Category Archives: Sloven Health

What if Sloven actually learned lessons?

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News today of another inquest in which the coroner identified failings in the ‘care’ provided to Louise Locke by Sloven. This inquest was delayed a few months ago after the documentation provided by Sloven was incomplete. Classic Sloven incompetence (or worse) that generates more pain. Nothing like having your mum’s inquest bumped to the new year because the Trust who couldn’t look after her in life continue to fail her in death. Nope. Nothing like it.

Anyway, Lesley Stevens was back on inquest duty. I can’t imagine how she gets out of bed of a morning given the awfulness she must sit through and defend on such a regular basis. Still, she gave the typical Sloven corporate speak end of inquest statement about lesson learning and yadiya blah bleurghdy bleurgh stuff. I’ve pulled together a table detailing a selection of these post inquest statements taken from newspaper coverage over the past two years or so. (And it’s probably worth another butchers (and a weep) at Rich Watt’s post about lesson learning from two years ago now.)

Learning lessons

What’s interesting here is both the emphatic insistence that lessons are learned and the immediacy with which Sloven claim to act; Immediately after her death; We have already undertaken a number of actions. Bearing in mind it takes months or typically years for inquests to take place these are strong claims indeedy. I remember Lesley Stevens talking the coroner and jury through the Sloven (apparently already) implemented improvements off the back of LB’s death at the end of his inquest. Fran was sitting at the back of the public gallery gently prevented by loving mates from repeatedly shouting out ‘That ain’t true. That’s not happening…’

What have they learned?

So what have they learned? Clearly very little. You can distill down the various shiny lists produced for the various coroners to a small number of categories; family involvement (red), staff training/risk assessments (blue), record keeping (mauve), care coordination and communication (green), clinical leadership (orange) and better decision making processes (brown). There are no new and dramatic lessons being learned here. Quite the opposite. Tired old non lessons that limply lie next to the dominant and empty vital and immediate action claims.

What will this achieve?

Then finally. The transformation claims. Less evident in the media coverage (thank goodness). If Sloven want a quick win from this brief analysis it’s ditch the big claims of improvement. Awkward. Embarrassing and fallacious.

sloven inquest commentary

 

What does all this mean? A few thoughts:

  • Sloven’s readiness to use loose phrases and recycled statements that bear no resemblance to proper action and accountability demonstrates their complete insincerity in actually learning or changing stuff.
  • The rote mechanical reaction and vacuous use of language needs to be challenged by the Department of Health, Monitor, the CQC, NHS England, the Clinical Commissioning Groups and the media, and held up to repeated and close scrutiny.
  • The fact they clearly are learning nothing from these preventable deaths demands urgent and effective attention. Hannah Groves died over three years ago and Sloven are still learning that they need to involve families and carers. Louise Locke’s inquest found that care coordination across agencies was still failing patients. Despite learning this at various points over the years.
  • And finally the space none of us really want to enter but has to be confronted. If Sloven had actually learned lessons, how many people would still be alive? Fuckers.

We’ve started to regularly discuss the futility of repeatedly making this shite visible only for it to be ignored. Busker John called round earlier and Rich said two or three times ‘Hey, tell John about the latest this, that and the other..’ Each strand of telling was worse and worse. Mencap gate. Louise Locke’s inquest.The latest (not yet public) whistleblowing detail. Harrowing stuff.

‘Blimey’, I said. ‘Imagine coming round and us just saying something like ‘Wow. Lovely sunshine outside…’

‘But it never stops,’ replied Busker J. ‘There’s always something new…’

Yep. And nothing ever happens.

Sloven and the snow sweepers

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I went to Helsinki this weekend. To catch up with my mate Ulla and her cheeky kidlets. The sea was frozen. There was a blizzard. And on the rooftops workers shovelled snow. Protecting pedestrians from risk of ice falls.

It was fun. It was blooming cold. A different landscape. Frozen sea. Frozen sea. Ice bucket lanterns. Life organised in negotiation/engagement with extreme weather conditions.

