Category Archives: Jeremy Hunt

The message

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My blood chilled, 20 seconds or so into the message left on my phone at work, when the caller seamlessly tipped from being sorry that LB died to calling me a vindictive cow. And didn’t hold back from sticking the boot in.

Another day. Another Sloven related failure.

The kids, love em, and their cousins/mates, were instantly outraged, enraged and upset. Their united, supportive and vocal position, that this is so fucking wrong, continues to be one of the lights shining through this complete fuck up. Combined with widespread condemnation by so many others.

The call is vitriolic, nasty and beyond inappropriate. But it’s simply part of a set of improbably, inappropriate, nasty and worse responses we’ve endured since LB died. Evidence of a system in which defensiveness, bullying and family crushing flourishes.

Just a few examples:

The letter from Katrina Percy.

The Dr Crapshite stuff and mother blame.

The Oxfordshire County Council commissioner’s  letter to disability activists

The Sloven briefing to David Nicholson…

This afternoon, Luciana Berger tabled an Urgent Question in parliament about Sloven. There was anger, much sense and serious concern demonstrated by those present. (Not Burt). John Bercow concluded the debate stating that Sloven need to see the Hansard documentation of the debate. Good.

But not good enough.

We’re beyond weary. Bouncing between extreme love for the likes of Luciana Berger, Norman Lamb, Paul Lelliott and others at the CQC, Andrew Smith, Deb Coles (and the unfailing support and contributions of #JusticeforLB campaigners).   And the pin drop pots of non action wedged within the Department of Health, NHS Improvement and NHS England.

Listening to this message was unspeakable. Reading the documents listed above was unspeakable. I don’t know how much more unspeakable we are expected to endure. We were, hilariously, stupidly, copied into an exchange about the governors response to us in which a Sloven comms person advises the governors to ‘soften the tone a bit’. Just astonishing.

Why don’t you all re-read Mark Aspinall’s emergency motion and recognise your craphole, seedy actions for what they are. We ain’t the problem here. As much as it makes you feel better to think so.

In the spirit of the openness of the campaign, I’ll just say you are all a fuckingpileoftosswankpisspotfuckscummerybastards.

 

 

 

 

Dark places and being peggable

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The leaking of the Sloven governor’s emergency motion was a bright spot. Whatever bickering and political wrangling it has generated, Mark Aspinall called it as it was, and is. Simple as. It’s now up to the remaining council members to demonstrate their integrity and act accordingly. With appropriate scrutiny from the regulatory and public gaze.

This latest twist has generated a lot of ‘thank fuck for that’ type comments from family, friends, colleagues and supporters. People have been coming up to us in the street, on the bus, in lifts, saying they can’t understand how the Sloven board are untouched (well other than Mike Petter’s (possibly stage managed) exit). Nope. Neither can we.

We get emails from people about how the campaign has given them the energy, confidence, fight to try to get some accountability and justice for the death of their child, sister, brother, partner, parent, friend. This is sort of good. Only ‘sort of’ because the system shouldn’t be so consistently shite. We shouldn’t have to draw confidence from other people’s experiences. The right thing should be done. With the lightest of family involvement. But we all know this is bollocks when it comes to preventable deaths in the public sector. Particularly those involving certain people.

There has also been a lot of ‘inspirational mum’ stuff…

One of the things that came through clearly from the STATT records was that LB fully expected me to come and bring him home. [Howl]. Of course he did. I was his mum. I fought his corner with every bone in my body from the moment he was pegged as peggable. From the moment he started at an ‘integrated’ nursery in which the induction session involved only certain parents and pointing out separate pegs for the special needs kids who ‘get transport’…

Endless battles. Transport, after school club, respite, getting a diagnosis of epilepsy, transition, direct payments, disabled parking bays….

And then, stupidly, thinking he was temporarily in a safe space, if nothing else…

When I got the STATT records, back in the day, I cried in a new way. A different way to when LB died. Which was also indescribable crying.

Over two years later, we sat through the inquest evidence. Further unfolding of the (inevitable) preventable death of LB. With a topping of toxic mum blame. And still no accountability.

The simplicity and truth and certainty LB felt, recorded in the records. Even in that space. A space in which he was brutalised and had pretty much everything he recognised stripped from him. A space in which he was told to attend stupid fucking tea and cake groups because he’d be allowed home earlier. A space in which he was given bonjela to put on his tongue by a careless and arrogant psychiatrist who denied he was having seizure activity.

