Category Archives: Monitor

Jeff Vader and getting it right

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The day after posting LB ain’t no Han Solo, I received an email update from the Health and Safety Executive (HSE). There’s a pattern here that wouldn’t take the brightest social science analyst to identify. That is, being called out on social media for crapness can* be an effective mechanism to generate some action. This is a good thing. I mean let’s face it, us public ain’t typically served well by ‘official’, pigeon post type PALS and PHSO processes. (These organisations shouldn’t need calling out, of course. That we’ve consistently had to ask for updates over the past 3 years of so is an indication of how poorly families are typically treated.)

The action or response these blog posts or tweets generate varies. We’ve typically had stilted and clipped non updates that I read as woven with “vexatious” whisperings and stabbing needles. Them pesky parent-type stuff.

The latest communication from the HSE included acknowledgement and recognition that we shouldn’t have had to ask for an update. Good. A straightforward sorry, an explanation for the delay in updating and an update. Including notice that the investigation will be continuing beyond the expected end of October deadline. Not so good. But when you get an explanation for this delay it’s slightly easier to suck up. I replied with a brief, Han Solo, related question.

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Today I received a detailed explanation of the complexity of different investigations and differing time frames. This was followed by a second email again acknowledging a failure to keep us updated and some reflection on what the experience must be like for families. These emails have reduced my intense rage about the length of time this investigation is taking. No mean feat. I feel reassured and relieved.

This respect and decency stuff isn’t complicated. Treating people who have been battered into unspeakable spaces by the actions of  health or social care organisations as human, with honesty, care and thoughtfulness shouldn’t be so difficult. Hopefully the other involved strands of the NHS can learn summat from this.

1. Update families regularly (even if there is no news).
2. Try and put yourselves in their shoes. Imagine what it must be like.
 

LB funnily enough wasn’t a Star Wars fan. But he laughed until he cried each time he watched this clip. Which was a lot.

*The effectiveness of this mechanism needs scrutiny. There’s a social media campaign type ‘labour’ that needs unpacking to identify what works and what doesn’t. To help families and campaigners [and NHS and social bods] be more effective.

Weepage, seepage and who cares?

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Dunno why, maybe the anniversary of LB’s inquest, but I’ve been having a weep fest over the past few days. I think about LB all the time. He’s never more than seconds, occasionally minutes and very rarely an hour or so, from my waking mind. I’d got to a state (hate to stage this grief stuff) where I could think about him in different ways. With the occasional, typically left field, gut punching moment. Sparked by a word, a smell, a thought, sound or memory. Moments of near meltdown (I know, the irony), fright, (at the) sheer horror, brutality and worse.

This week I’m back to just crying. Or weeping. Or something else. I don’t know what to call this thing. Maybe weepage. A sheet of tears. There’s no movement. No sort of sobbing and dabbing with a tissue action. No drama. Just moving wetness.

I cried last night re-reading my older sister’s handwritten letter to each Sloven board member. In 2014. Two years ago. Can you imagine?

I cried looking through another pile of photos that have shifted to the surface of home clutter this morning.

I cried sitting at the back of the Oxford to Heathrow coach this afternoon. For pretty much the whole journey. Watching a stream of heavy haulage lorries and coaches. After receiving an update from the General Medical Council. The supplementary expert report is now with Dr M (again). She has two weeks to respond before it goes back to the Case Examiners. Another never ending story.

The Nursing and Midwifery Council investigations? Who knows. Tumbleweed.

We were told, months back, during a meeting with Norman Lamb and the Health and Safety Executive, that some report was with some panel and we would hear something in October. No doubt we will have to chase up any (non) news ourselves.

I think my new tear configuration has (re) emerged because of the utterly shameful banality  of the public sector response to what has happened. A year ago an inquest jury determined that LB died from neglect. He should not have died. He was effectively killed. And nothing has happened. And a recognition that this sustained cruelty can’t continue indefinitely. We (a collective #JusticeforLB we) could not have done more to counter the darkness of the #NHS and social care at its worse, with light. And brilliance. And there is still no accountability.

