Thanks (it was his tongue btw), Sara

We went on holiday last week. Starting from the battered position of getting the ‘updated’ version of the OCC ree (I refuse to call this a report as it bears no resemblance to anything I’d call a report) at 5pm, the day before we left. The issue of records cropped up again when we were away. Relating to whether LB bit his tongue or his lip in the unit.

This is a nonsensical question that underlines the importance of families documenting interactions with health and social care professionals meticulously. And even then, how their records are not really records.

In a complete panic, back in May 2013, I emailed the STATT manager to say that LB had had a seizure and accidentally typed lip instead of tongue. This typo has become part of the official record and has seeped into both the original Verita report (extract below) and the documents for the coroner.

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It was a typo. One I realised and corrected the following morning, first thing, in a follow up email to the manager who’d replied to say he had contacted the consultant.

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This email didn’t make it to the ‘official record’.

The lip/tongue question remains an issue. A confounder in getting accountability for LB’s death. [Yes, he died. He drowned. You fuckers].

This raises so many questions about what families can do to make sure their records, their version of events, are treated with respect and fully engaged with. To avoid being dismissed, misrepresented or ignored.

I typed lip instead of tongue that evening because I was so intensely distressed by the thought LB had an unwitnessed (unwitnessed??) seizure in that place. It was a simple typo.

Back from holiday. Sitting at the computer on a sunny Sunday afternoon to gather more evidence that fell outside the official Sloven/OCC record, I can’t help asking;

Really? Are you really making us go through these hoops?

Why?

Records and the internet web log

In a superlative moment of classiness, the OCC Director of Social Care sent me a red flagged email at 5pm this evening with a revised version of his shoddy little review. And responses to my concerns.

Yep. 5pm on a Friday evening. I hadn’t had a bad day up to then really. I had an emergency appointment at the dentist because my tooth cracked the other day. No big deal in the toxic world of trying to get accountability from public bodies. I then worked at home reading a thesis and catching up on other tasks. Halfway through reviewing a book chapter (deadline today/ironically about social media use) the email pinged in. End of that review. Instead the typical and now familiar deeply intense rage, frustration, bewilderment and distress.

LB died. He’s dead.

Why the fuck are we dealing with shite still?

[Brief background to the review; OCC commissioned an external consultant without telling us. They sent the review to Verita. Verita said we should see it. OCC emailed it without warning back in March. Under duress I identified the inaccuracies.]

The only good thing I can say about this latest documentation is that a potential PhD student now has more ‘riches’ to pore through and analyse in trying to understand the workings of public bodies under challenge.

The revisions to the original report? Extraordinary.

A few examples…; SR says x, y or z but “there is no record on file to this effect”. “There is no file record of that contact. SR advises that it took place.” “The Care Manager arranged a further visit on 31st August to meet CS, but 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.” He even states there must have been two meetings on one day because I said the care manager wasn’t present and the record says she was.

What is actually happening here? Why do ‘records’ trump what happened? Apparently there is no ‘record’ that I waited in all day for a visit from the care manager who was a no show. Parents/families now responsible for making sure social services keep accurate records…

What makes these partial, half arsed and biased ‘records’ the ‘truth’?  I asked OCC to look at the different interpretations of one afternoon where the OCC ‘recorded’ version was sanitised off the planet. My blog presented an alternative description of an afternoon etched in my brain.

Completely misunderstanding my point, the response today was;

SR has recorded a different perspective on her internet web log. Having reflected on the implications of this comment, I have added a recommendation to my report that OCC provide guidelines to staff, service users and the public that postings on web based social media are not part of the case management or complaints and comments procedures. I do not consider it appropriate to comment on a social media posting.

There is a clear issue here that public bodies don’t get social media and see it as something threatening. Which it isn’t and shouldn’t be. [This was in evidence earlier today. Sloven while hosting a shindig for their learning disability/mental health staff started blocking campaigners on twitter when challenged about inaccuracies (or simply asked questions)].

I’m not claiming my version of what happened that afternoon is more ‘truthful’ or that local authorities/NHS Trusts should be looking for clues about their patient care on blogs or social media. I’m saying that ‘official records’ are not infallible. They are created by people. Like this blog is. Or any other account of something. It’s ludicrous, short sighted and problematic to only accept what is written in a particular space, by a particular ‘professional’, as ‘truth’. As the revisions of this craphole report demonstrate.

I suspect part of the (sustained/tooth shattering) battering we are getting from Sloven and OCC is due to our use of social media. The ‘records’ are under threat. Emails/tweets/posts contradict and challenge official versions. We’re shining an unwelcome light on stuff that has probably gone on in darkness for years. And doing things the ‘wrong way’.

You can’t shout down, bully, deny or try to ignore what is perfectly legitimate challenge to a system that is steeped in wrongness. A wrongness recognised by those beyond LB’s family or friends. To try to do so is to show contempt for democratic processes. For basic human rights.