A space in which a combination of Sloven incompetence, arrogance and obsessive focus on corporate identity and reputation (rather than basic patient care) together with disinterest from local commissioners, a wider inertia and disregard within health and social care, led to a vacuum in which he (like so many others) died.

A space now documented and evidenced at length. With no accountability. I’m not ‘inspirational’. I’m just doing what I always did for him, until I took my eye off the ball and handed the baton over to a (known to be failing) organisation. And I will continue to do it until there is justice. And accountability. Along with the other #JusticeforLB campaigners.

Sense and reason, at last

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After nearly three years of atrocious responses from Sloven to what happened to LB, this document arrived anonymously in the Justice shed earlier. An emergency motion presented at the governors meeting on April 26th. Apparently, from what we can glean from Michael Buchanan’s tweets and other sources, some of the governors were taken aback by the never before seen candour and transparency they were confronted with, without warning.

Petter, then chair, decided that the motion would be held back to an extraordinary meeting to be held within 7-10 days of the CQC report being published. I suppose to allow certain people the space to recover their shock and horror that, for once, their cosy slumbering and collusion with the board was being challenged.

I can’t describe what it feels like to read these words. Such a careful, reflexive, comprehensive and sensible engagement with the catalogue of failings since Mike Holder’s report in 2012.

I’m not sure I’d add anything other than, good on you, Mark Aspinall and the other governors who expressed support for it. What a refreshing contrast to the simply offensive letter we were sent on Thursday. And here’s looking forward to the extraordinary meeting in the next week or so.

-REBbBU_

H_jywKsp

The confidential confidentiality agreement

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confid

Back in October 2013, Fran was going to be the family advocate on the Sloven investigation into LB’s death. This descended into farce almost immediately as Fran was banned from being involved because of some trumped up nonsense around Oxfordshire Family Support Network. And then unbanned. Once back, Fran’s involvement only spread to one meeting before Verita were commissioned to do an external investigation.

At the meeting with two Sloven employees (one of whom wrote the leaked quality and safety review nearly a year before LB died; the report which Verita, NHS England and NHS Improvement are now arguing was disclosed (my arse)), Fran was given a lifelong confidentiality agreement to sign. She took a hard copy away to get it looked over, slightly bemused as it had bits crossed out and handwritten amendments.

She was surprised to receive several missed calls from the clinical director the next day (on her home phone and mobile) desperate to get hold of her and two messages. This is the first message (early evening). It was followed by a second message first thing the next morning asking her to get in touch. And more missed calls across the morning.

The life long confidentiality agreement itself was now confidential and not to be shared with anyone (not even a legal representative). Complete and utter Sloven nonsense. Typical bullying and bombastic approach. Terrible, terrible interaction with a family friend/member of the public. No whiff of care, concern or sensitivity around the fact that a young man drowned in their care. Just a dehumanising ‘mum and her solicitor’ and agitation.

What a sign of what lay ahead.

ps. Fran’s son, James, still uses Sloven services. Her willingness to publicly share this message and story is a testament to her not being cowed by bullying services who too often hold families over a barrel of fear. She said to me an age ago that she had been a whistleblower as a nurse in her early twenties. ‘Before ‘whistleblowers’ existed.’ She just called out poor practice. I think she’s right. This is the only way change will happen.

The governors response…

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Regular readers will know I spent ages writing a letter to the Sloven governors at the beginning of the year outlining the boards (barbaric? inhumane?) treatment of us since LB’s death. It was a deeply distressing task which took hours. I didn’t cover every bit of action (or non action) because it would have been unreadable. The letter can be read in full here.

It ended with this paragraph:

letter

Only one governor, Mark Aspinall, demonstrated any interest in responding properly to my letter, as I chased up an answer every few weeks for four months. Apparently it was taking a long time to go through all the points I raised and getting the governors to agree to a reply. Last week we heard from Jim Mackey that NHS Improvement had followed up the non response with the trust and had requested a copy of the reply too.

I received this letter the next day.

[Before reading it, you should probably make sure there is nothing breakable within reaching distance. In all seriousness.]

gov letter 1

gov letter 2

Please hurry up someone and do something with this totally toxic, festering bunch of self satisfied and equally stupid, pointless people. I now have rage feelings in parts of my body I didn’t know existed before. LB died [he died???] and you – the board and now the governors – have treated us with contempt, disrespect and much worse.

How is this remotely acceptable? And how do any of you, and I mean all of you, possibly sleep at night?

 

Media melange and a missing CEO

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24 hours. The Today programme, BBC Five Live, BBC Breakfast News, Channel 5 and ITV News, Community Care and Oxford Mail. No words (other than appreciation for thoughtful and engaged interaction from all, and some photo captions).

