Antelope House and those old tear waterfalls

I’m stripping this post back to the minimum in an attempt to try to help Jim Mackey, Jeremy Hunt and others understand the gravity of what was/is happening here. Screen grabs, minimal text and links.

Going back to 2011 when the CQC found major concerns at a Sloven run mental health unit, Antelope House, after the death of Michelle Connor.

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In response to this inspection, Percy pitched up to a Hampshire and Southampton Health Overview and Scrutiny Committee Joint Meeting to answer concerns. She typically dismissed the seriousness of the inspection report. The deeply inappropriate ‘we’re no worse’ excuse dragged out five years later when the Mazars review was published:

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And went on to state:

Overall, a shift in the culture of the organisation was needed, and bad practices of the past needed to be left behind.

Bad practices of the past, eh? A set of responses were presented, summarised here (worth reading in full if you can bear to):

  • Internal inspections were currently going on across the whole trust.
  • An audit and completion of all care records was completed within 12 hours of receipt of the CQC draft report.
  • Care plans are now subject to regular, unannounced spot checks.
  • Implementation of immediate training and training scheduled for the near future.
  • The locked door policy was not being fully implemented.
  • Patient experience is important. Sloven want to return the trust and confidence of the public.
  • And a load of other utter bollox. Including training is embedded into practice, “a very senior nurse”has been brought in to provide the clinical leadership needed. Oh, and “The CQC unfortunately did not speak with service users whilst undertaking their inspection.”

Recommendations that have been regularly and repeatedly ringing ever since. With each death and inquest. Oh, and there was the usual evidence of the (Percy) Sloven way. A focus on ‘awards’ and glitziness to distract from the serious issues.

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The meeting ended with blankety blank type shite.

A year later Hannah Groves died…

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And other unfoldings…

ah3In the meantime, Sloven took over the Ridgeway provision in Oxfordshire. Apparently experts in mental health and learning disability provision (despite all these experts having left in the previous year or so). Ms Percy was huffing her puff and stuff online, regardless.

Once the lucrative contract was signed, Sloven withdrew from pretty much any engagement with the Oxon services. The white noise they talked about in the 2011 meeting didn’t translate into action. Just words to appease vaguely interested audiences. The 12 hour urgency type stuff was fakery. The exec never took the very obvious health and safety failings seriously. And haven’t since.

Here we are. Five years on. Deaths. More deaths. And closure.

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However, Southern Health did not believe that the areas requiring improvement were of a serious nature, and were not of the scale seen on recent documentary programmes (e.g. Panorama programme on Castlebeck). [2011]

Our beautiful, beautiful boy. A life (one of many) snuffed out because the Sloven exec (and those who should have been keeping watch from above) simply didn’t.

There was a ruling yesterday by the judge in the horrific Alton Towers crash case. So much resonates here.

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Sloven’s catastrophic failure to assess risk, woefully inadequate safety procedures, failure to communicate and being a shambles explains why LB, and so many others, died. Well, with a hefty dose of arrogance, an obsession with reputation and awards, and stupidity. Typing this through a now familiar waterfall of tears and rage, I don’t understand why we are still fighting. Why people are spending their time digging through this shite, committed to exposing the grubbiness that is publicly available, when so many are paid to do so and don’t.

If anyone from NHS Improvement, NHS England, the Health and Safety Executive or Department of Health (well anyone, really) could explain why we still have no answers or accountability over three years after LB’s death, please do.

This is state sanctioned cruelty.

An exemplar in absurdity (and conkers)

A sort of follow on from the (updated) The Talented Mr Martin and viral impact post. Underpinned by continuing incredulity at the removal of the Talentworks website. A ‘leadership’ consultancy with the tagline:

Meet the Talentworks team… hired for our large brains, love of psychology and impeccable dress sense.

Yes. Really. Well, and at least £5m of public money.

In the continued absence of any apparent scrutiny from NHS Improvement and others who should, we’re left digging deeper into shit we should never have to go near.

Talentworks. A virtual collective of people with large brains… etc have not only been getting obscene amounts of dosh from Sloven. They’ve also been working closely with Thames Valley and Wessex Leadership Academy (TVWLA). An academy led until last year by Katrina Percy.