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In a blink I was back on the coach to Oxford. No snow. My phone working again. A text from Agent T alerting me to papers for the Sloven Governors meeting. Over a hundred pages. I half skimmed them, blearily peering out of the window at the passing motorway. Dull. Damp. Dark. No snow.

Among the jargon filled pages was a statement from a Mencap appointed governor. An extraordinary statement that went unchallenged at the time and was published in full in the minutes (p18). We should take comfort from the gap in training LB’s death has made visible and this could be an opportunity for Sloven to fill this gap. Followed by yet another non apology from the Board chair.

On behalf of the Trust, Mike apologised for the failings in care that had led to Connor’s death”.

I don’t know. I don’t know if Sloven are just uber shite or whether this level of unreflective, stupid, ill formed, half arsed minuted (and agreed?) commentary is typical to most Trusts. I hope the former because if it is endemic we are all fucked.

Meanwhile, a hastily (half) convened gaggle of Monitor/CQC bods with clipboards pitched up to vaguely look at the Sloven roof tops after publication of the Mazars review. Half wagging fingers at teetering snow. Empty gesturing. Missing the point. Deliberately missing the point. Which is almost too awful to contemplate…

It really doesn’t matter that certain people die [die?] early.

[Apparently three Sloven governors resigned at their meeting yesterday. And there is more whistleblowing afoot. Thank you].

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Experiencing Mazars, fuzzy boundaries and rank closing

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I was working through the open docs on my computer yesterday evening and came across a PDF called 2642_001. It was one of the numerous docs we received the week before LB’s inquest began last October last year. At that point (intense stress, distress, fear and anxiety) I skimmed through them.

I couldn’t remember this particular document. Discovered by a Sloven IT bod, buried in the dark and dank basement of the RiO system. RiO, of course, was the focus of many a boring and repetitive moment during LB’s inquest. [I’ve heard on the leak line that Sloven are currently trialling a new version of RiO… How much money, time (and lives) have been lost through such a clunky and craphole piece of software?]

LB was listed as living in Tadley, Hants. In stark contrast to the scrutiny Sloven placed on the Mazars review. Accuracy aint necessary in generating learning disabled patients records. Address? The moon. Diagnosis? Anything and everything to do with early (natural) death inevitable. His discharge date was 4.7.13 and discharge method ‘6-Client deceased’. [Howl].

Someone we’ve not heard of before ‘diagnosed’ LB with various things in this document. The speed of ‘cover up and protect’ activity very apparent here. Like the ‘Mother’s blog briefing‘ circulated within 24 hours of LB’s death.

death diagnosis

Astonishing for so many reasons. But not surprising in light of the Mazars findings. Careless reporting of and burying unexpected deaths. Constructing ‘best case scenarios’ (i.e. nothing to see here). The Sloven way. While raking in vast sums of money to ‘provide’ care on a weekly basis. The cost of LB’s stay in STATT was around £3500 per week. PDF 2642_001 details he received 1 of a possible 40 specialist assessments. The Incident Management Assessment (IMA) we eventually received via the coroner [Sloven have right old sticky paws when it comes to disclosing any information] states that LB’s seizures were rare and nocturnal.

Fabrication. Fabrication. Fabrication.

Reputation. Reputation. Reputation.

The Mazars review

There has been no real action taken in response to the Mazars findings. Publication just before Christmas was cynically timed to facilitate deep burial of bad news. There’s no other explanation. The findings clearly present failure at Board level, a carelessness and disregard for particular lives and an unknown number of deaths which could have been prevented if earlier deaths had been investigated. A breach of human rights on an unprecedented scale in NHS provision. 

According to the Monitor CEO who I met very briefly with this week if the CQC flag up any issues on their unannounced inspection in the next two weeks [I know] they will consider action. In the meantime they will stick an Improvement Director in Sloven towers. There’s no other information about this Improvement Director.

