Another day, another delivery
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Category Archives: Monitor
Wight, wrong and mateyness
I went to the Isle of Wight Adult Safeguarding Board conference this week. Going to speak, meet, or be part of an event, as ‘LB’s mum’ or part of #JusticeforLB tends to be fascinating, depressing or a waste of bloody time. We’ve sort of learned, in the Justice Shed, that these things are typically about pomp and performance (and box ticking). Not substance. The Isle of Wight invite seemed different, the ‘invitee’ clearly seemed to get it and I went.
Graham Enderby kicked off the day. Talking about Harry and ‘the Bournewood Case‘. A remarkable story of (family generated) tenacity, guts and integrity. And wrongness. Leading to ground breaking changes. His story featured an early appearance by one of our favourite barristers. Human rights in action. Simple as. Graham socked it to the audience of 200 or so, health, social care and police bods, housed for the day in an enormous boathouse on the Cowes waterfront. Without artifice, excuse or fudging. The following speakers similarly demonstrated integrity by the bucketful. It was uncomfortable at times. Informative. And reassuring that professionals got it and were prepared to step up and say what needed to be said.
My bit was towards the end. Before showing The Tale of Laughing Boy I carelessly asked how many people had heard about LB or #JusticeforLB. I felt almost apologetic playing the film to such an audience a spit from the home of Sloven. They must have had a constant diet of LB, #JusticeforLB and the Mazars review for months now…
Less than half (easily) of the room put their hands up. One of those cartoon screechy brake moments. Really?
Re-watching the film, made this time last year, was a further bash in the chops. The naivety around the ‘reaching for the stars’ stuff. Back in the day. Pre inquest. Pre Mazars publication. Pre every other atrocity that has happened or continues to happen. In full view.
The lack of response to the Mazars review is scandalous. Jezza Hunt and his merry band of human factor/HSIB peeps are, at best, naive to believe, not care, (or just argue) that creating ‘safe spaces’ and a no blame culture within the NHS will lead to a reduction in the premature deaths of learning disabled people. This is simply absurd. And closes down any scrutiny of the systematic erasure of the lives of people who are clearly perceived to be expendable and burdensome within the NHS (and social care).
I was surprised by how people responded to the film/talk… Genuine distress, discomfort and talking about what action to take. I shouldn’t have been surprised. That low bar kicking in again. This is exactly how people should respond to hearing what happened to LB and the unfolding of events since. Something Jezza, NHS England, Monitor and the CQC have systematically tried to stifle.
I caught the ferry back with Graham. We shared stories, horror, outrage, atrocities and chuckles.
I wish there was similar openness, recognition and engagement from Jezza, CQC, Monitor and NHS England to what is now a clearly documented, evidenced and consistent happening. But what’s a few (hundred/thousand) learning disabled lives between mates?
The moon on a dick
Dear Moon,
Out of people to write to so thought I’d try the moon. Or a moon. Any moon really. Full or otherwise.
Jezza Hunt, the Secretary of State today made a speech about patient safety. He starts with ‘intelligent transparency’. Word rubbish. ‘Intelligence’ doesn’t mean anything other than fake measures of fake, plumped up fakery. LB scored below zero on ‘intelligence tests’ but beat the pants of most of us for getting stuff. For just being. But ‘intelligence’ carries weight. It’s a sought after marker of summat.
‘Intelligent transparency’ leads to action he tells us. And then goes on to explain how it doesn’t. [I know, just try to hang in there if you can…] Each NHS trust in England has been asked to self report their annual number of avoidable deaths. Yes. Self report. Mark your own homework. I think we can anticipate a chunky zero from at least one trust not 100 miles from here. And, even more absurd… the way in which each trust does this marking varies so there is no ‘national standard’. Across the, er, National Health Service.
Some may use an abacus. Some may use a mix of patient and local roadkill intelligence. Some may use quantitative or qualitative methods. Some may just count how many toenails they can ping into the bin in the corner of their office from their swivel chair. It simply doesn’t matter. It’s action. That comes from intelligent transparency.
What matters is that trusts are, at last, estimating avoidable deaths and being open about it.
There are a few Mikes involved in this new process. Richards and Durkin. A coming together of the Care Quality Commission and NHS England. Richdurk. An integral part of making the NHS the world’s largest learning organisation. [You gotta read some of this stuff for yourself, Moon. Sorry. There are sections that are so full of bullshit I can’t precis them…]
Picking up the speech from ‘A true learning culture must come from the heart … ‘ [not the tagline for a new Sunday night BBC drama but the actual words of the Secretary of State]. He talks about the suffering band of rellies who have cried out to him in frustration about the lack of accountability. Blimey. What a patronising and demeaning load of guff.