I’m rubbish with figures but the Talentworks ‘blah blah’ work with the Thames Valley bunch (Financial Summaries available here) seems to involve a shedload of dosh for the two years Percy led the academy (around £500k and £370k)  dropping to around £20k after she stepped down. [As an aside, how could Percy dismiss Mike Holder’s safety concerns while championing Chris Martin and his jibber jabber? [howl]]

A brief browse of the Talent Management pages on the Thames Valley Leadership Academy pages:

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A teeth achingly meaningless statement. Just noise. How the Wessex leadership gang allowed this to be published on their website makes me want to weep. I’m left wondering (again) is this about stupidity, incompetence, fear, corruption, bullying, greed, narcissism or simple slumbering?  The focus on this hocus pocus crap, while staff were left without leadership, untrained and unsupported to provide the most basic care to keep LB and so many other patients alive [alive], is haunting.

More bollocks…

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Greater pipeline intelligence? A driver of culture change? It’s like the Stepford Wives meet NHS England.

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I’ve not read this blinky blonky table yet. The headings alone suggest nonsense. I just want to know who authorised payments for this ‘work’? Where were the internal (and external) audit processes? Did no one ask what is this about and is it effective?

Did Talentworks really have a blank cheque to do whatever?

What are the links between Chris Martin, Katrina/Iain Percy and others?

What does it mean that Talentworks have withdrawn their website?

What the actual fuck?

Here’s a photo of conkers we collected in the park earlier. I bloody love this photo. These are conkers. As simple and uncomplicated as.

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No (NHS) improvement (whatsoever)

More tales of dismal practice and bullying at senior Sloven levels are arriving in the shed. [Thank you for speaking up]. Apparently Mark Morgan, the Director for Mental Health and Learning Disability has a bit of a tawdry background. A serial interim manager, he was reported to be earning £28,000 a month back in 2014 at the Medway Foundation Trust. His director blurb on the Sloven page states:

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Bit of a funny statement about ‘pending a recruitment process’ but it turns out that Morgan (allegedly) wasn’t appointed when he was first interviewed for the post. Not very confidence inspiring and means he was an interim for longer than necessary [yes, my fingers can barely type these words, the level of absurdity is so extreme.] Prof Hatton was keeping a careful watch on the data and tweeted:

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Mark Morgan was paid just under £300,000 for 8 months work.

[Fill in your expletives here:_________________________________  I’m out]

This afternoon, a 38 page investigation report into the care of a patient at the Ridgeway Trust. This is the assessment and treatment unit that takes Oxon patients now the STATT unit is shut. The harrowing complaint, made by the patient’s mum (terribly difficult woman I’ve heard, and no doubt has “hostile” written all over her son’s files) has 29 items relating to the unit in 2014-15.

The covering letter is from Julie (scores on the) Dawes who must be wondering what she’s wandered into but I’m assuming Mark Interim Morgan must have signed it off. It’s under his remit. A tiny bit of context here for any new blog readers:

In 2013 the CQC failed an inspection of the STATT unit where LB died. It found a hideous set of failings including a lack of therapeutic environment [howl], poor record keeping, no involvement from people using the ‘service’ and so on. 

Today’s report upheld complaints in 13 different categories of complaint:

access to services, communication, discharge, nursing care, failure to follow procedures, record keeping, attitude, clinical care,funding, medication and prescribing, aids and appliances, code of openness and equipment

Some low lights:

  • A lack of active engagement with the patient’s mum.
  • Failure to record incidents on RiO or Ulysses or inform families
  • No therapeutic engagement with patients
  • Little access to the community because of low staff levels
  • A distant and unhelpful psychiatrist at the team meetings
  • Misreporting of the patient’s activities at the team meeting
  • Inconsistent communication
  • Failure to effectively minute meetings or act on action points
  • Trust and NICE guidelines were not followed around medication use
  • No specific care plans or risk assessments around observation levels* and their purpose.
  • No discharge report received ‘because of an administrative error’.

LB didn’t get to the discharge bit. Otherwise this is pretty much a repeat of the failings identified three years ago. Sloven clearly are clueless and have no learning disability and mental health expertise at senior level. They don’t get it and they don’t give a shit they don’t get it. While Dawes is cognisant of the failings the report identifies how can any patient/member of the public have any confidence that the recommendations (listed below) will actually happen? We have been told over and over and over again that lessons have been learned and improvements made.