The only way there will be any resolution – not for us because that clearly ain’t going to happen – is for NHS Trusts, local authorities, regulators, the Department of Health, government, etc, to embrace the use of social media. To engage with patients, people, constituents and use these interactions as a resource. Something valuable and insightful, not something to be feared. Something to build on, work together and thrash through challenges, obstacles, difficulties…

As much as OCC, Sloven and others may resist or dislike it, the future is the internet web log.

The Tale of Laughing Boy

 

This year #107days ended with the launch of The Tale of Laughing Boy produced by My Life My Choice and Oxford Digital Media with funding from Oxford City Council. Tommy, Tyrone and Shane from MLMC worked with Oxford Digital Media (who gave their time – blooming shedloads of it – for free). Saba Salman has written a review of the film here. Since the online launch there has been a remarkable response to the film.

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It’s being shared widely as it should be by a range of people and organisations; CQC, providers, commissioners, charities and other third sector organisations and people. Even Mencap.

A screening was held last Thursday evening at the Old Fire Station in Oxford to a full house. Including our MP, Andrew Smith, BBC Oxford news (tv and radio) and the Oxford Mail. Andrew Smith, love him, was all over Sloven’s potential ‘land grab‘. Absent were representatives from Oxford City Council, Oxfordshire County Council, Oxford Healthwatch and the Oxford Clinical Commissioning Group. Typically staunch supporters of the work of My Life My Choice.

I was chatting on Skype with a colleague yesterday. He’s arranging a screening of the film at his university over a lunchtime. He was shocked when I mentioned the Oxon screening boycott. He couldn’t understand how people (ordinary, decent people) can seemingly so easily ditch their humanity and act as state agents.

I gave him the briefest outline of the early, and as yet unpublished, findings from the Mazars death review.

He visibly froze.

Kerching and Katrina

I am absolutely delighted that we’re going to be forming a partnership between Southern Health and Ridgeway. I believe our combined effort is really going to provide superb world class services for people with a learning disability across the whole of the area we cover.

Katrina Percy, Sloven CEO, March 2012 

What Katrina Percy forgot to add to this ‘welcome to my empire’ speech was… and if we cock it up, we’ll flog the Slade House site and other Oxfordshire land for a massive profit and buggar off back down south.

Yep. For some reason [piss up/brewery/Oxfordshire County Council?] there was no penalty type clause in the contract awarding the tender to Sloven. Gifting them land and property worth millions. Rumour is the Slade House site will be used to develop student accommodation.

Astonishing.

Andrew Smith, our bloody brilliant MP, and our equally fab local BBC Oxford news team are all over this. As Andrew Smith said in an interview last week; “This is unacceptable to the public, unacceptable to LB’s family and unacceptable to me. I will fight it.” Good.

Sloven – any thought of providing ‘superb world class services’ for learning disabled people long gone – issued a statement saying ‘We are carefully considering our options. No decision has been made’. ££££££Kerching££££££££. The Department of Health issued a statement saying something like “er, none of our business, piss off and sort out your mess locally.” A teensy bit shortsighted really.

Hmmm.

If Sloven think they are going to profit from LB’s death and parasite this money out of the county, their reputation management indicators will be flashing London bus red for some time. As simple as. It’s just wrong.

Of course they may do the right thing without a fight. That would be priceless.

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LB’s buses at the end of yesterday

 

#107days again… Er, really?

Naive beyond naivety. We were pitched into a completely devastating, toxic, harrowing and obscene space/journey on July 4th 2013 without warning. In an instant. From pretty much nought to a billion with the opening (as kind and sensitive as you can possibly be in the circumstances) words of an A&E consultant. On that baking, baking hot July morning. The snuffing out of a young life and unleashing of horror, devastation, disbelief and pain that defies description.

From thinking about the prom on the bus to work to autopsies, coffins and cremation.

We had no idea then that two years later we’d be locked in a foul, stench ridden, rotten corner with both Sloven and Oxfordshire County Council (OCC) doing their best to extricate themselves from any responsibility for what happened. Sloven by withholding documents, pulling dirty stunts like arguing drowning is a natural way to die, sending bullying letters and consistent obstruction. OCC by conducting a secret and completely biased (non) investigation into what happened. We had no idea that the actions of both (public) bodies (and others who remain shadowy in the background through their non action) would actively add to and increase the intensity of pain and agony.

Bastards.

Naively and even despite the above, we thought that #107days this year (we never expected or wanted to have to revisit the almost spontaneous explosion of goodwill, celebration, solidarity, commitment, awesomeness and magic that unfolded last year) would incorporate the outcome of various ongoing reviews; General Medical Council, Verita and Mazars.

A nonsensical expectation.

