Category Archives: Oxfordshire County Council

Updating LB

Posted on by
2

Hello matey,

Three years now. Well we’re into the fourth year really. I thought I’d update you on where we’re at in terms of justice and accountability. Not far really. [Sorry]. Various investigations limp on. The General Medical Council (GMC) has spent over two years collecting evidence about the clinician who was kind of in charge of you. You know. That woman who spoke to you for about 15 minutes across your whole time in STATT from what I can tell from the records. And gave you Bonjela after you had that seizure. She’s got about a week left to respond to the allegations the GMC have put to her. We’ve no idea what these allegations are because it’s all secret squirrel stuff. She’s working in the Emerald Isle now. Still responsible for patients.

She pitched up at your inquest in October with a barrister who was like the worst of worst baddies in a Simon Pegg film. He, like Sloven peeps, questioned whether we wanted you home. We did. I’m so sorry if that got lost over those hideous weeks in the unit. We stupidly, stupidly thought you were in a safe space while support was being sorted. Turns out all the failings in the unit were written in a report the summer before you went there. But nothing was done. [Howl…]

Your inquest went as it should have done. Superb legal representation (as you’d have expected) and a jury of nine members of the public who listened and understood how deeply you were failed by Sloven.

Other investigations are going on. Still. We met three people from the Health and Safety Executive (HSE) on Thursday with Norman Lamb. The meeting was in Portcullis House which you’d have loved. Heavy weaponery, police presence and security… The meeting was disappointing. Not the objective, razor sharp, robust, investigative scrutiny I imagined. Mind you, the writing was on the wall given the speed in which they slapped a charge against a production company for Harrison Ford’s leg injury in June 2014. 

There seems to be a fog engulfing and dispersing any critical challenge by public bodies of public bodies. And when you stupidly ain’t considered to be fully human, that fog just thickens. 

We managed to get a review commissioned by NHS England into deaths in Sloven ‘care’. This found a scandalous lack of interest or engagement in investigating unexpected deaths. We thought this report would lead to sharp and immediate action. But nah. Seems like this is ok.There’s a bit of tweaking going on round the edges but no commitment to really looking at these deaths or to act with any conviction. You’ve been mentioned a few times in the House of Commons though which would make you smile. 

Meanwhile, Sloven failings continue to pile up. They are seriously shite. NHS Improvement sent in a troubled shooter, Tim Smart, to look at leadership failings. He spent a few weeks there, avoided speaking with families, got some psychometric testing organised and decided there were no leadership probs.

I can hear you saying ‘Mum? Why mum?’ into infinity and beyond.

I dunno. I was waiting for the Scooby Doo gang to pitch up and unmask him as Mr Crawls or one of the other villains in the end. Such a nonsensical, cartoonish judgement. Apparently Alistair Burt, the social care minister, is still looking into it but for some reason, that rag bag bunch of muppets remain in post. 

These systems we loosely brought you up thinking were good, right and just, simply and sadly ain’t fit for purpose. While the public have stepped up and created an explosion of brilliance around you, your life and the lives of so many other people, you were and continue to be well and truly fucked over by those you always firmly believed in. 

There was a story in the Guardian mag about you a few months ago. A very funny journalist, Simon, came round and later a photographer. You’d have liked them both. Joel souped up some of our old photos. Like this one. No orange binoculars but the old shower cap and goggles. Rocking life as you always did. Your way.

Connor

Connor

xxx

The judgement

Posted on by
9

Tim Smart makes public his judgement today. Smart was sent in by NHS Improvement, on the back of the findings of the Mazars review, of failing CQC inspections stacking up since 2013. Of clear warnings about safety issues flagged up as far back as 2011. Sent in on the back of (and only because of) the actions of people who have campaigned relentlessly, stepped up and refused to accept typical NHS (public sector) whitewash/cover up.

This has been an almighty battle. It too often is when the NHS fails. With the enduring culture one of deny, bat aside, ignore, obstruct, deny further, smear and obliteration. We have a series of NHS scandals (followed by reviews, well meaning but ultimately empty recommendations and rhetoric) to draw on. So much evidence. So little action.

