Sense and reason, at last

After nearly three years of atrocious responses from Sloven to what happened to LB, this document arrived anonymously in the Justice shed earlier. An emergency motion presented at the governors meeting on April 26th. Apparently, from what we can glean from Michael Buchanan’s tweets and other sources, some of the governors were taken aback by the never before seen candour and transparency they were confronted with, without warning.

Petter, then chair, decided that the motion would be held back to an extraordinary meeting to be held within 7-10 days of the CQC report being published. I suppose to allow certain people the space to recover their shock and horror that, for once, their cosy slumbering and collusion with the board was being challenged.

I can’t describe what it feels like to read these words. Such a careful, reflexive, comprehensive and sensible engagement with the catalogue of failings since Mike Holder’s report in 2012.

I’m not sure I’d add anything other than, good on you, Mark Aspinall and the other governors who expressed support for it. What a refreshing contrast to the simply offensive letter we were sent on Thursday. And here’s looking forward to the extraordinary meeting in the next week or so.

-REBbBU_

H_jywKsp

The confidential confidentiality agreement

confid

Back in October 2013, Fran was going to be the family advocate on the Sloven investigation into LB’s death. This descended into farce almost immediately as Fran was banned from being involved because of some trumped up nonsense around Oxfordshire Family Support Network. And then unbanned. Once back, Fran’s involvement only spread to one meeting before Verita were commissioned to do an external investigation.

At the meeting with two Sloven employees (one of whom wrote the leaked quality and safety review nearly a year before LB died; the report which Verita, NHS England and NHS Improvement are now arguing was disclosed (my arse)), Fran was given a lifelong confidentiality agreement to sign. She took a hard copy away to get it looked over, slightly bemused as it had bits crossed out and handwritten amendments.

She was surprised to receive several missed calls from the clinical director the next day (on her home phone and mobile) desperate to get hold of her and two messages. This is the first message (early evening). It was followed by a second message first thing the next morning asking her to get in touch. And more missed calls across the morning.

The life long confidentiality agreement itself was now confidential and not to be shared with anyone (not even a legal representative). Complete and utter Sloven nonsense. Typical bullying and bombastic approach. Terrible, terrible interaction with a family friend/member of the public. No whiff of care, concern or sensitivity around the fact that a young man drowned in their care. Just a dehumanising ‘mum and her solicitor’ and agitation.

What a sign of what lay ahead.

ps. Fran’s son, James, still uses Sloven services. Her willingness to publicly share this message and story is a testament to her not being cowed by bullying services who too often hold families over a barrel of fear. She said to me an age ago that she had been a whistleblower as a nurse in her early twenties. ‘Before ‘whistleblowers’ existed.’ She just called out poor practice. I think she’s right. This is the only way change will happen.

The governors response…

Regular readers will know I spent ages writing a letter to the Sloven governors at the beginning of the year outlining the boards (barbaric? inhumane?) treatment of us since LB’s death. It was a deeply distressing task which took hours. I didn’t cover every bit of action (or non action) because it would have been unreadable. The letter can be read in full here.

It ended with this paragraph:

letter

Only one governor, Mark Aspinall, demonstrated any interest in responding properly to my letter, as I chased up an answer every few weeks for four months. Apparently it was taking a long time to go through all the points I raised and getting the governors to agree to a reply. Last week we heard from Jim Mackey that NHS Improvement had followed up the non response with the trust and had requested a copy of the reply too.

I received this letter the next day.

[Before reading it, you should probably make sure there is nothing breakable within reaching distance. In all seriousness.]

gov letter 1

gov letter 2

Please hurry up someone and do something with this totally toxic, festering bunch of self satisfied and equally stupid, pointless people. I now have rage feelings in parts of my body I didn’t know existed before. LB died [he died???] and you – the board and now the governors – have treated us with contempt, disrespect and much worse.

How is this remotely acceptable? And how do any of you, and I mean all of you, possibly sleep at night?

 

Media melange and a missing CEO

24 hours. The Today programme, BBC Five Live, BBC Breakfast News, Channel 5 and ITV News, Community Care and Oxford Mail. No words (other than appreciation for thoughtful and engaged interaction from all, and some photo captions).

Oh. And no sign of Katrina Percy.

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Thursday. 20.36. Train to Manchester, Piccadilly.

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22.00. Holiday Inn. Media City, Salford.

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Friday. 5.30. Holiday Inn. Media City, Salford.

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6.15. Recording the Today Programme. In a pod.

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7.20. Slap. And a bit of banter.

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12.30. Botley Community Centre, Oxford.