I’ve nothing else to say about Jeremy Hunt, NHS Improvement, NHS England, Oxfordshire County Council and the Oxon CCG. It’s all been said repeatedly.

The system is clearly broken.

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* This reminds me of LB’s psychiatrist (currently missing in Ireland) who when asked by Paul Bowen to explain the difference between an observation and a ‘check’ at LB’s inquest, said “Ah, now I’d have to really drill down to do this”. These are people’s lives.

Take. what. you. need.

I was at the Disability Studies Conference at Lancaster a week or so ago where I met a small group of Icelandic academics/self advocates. I was delighted to hook up with them because I love the work of Kristin Bjornsdottir and team. And their campaigning. The George Fox building, where the conference was held, was dotted with these posters…

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Kristin talked about using #JusticeforLB in teaching and subsequently posted this:

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Wow.

Tim Smart resigned unexpectedly (but not surprisingly) today. Both Sloven and NHS Improvement demonstrated what Chris Hatton described as ‘a mulish aversion to honesty’ in their press statements about his resignation.

There is no candour. No honesty. We’re left with a ‘trust’ with an interim CEO, no Board Chair, no Chief Operating Officer, no Communications Director and 8 governor vacancies. Well, and financial irregularities over contracts worth millions. And a dodgy new (or old) made up post for Katrina Percy costing around £250k. And left with a deputy board chair who shared the findings of the Mazars review pre-publication with his teenage son who rubbished the findings on social media.

Wow.

What a complete and utter (chilling) shambles. Meanwhile, Jeremy Hunt repeatedly deflects MPs questions with non answers.

It’s more than apparent that the likes of Jim Mackey and gang, the remaining Sloven senior exec and ex-CEO, really need to take what they need. And act accordingly.

Or do one.

 

A cheeky bit of media advice to Smart and gang

Video

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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3 2

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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

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:

image

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.

Of mice and (NHS) monstrousness

A story ‘broke’ yesterday about extortionate NHS interim director costs. Sickening figures of waste, greed and mismanagement. At senior levels. Again.

In another of those ‘you couldn’t make it up’ NHS moments, the highest paid interim Improvement Director named in the report, Steve Leivers, was helicoptered into the trust Tim Smart, now Sloven interim Board Chair, previously ran. Yes. Really. Not Smart in non action. Again.

I read this latest news having been unable to move beyond Chris Hatton’s recent analysis of Sloven’s annual report. Cut and paste Katrina. And extraordinary senior exec salary figures. With Lesley Stevens, Medical Director at the top of the ‘leader’ board. A cool £365-70k per annum including jaw dropping pension contributionsHow can she possibly ‘earn’ this sort of dosh? Let’s have a look at her performance during LB’s inquest last October.

Lesley Stevens and LB’s inquest

Reasonably confident while reading out her evidence and then being (sleep) walked through clearly rehearsed questions by the Sloven barrister, she floundered big time when questioned by the six remaining barristers. Her answers so deeply insubstantial (a generous interpretation) it was as if the courtroom had switched to watching CBeebies.

£365-70k per annum…

Some examples:

LS1

LB died in July 2013. The (post Mazars review) CQC inspection in January 2016 found the Sloven epilepsy policy had yet to be signed off. Paul Bowen, QC, carefully questioned each Sloven staff member about their knowledge of epilepsy during LB’s inquest. No one answered in other than the vaguest ‘ain’t got a clue’ terms. There was no up-skilling staff over two years after LB’s death.

[Howl].

LS3Here Paul Bowen seeks clarification of Stevens outlandish statement that all learning disabled patients with epilepsy were reviewed before the CQC inspection in September 2013. At that point, Sloven were still spinning the line that LB died of natural causes. They did nothing to check the provision in STATT (it failed on all 10 domains inspected 6-8 weeks after he died) let alone review patients with epilepsy in their wider provision/outposts.

A blatant and contemptible lie. Perjury to us herbs outside of senior NHS circles.

LS2Paul Bowen tries to drawn Stevens on the failure of the RiO system. A failure that persists to this day. She resorts to her default response. A murmur/mutter noise reminiscent of the dog ate my homework type responses from school. Not the sharp, authoritative, informed, engaged response you’d expect from a senior exec at an inquest over two years in preparation, with nearly £300k squandered on ‘defence’ costs.