The Sloven story, like any story, has many versions. The focus and attention of the post apocalyptic reviews conducted by Tim Smart, the improvement director (forgotten his name… Clive summat?) and the independent consultants brought in to review governance will all use different (but I suspect similar) lenses. None of them have engaged with families.

After a late, late night worrying about what is to unfold I’m left thinking If the people who died weren’t learning disabled or didn’t have mental health issues, none of this would have happened. If it had, to non disabled people, the CEO and board would have left Sloven pastures long ago.

A simple and damning as.

Leadership and contact traces…

Posted on by
3

L1019565-2[…or chandelier and glitziness]

John Sutherland, police commander, has written a cracking post  identifying 10 things he’s learned about leadership. Sloven CEO, Katrina Percy (KP), wrote a piece for the NHS Leadership Academy in August 2014. In this brief (under 400 word) piece she flags up her maternity leave and the problems she returned to. [No mention that these problems were an outcome of the (non) actions she took before maternity leave]. In the same month she wrote a letter to me in which she further elaborates on her “leadership” style.

Here I meander through Sutherland’s 10 points (summarised in italics below) and the Sloven approach to “leadership”. It ain’t a pretty read.

I.     It’s people stupid

Leaders who don’t care about people aren’t leaders at all. They might be bad managers, but that’s really not the same thing. People are precious and rare and extraordinary and brilliant and brave and creative and resourceful and kind. They are also thinking, breathing, feeling, bleeding, sometimes flawed souls who, every now and then, need a helping hand. Great leaders understand these things. They understand people.

KP doesn’t understand people. Though she talks a good ‘staff’ game. Notably the ‘thousands of staff I lead’ [shudder…]. These are the people she is ‘keen to support and promote wherever and whenever they do’ things brilliantly. Services and families are below staff ‘and partners’. Patients don’t feature. Tim Smart, interim Board Chair, clearly gets the people bit. He was open about this during the meeting with My Life My Choice.

II.     Every contact leaves a trace

Every time two objects come into contact with one another, an exchange takes place – fingerprints found at house that’s been burgled; microscopic fragments of broken glass found on the clothes of the burglar. Every time two people come into contact with one another, an exchange takes place. Spoken or unspoken, for better or for worse. Great leaders understand not only that what they do is important – but that how they do it is equally so. Because every contact leaves a trace.

Since the Holder report (2012) there has been more contact trace in Sloven dealings than in an entire box set of CSI. The Sloven CEO and board have consistently failed to recognise this. Contact trace is even more important (in a non criminal context) where this trace can be circulated and re-circulated on social media. Since Smart’s appointment there have been some traces of fresh air through Sloven corridors. Not least the mediation agreement, statement and subsequent inclusion of LB’s pic on the Sloven front page for four weeks.

lb

III.        Leadership is service

The first responsibility of a leader is to serve. Before anything else, to serve. If the pursuit of my own ambitions has become more important than the cause we all serve, then I have lost my way. If my promotion matters more than your progression, then I am in danger of losing myself.

The words ‘serve’ and ‘service’ were clearly replaced by reputation, dosh, ruthless ambition some time ago. Down Sloven way.

IV.     Everything can’t be a priority

If everything is a priority, then nothing is. Leaders have to decide what matters more. Leaders need to be absolutely clear about what’s most important – particularly in a world of limited resources. And they have to be consistent about it. 

In her letter to me, KP argues

good leadership is founded on a determination and deep commitment to do what is right for all parties concerned, not necessarily what might be either easiest or most popular at any particular moment in time or demanded most loudly or persistently by one group or interest than another.

This self defeating and clumsily constructed statement is yet another attempt to stick the boot in. In fact Sloven do prioritise. Their reputation. They always have. Sutherland should perhaps revise this point to capture effective and reflective prioritising.

V.     Two ears, one mouth

Great leaders are great listeners. And they understand that there is a difference between listening and hearing – and between hearing and actually doing something about what’s been said.

