Jury bundles, floor plans and photos

L1015667A full on few weeks. Writing witness statements for the coroner a hideous task. Reliving everything that happened. Again. He died? While having to discard what we now know [unit records/CQC inspections seared into my brain/eyelids]. So blinking painful. Then a week or so later, receiving Sloven witness statements. Piercingly painful, sometimes enraging reading.

More reading as both big reviews commissioned by NHS England around LB’s death pitched up. The broader Verita review building on their original review which found LB’s death preventable. And the Mazars review into deaths in Sloven’s mental health and learning disability provision since 2011. These have been circulated for ‘factual accuracy checking’ (just drips off my tongue these days) and won’t be published now until after LB’s inquest. Around 500 pages that must be generating agitational agitations at top Sloven towers level. As it fucking should.

Yesterday was the fourth pre-inquest review hearing at Oxford County Hall. My Life My Choice turned up in force. It makes a difference to see family/ friends/campaigners in the public gallery. Sort of counteracting the apparent ease with which LB’s life seemed to be treated in a ‘deleted/trash emptied’ way. Like so many other people. George Julian brilliantly tweeted much of what was discussed on a new dedicated campaign account; LB’s inquest.

It was just incredibly sad. I don’t know. Maybe more so than the previous three meetings (if that’s possible). Earlier hearings involved thrashing out issues around whether or not the inquest should be an Article 2 inquest with a jury. This related to LB’s human rights – something he was always so (rightly) hot on – under the European Convention on Human Rights. How the state has a duty to protect life.

Back in the day, these were important points to us and we were worried Sloven would derail them. Yesterday it was confirmed that LB’s inquest will start on October 5th for up to two weeks. Discussion turned to witnesses, jury bundles, floor plans and photos.

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Preparing for your child’s inquest

    • Is possibly one of the saddest tasks ever
    • Truth, justice and accountability fought for in a process with unimaginable physical and emotional impact
    • Enormous financial cost
    • And so far from guaranteed

Don’t ever tell me this is an inquisitorial process.

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No permission necessary

More insight into how Oxfordshire County Council (OCC) treat the people/families they exist to serve while protecting their ‘own’. We raised numerous issues about the secret review OCC commissioned once we were aware of it. A review that clearly should be binned it was so deeply flawed.

Instead, the OCC social care director wrote to us in May stating ‘the report was prepared by someone independent to the Council and the appropriate course is for him to respond to your comments’.

Pretty pompous really. Particularly given that the director failed to mention that OCC would feed into the ‘independent person’s’ response with their own comments on each of the 61 points raised. A document included in the latest subject access information. I think we can probably all agree to ditch any claim to ‘independence’ at this point. The internal claim boat long since sailed given the circulation list. So, a review that is neither independent nor internal. Mmm.

The extract below covers points 5/6 of the OCC responses to the issues I raised written for the person who produced the review. Capturing so much in few words. And carefully placed dotted black ink.

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The consultant, carefully shrouded in secrecy and protection. This is his personal information and we would need to seek his permission before sharing anything…

LB and our personal information?

No permission necessary.

[Postscript: In documenting these (what are, to us) chillingly, consistent accounts of crap practice and worse, I’m not suggesting that Sloven/OCC are monstrous providers/organisations. I suspect these practices are widespread.]

Desperate lady and the four Ds

L1015447The missing Subject Access Request (SAR) info has pitched up from Oxfordshire County Council (OCC). A glimpse into OCC tower skedaddling after dropping the secret review bomb on us in March. It still makes no sense to me. This whole secret review business. Or OCC’s apparent inability to understand how we feel. One senior person wrote in an email;

It feels we allow this desperate lady to shake us all…

Desperate ladies and faux reviews. We clearly need new words to capture these processes. An ‘independent’ consultant brought in (at what expense?) to work with a public sector body to produce… erm, what? Statements like ‘commissioned an independent consultant/organisation’ are trotted out so readily by these organisations, promising so much, so official. Strip em back and it can simply be dosh passing hands to produce pretty much nothing dressed up as something.