Sloven meanwhile appointed an ex-Monitor Regional Director to their board this month. Fuzzy boundaries and all that. The stench from sordid and sneaky ‘deals’ seemingly conducted behind closed doors so depressing. I think one of the resounding sadnesses in the Justice shed is how much this experience has exposed (for us) the level of collusion, stitch up and corruption that operates (without check) within these publicly funded bodies.

We received a cheeky copy of Slovens internal briefing about the ‘unannounced’ CQC inspection last week [thank you]. This briefing can be summarised as ‘get the posters up, all hands on deck, persuade staff not to take annual leave till Feb and crank up the quality of death reporting which is still rubbish’. Farcical fakery and nonsense.

We’ve now had 2.5 years of Sloven dealings. Setting aside our personal experiences, documented at length on these pages, Sloven are clearly a ship with shite leadership at the helm. Board member performance (apart from some non execs) at the extraordinary board meeting on Monday was truly excruciating. The CEO, whose only connection to leadership seems to be the number of times she mentions the word, repeatedly deferred to the Chief Operating Officer who cooed beside her awkwardly. When asked directly how he felt about being cosied up with the leadership trinity of Percy, Petter and Grant, he broke into an overly long speech which included the word ‘proud’ so many times I expected the Dambusters film score to burst out from some hidden speaker in the cramped and heated room.

You could argue (and I’m sure that the Monitor/CQC/NHS England trinity have) that being faced with a room full of raging members of the public after publication of an incredibly damning report can only be unsettling. But there’s no evidence of effective Sloven leadership in any setting/context. A focus on expensive nonsense like the ‘Going Viral’ programme; an inability to see that they are spending money on crap consultancy;  minutes and quality and annual accounts you can drive an Eddie Stobart truck through;   recorded performances online that are unconvincing... The list is endless.

A favourite in the Justice shed – Woman on all Fours – is just one example of this:

Humour aside. It’s clear that people are dying early and unexpectedly in this organisation. Denied the opportunity to lead everyday lives. Doing stuff that other people just do.

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Sloven routinely ignore and cover up the deaths of certain people. We know this. And this is apparently acceptable across NHS England, Monitor and the CQC.  Perhaps it’s time for some honesty (candour and transparency) across these publicly funded bodies. Either have the guts to say that some lives aren’t important and if these people die early, that’s fine.

Or fucking do something about it.

Post-mortem stuff

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Warning: upsetting content…

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A coroner concluded that 24 year old Sarah Davies died of natural causes due to unknown origin this week. She was found dead in the Tarry Hill ‘care’ ‘home‘. The pathologist originally said she died of SUDEP (sudden death through epilepsy) but changed his mind during the inquest and said her death was unexplained. He admitted he hadn’t sent samples of Sarah’s brain for further analysis as he should have done. Sarah’s family are understandably distraught to not get any answers from her inquest. [Matt O’Donoghue live-tweeted the whole hearing. It’s harrowing reading. And uncannily similar to LB’s inquest.]

When it emerged there were serious omissions on the part of the pathologist at Sarah’s inquest I was pitched straight back to the week after LB’s death. That baking, baking, long, hot summer when our lives were shoved into a black hole of insensible grief, horror, anger and incomprehension.

Charlotte, our newly appointed solicitor, working with INQUEST, advised us to make sure the pathologist followed the guidelines for patients with epilepsy. Unimaginable phone calls. A house full of people. Flowers. Tears. And terrible decisions to be made. He hadn’t. He hadn’t? They were ‘just guidelines’. I still can’t write much about this episode.

Some emails from this time …

The reason I mentioned a second post-mortem is because the current cause of Connor’s death is unascertained and it may be that a different pathologist could assist in providing further clarification, or it could be that Connor’s case is one in which the post-mortem examination itself cannot provide clear answers. I am sorry to be so blunt but I want to be sure that you can make an informed decision. (received 10.7.13)

In terms of a second autopsy, Connor has been moved to the funeral directors and we’re reluctant (though would if it would make a difference) to have a second postmortem. (sent 11.7.13)

I did say to the coroner that the guidelines are written with a view to persuading family members who may be resistant for whatever reasons to the sampling of the brain tissue and we weren’t consulted. (sent 12.7.13)

After a bit of a battle with the coroners office because they were reluctant to do anything, they’ve taken the brain tissue sample and Connor is now back at the funeral directors, thank goodness (my levels of what is ‘good’ are so low after this latest mess up). (sent 12.7.13)

[Howl].