I wonder where, in the structure of the NHS, effective support and attention exists for brutalised families. Who should know the answer to this. And why the fuck I’m having to ask.

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The Shaw Report

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

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

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

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

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

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Two and a half years ago.

A year and a half before LB’s inquest.

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

A cheeky bit of media advice to Smart and gang

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We’re weary in the Justice shed. Weary of the continuing horrors, absurdities, scandals, lies, deceit, cover ups, failures in accountability, delay, obstruction, lack of decency, sense and fairness. Broken Trust, shown this week, was pretty horrific and devastating for families involved to watch. In the spirit of productiveness, and to distract from raging, I thought it might be useful to offer Tim Smart and other senior NHS bods a few pointers in engaging with the media. His interview (and Katrina Percy’s) with David Fenton was an exemplar in how not to. Just a few twitter responses:

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Now I certainly ain’t no expert in media appearances. We have no comms team/resources behind us. In fact the only time I was on local radio before this devastating unfolding, was for work. I forgot the third (stereotypical) characteristic of autism through a rabbit in headlights/fear situ. Deeply awkward and embarrassing at the time. Now just budgie feed.

Here’s the transcript of the interview with Smart with thoughts and suggestions added in red. Please feel free to add further reflections/advice in the comment section below. There is clearly plenty to learn.

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1Obviously this interview will have been edited and mucked about with. But the ills and errors were spoken and so available to produce this version. Thoughtfulness, care, honesty, reflection and openness are the very basic ingredients. With knowledge, underpinned by experience, and broader understandings of and engagement with the wider context essential at such a senior level. At a senior level, and on these massive salaries, I’d also expect a clear understanding of media engagement (and the potential pitfalls) and some ease (taught or otherwise) of sitting in front of a camera or microphone.

The third ‘autism characteristic’ I forgot, back in the day, that afternoon at BBC Radio Oxford, was ‘theory of mind’. I was mortified at the time. I resolved to avoid announcing a number of things, in advance of listing them, and to prepare a list of key points in advance. I hope Smart, Percy, and those around and above them, are revisiting the seriously gut wrenchingly awful presentation of Sloven senior culture presented in Broken Trust. And that serious questions are being asked around what has, and continues to happen, at higher levels. 

The Bode files

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Still struggling to absorb the latest leaked documents: two letters from Carol Bode, previous Sloven board chair, to Monitor (now NHS Improvement) flagging concerns in 2011 and to Alistair Burt in July 2016.

The 2011 letter is 9 pages long with appendices. My first response, other than horror, was surprise to read an authoritative, sensible and thoughtful letter. Our communications from Katrina Percy and other Sloven execs have been grim, silly, hot air, lying bullying bullshite. Exemplified by the letter Katrina Percy sent me in August 2014 but also Simon Waugh categorically denying Sloven were monitoring my blog.

The back story is Hampshire Partnership NHS Foundation Trust (HPFT) merged with Hampshire Community Healthcare (HCHC) [Katrina Percy’s stamping ground] creating Sloven in 2011. Senior HPFT bods left and within a short space of time HCHC directors dominated the board. A cheeky little Percy coup d’état with only Helen McCormack remaining from HPFT by 2013. Extraordinary and deeply alarming. Particularly, as Bode raised issues around the expertise of the board two years earlier:

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Not only foundation trust expertise but also mental health and learning disability expertise. Before the Ridgeway takeover… [Howl]

Though carefully worded, Bode also raised issues around Percy’s leadership approach:

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Sadly, there were no fresh eyes. Simon Waugh, the replacement board chair was replaced by Mike Petter, an old mate of Katrina Percy’s from her pre-Sloven days. A now familiar path of rewarding mates with jobs/contracts.

In her letter to Alistair Burt, after Smart’s board judgement on June 30 this year, Bode states:

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If only Monitor had listened and acted… These pages could still be filled with hilarious anecdotes.

You fucking bastards.