OCC continue to describe the review as an ‘internal review’. Rank dishonesty that no body seems prepared to challenge. No one has stepped up to say ‘You shared LB’s records without telling his family, paid someone to conduct an investigation into what happened without involving his family, and circulated a report to various organisations before his family knew the review existed? What the fuck were you thinking? 

Desperate ladies. 

We’re increasingly disturbed by the ease in which conjecture, subjective judgement and sweeping statements are made and presented as incontrovertible ‘facts’ by reviewers/public bodies. Untouchable bodies. Untouchable processes. Meanwhile, what families say or do is dismissed or discounted. Individuals derided and discredited. The four Ds. I was given the opportunity to comment on the review so we should stop bleating about it or make an official complaint. Public bodies protected by a veneer of respectability that bears little scrutiny but remains remarkably enduring.

What a old shitty business.

While OCC were posting this latest, late, info, Rich and I were in Chicago. Attending a session dedicated to LB at the Society for the Study of Social Problems annual conference*. Last year, a motion proposed by Mark Sherry was unanimously passed demonstrating SSSP support for how simply wrong what happened to LB was. Sitting in that session, on the other side of the Atlantic, I couldn’t help reflecting on how most people just get this wrongness. People in the audience who knew nothing about LB gasped when they heard what happened. And yet we’ve had over two years of crap thrown at us by public bodies. Crap that has, ironically, according to Mark Sherry in his presentation, contributed to the strength of support for the #JusticeforLB campaign.

Plenty of learning in this. If Sloven and OCC can ever get beyond their positions of prickly defensiveness and refusal to listen and reflect.

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*More on this to follow.

The public have left the building

Two local authority (LA) related stories bounced into my twitter feed yesterday morning. The first detailing a judgement in a family court hearing where the judge found an attempt by the LA to trump up a case against a father reprehensible:

To describe the social workers’ written and oral evidence as merely grudging when it comes to the care and security the father has given his children is too generous; Ms Wilkinson was certainly both grudging and defensive when giving oral evidence; their unprofessional attempts at case building are reprehensible. (47-52)

The second was about a social worker in Oldham who was wrongly dismissed after being blamed for the death of a man in his care. Here, the LA investigation was judged to be ‘seriously flawed’, setting out ‘with a mindset predisposed’ to find the social worker guilty. (The LA remain convinced they acted appropriately and with integrity despite this ruling). Shocking stuff. As Rich said ‘I don’t pay money for public bodies to fit up citizens…’

This took me back to the Oxfordshire County Council (OCC) ‘review’ (‘revised version’) and their response to my issues with the content (setting aside, momentarily, the issues around conducting a review secretly and then circulating it to various organisations before lobbing it at us with no warning). There are three overlapping areas I want to touch on here. With the odd swear or few.

‘Us’ and ‘them’
There are clearly marked differences in the framing of OCC staff actions and ours (mine) in both the review and response. It’s not hard to detect a ‘predisposed mindset’ in the way these different ‘parties’ (yes, parties) are discussed and levels of credibility/validity attached to the differing accounts of what actually happened. Any actions involving me are stripped starkly back in contrast to those of OCC staff which are typically dusted with mediating factors.

For example, the review originally reported I cancelled one meeting when I’d asked for it to be rescheduled (I write, waving a copy of the fucking email pointlessly in the direction of OCC towers). The review now states:

The records indicate that this was cancelled by the family but SR has advised that she asked for the meeting to be rescheduled which is not recorded on the file.

When OCC staff and a respite manager were a no show at a later meeting the response is; Records show that an appointment was offered and the care manager was hoping to visit with the respite care manager. There is no record that this took place or was later followed up by either party.