Instead, we have no outcomes and an additional ‘thing’ to add to the wait list; the revised OCC ‘investigation’. [This is a ‘might as well wait for the fucking cows to come home’ item supposed to be finished in June.]

So what the fuck are we actually waiting for? And why?

What’s the big mystery?

LB was a fit and healthy young dude with a diagnosis of epilepsy. The STATT unit he was in was clearly crap. It was taken over by a “Trust” based 100 miles away 8 months before his death. OCC and the Oxfordshire Clinical Commissioning Group were apparently happy to shell out £3500 a week for his non care indefinitely. An independent report published 16 months ago established his death was preventable. The unit has since shut and a series of failed CQC inspections across the county have highlighted the maggoty state of provision in Sloven’s “Northern patch”.

As a vague aside, no one seems to be (publicly) going near the question of what happens to the prime chunk of land that the STATT unit was on. If it’s sold, who gets the readies? If the dosh goes to Sloven and into their southern based coffers where does that leave people/kids in Oxfordshire who need support? Ho hum. Awkward questions that won’t disappear but a brief glance at Sloven’s latest Board papers for the meeting tomorrow suggest that property sales form part of their ‘business’.

property disposal

Setting aside the monetary considerations which, along with reputation, seem to be the only thing Sloven and OCC respond to, I keep coming back to the question; what the fuck are we waiting for?

Dan Goodley and Rebecca Lawthom raised this question as they took the #JusticeforLB flag back to Glastonbury for a second year;

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Without answers, they repeated their remarkable commitment to sharing what happened to LB with Glastonbury revellers. They managed to share LB’s story, keep the flag flying high with no flagpole breakages and hook up with Rosie and Jack. Love em.

Legendary work.

Keeping the hope flickers well and truly fanned. With joyousness, humour, love and dedication. Maybe someone/organisation with any power/influence will step up too. And act. As we continually say, it ain’t rocket science.

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Of moths, pride and Paloma Faith

We’ve got a moth infestation. To the extent that I now wander round obsessively fixated on looking for tiny thin dark/black marks on walls, especially near door frames or down the sides of furniture. And then crush em. We’re going to have to repaint pretty much everywhere. Or extend moth cull to a level in which it resembles some new decorating technique; “papery flakery. In dull grey to blackish.”

Rosie was my fellow moth destroyer. We had some hilarious days a few weeks ago. Systematically searching them out with a spongy baseball bat. But Rosie’s left home now. Gone to moth free pastures [I hope]. I wonder if LB might have taken up the cause. I don’t know. He was a dedicated and committed litter hound and did a cracking number (with constant encouragement/involvement) on weeds in the front garden. I’m not sure if fleeting, flitsy/flaky insects would have rocked his boat.

Rich and I went to London today. Leaving the moths free to do what they do in a day. [Bastards]. We watched a good chunk of London Pride. Loving the brilliance, joy and creativity. A bit bored/frustrated by the (often lengthy) patches of corporate overkill. London buses featured consistently which was ace, though we were staggered by the ‘wheel stewards’. Every bus/vehicle in the parade/procession had dedicated wheel stewards. For each wheel. On a route fenced off from the public and organised to the hilt. L1014426 L1014283 L1014471-2 L1014306 Wheel stewards? LB was in a specialist NHS unit with a ratio of four staff to five patients (plus the wider learning disability specialist team) 24 hours a day. At a cost of £3,500 per week. And he died?

With no accountability, still.

Wow.

How the fuck does that work?

In more positive news, the #JusticeforLB flag has been flying at Glastonbury. Paloma Faith’s set tonight. Action not bullshit. As always.CIhnOmNWsAAl5sG.jpg-large

Running out of titles

Wondering what we can do really. In a bit of a despondent way. The update I posted this week illustrates how public bodies can simply delay. With seemingly unlimited doses of delay powder. A sort of modern wday ‘smoking out’ policy. Earlier today I found out that Oxfordshire County Council (OCC) are delaying their response to my Freedom of Information request about their ‘investigation’ because a Public Interest Test is being carried out.

I don’t know what this means and the FOI dept at OCC were unable to enlighten me beyond the fact it will involve a delay of up to 20 working days. Another month potentially. It would be bloody brilliant if they could soup it up a bit and complete this test (test?) in days rather than weeks but given the weighty blanket of on going delay, I’m not going to anticipate anything. July 22 is the new date.

I don’t have a bar anymore. That was crushed somewhere along the way. When we realised that these public bodies can do whatever they want to devastated parents/families and no one will stop them. I now expect the worse and, so far, that has been spot on.

Another parent, Nic, whose child died a few months before LB posted this on my blog yesterday.

nic

Nic regularly posted comments in support, in shared grief, rage and despair at the impossibility of trying to get accountability, justice or anything to make sense of the apparently casual and brutal chucking aside of much loved children’s lives. One of the first comments she made included the request ‘More photos please’.