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13.00. Channel 5 and ITV News. Wind and sunshine.

Stevens and the RiO fantastic

Oh dear. Reading the 24 page statement Lesley Stevens, Sloven Consultant Psychiatrist and Medical Director, provided  at LB’s inquest in October 2015 in the light of the leaked document.

It’s the stuff of many posts but to kick off briefly here…

Stevens says:

The report from Verita concluded that Connor’s death was preventable because he should have been subject to “line of sight/sound” observations whilst bathing and would have been had appropriate risk assessments and care plans been in place.

and

Following the CQC inspection in September 2013, the Trust stopped admitting any further patients to the STATT unit, to enable it to address the failings identified in the CQC’s report.

The same failings identified in the August 2012 review that remained buried until a week or so ago. Steven’s report (drawing on the much used Sloven technique of obliteration through jargon and word length) contains 12 pages about Sloven’s epilepsy map and toolkit. 12 pages. Completely unaware, over two years after LB’s death and all the changes allegedly implemented, that RiO doesn’t allow any recording of epilepsy information, she states:

The health professional undertaking the core assessment must assess the risk using the RIO (a software package) risk assessment form. NICE (2012) guidelines state that the following risks should be assessed as a minimum:

  • Bathing and showering
  • Preparing food, etc, etc

A failing so serious, the coroner flagged this up in his Prevention of Future Death report:

epilepsy shite

So blinking awkward. You’d think any organisation would be rigorous both in the changes made after the preventable death of a patient (typed this laborious phrase so many times now, I’m inclined use ‘killing’ as shorthand) and to check, double check, test and review everything that goes into a report to a coroner. Not the Slovens though. Nah. They just make it up.

Just noise. Public noise. White noise.  HSJ award winning noise. And it apparently doesn’t matter.

image

Sloven and the ligature risks

A few weeks ago, we found out someone sent an anonymous letter to the Sloven CEO in 2011 flagging up health and safety concerns. Katrina Percy was, of course, totally oblivious. An independent Health and Safety consultant, Mike Holder, was appointed to troubleshoot. Two months later, he handed in his notice. Sloven were not prepared to listen or act.

Holder has shared the relevant documents and his leaving report with the Care Quality Commission (CQC), the Health and Safety Executive and Hampshire MPs, Suella Fernandes and Kit Malthouse. I caught up with some of this paperwork this evening. A couple of things leap out (outside of Holder’s meticulous detailing of the myriad ways Sloven were breaking Health and Safety legislation). These relate to ligature risks.

Holder shared this diagram showing the increase in ligature incidents over four years with the Interim Director of Nursing and AHP (dunno what AHP stands for) in Feb 2012.

lig incidents

Her reply is enough to make hair follicles seal up:

Nurse reply

Holder’s reply. Challenging the nonsensical with sense and clarity:  

Holder reply

Rich and I chatted about this earlier. He was reminded of this quote from Clifford Geertz, a classic anthropologist

I have never been impressed by the argument that as complete objectivity is impossible… one might as well let one’s sentiments run loose. As Robert Solow has remarked, that is like saying as a perfectly aseptic environment is impossible, one might as well conduct surgery in a sewer. 

Sloven clearly and consistently embrace the sewer approach with an abandon and a carelessness that is sickening. [There was another report today about the death of another patient/Sloven failings. Lesley Stevens, who seems to have a full time job attending inquests, was again bleating about ‘changes’.]

Changes my arse.

Dipping back to Feb 2012, the second, related point, is around action plans and (non) actions. Someone working with Holder emailed him with serious concerns around ligature risks. The assessor was concerned that either the risk scoring was inaccurate or signalled a general lack of understanding about how to complete ligature risk assessments. Both were deeply worrying. He concludes:

Finally there are action plans in each of the assessments which list all the points where actions are required; there appears to be no record of any actions being completed. This raises the question as to whether the actions have been completed at all, and the assessments not updated to reflect that, or whether the actions are still outstanding.

The same old, same old shite. Across four years now. Documented and shared with the senior management team. Who ignore it.

Given that Holder’s appointment came about because of an anonymous letter raising safety issues, you’d think his resignation and the various health and safety breaches he identified in a couple of months, would be taken seriously.  But no. It was business as usual. Six months later, in August 2012, a quality review, detailing shocking failings at the unit where LB died, was similarly ignored. [Howl]

Fast forward to April 2016, whipping past numerous failed CQC inspections, numerous deaths, inquests and Prevention of Future Deaths reports. Past the publication of the Mazars review… to which Sloven, four years after the above discussion about ligature risk, applied the same baseline stats (non) defence. The latest CQC inspection report will be published later this week. The Sloven senior team are, by all accounts, mounting their schmooze counter-attack. There isn’t a reflexive bone in their collective body that allows them to think, hang on a minute… We’ve really ballsed up here. Repeatedly. Patients have died. Repeatedly. And we clearly can’t do what is needed to improve the services we provide…

Nah. Nothing like it.