So I’m solely responsible for the non happening of the first meeting and jointly responsible for the second. With ‘hoping’ attributed to the actions of OCC staff. And a dismissal of the email exchange I have confirming the time and place of that second meeting.

This bias is an inevitable outcome of excluding us from the investigation. One sided investigations easily lead to a notoriety (in differing strengths/dilution) developing around the person who is the focus of the investigation.  Fleshed out humans from OCC were able to talk about what happened. Our contribution was reduced to scant mention in ill kept ‘official’ records. Written about us.

A flaky and shifting ‘evidence’ base
The flaky and shifting ‘evidence’ base underpinning both the review and response is striking. Some of the points I raised were accepted (things like removing words like ‘although’, ‘however’ or ‘providing consultation’).

Several points were dismissed. ‘Not within the terms of reference’ or ‘I couldn’t possibly comment’ type responses sprinkled here and there. Other points I made are added in, quoted verbatim and/or sandwiched between ‘pwah, not according to our records…’ type statements.  Making for a bizarrely unprofessional and odd document. [You really can’t conduct a review without involving relevant people, then invite comment after publication/circulation and try to fudge in/ignore the issues they inevitably raise. It doesn’t work].

Funnily enough, these same ‘official’ records can be teased, squeezed and transformed when it comes to interpreting OCC actions. I didn’t meet with a staff member on a particular date but the ‘signing of a support plan with SR’ noted in the records was (and remains) ‘assumed to be a meeting’. The (non) attendance of a staff member at another meeting is recast in the revised document as ‘SR has advised that the care manager did not attend this planning meeting, so it may be the case that there were two meetings that day’.

The no show I referred to earlier is presented as; ‘The reason is not confirmed by the record. SR has advised that she waited at home all day for the visit to take place, but there is no record of the services being informed of that’. [One of the many things I’ve learned over the last two years is that families have to record every happening. This, of course, is a sure fire way of being labelled even more vexatious than many parents of disabled children already are. But making decisions about what levels of crap service to shout about and what to suck up (leaving little space left to do much other than complain) is a shortsighted approach when something catastrophic happens.]

More leaps are made. Unsurprisingly always in OCC’s favour. ‘This was the impression given from the records’, ‘My view from the records and discussion was that x’s actions were satisfactory’. ‘This was my view of the relationship as reflected from the emails and my discussions with staff.’ ‘I am not making any judgment here on how plans were made, but it remains the case that discharge planning was moving forward at this point’. Ah. Yes, of course. If you’re looking through OCC tinted bins with more than a hint of eau de make it up when the evidence don’t quite fit splashed around your chops. LB was in the unit for 107 days and fuck all had actually been done to discharge him. [NB. Distinguishing action (that is stuff that is done) from talk about action is an essential exercise in evaluating provision/service].

Further evidence of bias (and that the review is really about my actions) can be seen in another meeting example. The original review stated I wasn’t present at a particular meeting with the school/OCC staff. ‘I.wasn’t.supposed.to.attend.’ I jabbed out on the keyboard that awful Sunday I spent pulling together the issue list. The amended ‘review’ now states; ‘SR was not required to be present on this occasion, the purpose of the meeting was to seek CS’s views and gather information from the school‘. Simply deleting ‘SR did not attend’ would be the obvious thing to do in a balanced, evidence based review. But of course this ain’t a balanced, evidence based review.

Power and destruction
Finally, I raised the point that LB’s death wasn’t tragic. It was preventable. A point that surely tramples over the process nonsense that the review is obsessed with. A young dude died. He died. Aged 18. He shouldn’t have. In circumstances in which state bodies, directly and indirectly responsible for keeping him safe from harm, clearly failed.

Nah. Instead of simply removing mention of ‘tragic’ from this ‘review’ (a fairly insubstantial amendment given that ‘second’ meetings on the same day were being trumped up) the (cruel and completely contradictory) response was  ‘It is not part of my terms of reference to comment on the events surrounding CS’s death’. Four mentions of LB’s ‘tragic’ death remain in the revised ‘review.’