PostScript: Thank you for trying, Carol. And thank you to the peep/s who send us these documents. There remains nothing like transparency and candour within official channels.

When troubleshooting goes bad…

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Blimey. More documents pinging mysteriously into the Justice shed. Including a letter written by the then Sloven board chair to Monitor (now NSH Improvement) raising serious governance concerns in 2011. [Yes. Really]. At first graze, a dense, detailed, informed, harrowing and enraging addition to an apparently unlimited evidence pile highlighting Sloven governance failing.

I’m typing this post listening to Laura Veirs. A vague balm. Rich and I have spent the last three days since the faux announcement of Katrina Percy’s (yet to be properly confirmed) ‘resignation’ in a harsh and agitated space. It’s not about her, as a person. It was never about her as a person. Blimey. She didn’t make it to the Connor Manifesto. But it’s becoming more and more about her. 

Percy failed to lead effectively. We all know that. The board failed, and continues to fail, as an executive board. The Council of Governors remain split between an enlightened minority and the waste of space rest. There remains a consistent and shocking lack of competence, authority, knowledge and sense among both the board and council. Backfilled with a frenzied focus on reputation and apparently unlimited funds to buy in whatever spurious consultancy or legal support they think will magic away the disorder that surrounds them.

Deeply depressingly, the documents leaked to us today were shared with Tim Smart to provide context to his review of the board. Now we don’t know (I don’t think anyone really knows) what Smart based his (30 June) judgement of the board on. We do know he scathingly dismissed the Mazars review during the meeting with My Life My Choice and we now know he must have dismissed the serious concerns raised by the board chair back in 2011.

We also know he agreed to the very recent secondment of Sandra Grant and Flash Gordon to new pastures (as well as gifting Percy a substantially reduced role on a CEO salary). Why you would give a board under serious scrutiny a clean bill of governance health and then start seconding execs five minutes later is a mystery. Oh. Unless you finally, and belatedly, realise the board is as grubby as they come.

Indeedy, it’s probably about time some of the spotlight shifts to Smart and Jim Mackey (the CEO of NHS Improvement My Arse). What this pair of muppets are doing is beyond me. Did they really not anticipate the inevitable backlash against such offensive and scandalous news? Did Smart not realise erasing all whiff of failure in Percy’s leaving statement, blaming press interest, would simply enrage and inflame? What an almighty pigs ear of executive and regulatory ‘action’.

Ironically, one of the biggest failings here is candour and transparency. From where we’re sitting, it appears Smart made the wrong judgement on June 30 because he is incapable of listening. Days later Michael Buchanan broke the news about dodgy contracts. Patient deaths are clearly nothing compared to doshing your mates £millions for going viral nonsense. Once Roy Lilley was on Radio 4 condemning the spiralling of a £300k contract to £5m, the writing was on the wall. Failing governance a go go.

Instead of a clean sweep, an acknowledgement of failings – of letting down hundreds of patients and their families, of a board gone bad – Smart, Mackey (and Hunt?) ballsed it up. Big time. Generating more media attention and public outrage than the publication of the report revealing that Sloven investigated less than 1% of the unexpected deaths of learning disabled people over four years. A report that led to the appointment of Smart as the troubleshooting interim chair.

What a stinking mess. Do the right thing someone. Please.

When trusts go bad

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Walked into Oxford earlier with Rich. One of those days when there were no end of brilliant photos to take. Including a cheeky bee.

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Got home to find out one of the rebel governors, Peter Bell is under formal investigation by Sloven. Yep. Sloven are formally investigating the actions of a (rare) governor.

Sloven who:

  • initially said LB died of natural causes and all due process was followed.
  • tried to stop the publication of the first Verita investigation which found LB’s death was preventable.
  • spent nearly £300,000 on legal expenses at LB’s inquest to try to avoid accountability.
  • spent nearly £50,000 to try to sink the Mazars review into their death reporting.
  • have been found to be failing by numerous coroners over the past five years
  • etc, etc, etc…

Blimey. A formal investigation…
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‘Seriously derogatory remarks’…. Not sure where, in the guvs’ code of practice, it states ‘thou shalt not say owt negative against the hallowed trust’. What a load of bullying bullshite. Those of you following this deeply harrowing tale of a trust gone bad will know that an extraordinary meeting to discuss a vote of no confidence in the Sloven leadership was stopped on May 17 by interim chair, Tim Smart. He got the Capstick heavies involved. The discussion remains to be had. Now this.

