Going global and getting it

In a week in which the Justice Shed was rocked by the police decision not to put a case to the Crown Prosecution Service, there were some brighter moments. Internationally. Katherine Runswick Cole and Dan Goodley spent a chunk of last week flying the LB flag in Australia. They were at the Centre for Disability Studies, University of Sydney for various activities including a symposium on institutional disablism and workshop about the value of self-advocacy.

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Katherine then went on to New Zealand to meet with The Family Network and University of Otago, School of Education, where she shared the platform with Paul Gibson, the New Zealand Disability Rights Commissioner (pictured third from left below). And continued the tradition of LB flag flying brilliantly. Seriously. Did anyone imagine the symbolism, reach and resilience of this wondrous piece of cloth?

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The international spread of #JusticeforLB continues next week as Rich and I head for the Society for the Study of Social Problems annual conference in Chicago. A resolution proposed by Mark Sherry about LB’s death was agreed at last years conference. As Mark wrote to me at the time:

Sara, there were hundreds of people involved in motion. It went to a Directors (or Chairs) meeting, before it went to the general assembly. There were some minor ammendments, and people wanted elaboration, but it eventually passed unanimously. I was very moved, I left that session close to tears. There are good people in the world. I will scan it and send the entire resolution to you. But the massive outcome is this: “Be it further resolved that SSSP add a special session at our next conference in honor of Connor Sparrowhawk. The session will ensure that the issue continues to be discussed into the following year, with scholars examining the social problem further”.

And it is. Next Friday morning.

Among the horror, incredulity, uncertainty and and intense relentlessness of trying to gain justice and accountability from publicly accountable bodies in England, so many people, groups and organisations get it so blinking right.

Solidarity. As simple as.

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True detectives, (in)justice and the law

[9.8.15] I’m writing this in advance of a meeting with the police tomorrow at 4pm. A meeting that will, I suspect, involve closing the investigation into LB’s death. There won’t be enough evidence to put a case to the Crown Prosecution Service (CPS) to bring a charge of corporate manslaughter against Southern Health NHS Foundation Trust (Sloven). These charges rarely happen in the NHS and early findings from the second Verita review suggest that Sloven will slither away, largely untouched. Despite numerous failings documented in their Oxfordshire provision (the ‘north of their patch’). Captain fantastic spending on consultancy that should never be necessary. Pricey legal representation will reduce reputational damage to a blip. Blips will be obliterated with tedious (meaningless, utterly meaningless) ‘lessons learned’ bleats. Blips, bleats and back to business [because that’s what it’s about] as usual.

The young dude who, stuck in a now acknowledged, recognised and subsequently closed Sloven run hell hole, denied his right to life. Unsupervised in the bath. Despite a diagnosis of epilepsy and documented concerns about increasing seizure activity. A life too easily swept into the ‘we couldn’t give a flying fuck’ corner. Like so many others like him.

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We first met the police the morning LB died. In the ‘relatives room’ in the John Radcliffe hospital. A space of abject, unspeakable horror. Disbelief, horror, tears, howling horror, sugary tea, organ donation talk, horror, tea, tissues, tears. An hour or so earlier, I’d been on my way to work on the number 8 from Barton to Oxford city centre. Fran and I texting about the school prom the following evening.

The care and sensitivity the A&E team demonstrated was matched by the two police officers who pitched up that morning. Their involvement seemed to be a formality at first. There didn’t appear to be anything suspicious… ‘No’ we managed to say. Among the tears, tea and tissues. LB should not be dead. Dead? 

Since that morning, the police investigation started, stopped, restarted after the first Verita report findings and now, who knows. The bar for a corporate manslaughter charge is so high, it’s almost meaningless. Particularly in the NHS. You might as well chuck shedloads of documented shite practice into the nearest skip as the one email/letter/report/piece of evidence that demonstrates that the board clearly knew that practice was shite and did crap all, is so unlikely to be found. Despite the blinking obvious fact that NHS trust boards should be aware of the level of shite practice that happens on their watch. Particularly when they’ve taken over known failing or dodgy services.