Oh. And no sign of Katrina Percy.

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Thursday. 20.36. Train to Manchester, Piccadilly.

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22.00. Holiday Inn. Media City, Salford.

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Friday. 5.30. Holiday Inn. Media City, Salford.

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6.15. Recording the Today Programme. In a pod.

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7.20. Slap. And a bit of banter.

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12.30. Botley Community Centre, Oxford.

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13.00. Channel 5 and ITV News. Wind and sunshine.

Sloven and the ligature risks

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A few weeks ago, we found out someone sent an anonymous letter to the Sloven CEO in 2011 flagging up health and safety concerns. Katrina Percy was, of course, totally oblivious. An independent Health and Safety consultant, Mike Holder, was appointed to troubleshoot. Two months later, he handed in his notice. Sloven were not prepared to listen or act.

Holder has shared the relevant documents and his leaving report with the Care Quality Commission (CQC), the Health and Safety Executive and Hampshire MPs, Suella Fernandes and Kit Malthouse. I caught up with some of this paperwork this evening. A couple of things leap out (outside of Holder’s meticulous detailing of the myriad ways Sloven were breaking Health and Safety legislation). These relate to ligature risks.

Holder shared this diagram showing the increase in ligature incidents over four years with the Interim Director of Nursing and AHP (dunno what AHP stands for) in Feb 2012.

lig incidents

Her reply is enough to make hair follicles seal up:

Nurse reply

Holder’s reply. Challenging the nonsensical with sense and clarity:  

Holder reply

Rich and I chatted about this earlier. He was reminded of this quote from Clifford Geertz, a classic anthropologist: 

I have never been impressed by the argument that as complete objectivity is impossible… one might as well let one’s sentiments run loose. As Robert Solow has remarked, that is like saying as a perfectly aseptic environment is impossible, one might as well conduct surgery in a sewer. 

Sloven clearly and consistently embrace the sewer approach with an abandon and a carelessness that is sickening. [There was another report today about the death of another patient/Sloven failings. Lesley Stevens, who seems to have a full time job attending inquests, was again bleating about ‘changes’.]

Changes my arse.

Dipping back to Feb 2012, the second, related point, is around action plans and (non) actions. Someone working with Holder emailed him with serious concerns around ligature risks. The assessor was concerned that either the risk scoring was inaccurate or signalled a general lack of understanding about how to complete ligature risk assessments. Both were deeply worrying. He concludes:

Finally there are action plans in each of the assessments which list all the points where actions are required; there appears to be no record of any actions being completed. This raises the question as to whether the actions have been completed at all, and the assessments not updated to reflect that, or whether the actions are still outstanding.

The same old, same old shite. Across four years now. Documented and shared with the senior management team. Who ignore it.

Given that Holder’s appointment came about because of an anonymous letter raising safety issues, you’d think his resignation and the various health and safety breaches he identified in a couple of months, would be taken seriously.  But no. It was business as usual. Six months later, in August 2012, a quality review, detailing shocking failings at the unit where LB died, was similarly ignored. [Howl]

Fast forward to April 2016, whipping past numerous failed CQC inspections, numerous deaths, inquests and Prevention of Future Deaths reports. Past the publication of the Mazars review… to which Sloven, four years after the above discussion about ligature risk, applied the same baseline stats (non) defence. The latest CQC inspection report will be published later this week. The Sloven senior team are, by all accounts, mounting their schmooze counter-attack. There isn’t a reflexive bone in their collective body that allows them to think, hang on a minute… We’ve really ballsed up here. Repeatedly. Patients have died. Repeatedly. And we clearly can’t do what is needed to improve the services we provide…

Nah. Nothing like it.

This CQC inspection was part of Jezza Hunt’s response to the Mazars review. It was the necessary first step before the CQC and NHS Improvement decide on any regulatory action. [I know]. Given the inspection identified failures generating warning notices a week or so ago. Given everything that has gone before. Given everything. There cannot be any more propping up of this toxic senior management shower. Surely.

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‘Oh Katrina,…’

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I can still hear Shaun, from My Life My Choice, asking this question at the extraordinary (extraordinary) board meeting back in January:

Oh Katrina, you were clearly struggling. Why didn’t you ask for help?