Truly, truly extraordinary.

Extraordinary timescales too. An ‘investigation’ into the actions of a governor with such priority it can be sorted in a month. We’re into the fourth year of investigations into LB’s death. GMC, NMC, HSE.. Every one of them drawn out because of Sloven slovenliness. Delay and obfuscation.

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LB died. He died. Without any accountability. But the investigation into the actions of a governor is racing on. Interviews, evidence collecting and all. By an organisation who failed to investigate 100s of unexpected deaths in their care. I almost think I’ll wake up in a mo. Surely this can’t be happening in full view of NHS Improvement, NHS England, the CQC and Jeremy Hunt?

Surely…

In a final piece of [no words left] the Sloven annual report has been signed off.

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My incredulity monitor has finally broken.

Updating LB

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Hello matey,

Three years now. Well we’re into the fourth year really. I thought I’d update you on where we’re at in terms of justice and accountability. Not far really. [Sorry]. Various investigations limp on. The General Medical Council (GMC) has spent over two years collecting evidence about the clinician who was kind of in charge of you. You know. That woman who spoke to you for about 15 minutes across your whole time in STATT from what I can tell from the records. And gave you Bonjela after you had that seizure. She’s got about a week left to respond to the allegations the GMC have put to her. We’ve no idea what these allegations are because it’s all secret squirrel stuff. She’s working in the Emerald Isle now. Still responsible for patients.

She pitched up at your inquest in October with a barrister who was like the worst of worst baddies in a Simon Pegg film. He, like Sloven peeps, questioned whether we wanted you home. We did. I’m so sorry if that got lost over those hideous weeks in the unit. We stupidly, stupidly thought you were in a safe space while support was being sorted. Turns out all the failings in the unit were written in a report the summer before you went there. But nothing was done. [Howl…]

Your inquest went as it should have done. Superb legal representation (as you’d have expected) and a jury of nine members of the public who listened and understood how deeply you were failed by Sloven.

Other investigations are going on. Still. We met three people from the Health and Safety Executive (HSE) on Thursday with Norman Lamb. The meeting was in Portcullis House which you’d have loved. Heavy weaponery, police presence and security… The meeting was disappointing. Not the objective, razor sharp, robust, investigative scrutiny I imagined. Mind you, the writing was on the wall given the speed in which they slapped a charge against a production company for Harrison Ford’s leg injury in June 2014. 

There seems to be a fog engulfing and dispersing any critical challenge by public bodies of public bodies. And when you stupidly ain’t considered to be fully human, that fog just thickens. 

We managed to get a review commissioned by NHS England into deaths in Sloven ‘care’. This found a scandalous lack of interest or engagement in investigating unexpected deaths. We thought this report would lead to sharp and immediate action. But nah. Seems like this is ok.There’s a bit of tweaking going on round the edges but no commitment to really looking at these deaths or to act with any conviction. You’ve been mentioned a few times in the House of Commons though which would make you smile. 

Meanwhile, Sloven failings continue to pile up. They are seriously shite. NHS Improvement sent in a troubled shooter, Tim Smart, to look at leadership failings. He spent a few weeks there, avoided speaking with families, got some psychometric testing organised and decided there were no leadership probs.

I can hear you saying ‘Mum? Why mum?’ into infinity and beyond.

I dunno. I was waiting for the Scooby Doo gang to pitch up and unmask him as Mr Crawls or one of the other villains in the end. Such a nonsensical, cartoonish judgement. Apparently Alistair Burt, the social care minister, is still looking into it but for some reason, that rag bag bunch of muppets remain in post. 

