whatever way you cut it, this strikes me as a catastrophic fail on the part of St Andrews. “The UK’s leading charity providing specialist NHS care.”

They couldn’t even be bothered to proof read the final report.

A tale of two releases

A Bermudian journalist, the only independent journalist on the island, popped up on twitter this week, tracking down details of the recent announcement that St Andrews Care (who were the subject of the documentary, Under Lock and Key) are going to ship patients from Bermuda to their ‘care’. He published this story.

Here is the original news release published by St Andrew’s. Tiny type, sorry.

St A bermuda news

And the revised one after the press started to get interested.

St A bermuda news 2

To save you squinting too hard at them both, the main differences are:

St Andrew’s has achieved a ‘new first’, not by winning ‘an [sic] contract to provide care to forensic patients’, as originally stated, but by ‘by being selected as a preferred provider to support the Bermuda Health Hospitals board in providing care…

Bit of a difference, raising questions about what is actually going on between St Andrews and the Bermuda Health Hospitals Board. And whether there is there any scrutiny of these negotiations.

The sentence about Bermuda being a small island with limited resources and people with mental illness being held in the island prison system has been removed.

Mmm. Probably best not bite the hand that feeds you. The original statement suggests that, possibly, there may not have been much consideration of the tender process, context and history on the part of St Andrew’s.

Instead of the the ‘contract being awarded at the end of February’, the story has changed to ‘contract negotiations are now being started’.  Puzzling. How these dance steps are being played out between the Bermudian system and St Andrew’s, outside of any apparent transparency,  engagement or public consultation is chilling.

The second press release drops any mention of three patients ‘set to travel to Northampton as part of St Andrew’s Men’s mental health pathway, with up to nine patients due to join St Andrew’s in the coming months’. I’m relieved this is currently disappeared. The way it was written sounded like the first three patients and the subsequent 9, were coming to join some sort of corporate team building exercise. Not wrenched thousands of miles from homes and families they will, more than likely, never see again. I’m sure it won’t stop this happening but any reflection on and consideration of what is being plotted can only be a good thing.

Finally, the statement from the Executive Director of Nursing and Quality has been revised. The opening sentence about ‘bringing the charity income from new sources’ is deleted. 

Income from new sources… Before the health and well being of these patients. Extraordinary. Since when did a massive charity need new income? Given the gargantuan salaries of the exec board and this latest money spinner, the Charity Commission should be having a bit of a snifty around this bunch. I can smell em from here.