One of the terms of reference of this ‘review’ (lifted from the broader Verita review that it was always was designed to feed into, despite the re-storying of events by OCC lawyers) was to explore ‘the contact between adult social care, CS’s family and school’. Buckets galore needed to catch the dripping irony here. We can only really draw the conclusion that this review was never about reviewing, learning or trying to improve any aspect of OCC provision. Instead, like the family court case and Oldham social worker story, it was an attempt to discredit while trying to preserve the ‘self righteousness’ of the local authority. Because they can. Regardless of the impact their nasty actions have on the people they pretend to serve.

Surely it’s time for a rigorous and critical overhaul of these pernicious practices that suggest the public in ‘public’ sector have long since left the building?

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The leader of the pack

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I met the Leader of Oxfordshire County Council (OCC) this afternoon. I asked for a meeting after the latest crap OCC action; due to an ‘oversight’ they missed the deadline on my subject access request before they found it (after I chased it up). I wanted to try and explain to him what it was like to experience such relentless crap after LB died [he died?] in provision they commissioned.

He listened. Someone busily typed everything said. He said he didn’t know about some of the points I raised. He’s going to look into why we weren’t informed that OCC were conducting an ‘independent review’ into what happened to LB. Why this supposedly internal review was circulated to various organisations (including NHS England, Southern Health NHS Foundation Trust and Verita) over two weeks before we received a copy. Why we were emailed a copy of this [foul] document without warning at 9am one Monday morning. Why, in the two years since LB died, there is nothing OCC have done that I can call ‘good’.

Why, after everything that’s happened since LB’s death, including producing and circulating a report that should never have seen the light of day, OCC staff seem incapable of thinking; Jeez, their child died in care we commissioned??…/We cocked up with that review. For goodness sake, let’s hurry this FOI through and not wait till the final day before responding…/Blimey. We’ve now ‘lost’ their subject access request??? So and so, make it a priority for the next few days would you? The least we can do is respond in a couple of weeks rather than a month’… And so on.

The content of the review (original and “revised”) is with our solicitor. The meeting today was about process. So that was that. In and out in under 15 minutes. I don’t know if he got any understanding of how much additional distress the public body he leads has caused us. We’ll just have to wait for his response.

Dead times and fuzzy felt versions

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

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

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

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

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

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

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Sleight of hand mastery

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Went to a do yesterday that involved Rajan, the Magic Man. He’s a sleight of hand master. Funny old credentials but he was pretty impressive and entertaining. One of only 200 members of the inner magic circle apparently. A group that meet each Monday somewhere in Euston to share stuff they can only talk about with each other. Bit like academics but in bigger numbers.

I was struck by how Rajan’s performance contrasted with how Oxfordshire County Council (OCC) and Southern NHS Health Foundation Trust (Sloven) have behaved over the past two years in relation to what happened to LB. SlovOCC have consistently tried to distract attention from what happened. Using various sneaky practices including non-disclosure of documents. Categorising something as nothing, nothing as something. And smear tactics… Rajan used a combination of skill, experience, humour and charm. And a fair few cheesy jokes to disarm, distract, entertain and puzzle. SlovOCC have no finesse with their ‘trickery’. Instead they seem to draw on a bullying and/or incompetence combo.

This morning another red flagged email arrived at 9am from OCC. My subject access request from May had been, er, ignored due to an “oversight” and the deadline (today) had expired. It will now take another month. Eh? I had to hand in my driving licence and a £10.00 cheque back  in May. The driving licence was sent back to me in the post and start date for the request logged as June 2nd. How the hell could it then go missing?

The Director of Social Care has launched an investigation apparently. Almost hilarious as always, though of course it ain’t. He’s informed us of this investigation. Unlike the original investigation that sparked the subject access request. I’m baffled as to how this latest sight of hand example hasn’t pushed a few warning bells that maybe crapola practices are alive and kicking within SlovOCC. But nothing seems to do that.