When LB died I’d been blogging about him and we were given advice via twitter about what steps needed to be taken. I’ve not revisited the failed post-mortem thing since. I can’t imagine how Sarah’s family must feel. No answers because essential tests weren’t conducted.

Just because.

Because Sarah and LB’s (and many other) lives simply don’t count. And in death they aren’t worthy of the typical and expected scrutiny applied to others.

It’s inhumane families have to fight to get answers in these circumstances. And, if they ain’t armed with the relevant info, the space to get answers or accountability is severely compromised by (further) crap actions by professionals. We  shouldn’t be policing whether post-mortems are conducted properly. Or be consigned to a netherworld of no answers when this well documented process is cocked up by professionals on inflated salaries and no whiff of accountability.

I’ve not got a typical punchy demand some action end bit here. With a hefty swear or two.There doesn’t seem any point. I’ll just end with another email extract from that week.

I think this search for answers/campaign or whatever it is or becomes, is important. (sent 12.7.13)

One of those days

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I went to work this morning via a brief meeting with Monitor. Based near Waterloo Station. After publication of the Mazars review in December I was invited to meet with Monitor to:

discuss the process which we are going through, jointly with the CQC, to establish the key issues which require addressing to ensure improvements are made at the trust and that the wider concerns raised by the report are addressed.

I chased up this meeting last Friday and it was arranged for 9am today with the CEO, Medical and Nursing Directors and Complaints Manager. Assuming the key issues issue was still open, I set off on the Oxford Tube at 6am. A front of the bus experience.

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After introductions, the CEO began by apologising for LB’s death. Bit odd, really after all this time but a solid apology. I wondered if the Tom effect is spreading. We moved on to what Monitor is going to do about the Mazars review and Sloven. Very little really. The Mazars review is being read carefully, CQC will inspect and if failings are identified Monitor will act on them. Apparently. There was no evidence to remove Board Directors/CEO.

At this point my heart slowly melted. Having sat through over two hours of the Sloven ‘extraordinary board meeting’ yesterday when the only two words the CEO and Board Chair could string together were ‘action’ and ‘plan’. And the action plan they presented lacked clarity and included typos. Hearing My Life My Choice trustees describe their concern about safety in Slovens ‘care’. Having read the Mazars review. Having experienced over two years of relentlessly crap actions. Having heard so many other harrowing tales from families…

These words made no sense to me.

Sitting round a table, on the third floor of Wellington House, I lamely raised a few issues. Like how it probably wasn’t a good idea to take shiny new Sloven policies at face value. Despite their epilepsy toolkit no Sloven staff member at LB’s inquest demonstrated any knowledge of epilepsy two years after his death. And so on. Stuff written over and over again here and in other spaces.

There was no discussion. Whether that was because I was clearly so incredulous, enraged and upset or whether it was because there wasn’t really anything to be discussed I don’t know. Action was clearly already decided and agreed with Sloven. I asked what I was doing there. To receive a formal apology was the answer. The meeting ended at 9.06am. Publication of the Monitor press release pretty much beat me back to Oxford. A six hour round trip. For a six minute meeting.

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So what is the action? Sloven have agreed to implement the Mazars recommendations, get expert assurance on these improvements and Monitor will appoint an Improvement Director “to support and challenge the trust as it fixes its problems” I’m reminded of some pretty bizarre conversations back in 2014 when we were encouraged by a few people, including David Nicholson, to meet with the Sloven CEO to help her to understand where she was going wrong and ‘find her way’. How anyone can maintain a leadership role when they are so clearly out of their depth is beyond me.