[Update: 10.8.15]

The police haven’t the evidence to put a criminal case before the CPS. The bar of ‘gross’ negligence hasn’t been met. Negligent yep. Gross negligence no. Their investigation is now effectively closed. Our definition of ‘gross’ negligence a world away from that of the law. LB died. He barely gained a scratch in 18 years in our care but died in specialist NHS provision completely unnecessarily. The 2011/12 quality account flagged up the failure of Ridgeway Partnership to improve their epilepsy related practice and the necessity for this to be sorted as a priority. But hey ho. Wait till someone dies and then ban everyone from bathing on the Slade House site for six months. No one from head office way down south will know (or care).

The police, particularly the detective constable who happened to be on duty that morning, and his sergeant, were committed to thoroughly investigating what happened. The contrast between their consistent decency and humanity and the cruelness and unresponsiveness demonstrated by other public agencies is striking. They engaged with us as human beings, people who have and continue to be put through the unimaginable. The law simply seems to be a too crude tool with a measure of injustice built into the system.

I drifted a bit. Sitting in the kitchen with the three officers as they talked us through the investigation. And wondered what LB would think. He had an unwavering lifetime love of the police and the law. Of justice and human rights. He would love the attention to detail and careful process being described. It would be something he would return to endlessly. The source of a billion questions.

‘Why did they close the case mum?’

The public have left the building

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The skip, old rubbish and other stuff

On leave this week and we hired a skip to get rid of old rubbish, broken stuff and other stuff. A major, well overdue, sort out. LB’s camera turned up this afternoon. The battery still working. I downloaded the photos. Buses, heavy haulage and the odd photo of him.

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Not sure what else to say really.

The leader of the pack

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

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

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

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

Dead times and fuzzy felt versions

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

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

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

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

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

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

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We need to talk about Mencap

The CQC published a chilling review of a Mencap run ‘service’, Precinct Road in Hillingdon, on Friday. Yep. Mencap. Documenting so much so wrong I can’t summarise it here. A series of human wrongs.

This went under the radar until Mark Neary came across it this morning and started to tweet about it.  A teeny tiny (anti) press release was eventually published later today stating very woodenly;

Mencap takes very seriously any requirements and recommendations on how to improve the quality of support we provide. After a recent CQC inspection of Precinct Road in Middlesex we have apologised fully to the people we support and their families.

We have taken immediate steps and great care to fully address the actions outlined by the CQC’s requirements and recommendations. Our procedures and environment at Precinct Road have improved as a result.

Mencap is committed to ensuring that we offer the highest quality care to enable people with a learning disability to live the lives they choose to live.

This was missing the hallmarks of a typical Mencap press release; speed and a grandiose statement by the Chief Exec – usually in cahoots with the CEO of the Challenging Behaviour Foundation – ‘calling upon the government’ to do diddly squat. (Ensuring their continued seats at any table, breakfast or otherwise, where endless, pointless but costly discussions about the provision of services can be chewed over a doughnut or ten). Oh, and no link to the CQC report. Breathtaking.

I’m left thinking… Mencap (or Menace as my autocorrect keeps calling them):

  • How could you possibly be required to improve the services you provide given you are the (self proclaimed) ‘leading voice of learning disability’? With the £b?/millions you have at hand?
  • Why did it take a CQC report to make you act at Precinct Road when it’s clear from the CQC report that the problems identified were apparent for several months?
  • Why have you only apologised to the four people who ‘live’ at Precinct Road and their families? Surely you should issue a wider apology. To all those you ‘support’ and those who fundraise and volunteer for you?
  • How you can possibly say you are committed to ensuring you offer the highest quality care to enable people with a learning disability to live the lives they choose to live… when you don’t?
  • And finally. Are you a provider or a campaigning charity? Because you clearly can’t be both.

Sleight of hand mastery

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

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

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

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

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

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

Grated finger tips and sick sifting

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

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

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

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

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

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

Vat of vomit anyone?

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

Bastards. 

 

FOI disclosure day

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

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

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

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

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

Wow.

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

Wow.