"And bung a copy to the commissioners, NHS England, Sloven and the top brass of OCC..  The more the merrier in the circs. Cheers."

“And bung a copy to the commissioners, NHS England, Sloven and the top brass of OCC.. The more the merrier in the circs. Cheers.”

Grated finger tips and sick sifting

L1015039Forced back to the cardboard boxes of records/letters/reports stacked up in what was going to be LB’s bedroom this evening. I have to provide evidence to support my witness statement for a disciplinary council investigation. I gave the statement on Monday. Another annual leave day spent doing stuff so awful I’d rather grate my finger tips, sprinkle them with a mix of lemon juice and chilli, and sift through a vat of day old vomit separating out the chunks. But hey ho.

The road to accountability is a completely unnecessary and inhumane process when public bodies are involved.

The interview was thorough and searching. Deeply, deeply saddening and distressing. Re-living the horror of what happened [he died…???] but also reflecting on how the whole happening was simply a disaster waiting to happen. So many big and small craphole pieces in place.

Tonight the evidence. Grated finger tips and sick sifting again appealed but ain’t an option. Sadly. If we want any accountability for what happened, the catastrophic unfolding of something that turned out to be so bleedingly obvious has to be revisited. And then revisited. In heartbreaking and harrowing detail that will, eventually, become public.

I’m halfway through the task. After the way in which OCC responded to the ‘factual inaccuracies’ I raised [she said but we don’t believe her because it ain’t in our records…] I’ve developed a new system which involves screen grabbing relevant sections as well as referencing them. Creating a form of collage artwork. A word document of colour, shape and heartbreaking content. My word is clearly meaningless without ‘real time’ evidence. Southern Health NHS Foundation Trust* and OCC can record whatever they like, or choose not too, and it counts as ‘fact’. We have to show original workings where they exist. Deeply unfair and discriminatory but being discredited and discounted is now a familiar experience.

At least I can record this toxic process. With space here and on other online platforms, and the writing tools to make it visible. The attempts to discredit we’ve experienced so far are pretty shocking but LB and thousands of dudes like him are simply disregarded. No space, no platform, any tools to communicate ignored/crushed… lives extinguished or ruined through neglect, disregard and worse. Discounted in life and death. A sustained form of blatantly ignored eugenics. Acted out in full view.

Vat of vomit anyone?

*I’m reluctantly ditching ‘Sloven’ on this blog because they are so fucking focused on their reputation proper name checking is probably sensible.  Sigh. I had no idea this would be so blinking hard.

Bastards. 

 

FOI disclosure day

L1015020-2FOI disclosure day. Though it wasn’t really. Lengthy explanation from OCC about how exemptions under Section 40 and Section 36 were upheld, leaving me with a batchlet of process emails around the secret review. Ho hum.

The review was commissioned in July 2014 “in preparation for the independent investigation currently being commissioned so we can be better informed and contribute effectively.” Ah. This completely contradicts the letter from OCC legal services a month or so ago in which they argue the review was an internal jobby to look at OCC processes not a further attempt to look at the events leading up to LB’s death; “The original purpose of the review was caught up in the wider investigation […] With the announcement of an independent review it seemed sensible that this internal review stand as the Council’s input into the Verita Independent review”.

Mmm. Tasty, tasty behaviour from a public body that exists to provide services for, er, us. Nothing like transparency and candour down County Hall way.

Fast forward to this March and there were a flurry of emails between 13-15 March distributing the internal review to Sloven, Oxfordshire Clinical Commissioning Group, NHS England and the executive of OCC. Verita already had a copy.

I was sent a copy on March 30th. Two weeks later. First thing Monday morning. Without warning.

Wow.

All those [external] people read that shitty, damning ‘internal’ document before we even knew it existed… 

Wow.