Collusion, delusion and constructing myths

Posted on April 9, 2015 by sarasiobhan

Over a week now since the Oxfordshire County Council ‘independent review’ into LB’s death hit my inbox. Without warning. Since the awkward, slippery discussion with the Deputy Director of social care silence has again again descended on County Towers.

There’s a dog eared copy of the review by my computer. Well it’s not really a review. More 21 pages of typed words that have made me feel quite ill. A second state body acting in an explicitly self serving and systemically toxic way. Apparent sole concern; reputation safeguarding. Negating our experience and creating myths around what happened. OCC present LB’s death as largely due to a series of flaky decisions/non action by me.

The level of fabrication about what happened, is chilling. I’ve got an ‘intentional? No surely not… must be incompetence…’ loop in my head trying to make sense of this review. Then the fact LB died crashes in. [He died?] Followed by ‘these are public bodies… NHS? County Council?’ The world spins. There is no sense.

I’m haunted by the power that’s become so blinking visible through Sloven and OCC actions (and the equivalent non action by other publicly funded bodies that you’d think would intervene).

We live in an evidence based age and this OCC review has the stamp of ‘authority’ from, er, OCC. Independent Case Review: CS (dob. 17.11.94-d. 04.07.13) is a document that can be shared with all sorts of people/organisations across time. It’s already shared with Verita and apparently will be heading the coroner’s way. I’ve been told publicly by the coroner to stick to facts not opinion at the inquest. There is no question that any ‘official documentation’ given to the coroner might be a bit flaky. Publicly funded bodies have teflon coating and headed notepaper that guarantee ‘truth’ and legitimacy.

I haven’t gone through the review, line by line for factual inaccuracies. It’s too depressing, distressing and I work full time. But dipping in, randomly, the howlingly biased framing makes my brain weep. I’m portrayed as the never never; never doing this that and the other. OCC staff are the always and forevers. Staff member X returned from annual leave and “started work to bring professionals together to look at how CS could return to life in the community” (April 10th). Cue the Dambusters theme.

There’s no sniff of any scrutiny of the findings. Or basic reflection about them. Not by anyone; the ‘independent’ reviewer, the shiny new Deputy Director (who allegedly added an additional layer of quality assurance), other readers or the Director who signed it off and then pinged it, out of the blue, into my inbox.

No one seemed to stop and think;

‘Er, erm. Hang on a minute, Quite a few things don’t stack up here. I mean was his mum really ignoring all advice in an obvious crisis situation as this review suggests? Why would she? I don’t understand. Didn’t this set alarm bells ringing for staff? There seem to be a lot of questions for me. For instance why would it take X three months from April 10th to organise a meeting to bring professionals together? That’s a long time for a young laddy to be locked away. Should he have really been in there? I mean, if nothing else, this provision cost £3500 per week. And did we have permission to share his health and social care records without his family’s permission? Why weren’t his family involved?’

Nope. No one spoke up.

And no one seems to have asked the obvious question: ‘A young dude died here. We all know he should be alive. What the fuck went wrong?’

Farcical inaccuracies

Posted on April 2, 2015 by sarasiobhan

It turns out that now OCC have published this report without our knowledge, and shared it with at least one external organisation, I’m expected to go through all 21 pages and highlight the factual inaccuracies contained within it. [Warning: the report apparently took 8 months to publish because the new Deputy Director of Social Care wanted it to be as robust as possible and added quality assurance. Hard hat time for those who need services in Oxon.]

Can you imagine wading through old emails from a time when your son was still alive [he died?] to correct a report you didn’t know was being written? In your own time? Serious brain melt. How much was matey boy paid to write this rubbish I wonder.

Deep breath.

Here’s just one example around respite. (I don’t think OCC can seriously expect me to keep this confidential in the circumstances). The report is so biased it’s almost comedic. Definitive statements about my ‘failings’ (without evidence) throughout but light touch on OCC on any dodgy ground. The ‘it appears from the records’ consistently falls on the side of the council with no consideration the records might be a little bit partial.

Not quite what happened. As the email exchange below demonstrates. I waited in all day for the three of them to turn up. The care manager eventually called to say she wouldn’t be able to come round after all. She’d run out of time. Bit of a shocker really in the circumstances. During that call she described the respite centre as a building with a snooker table and made it a completely unappealing option.

More mysterious reporting about respite here:

In contrast, from my blog, 18 March 2013:

And from March 19th…

How can the records possibly show “I did not take up the offer”? It’s just made up rubbish leading to one of the cracking conclusions:

Ah. It was all my fault. Trial by a ridiculous, crap and biased report. I’ll leave you with one more nonsensical snippet while I crawl off and wonder what the hell is going on.

Postscript: It would not be possible to rebut a lot of this stuff without having documented the experience on the pages of this blog. So important to keep detailed notes. And so blinking wrong.