KP’s letter is an exemplar in not listening. A bombastic exercise in ‘me, me, me…’, brutal in callous delivery. Statements like it was ‘absolutely right’ for us to (4 mentions), ‘I believe/strongly believe’ (8 mentions), ‘deeply proud’ (1 mention) and ‘absolutely confident’ (1 mention) are breathtaking in both number and emphasis in a two page letter. Ally Roger’s analysis of KP’s communication further explores her use of language and what it reveals. Contempt and disregard basically.

VI.     Leadership requires bravery

Having courage doesn’t mean that you never feel afraid. It means feeling afraid and doing the right thing anyway. It is both physical and moral. Great leaders stand for what is right, even if it comes at personal cost. Great leaders stand against what is wrong, even if it comes at personal risk. Great leaders have difficult conversations (with people, not about people). And they do these things constructively and positively and professionally – because bravery and bullying have nothing whatsoever in common with one another.

I suspect KP thinks she’s brave. She’s refusing to step down, insisting she needs to steer the flotilla out of the darkness. This ain’t bravery (see IX below). It’s a combination of arrogance and complacency (and stupidity?) She’s not having difficult conversations with people. Audio recordings of Sloven board minutes make it clear there’s little ‘standing against what is wrong’. Little of anything at all.

VII.      The difference between activity and progress

Being busy and making a difference are not the same thing. I played a game in my younger days that involved placing my forehead on an upright broom handle and spinning round in rapid circles, before affording my  friends the opportunity to have a good laugh at my attempts to walk in a straight line. Plenty of movement. No progress whatsoever. I know a lot of busy, dizzy people.

The Sloven leadership has nailed talking the talk and making no difference. From burying the Holder report, to repeatedly not ‘learning lessons’ at inquests and failing CQC inspections. They must be dizzy at the sounds of their repeated (and meaningless statements).

Chillingly, in the 26.1.16 board minutes (around 3hrs 36 minutes) in response to James Younghusband’s mother asking KP about the Holder report and identified ligature risks, she responds that the Holder report is archived and they’ve only found the process documents not the ligature risk report. Eh? Those old contact traces? What did KP say about this back in 2014…

Firstly, openness and transparency are fundamental when things go wrong…

VIII.     Leaders must be dealers in hope

The more challenging the context, the greater the responsibility that leaders have to deal in hope – to tell the kinds of stories and to paint the kinds of pictures that get people up out of their seats and cause them to come, running. It’s not the critic who counts.

Hope schmope. The Hansard transcript from the recent Westminster House debate details the lack of hope being generated by Sloven leadership. The NHS Staff Survey similarly illustrates increasing staff disillusionment with working there:

staff

Hopeless.

IX.     Leadership is about character

It was the American General, Norman Schwarzkopf, who said:  ‘Leadership is a potent combination of strategy and character. But, if you must be without one, be without the strategy. Who I am matters. What I believe in and what I stand for matters. Great leaders ask you to do as they say. And as they do.

When the latest shedload of contact (CQC) trace hit the fan in May, KP (again) disappeared. Lining up sidekicks to face the barrage of press interest (badly) and without apparent support. Again, the ghost of the Leadership Academy trace (ironically called ‘When the going gets tough’) shows KP arguing:

Visible leadership is crucial, for both staff and patients.

X.     Legacy

Great leaders provide the shoulders for others to stand on. To adapt a quote from the journalist Walter Lippman: ‘The final test of a leader is that they leave behind them in others the conviction and the will to carry on.’

Not sure about number 10 in Sutherland’s list to be honest. I suppose we will hope KP leaves so we can tell what’s left behind.

There it is. Leadership. And nothing like leadership. In a Sloven nutshell.