So here’s another pic from that holiday in 2010. When we were walking a completely different path. And, on a more cheery note, the #JusticeforLB flag is returning to Glastonbury this year with the legendary Lawthom Goodley crew. Bloody good timing in the circumstances.

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Updating the update. Of the update.

We’re fast approaching the second anniversary (hate, hate, hate using this word for this) of LB’s death [Howl]. 16 months after an independent report was published stating LB’s death was preventable.

Here’s an update of the latest update (March 2015). As always (and clearly forever) in no particular order:

1. The inquest: A fourth pre-inquest review meeting is being held at 2pm, September 9th, Oxford County Hall. All welcome. It’s a very public affair. The full inquest is scheduled to start on October 5th. Sloven have “unreservedly apologised” for LB’s death (as the curious Tory template (repeatedly) reminds us) but this hasn’t stopped them pulling all sorts of tricks along the pre-inquest journey. Including a bit of desperate back pedalling from that unreserved apology to argue that drowning is a natural cause of death.

2. Disciplinary councils: We referred one clinician to the GMC in May 2014. This investigation continues, slowed by some additional stuff that has cropped up. Apparently Sloven disciplinary processes led to an undisclosed number of undisclosed staff members referred to the (undisclosed) NMC. Who knows?

3. Police: The investigation continues. Staff interviews are underway.

4. Health and Safety Executive: The investigation (apparently) continues in line with 3. above.

5. Oxfordshire County Council: We’ve received legal advice on the “independent” report OCC commissioned into LB’s death without our knowledge. It seems that it is defamatory so there is ongoing legal action relating to this. OCC are sticking to the ‘We did nothing wrong’ line. Chilling really. The consultant is apparently working through the list comments/issues I was forced to identify a few weeks ago to revise the original report. I still say chuck it in the nearest bin but what power do we have? [I’m dreading receiving another version given the methodological approach].

6. Verita 2: This second, broader investigation into what happened to LB remains ongoing.

Mazars death review: The review into deaths in Sloven learning disability and mental health provision since 2011 has been extended by NHS England to allow additional work to be done. Given the announcement this week of a national review into the premature deaths of learning disabled people, this extended work makes sense.

So. That’s it really. When we sadly started #107days again this year, we naively thought some of these investigations would be completed during this time. It’s now clear that this ain’t going to happen.

It’s all a pile of cock rot really.

I’ll leave you with this pic from a holiday we had in July 2010. When life still had colour, beauty and the extraordinary (in a good way).

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Space, place and managing snow

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Just under two days in Tromso this week. Midnight sun land. Well not much sun but spectacular sights. And so much daylight. Which was strangely mesmerising. I learned a lot from colleagues about life in northern Norway. Including snow management techniques. The importance of building capacity to allow space for snow. Built on an understanding that the snow ain’t going anywhere fast and everyday life needs to continue.

Sloven and OCC don’t seem to understand the need for this space when it comes to grief and families. Instead they just shovel, or try to. A process that’s destructive, counter-productive and hugely damaging.

There are policies that try to create space for grief within the NHS. The sensible and straightforward Being Open framework, for example. But policies are just words if they’re ignored. As meaningless as the non-apologies identified by Ally, LB’s cousin, in her recent dissertation on Sloven communications.

There are obvious differences between heavy and sustained snowfall and grief. But I find it hard to understand how the grief stuff, something so agonisingly accessible – most people can, if they can bear to go there, have the beginnings of imagining what such grief feels like – is dismissed or ignored. Intensely human, deeply emotional and gut wrenchingly awful experience is trampled over, ignored or worse, by the public bodies responsible.

How do we get it so blinking wrong?

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Extreme spaces and a touch of Marge Simpson

Another full on week. Thursday morning, the Private Members’ Bill ballot. Thursday afternoon, there was a meeting of the Expert Reference Group for the ongoing Mazars death review. This review, commissioned by the Real David Nicholson before his retirement from NHS England, was viewed as a tick box exercise by some. Sigh.

Friday morning we had an intense and, in places, deeply sad meeting in London talking through legal stuff. There was a bit of swearing, a box of tissues and a shedload of sensitivity.

Tonight we went for some nosh to celebrate Rosie moving to Bristol before starting her first full time job. On the way home, she was chuckling about the time I dipped back into the St Giles fair on my way back from a meeting a few years ago to have another cheeky go on the coin pushing machine. Apparently Tom texted me asking where I was and what was for tea, sending me into a spin about being a rubbish mother.

“You did what?” said Rich. “I didn’t know about that! Marge Simpson is a secret gambler…”

Setting aside what OCC would have made of this story in their craphole review, I just want to say; Good on yer, Rosie. It’s a fab job, brilliant opportunity and you bloody deserve it.

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