Of course there were Monitor enforcement actions back in 2013. And Sloven put the same jolly spin then as they have now; just a few weeks of ‘working with Monitor’.

On the way to work, I just thought about how we were kidding ourselves that anyone (senior) in health and social care really gave a shit about learning disabled people. The Mazars review is a truly shocking report and the only appropriate response so far has been demonstrated by the discussion in the House of Commons when it was leaked. I was reminded of Rob Greig’s anecdote when he was told years ago by a CEO that jobs aren’t lost over the learning disability agenda.

We ain’t really progressed at all. Sadly. #JusticeforLB has contributed more than than most of the highly paid/rewarded people/organisations in this area for two years now. We have no budget and the work is done in our spare time. That is, pretty much every minute outside of our working hours. I think it’s fair to say that morale in the shed is pretty low right now. I’m just glad we’ve shone a fierce light on the shameful practices and fakery of NHS and local authority practices. Practices done and sustained by people.

Update: I received a briefing about the Monitor meeting this morning (13th Jan) from NHS England. You couldn’t make it up. It says Monitor will announce their actions on Jan 12th. So the 9am meeting was purely about squeezing in a meeting with me before then. A meeting for the sake of saying they’d met us. Breathtaking. Six hours travel for a 6 minute meeting. And no expenses paid.

 

 

 

 

 

Chairs, ships and learning journeys

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I keep meaning to write something about the money Sloven spent on legal representation to defend their reputation during LB’s inquest. My Life My Choice received this information from the Sloven Board Chair earlier this week. £300,000 apparently. £300,000. And we are to blame. Yep.

But as always a new bit of Sloven crap is always around the corner. Tonight this included a reply to my painstakingly written letter (emphasis on the pain) to the Council of Governors (which is chaired by the Board Chair) from the Board Chair. [I know]. Here it is, with my thoughts in bold.

Dear Dr Ryan and Mr Huggins

Thank you for providing me with a copy of your letter to the Council of Governors of Southern Health NHS Foundation Trust. Firstly can I take this opportunity on behalf of the Board, Council of Governors and the Trust as a whole to unreservedly apologise for the actions that caused the death of your son, Connor, and the hurt that you have been put through since that time.

It’s worth returning to Ally Roger’s superb undergrad dissertation here. Ally talks about passive sentences which are constructed to show no one is responsible. She says such manipulations of participant responsibility may or may not be deliberate. ‘The actions’ and ‘the hurt that you have been put through’ used here suggest that the Board Chair ain’t really taking ownership of the flourishing apology he offers. 

Connor’s death was preventable and this is accepted by the Trust and we are truly sorry that he died.

I’m dunno why we keep hearing this ‘accepted by the Trust’ line. A more heartfelt ‘We know LB’s death was preventable and happened because we failed to look after him properly. We take full responsibility for his death’ is more appropriate. Where does ‘accept’ come from? It’s so grudging, particularly when it was bleedingly obvious from the second it happened that LB should never have died [Howl]. Such peculiar and upsetting phrasing. I don’t doubt the truly sorry bit here which is owned of course. They must rue the day really given everything that’s unfolded.

In your letter you refer to the Mazars ‘review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust’ recently published.

So the only point picked up by the Board Chair in his response to my lengthy and detailed letter is the Mazars review. Wow. All the other stuff, like the upset and distress caused to our kids by the actions of staff during the inquest (and the content raised during that two weeks) just dismissed.  The focus, as ever, on the reputation stuff. 

It is worth putting on record that the Trust accepts the recommendations contained within the report. We fully accept that the quality of processes for investigating and reporting a patient death required improvement.

The hole digging just gets deeper and deeper. Putting on record? Eh? The Mazars review clearly details the extent of failings. The pre-publication challenges were dismissed. Sloven cocked up. No one (well outside of Monitor/CQC/Dept of Health) is asking if Sloven ‘accept’ the findings. This repeated positioning can only demonstrate how deeply dysfunctional the organisation of the ‘NHS’ is. 