 

 

 

The magic wand

Posted on by
11

Friday afternoon I left work mid afternoon and went to the cemetery. The outcome of the ‘settlement’ reached on Wednesday was impossible to make sense of. I just kept crying. On the bus home I received an emailed letter from Lesley Stevens (Sloven Medical Director). About the unethical study they are conducting into families experiences of their death review process. The letter inviting people to take part is being reviewed and revised by three ‘service users’, the Health Research Authority have said no ethics approval (or ethical thought apparently) is necessary and Stevens defends the use of the questions being asked of bereaved families (e.g If the review process had been perfect – if it had been everything that you would want it to be, what would it have looked like for you?) with reference to the “Magic wand” question:

“if you had a magic wand, and could have three wishes granted…” (see Verma, N., (2014) Appreciative Inquiry: Practitioners’ Guide for Generative Change and Development) and the standard Solution Focused “miracle” or “future perfect” question: “Suppose a miracle happened tonight?” (see Jackson & McKergow (2002), The Solutions Focus: The simple way to positive change).”

magic wand

I read the letter. Blinked. Read it again. And bizarrely (after all this time) realised that Lesley Stevens and a sizeable chunk of the Sloven board will simply never understand (or refuse to understand) that LB died. Or engage with what #JusticeforLB has revealed over the past three years. The burying of the agreed public statement in a PDF, off a link from the Sloven news page, demonstrates the same old, same old, contempt and fakery despite an apparent “successfully mediated settlement” reached on Wednesday. A point not lost on others…

mills tweet

This afternoon I sorted out some photos for Open Democracy who are going to publish the public statement as a word document so it’s permanently searchable online. [A PDF is not…]

As I did, I thought again about Steven’s reference to “a magic wand” or “a miracle” happening. And wondered [again]… how can these people possibly be in charge of an NHS trust? Still.

magic wand 2

L1019735.jpg

 

Oh Mencrap… really?

Posted on by
17

Hearing rumours that Mencrap have lined up a ‘Five years since the Winterbourne View Panorama film was screened’ media thing. Tomorrow.

Sigh.

Really?

What do they actually do…? (Serious question.)

Brilliant journalism uncovered scandalous, horrific, abusive practices in a (privately run) assessment and treatment unit in Bristol back in 2011. This generated a moment that led to a mass signing up of pretty much everyone/organisation connected to learning disability in the UK. To what turned out to be a combo of earnestness, pomp, ridiculous bureaucracy, ultimate pointlessness and ill thought out promises. At enormous cost.

The Winterbourne View Joint Improvement Programme (WVJIP). [Shudder].

A programme that gradually petered out into a Bubb’s breakfast. The 50 odd signees remaining largely silent on their  collective failures.

We’re left with a  handful of dedicated and deeply committed staff at NHS England sticking their fingers in various life dykes with the support of pockets of dedicated and deeply committed groups/individuals across the country.

Pretty much the same number of people continue to (not) live impoverished (and brutalised) lives in assessment and treatment units across the country as there were in 2011. Many, many more are leading impoverished (and brutalised) lives in independent supported ‘homes’. Some of which are run by Mencap.

Winterbourne View has remained the cultural touchstone for repeated and deeply serious failings in learning disability provision. Why? I suspect partly because it suits Mencap. A quick win for (vacuous) media coverage. And partly because it was run by a private (not NHS) provider.

What was exposed at Winterbourne View was barbaric. The publication of the Mazars review in December 2015 flagged up so, so much worse. The systematic ignoring (or worse) of the preventable deaths of learning disabled people by an NHS trust. Less than 1% of unexpected deaths were investigated.

Less than 1% of unexpected deaths were investigated…

The response of Mencap to the Mazars publication?  Puffery about Mencap greatness. Shockingly and deeply inappropriate.

*Mencap’s repeated and self serving focus on ‘Winterbourne View’ further demonstrates the gap between Mencap and the people/families they claim to be the voice of. Learning Disability England is being launched on June 14. Reclaiming ‘voices’. Thank fuck.

 

Watching the consultants

Posted on by
9

After Tim Smart*, new Sloven board chair, astonishingly announced at Tuesdays meeting that he was commissioning an independent review into Sloven board performance, Chris Hatton totted up the Sloven spend on external consultancy for the last three years. Over £8 million. £8 million… Wow. Given they continue to fail deeply, they really ought to get this dosh refunded. (And stop commissioning consultants.)