This CQC inspection was part of Jezza Hunt’s response to the Mazars review. It was the necessary first step before the CQC and NHS Improvement decide on any regulatory action. [I know]. Given the inspection identified failures generating warning notices a week or so ago. Given everything that has gone before. Given everything. There cannot be any more propping up of this toxic senior management shower. Surely.

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‘What the Verita?’ and broken narratives

Been at a Broken Narratives conference this week in Prato, Italy. Fascinating papers and people, good company, sunshine and piazzas. What a privilege. Now I’m thinking about Verita and the two ‘independent’ reviews they did about LB [howl]. For which they must have been paid a costa del fortune.

We were naffed off with the second review pretty much from the start really. And the finished version made no sense. Having read the transcripts from the staff interviews for the first review, shared with us before LB’s inquest, our confidence dropped to the level of ‘What the Verita?‘ Flimsy interviews, heavy on the interviewer blather and little or no probing.

Mmm. What the Verita indeedy?

verita

The second paragraph on their website blurb is a bit peculiar. It seems to be a veiled way of reassuring organisations [the NHS] that might want a bit of shonky, that they do a good enough job without doing a thorough, robust and warts and all investigation. Stating our approach is always measured, appropriate and focused on improvement pretty much says ‘we do superficial, skeletons remain buried and we’ll come up with a few suggestions’. And this is exactly what they did.

The first review, focusing on the immediacy of what happened to LB, failed to uncover that a patient died in the same bath as LB several years before. Despite two of the staff Verita interviewed being present on both occasions. [No words]. Despite the original terms of reference (a) including direct reference to the earlier patient and the slightly revised terms of reference (b) alluding to it:

(a) ‘to review how learning out of concerns from a previous similar incident has been embedded in practice and informed care practice and safety’

 

(b) ‘to review how learning out of concerns from any previous similar incidents/external reports has been embedded in practice and informed care practice and safety.’

Verita just ignored this in their first review. Their methods simply failed to uncover what was clearly a very well known about earlier incident. I suspect it’s hard to ‘forget’ being present when someone dies whatever the circumstances…

In an NHS hospital.
In a bath.
And a second person dies in the same bath

Nah. It really shouldn’t take a police investigation, an unfinished HSE investigation, two ‘independent’ reviews and almost an inquest to not unearth this.

Moving onto the baffling and serious pile of crap, second review (Verita2). We declined to comment on the draft we received last summer. George Julian who represented us on the expert review panel similarly withdrew from the process. She details her 10 reasons why here. I wouldn’t recommend wasting time reading the review. It is truly nonsensical.

Sloven’s legal team clamoured to get Verita2 admitted as evidence to LB’s inquest while spending £42,000 [of public money] in legal fees to try to sink publication of the Mazars review. [This underlines how non independent Verita really are]. It was eventually published, to silence at the end of October 2015.

Last week (was it really only last week?) we were leaked a Quality and Safety Review written by a Sloven employee in August 2012. This clearly documents numerous failures at STATT where LB died and the next door unit, John Sharich House a few months before Sloven took over the provision. In Verita 2, Finding 5 states:

The trust undertook appropriate, adequate and reasonable due diligence into the quality and safety of the services prior to acquisition. The due diligence reviews did not identify any acute concerns about the safety of services in STATT. The more acute concerns were focused on the non-Oxfordshire services.

Mmm. Awkward. Gut wrenchingly, howlingly, awkward.

I emailed a Verita partner to say, erm.. little bit of a cock up here, matey. Twice. He emailed back, very sharpish, to say they’d seen the review I mentioned [clearly they hadn’t or they couldn’t possibly produce Finding 5] and there was no mention of the earlier death in the staff interviews. He finished by saying Verita ‘obviously investigated in detail the processes and practices within the unit – these underpinned the conclusions reached in the report’.

Blimey.

I think, in this inhumanely long, tortuous and consistently distressing journey we’ve learned there is nothing obvious on the part of the actions of any of the state, or state appointed representatives, other than deny, deceive, batter and deflect. Verita did (can’t even call it conducted) two, very well paid, reviews. Neither hold up to scrutiny.