Oxon Classy Council

Posted on March 30, 2015 by sarasiobhan

Here’s the gig. I get to work this morning and receive an email from the Director of Adult Services, Oxfordshire County Council (OCC). It turns out they commissioned an independent review into LB’s death last year. And, for some reason, he’s decided to send it to us today.

Eh?

The email ends: As you know this report was undertaken and will be shared as part of a confidential investigation. I would ask you to respect the confidential status of the report. If you need to share the contents to third parties (other than your immediate family) then you should seek our written confirmation.

Eh?

It turns out they handed over LB’s health and social care records, without our knowledge, to a social care consultant.

He then interviewed various people, including LB’s teacher, before writing a report so riddled with inaccuracies and bias (the usual we did great, mum is unreliable/flaky rubbish) you might as well chuck it in the nearest skip. But then of course they won’t. It has already been shared with Verita and it will be given to the coroner among other people.

I can’t describe really what it’s like to find out that an independent review has been conducted into your dead son’s care without you knowing. Surely that’s the baseline of respect? That it details things like your kids’ dates of birth, and includes stuff like “SR cancelled the meeting”, when I didn’t, or “SR advised to contact the respite centre at Saxon Way. The records show that SR did not take up the offer”, when I did, but omits things like mentioning that the staff member who suddenly upped her game on the communication front did so because she was under supervision after we’d complained about the service.

Typical OCC slippery shite.

I spoke to the Deputy Director this afternoon who first denied sharing records despite the report stating: “Methodology: I have reviewed all the records held by the local authority for both Children’s and Adult’s Services…I have also reviewed copies of the Health Service RIO notes from 11 Jan to 19 March 2013 for the psychology and psychiatry service…””) and then suggested the reviewer was internal at that point because they were paying him. Astonishing. Howl inducing. How can people say and do such hideous things? He died.

By the way, OCC (and Sloven), if your strategy is to grind us down until we either slope off in despair or are destroyed, this was a cracking move.

Are you allowed to conduct an independent review of “the support that had been offered to LB and his family” without informing us?

Are you allowed to share LB’s notes with an external person without our permission?

What happens now an inaccurate report is being circulated?

A commissioning tale

Posted on March 24, 2015 by sarasiobhan

I re-read the FOI docs from Oxon County Council (OCC) at the weekend. What they demonstrate is so depressing I thought I’d write a bit about them with the hope that other local authorities/commissioners might look at their own responses (and their staff responses) to learning disability type issues in their work and think differently.

The unit LB was in (STATT) was jointly commissioned by OCC and the Oxon Clinical Commissioning Group. OCC were in charge of reviewing the quality at the unit. What still astonishes me is that, after LB died, there was no immediate flocking to STATT to check the quality of the provision. In fact, an updated quality control review conducted in May 2013 was being circulated on July 22, just over two weeks after LB died:

Clearly no concerns whatsoever about the quality of provision at the unit. And LB?

Who?

At this stage of course, Sloven had decided he’d died of, er, natural causes, so everyone could carry on with business as usual. Learning disability trumping every other part of a quirky, gentle, humorous, young dude. To such an extent that no one in Sloven, OCC or OCCG seemed to say “Eh? 18 years old? In the bath? Something is clearly wrong here.”

Rich and I have often thought how, if LB hadn’t died, the provision at STATT could have continued indefinitely but really it wasn’t his death that put a stop to it. It was the CQC pitching up two months later. They failed the unit on everything and published an inspection report that makes the back of my hands prickle, it is so damning. It documented a place that had long lost any whiff of care. A space empty of any meaningful interaction, any therapeutic engagement, dirty, unsafe, empty and toxic.

A shocking, shameful uncovering.

So how did OCC towers respond to this? They’d allowed a group of people to ‘live’ in such a terrible environment even after a young person died? At a cost of £3500 per week each. (Around £112,000 in the time between LB dying and the inspectors arriving). The response seems to be a mix of fear, defensiveness and bravado. And statements that reveal the inhumanity with which learning disabled people are both treated and perceived.

Again, an astonishing response. On so many levels. But no one challenged it. Despite the blinking, bleeding obvious awfulness of it…

Perhaps an essential ingredient for culture change is a more critical engagement with how applicants perceive learning disabled people at a recruitment/promotion level. Involving learning disabled people and families in the process. Having the wrong people in the wrong jobs clearly allows crap ‘care’ to continue. And, at worst, actively contributes to it.

OCC, ‘the BLOG’ and power

Posted on February 8, 2015 by sarasiobhan

Bit of a ragbag ramble this evening. Including some tips for social care bods. I had a bit of a sort out today and a few choice docs from Oxfordshire County Council (OCC) popped up. Now OCC are doing a seriously cracking job at keeping their heads down so far, despite clearly being concerned that their involvement in what happened might come under the spotlight at some point. A lot of their exchanges are fuelled by this blog (or “the BLOG” as they call it).