Yesterday I received a private and confidential letter from our (least) favourite medical director, the hapless Lesley Stevens.

image (30)

Astonishingly crass but I’d expect nothing less from Sloven, who wouldn’t recognise a bereaved family if they sat in the middle of a funeral service. No thought for the poor buggars receiving this letter, just Sloven, Sloven, Sloven all the way.

Still, at least they are doing some research I thought. And went on to read the credentials of the independent researcher. Ah. They ain’t independent. Or a researcher really. They worked for Hampshire Partnership Trust (predecessor to Sloven)… Sigh.  I emailed to find out more details about the study.  Turns out it isn’t really a study. It’s a ‘service review’. No real details are available other than the (non) independent (non) researcher will ‘interview family members that come forward and to write that up in a report with recommendations on how the Trust improves the process’. Nothing like a bit of rigorous and ethical study. Nope. Nothing like it.

In the absence of a protocol or study design (just extraordinary) I was sent the interview questions. These, too, show a complete lack of understanding of the focus of the ‘study’. Reading them, for the first time in years I appreciated ethics boards. The final question is a cracker:

reviewCan you imagine asking families whose relative has died in Sloven care this question? We ain’t talking about an evaluation of the Royal Mail complaints process FFS. If it had been everything that you would want it to be…?

My jaw is almost permanently clamped shut at the lack of anything remotely human these muppets do these days.

Now, for those mysterious callers and poison pen letter writers among you, I ain’t being picky, vindictive or vexatious here. This is a public sector body squandering millions on shite, continuing to ride roughshod over patients and families while openly failing. It is simply wrong. When I think of the lengths Sloven went to trying to bury the Mazars review, one of the most important, critically analytical and robust studies conducted within the context of the NHS, and yet they will trot out this non ‘study’ as hard evidence of whatever suits them in a few months time… No questions asked. No scrutiny. Nothing.

Not only that, they will very likely have caused additional distress to bereaved families in the process. Another ill thought through and clunky non action plan.

Stay classy, Sloven. As always.

*Not an auspicious start for Mr Smart, sadly. Further details of his bully board behaviour here.

An inhumane battering

Posted on by
15

I came across this letter sent to some disability activists by an Oxon County Council commissioner again today. Took my breath away. Again. A vicious and ill informed assault. Why?

I’ve been repeatedly vilified as LB’s mum. By senior (white, middle class) people who should not be working anywhere near health and social care. To save their own backs. Their salaries. Their status. Their fakery around their sense of who they are… In a sustained and nasty way.

Just one section of the commissioner’s letter:

OCC Commish letter

[Here’s one of the posts I wrote a week or so before LB died: Am I mainstream now, Mum?  [Howl]]

Have to say, if any OCC or Sloven staff member wants to suggest to my face that I was ‘reluctant to have LB back’ I’ll not be responsible for my actions. I loved that boy more than life itself. We all did. And always will. He was the family rule breaker. The comedian. The gentle and funny guide to different ways of living and being, with a wisdom we didn’t always recognise.

He was a fucking school boy…

Can you begin to imagine what it must be like to read the above extract? From a letter leaked to you a year or so after it’s written and circulated to who? To know you are being bad mouthed in all sorts of NHS/social care circles because some jumped up Trust, whose eyes were bigger than their bellies, were able to feed off a weak Oxon joint commissioning set up. Take over the Ridgeway. Leave it to fester…And your child drowns alone, locked in a bathroom, as an outcome?

Don’t you ever suggest I was reluctant to have LB back. If you do, have the guts to say it to me. Not circulate it in sneaky, sordid communications among NHS/LA corridors and wider. And to anyone who receives such tripe in their everyday work…. You can always call it out, you know. Shake off the stupidity, malaise and laziness and recognise/acknowledge that families aren’t the beasts they are painted to be.

As Tom, 16, said;  “When a mother tells you she’s sure her son’s had a seizure, he has.”