I thought my email would lead to them seizing the opportunity to defend their independent, robust and experienced reputation. And turn a lens on their practices; retract, respond, revise and openly talk about what they will do in future to make sure NHS Trusts disclose all the relevant documentation. But that was before I read their website blurb.

[Fill in your own words here. I have none. And feel free to swear your fucking socks off].

I listened to a diverse set of papers in the last few days. Thoughtful, engaged reflections about listening to the experiences of people who may not be able to articulate their experiences in ‘recognisable’ ways. People who are too often silenced by the actions of others (including researchers).

About trying to open up, challenge and change academic practices (it was an academic conference..) We heard narratives about dementia, cancer, trauma, brain injury, hearing voices, autism, sexuality, child sexual abuse

I’m now thinking that there are some truly broken narratives in spaces you wouldn’t think to look.

prato

Just imagine

Just imagine. Nearly three years after LB died. After two ‘independent’ reviews by Verita were published. After the police closed their investigation into LB’s death because they couldn’t find any evidence that linked the Sloven senior team to the crap provision at STATT. After a two week inquest…

Just imagine you get sent a previously unseen document, anonymously, via My Life My Choice. A document which shows that Sloven knew that the provision on the Slade House site was crap in August 2012. Nearly three months before they took over the Ridgeway provision.

A Quality and Safety Review, conducted as part of the Governance Work Stream. That details lack of clarity in care plans, risk assessments not updated or appropriate, issues with RiO, lack of assessment from the wider team, dirt, lack of maintenance, crap about Mental Capacity stuff, and so on. And so on.

August 2012.

So everyone knew it was shite. Nothing was done about it. And our son died. He died. 

And Sloven buried the document.

Thank you to the person who sent it.

I think we’re back to corporate manslaughter territory.

Fuckingtosswankerybastards.

 

‘Oh Katrina,…’

I can still hear Shaun, from My Life My Choice, asking this question at the extraordinary (extraordinary) board meeting back in January:

Oh Katrina, you were clearly struggling. Why didn’t you ask for help?

While she has been strongly defending her leadership this week of course Percy ain’t a lone ranger and has a board and a council of governors to support her/ensure good governance. She also received offers of help from outside the trust. Gary Walker contacted her back in December, for example. You can’t accept help though if you don’t think you need it. And despite Shaun’s wise words, Percy continues to deny failings.  To the extent she refers to “alleged ‘failings'” in her latest report to the board.

This truly astonishing position, so far from any whiff of candour and transparency, makes me wonder how many senior bods in NHS England and the like have toe curling moments reading repeated Sloven protestations.

The jury determination at LB’s inquest was not alleged ‘failings’. The Mazars report does not contain alleged ‘failings’. The CQC  warning this week makes it clear that there are longstanding failings:

We found longstanding risks to patients, arising from the physical environment, that had not been dealt with effectively. The Trust’s internal governance arrangements to learn from serious incidents or investigations were not good enough, meaning that opportunities to minimise further risks to patients were lost.

[Howl]

The Sloven response to the warnings issued this week are so blinkingly similar to their response to the warning they received in March 2014. With no apparent reflection they are simply repeating the shite they dredged up two years ago.

The CQC state longstanding risks, Percy talks about recent concerns. The CQC say action was only taken by Sloven as a result of the warning notice. Percy says good progress has been made. In both responses, Percy talks about “agreement” with Monitor/NHS Improvement about what needs to be done. And takes them both “extremely seriously”. In 2014, she is going to sort it all out “over the coming weeks”. In 2016, “I, and the Board, remain completely focused on tackling these concerns as quickly as possibly”. Jaw dropping spin exposed again by Ally Rogers.

Back in December, when the Mazars report was published, Percy argued the trust wasn’t an outlier in not reviewing the deaths of certain patients. An argument so wrong given the content of the report it continues to baffle. Really? Did she really say that? In a typical Sloven move, she/they also tried to position the trust as leading the way in improving death reporting at this point. This extract from an ITV report;

kp bullshit

Spin extraordinaire. Complete billy bullshit. And George Julian laid the ‘not an outlier’ argument well and truly to rest with a monumental analysis of trust responses to the Mazars review published yesterday. George’s post demonstrates that many trusts are doing a good job (thank fuck). And responses to the Mazars report you’d  expect [in the real world that is, not Sloven spin city]. That is, a determination to scrutinise current processes to make sure they are effective. How we are still dealing with this tinpot bunch of exec muppets who clearly wouldn’t know what ‘Deliver improvements in our quality governance and Board governance’ [2014] means, remains beyond me.

petter and percy