As the report observes there is a lack of clarity across the health and social care system regarding which agency should investigate deaths of patients in the community where they are being seen by a number of different health and social care organisations and we are keen to see clearer protocols put in place.

And bam. Straight back into their already familiar refrain; ‘We ain’t the only ones who allow people to die early and cover up their deaths…’ A truly rancid position. Underlining how this bunch learn nothing. How anyone responsible for such scandalous failings can turn round and say ‘Well, other trusts are just as bad’ makes me weep. For so many reasons. 

Such a morally, ethically and professionally impoverished argument. And for this, if nothing else, the Board and CEO should stand down. 

[One question I think about is what can Sloven/OCC do now?  Have we, as a family/campaign, been kicked into a space where nothing they say or do will wash? And if, yes, what does that mean? Typically, from what I can see, families are sooner or later presented as irrational and unworthy of engagement. Shoulder shrugging professionals demonstrate mild bafflement, back away and appeal to establishment cronies for pity/solidarity about being in a deadlock situation with such ‘problem’ people.

This week I was choked to receive a thoughtful response from a Sloven Governor. My response was to immediately flag it up on these pages and welcome it. [Sadly, she turned out to be one of two governors who beetled out of the meeting on Tuesday straight after recording was agreed… but I’m just about holding onto the genuine sentiment expressed in her email.] I spoke to another governor after the meeting. He seemed to get it. He was human, didn’t talk shite and we’ll probably meet him before their next meeting.

The point I’m trying to make here is that families don’t want to battle. And they don’t tend to choose to battle. They are forced to. The rage comes from the need to battle and what this need says about their relative who has been harmed. This rage is deepened too often, by careless, fake, ill informed, offensive and meaningless responses…]

We are working on a range of improvements to the way that our Trust reports and investigates deaths and these are being discussed with the Trust’s key regulators and commissioners. Although much of the work has started the Board will be formally approving this plan at the extraordinary meeting on Monday 11th January.

Yep. Of course. White noise. What relevance is this to the issues I raised in my letter? This again is purely reputational repair shite. 

The report identified and the Trust acknowledges that engagement with families and carers has not been to a good enough standard and this is an area that will be receiving particular attention going forward. I and the Board have a genuine desire to ensure that this Trust continually improves.

The Mazars report isn’t the first time non engagement with families has been identified in Sloven dealings. Here is an example from two years ago. I can remember when Rich Watts wrote this post. Before any sniff of the Mazars review existed. In response to the publication of Verita 1. When we naively (so blooming naively) thought that learning from LB’s death would shake up Sloven’s learning disability provision. To make out this is a newly identified issue is deeply offensive. Typical though of the Sloven way which is all about erasure. They try to erase every example of wrong doing by rigidly fixing on the future. It’s a form of bullying really. Dressed up as a ‘learning journey’.

I would be more than happy to meet with you and others to discuss what other improvements could be made so that we can ensure that lessons are properly learnt from Connor’s death and your experience of Southern Health NHS Foundation Trust.

The meeting ship has well and truly sailed, Mr Board Chair. In typical Sloven shitilla fashion. You have missed and/or stamped on every opportunity to do anything differently since LB’s death. And this non letter is further evidence of this. 

Step down. Move on. And allow genuine leadership to take over. [And please don’t attempt to fawn over us at the meeting on Monday.]

Yours sincerely

Explaining #JusticeforLB to a child

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IMG_0112-2Well LB was a bit older than you. He was very funny, loving and loved buses and Eddie Stobart lorries. He got upset and a bit low when he was 18 and ended up in hospital. It was a special sort of hospital. It cost more money each week for LB to stay in that hospital than most people earn in a month. It was run by a bit of the NHS called Sloven. The NHS is supposed to look after everyone in this country when they are unwell.