You stupid, self serving, arrogant, barbaric fuckers.

 

 

 

Dirty dealings and the Sloven gravy train

Posted on by
8

I wrote this filthy lucre post two months ago. About the Slade House site and rumours that Sloven are selling it and heading back down south with millions in their grubby (and negligent) paws. With the naivety (and relentless optimism) that has characterised #JusticeforLB though, we sort of believed Mike Petter’s (written) assurance to My Life My Choice:

“If it is sold by Southern Health, the money will go back into Learning Disability Services in Oxfordshire. If somebody else sells it, they might have a different idea.”

At the time it seemed odd to say ‘if somebody else…’ Mmm.

Naivety and optimism has taken a kicking tonight with the following unravellings and realisations:

  1. DocHawking tonight mentioned sale of the land by a private company; a sneaky bit of asset transfer which absolves Sloven [only in the eyes of devilish monsters] of ‘selling it’ themselves.
  2. Petter has gone.
  3. The Sloven board meeting tomorrow has a secret agenda item Declaration of Surplus Land/Property.

These, in turn, leave us wondering (again):

  • Why did Sloven want to acquire the known to be failing services run by the Ridgeway Partnership in 2012?
  • Why did they do zip all about improving these services or even being visible in Oxfordshire after the contract exchanged hands?
  • How much of a draw was the chunky Slade House site/land next to a recent development for Oxford Brookes student accommodation, within the Oxford ring road?

slade

Oxfordshire has had to endure failing learning disability services for over three years now. It cannot be possible that the resources the county have can be pillaged by a bunch of chancers. (Aided by the stupidity of Oxfordshire County Council and the Clinical Commissioning Group). Nah. No fucking way.

 

1000 days

Posted on by
11

As we get to towards the end of the third year since LB died my rage is reaching levels I had no idea existed. Probably in direct proportion to the mountain of shite that continues to unfold at Sloven towers. Despite enough evidence to sink the Harmony there is still no action.

Sloven, and everyone else who should have acted and hasn’t, has now stolen a further thousand days of our lives. 1000 days… during which we’ve been unable remember LB properly.

I hate the word grieve. I don’t want to ‘grieve LB’. And I’ve a serious dislike of ‘models of grief’.  I want to think about LB. I want the space to remember, in intricate detail, everything about him. His love, laughter, being, touch and smell. His sense of humour. His astonishing, duck like hair. His happiness, thoughts and reflections. His dislike of Simon Mayo and love of all things human rights. But I can’t.

I’m enraged that, like so many others, the remaining pieces of our hearts, those pieces that somehow hang in there despite the harrowing and incomprehensible death of our dude, are battered beyond recognition by state actions and non actions.

Inexcusable. And barbaric.

1000 days… And no end in sight.

image

 

Photos, postcards and a meeting postponed

Posted on by
17

13161735_10153432109400957_7151825164020684043_o-2

We found some old photos yesterday. And a postcard LB sent to Stan in 2008. Tears, chuckles and family banter. The postcard is addressed to Stanley McRogers, LB’s name for Chunky Stan. And pretty vague address details. How the hell did it get here?

image (29)

We decided it probably arrived because of the wonderful, intuitive work of a postman we had for several years. A postman who collected Marilyn Monroe memorabilia.

Tonight we found out the extraordinary governors meeting organised for 17.5.16 with a controversial agenda has been postponed. The official statement from Tim Smart, the recently board chair appointed by NHS Improvement, states:

smart shiteYou’d think a trouble shooting NHS Improvement appointed (interim) chair has sufficient understanding of the legal ramifications of proposed actions, or easy access to advice from NHS Improvement, to make authoritative decisions… But no. The flakiness of not only Sloven but the broader bodies around them once again laid bare. And yet more delay.

An hour ago I tweeted:

typos

It’s nearly 1am.

Sloven leading, as always, with actions that make fuck all difference to patient care…. They can’t sign off an epilepsy bathing protocol until nearly three years after LB died but they can change a typo on a news release after a tweet, late on a Saturday night.

Where is the human?