The Director for Social and Community Services didn’t write to us after LB died. Or after the CQC found appalling failings at STATT in a report published in November 2013. Or after the Verita report found LB’s death preventable in February 2014. Nope. He wrote on April 2nd (saying sorry ‘about the death of’ LB) in response to comments I’d written about OCC. [Tip 1. Write to families straight away if someone dies an unexpected death in provision you commission. Not just when you feel publicly threatened]. OCC also declined to attend the pre-inquest review meeting recently (‘nothing to do with us guv’) even though the coroner’s court is in their building [Tip 2. Send someone to inquest meetings when the person’s death was preventable].

There’s a long list of things we think OCC did wrong. Not least giving STATT a green light in their quality review at the end of 2012. A month or so before a Winterbourne View JIP team of three (including an Oxon commissioner) visited and thought the place was a shithole. The commissioner put in a decorating chit (and now says no crap other than shabby detected) while the other two assumed the commissioner would do something about the place. Other than a lick of paint.

OCC self preservation workings are very apparent in docs disclosed to us. For example, in response to a request from the Clinical Commissioning Group (CCG) to offer us a meeting (as I seemed to be softening on my blog. Yes, really), a senior OCC official’s response was What if she brings her solicitor along with her? I think we need to do a bit more thinking before offering a meeting out of the blue. S/he then decides if the meeting goes ahead an OCC person should attend too in order to know what the CCG geezer is saying. Wow. [Tip 4. Second guessing responses and back watching suggests a right old toxic culture which needs urgent attention/disinfectant].

This blog seems to have evened out (only slightly mind) the power differential between families and health/social care organisations. It features in so many exchanges in disclosed documents often with links to posts. Slovens solicitors wrote a pretty steaming letter to us a couple of weeks ago (copying the coroner in) because I’d made an error on a recent post (now corrected).

I was a bit mortified at the time as I’ve tried to be accurate throughout. But given the amount of ‘errors’ ~~cough cough~~ the Sloves have made throughout this foul process (and the slimy, smearing Briefing document they circulated to fuck knows who else in addition to NHS England, Monitor), one error is pretty remarkable really. In the circumstances.

What a murky, murky little biz.

Stay classy, y’all.

The Pre-Inquest Review

Posted on November 24, 2014 by sarasiobhan

Seventeen months after LB’s death, the pre-inquest review hearing is taking place tomorrow afternoon. In a room in County Hall, Oxford. The building where I used to attend meetings about provision for disabled kids in Oxford. Transport issues and cuts. The Parents Advisory Group.

There’s not much to say at this point. I’ve said it all on these pages. In various ways. Pretty relentlessly.

A tiny part of me still thinks ‘Really? The NHS? Behaving like a bunch of bullyboy thugs? Nah. Our beautiful dude died. He was young, fit and had his adult life ahead of him… Such a terrible, terrible preventable death would lead to care and concern, not cover up, delay, crap and deceit. Surely?’

A tiny part the size of a pin head now.

Tonight, we’ll be thinking about LB. In all his legendary awesomeness. And the comfort he felt in doing things his own way. Before he grew older and stuck his toe in a new and empty world of ‘adult services’. Where one size fits all and he wasn’t allowed to be.

Like so many young people like him.

I bloody love and miss you. xxxxxxxx

The writing on the wall

Posted on September 25, 2014 by sarasiobhan

Had a day off today and had a lovely lunch with lil sis, Sam. Once she’d gone, the latest FOI pinged into my inbox. More stuff from the County Council about STATT. This includes a second (in addition to the November 2012 quality review) Quality and Safety Assurance Review of the Oxfordshire Learning Disability NHS Trust (OLDT), just before the Sloven takeover, commissioned in September 2012 by NHS South of England. Conducted by an external consultancy.

The review states that the impending acquisition, issues arising from Winterbourne View and those relating to an inpatient client led to a renewed intensity of interest and scrutiny on OLDT by the Strategic Health Authority. It discovered an insular organisation, with high levels of restraint, a culture in which a casualness ‘about strict process’ had been allowed, variable (even ‘dysfunctional’) relationships with commissioners and a complacency of attitude that was characterised as a lack of awareness and transparency. The review concludes that the culture can ‘best be characterised as a combination of defensiveness and complacency in respect of quality, safety and risk‘.

It recommends that Sloven swiftly act to ask the right questions of senior managers and ‘gain more robust assurance about incidents, actions and outcomes’. It also recommends that Sloven review staff training requirements and work to reduce restraint use.