These systems we loosely brought you up thinking were good, right and just, simply and sadly ain’t fit for purpose. While the public have stepped up and created an explosion of brilliance around you, your life and the lives of so many other people, you were and continue to be well and truly fucked over by those you always firmly believed in. 

There was a story in the Guardian mag about you a few months ago. A very funny journalist, Simon, came round and later a photographer. You’d have liked them both. Joel souped up some of our old photos. Like this one. No orange binoculars but the old shower cap and goggles. Rocking life as you always did. Your way.

Connor

Connor

xxx

Photos, postcards and a meeting postponed

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We found some old photos yesterday. And a postcard LB sent to Stan in 2008. Tears, chuckles and family banter. The postcard is addressed to Stanley McRogers, LB’s name for Chunky Stan. And pretty vague address details. How the hell did it get here?

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We decided it probably arrived because of the wonderful, intuitive work of a postman we had for several years. A postman who collected Marilyn Monroe memorabilia.

Tonight we found out the extraordinary governors meeting organised for 17.5.16 with a controversial agenda has been postponed. The official statement from Tim Smart, the recently board chair appointed by NHS Improvement, states:

smart shiteYou’d think a trouble shooting NHS Improvement appointed (interim) chair has sufficient understanding of the legal ramifications of proposed actions, or easy access to advice from NHS Improvement, to make authoritative decisions… But no. The flakiness of not only Sloven but the broader bodies around them once again laid bare. And yet more delay.

An hour ago I tweeted:

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It’s nearly 1am.

Sloven leading, as always, with actions that make fuck all difference to patient care…. They can’t sign off an epilepsy bathing protocol until nearly three years after LB died but they can change a typo on a news release after a tweet, late on a Saturday night.

Where is the human?

‘Painted a different colour’ and the picnic spot

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Another day, another shower of Sloven related shite. The (one hour) Sloven extraordinary governor’s meeting next Tuesday has been ‘transformed’ [painted a different colour] into a set of observations by pretty much everyone other than the caretaker and cleaners who I suspect would have more sensible and insightful reflections than the newly appointed interim board chair, improvement director, nursing director, CEO and two other random peeps listed on the agenda. The emergency motion that generated the meeting has been pushed to a secret session after public questions. Within the one hour meeting.

Yep. Really.

[Essential context here from George Julian, Mark Aspinall and Peter Bell].

Beyond unacceptable. And so disappointing from Tim and the Turnaround Team. Big sis, Agent T, texted this morning in frustration to say ‘I don’t know why they surprise us every time. I think there must be a hint of not being pushed (or seen to be pushed) by some pesky families…’ This echoes Tom saying

The ridiculous thing about all of this is that when I look at what families demand from Southern Health and the way that they just don’t change I sometimes worry that maybe we are asking a lot or being unreasonable. But then I list the demands of the families and they shouldn’t even be demands, they are such basic requests that if asked on behalf of any other group in society would’ve been dealt with straight away with no barriers. So why does it take so long when it’s for those with learning difficulties?

Agent T and Tom are both right. We ain’t being unreasonable or pesky. We’re calling a failing trust out. Repeatedly. With enough evidence to sink a Sloven flotilla. Sloven, meanwhile, have shown no signs of recognising/acknowledging failings. Tom captures this brilliantly in his post.

Hey ho.

We’ll be heading to the Lyndhurst Community Centre on Tuesday for the unfolding of the fake governors meeting. Meeting My Life My Choice champs at Oxford station, picking up Agent T and Ally Rogers en route and hooking up with George Julian and others somewhere in the New Forest.

  • None of us should have to do this.
  • Thoughtful action by enlightened governors shouldn’t be closed down as it has been

I just hope there’s a good spot for a picnic after and a bit of sunshine. Sounds like we’ll be booted out sharpish.

In related news, My Life My Choice received a second mysterious letter recently. Written to then board chair, Simon Waugh, in May 2014. Copied into Monitor and NHS England. Wonder if they will be there on Tuesday?  I’m sure we’ll have enough egg sarnies and a flask of tea or two to share…

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