While she has been strongly defending her leadership this week of course Percy ain’t a lone ranger and has a board and a council of governors to support her/ensure good governance. She also received offers of help from outside the trust. Gary Walker contacted her back in December, for example. You can’t accept help though if you don’t think you need it. And despite Shaun’s wise words, Percy continues to deny failings.  To the extent she refers to “alleged ‘failings'” in her latest report to the board.

This truly astonishing position, so far from any whiff of candour and transparency, makes me wonder how many senior bods in NHS England and the like have toe curling moments reading repeated Sloven protestations.

The jury determination at LB’s inquest was not alleged ‘failings’. The Mazars report does not contain alleged ‘failings’. The CQC  warning this week makes it clear that there are longstanding failings:

We found longstanding risks to patients, arising from the physical environment, that had not been dealt with effectively. The Trust’s internal governance arrangements to learn from serious incidents or investigations were not good enough, meaning that opportunities to minimise further risks to patients were lost.

[Howl]

The Sloven response to the warnings issued this week are so blinkingly similar to their response to the warning they received in March 2014. With no apparent reflection they are simply repeating the shite they dredged up two years ago.

The CQC state longstanding risks, Percy talks about recent concerns. The CQC say action was only taken by Sloven as a result of the warning notice. Percy says good progress has been made. In both responses, Percy talks about “agreement” with Monitor/NHS Improvement about what needs to be done. And takes them both “extremely seriously”. In 2014, she is going to sort it all out “over the coming weeks”. In 2016, “I, and the Board, remain completely focused on tackling these concerns as quickly as possibly”. Jaw dropping spin exposed again by Ally Rogers.

Back in December, when the Mazars report was published, Percy argued the trust wasn’t an outlier in not reviewing the deaths of certain patients. An argument so wrong given the content of the report it continues to baffle. Really? Did she really say that? In a typical Sloven move, she/they also tried to position the trust as leading the way in improving death reporting at this point. This extract from an ITV report;

kp bullshit

Spin extraordinaire. Complete billy bullshit. And George Julian laid the ‘not an outlier’ argument well and truly to rest with a monumental analysis of trust responses to the Mazars review published yesterday. George’s post demonstrates that many trusts are doing a good job (thank fuck). And responses to the Mazars report you’d  expect [in the real world that is, not Sloven spin city]. That is, a determination to scrutinise current processes to make sure they are effective. How we are still dealing with this tinpot bunch of exec muppets who clearly wouldn’t know what ‘Deliver improvements in our quality governance and Board governance’ [2014] means, remains beyond me.

petter and percy

What does today mean?

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L1018852Version 1

The Care Quality Commission issued a warning notice to Sloven. Ahead of publishing the latest inspection report that took place in January (after publication of the Mazars review and Jezza Hunt’s apparently serious engagement in the House of Commons on December 10th). This warning notice allowed NHS Improvement (previously Monitor (I know.. keep up..) to issue a statement saying they’ve put an additional condition into the Trust’s licence allowing NHS Improvement to make changes at board level.

This now opens a space for some serious action to take place. Particularly given that the still to be published CQC inspection clearly demonstrates continuing failings by Sloven on top of the harrowing findings revealed by the #Mazars review and numerous CQC inspections over nearly three years. That they only made improvements after the warning notice suggests they don’t have a bloody clue.

A laborious and painstaking approach that needs to be followed to allow effective action to happen.

Version 2

Fuck all.

How was today for us?

I came out of a meeting at 1pm. To emails from the CQC and NHS Improvement. Calls from the BBC/ITV. Reading the CQC statement I felt a mix of rage, despair, distress, sadness and more rage. I arranged to go to BBC Oxford late afternoon. ITV Meridian to interview Rich. Updates during the afternoon about an anticipated statement from the Sloven CEO. Work (again) parked for another weekend/evening slot. Meal at mate’s house postponed.

Expectation and anticipation.

Katrina Percy, Mike Petter and the board would have to go. That was obvious. You cannot, given everything that’s happened, keep talking about making changes and doing crap all (or worse). The continuing and clearly evidenced shite was not only damning for Sloven but was also turning a spotlight on the Care Quality Commission and NHS Improvement. How much more non regulation could possibly (not) happen?

She said she wasn’t going to resign. She needed to lead. And then talked about leading in a way that no leader ever would. I spent a couple of hours in BBC Oxford. BBC News, live BBC 24 hour news and BBC Radio Oxford. Live BBC News was streamed in the various spaces I hung out in. LB’s photo constantly in the background.

I came out in early evening sunshine. Into Summertown. The 700 bus came along. I caught it instead of changing buses in Oxford. The bus finished it’s route in the grounds of the JR hospital. Where LB didn’t die.