Nearly 11 months before LB died. Everything that needed to be known about STATT was known. Documented, stamped and signed. A legitimated torture chamber. Post Winterbourne View.

We, knowing none of this, drove our beautiful and beyond loved boy, a couple of miles along the Slade, that cold, dark March evening. To his death. A death that could not have been more clearly written on the walls of Sloven Health and others.

You absolute bunch of fucking bastards.

The Sloven way: a lesson in arrogance and worse

Posted on September 20, 2014 by sarasiobhan

Reading the emails from Oxon county council and clinical commissioning group, I’m struck (again) by the astonishing arrogance of Sloven Health. I’d already heard that when they did their royal tour of Oxon to smooth over the ripples caused by LB’s death, the failed CQC inspections and Verita’s damning report, they came across appallingly. Gail Hanrahan describes one such meeting brilliantly.

I’ve only heard Sloven senior team members talk on the radio/TV news but it’s a throwback to past decades to hear people clearly lacking any understanding about learning disability talk nonsense about ‘the modern way’ and ‘false positives’.

This arrogance is also captured in the Oxon email exchanges about this tour. In one meeting they were apparently concerned that the focus on learning disability in “the north of our patch” was impacting on other services they deliver, and they appeared offended to be asked for a copy of their ‘detailed action plan’. The too big to fail monster clearly in action.

The letter KP wrote to us a month or so ago is another example of this. A letter steeped in ‘I’m absolutely right’ statements and worse. A document that will surely become an exemplar in ‘How not to engage with families of patients who have died through a dereliction of duty of care’ events in the future.

The story leaping out from the (hundreds of) pages of emails, reports, minutes from across the board, is that Sloven took over crap provision, did nothing to sort it and are pretty irked that the likes of the CQC and Monitor are now breathing down their necks.

Something is badly wrong when an NHS Trust demonstrates what we’ve seen and continue to see in last 15 months. NHS provision should surely be about continually trying to enhance and improve care provided. What else does it exist to do? (Obviously we have views on this but here we’re talking about what they ought and are funded to do).

Meanwhile, Sloven merrily collect HSJ awards while the police continue their investigation into LB’s death.

I suspect part of this arrogance comes from having apparently unlimited funds to try to make ‘problems’ disappear. Unlimited funding to chuck at legal teams to outmanoeuvre the odd family who are able (in a beyond unequal playing field) to avoid being crushed in the early days and just about drag themselves to the finish line years later.

A barbaric, inhumane situation. Seemingly condoned by those who must have the power to stand up and say “This ain’t right. It stops now,” and don’t.

A social media affair

Posted on September 18, 2014 by sarasiobhan

ryan5-26 Mid afternoon yesterday an unnamed person turned up at work, managed to find our office, handed over a memory stick, read out the password for me to unencrypt (disencrypt?) the files on it, checked they could be opened, got me to sign a letter and left. All very secret squirrel.

I was left with three heaving PDFs. Communications from Oxfordshire County Council and Clinical Commissioning Group mentioning me and/or LB between March 2013 to 27 July 2014.

I’ve only glanced through this stuff. Hundreds of pages. So just wanted to jot down my initial thoughts. In no particular order. And ignoring the stuff of ongoing police investigations.

There is pretty much no recognition/acknowledgement or reflection a young man died and he shouldn’t have done. No surprise now really. It’s largely about blame, self protection, reputation and process.

The pages are littered with mentions of ‘mum’. Please ditch the ‘mum’ stuff. It’s so blinking patronising and degrading.

The records start in September 2013. A six month chunk is missing. More carelessness or incompetence (or worse). Either way, not acceptable. Simply unacceptable.

Redactions are reasonable. Mostly names and occasional small sections of text blacked out.

Hints of sensible thought are present which is refreshing. Reflections that the findings of the Verita report are awful and media coverage can only be negative, for example.

A stand out thing is surveillance. There are transcripts of the Phil Gayle show (in which the Gman shines through with his piercing questions) and twitter, this blog were a constant source of discussion and even information. Rich’s ‘Move on down the Bus’ song was circulated among the CCG. One commissioning bod found out about the ‘bath ban’ on these pages. (For info, apparently it was instigated by a ‘nervous’ consultant and was lifted on the day of the CQC inspection… Any news on the staff disciplinary actions I wonder?)

I tweeted yesterday that I was beginning to understand the viewing figures of this blog. It must be bookmarked across Sloven Towers, the local authority and CCG. And, I suppose, other organisations outside of Oxfordshire who may be following with a mix of fascination at the complete shiteness of the whole situation and relief that they ain’t involved/implicated.

Of course it doesn’t have to be surveillance. Social media has created a space that offers health/social care professionals alternative ways of gaining insight into the experiences of people/patients. And the consequences of their actions and the systems that underpin them. One or two people in these exchanges seem to get that.