And he includes us in this shite with mention of Sloven. That painfully, awkward, 30 minute ‘meeting’ in the same (not safe) space as him allows him to nail us to his suffering family mast. We were forced to listen to him indignantly spout his human factor speak while he completely ignored our concerns that learning disabled people are being effectively erased.
[Families should be given a public health warning after experiencing the catastrophic death of a family member in an NHS setting. Alerting them to this parasitic leeching by public representatives who should actually be doing stuff. Instead of feathering their nests. And furthering their cult like causes.]
Turns out our attempts to get some sort of accountability for LB’s death is misguided. Bad mistakes can be made by good people and a ‘proper study of environment and systems in which mistakes happen’ is needed. And when patients are given an honest account of what happened alongside an apology, the impact is less litigation, lawyers and more rapid closure ‘even when there have been the most terrible tragedies’.
My arse.
The JezzRichDurkBromTit* version of human factors feeding into the new HSIB (Health Safety Investigation Branch) is simply absurd:
Affected patients or their families will need to be involved as part of the safe space protection. And while the findings of investigations will be made public, the details will not be disclosable without a court order or an overriding public interest, with courts being required to take note of the impact on safety of any disclosures they order. This legal change will help start a new era of openness in the NHS’s response to tragic mistakes: families will get the full truth faster; doctors will get support and protection to speak out; and the NHS as a whole will become much better at learning when things go wrong. What patients and families who suffer want more than anything is a guarantee that no-one else will have to re-live their agony. This new legal protection will help us promise them ‘never again’.
Er, sorry Jez, you made a bit of a leap there. Families want accountability. In the same way they want accountability when someone dies outside of the ‘safe space’ of the NHS. And how can you talk about a new era of openness in the same paragraph as court orders? Just barmy. Oh, and HSIB will only look at 30 deaths a year. And Jezza has decreed these will be in maternity services.
Intelligent transparency anyone?
Just boys and their toys.
*Hunt, Richards, Durkin, Bromily, Titcombe
A sordid little fail tale
Back in the day (2011), a staff member wrote a letter to the Sloven CEO raising concerns about various things including safety. She concluded:
The CEO bounced the letter to the Associate Director of Governance who wrote back saying that there were concerns and unfilled vacancies in the governance team including a lack of suitably qualified health and safety leadership. An interim Head of Health, Safety and Security was to be appointed for 4-6 months.
This interim head was Mike Holder. A couple of months later, Holder resigned over concerns about Sloven safety culture. He wrote a report in Feb 2012 detailing these concerns:
At present it is my professional opinion that Health and Safety is considered an adjunct to the Trust’s core business rather and integral element of it. This assumption is based on my experience with the Trust to date, the lack of resourcing applied to the management of health and safety and information governance with regards to the maintenance of statutory records.
Blimey. Warning lights a go go.
But no. By this time the Sloven headlights were on an NHS organisation, the Ridgeway Partnership, 100 miles away in Oxfordshire which included the STATT unit in which LB died. Ridgeway had some chunky land icing to tempt outside Trusts (including Calderstones) to take it over.
The story can be taken up at this point by the shuddery Verita 2 report* which found that after Sloven ‘won’ the Ridgeway in November 2012, the roadshow bolted back to Sloven towers, more senior Sloven staff resigned and the Oxfordshire services were left to fester in a slow cooker of discontent, fear, malaise and isolation from the mothership. Extracts from the Verita report state:
6.42 Difficulties arose soon after the acquisition in ensuring the availability of sufficient senior and experienced divisional managers to take forward vital post-acquisition actions. In particular to progress actions arising from the various quality assessments that had taken place before the acquisition.
6.50 A ‘business as usual’ methodology for a newly acquired service may appear appropriate if the service being acquired is mature and relatively problem-free. This was not the case in the Ridgeway services. Contact Consulting had warned of issues in local leadership; governance of serious incidents, along with particular difficulties about care issues in non-Oxfordshire services. There was also a need to begin dealing with the cultural change required of an established learning disability service joining a large mental health and community trust with a small learning disability service.
The writing on the wall. A baguette crumb trail through the NHS forest of cover up, fakery, denial and self interest. From 2011 to the present day. Evidence, evidence, evidence. Death. And evidence and death.
So where are we at? Two months after publication of the Mazars death review. Almost three years since LB was admitted to what we thought was sharp, specialist unit with a tiny number of patients and a shed load of staff… Five years after the original whistleblowing letter? Hold on to your hats, folks. We’re waiting for Monitor (NHS snooze hounds) to appoint a temporary, er, Head of Health, Safety and Security Improvement Director.
Yes. Really.
*This report really makes your skin crawl in its tortuous weaving through damning evidence to a conclusion that the Sloven board were not connected to LB’s death. The author left Verita straight after it was published.
mydaftlife 