When questioned by Adam Samuels, another barrister, about the reduction in Band 6 and 7 staffing reductions in STATT (and the next door John Sharich House), Stevens says:

LS4

‘We make savings where we have to make them…’ On frontline staff. While you continue to draw an obscene salary

Monstrous. And remorseless. Just one, among so many.

When did the NHS we grew up with, took for granted and loved, become so riddled with greed and rot… with complacency and arrogance, with inaction and protection. At senior levels?

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…
peter bell

‘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.

smart and percy

My incredulity monitor has finally broken.

Another sordid little tale of failure

Sloven have shut the psychiatric intensive care unit at Antelope House for 8 months. Reported in the media last week. The board papers published yesterday provide more detail (around p72).

The closing of these beds mean patients who really should not be, will be shipped to a unit in London. To a unit that ‘needs improvement’ according to the latest CQC inspection. Yep. Closing shite provision and shipping seriously unwell patients to sub-standard provision. Extraordinary.

The board papers describe how a ‘tipping point’ was reached:

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To the extent the Deanery raised concerns about the quality of Antelope House as a training place for Junior Doctors…. Deep breath. Hold on to something solid.

Sloven run a unit that isn’t a fit space to train doctors.

How can any NHS Foundation Trust run a unit that is not considered a fit space to train doctors?

What about the safety and wellbeing of the patients?

I suspect Deanery concerns led to the sudden closure of the ward at Antelope House. The CEO/Board could clearly ignore the 4/5 year of failings publicly documented over the past 3/4 years. Lives lost. Non lessons learned. Inquest after inquest after inquest, failed CQC inspection after failed inspection and the Mazars review.

Deanery rumblings and concerns around junior doctor training (with implications for Vanguard membership) generates ‘action’.

As my brain, again, slowly, slowly melts, I (easily) stumble upon a news report about Antelope House from September 2011. Yep. Really.

A report on failings identified during the inquest of a patient in 2008 and a recent (2011) failing CQC inspection report. Risk assessments not updated,                                                                                                                                                inadequate records, lack of training, etc etc. The same old same old failings. Identified over and over and over again. The then Medical Director, Huw Stone, long gone (sensible guy), did the old learning lessons spiel:

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Mr Stone, back in the day, 14 months before Sloven took over the STATT unit LB died in, said all care plans and risk assessments were now reviewed. Extra checks were conducted on standards of care. And further made up blarney. How any NHS exec can stand in front of the press/coroner and say these empty words when the lives of patients are at stake is beyond me.

No other words really.

I just wonder.

  1. How those who should be doing something about this continue to look the other way/slumber despite documented failings.
  2. How those around those who should be doing something about this, allow their colleagues, family or friends, to continue look the other way/slumber despite documented failings.
  3. How those directly implicated look the other way/slumber.
  4. When any of the the above will realise that we will continue to document this shite for as long as it takes.

 

 

I start walking…

Started walking to work this week. Prompted by consistently destructive levels of rage generated by the continued non action around the Sloven senior team.  (Despite an extraordinary evidence base of failings.) About 3-4 miles depending on the route. Monday was day 1. Bit spooky walking along a long, isolated stretch of footpath by the river to University Parks. Rich came with me the next day, love him. We found a spooked dog. Pippa. I got to work later than planned. I changed my route to High Street/George Street/St Giles…

Then went to Staffordshire, via Birmingham New Street, on Wednesday so walking was shelved. London on Thursday. Watching walking instead.

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Yesterday we walked to town. Raging slightly muted by pounding the streets. Absorbed by watching/snapping everyday life. Back on the High Street, a vaguely familiar couple were snugged up on the bench by the bus stop.

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I photographed them before. Four long years ago. In the life that was. As snug. Just mobile.

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George Street, Oxford. August 2 2012

Today I didn’t leave the house. Among working and hoovering I started reading Victim and Victimhood by Trudy Govier. Unpacking what and who a ‘victim’ is, what being a victim means and different ways of making sense of victim and victimhood. Silence, blame, deference and restoration. Hmm. I’ll keep reading. And walking.

And get a print of the photo to drop off to the couple who apparently sit on the same bench most days. And, I suspect, have a story or two to tell.

And wait. Still.