It turned out that Sloven didn’t really care about patients like LB. Or care about some of their staff.  Staff became fed up and some became pretty rubbish at their jobs because of this. They stopped looking after patients properly. LB had a thing called epilepsy which meant he could suddenly pass out. Staff knew this but the doctor in charge told them it wasn’t a problem.

One day LB was in the bath alone (which he shouldn’t have been) and passed out. He went under the water and died. We felt our world had ended. Sloven pretended LB would have died anyway. They said he died of natural causes. But people don’t usually die in the bath (or when they are 18).  Instead of being able to feel sad and think about our beautiful boy we had to fight to get Sloven to admit LB died because they didn’t look after him properly.

Sloven refused to do this and the people, like NHS England or Monitor, who were supposed to make sure Sloven did the right thing didn’t. Nobody who should have sorted this out, did anything. Usually when you work you have a boss who makes sure you do your job properly. And your boss has a boss. It turns out, in the NHS, the bosses of bits of it can do whatever they want. The Sloven boss, called Katrina Percy, and her senior team just carried on behaving badly.

We were worried some other people might have died because they weren’t cared for properly like LB. The boss of NHS England agreed to pay for a review into other deaths that happened in Sloven’s care.

Meanwhile, a lot of other people, all sorts of people, joined in the fight to try and get Sloven to take responsibility for LB’s death. They did all sorts of brilliant stuff. Sports stuff, music stuff, they made films, animations, held cake sales, did embroidery, gardening, drew pictures of buses, flew flags, put LB’s name on buses and trucks and all sorts. Lots of people began to know who LB is. There was lots of fun, love and happiness about LB and people like him.

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The trouble is, all this fab stuff didn’t stop Sloven behaving badly. They lied to us (and others) and tried to stop us finding out what happened to LB. They spent more money than some people earn in a lifetime on lawyers to do this. Money paid for from people’s taxes. Luckily, some brilliant human rights lawyers and barristers helped us. The inquiry into LB’s death, run by someone called a coroner, found that LB died because he wasn’t looked after properly. He should still be alive.

The report into the other deaths also found that Sloven didn’t care about lots of people like LB. When they died suddenly Sloven said they died of natural causes and didn’t try to find out why they’d died. Sloven were furious about this report. They said it was rubbish and tried to stop people reading it. Then they argued that other bits of the NHS were just the same. Allowing certain people to die early and then say it was natural causes.

We think Sloven don’t really think that LB and people like him are proper people. That’s why they didn’t do anything when they died early. Like a lot of things, they’ve got this completely wrong. We just need to work out what to do about it. Because LB’s death has shown us just how badly some people are treated in this country. And how those people whose job it is to actually do something about this, don’t really care either.

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891 days and Sooty tear time

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It has taken 891 days to receive a genuine, heartfelt response from a senior level Sloven/Oxfordshire County Council related bod. 891 days..

Serious Sooty tear time.

Dear Dr Ryan

Thank you for sending me a letter to the SHFT Council of Governors about the Mazars review of deaths.The letter has been circulated to all Governors.

I am happy to ensure that the points you make in the letter are shared at the meeting tomorrow but may not be able to provide an immediate response.

On a personal note, I would like to say how sorry I am about Connor’s death. I would be doing exactly what you are doing had he been my son.

Regards

Helen Keats

 

Thank you, Helen Keats.
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2016. Starting as we mean to go on.

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I don’t know. I don’t know if it was Chunky Stan’s death this week which was so blinking sad but immensely peaceful. Or the start of a new year. But the Justice shed is cranking up the volume. Enough is enough.

First. A letter to the Southern Health NHS Foundation Trust Council of Governors:gov 1

gov 2

gov 3

gov 4gov 5

Trust(s) and scandal

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No rest for the (lay) self congratulatory. Clearly. A few days after posting about #JusticeforLB related achievements, the Guardian removed their front page story about non-investigated NHS related deaths. Because of complaints (plural). Any naivety we entertained around other NHS Trusts learning from Southern (Sloven) Health NHS Foundation Trusts heavy handed and inappropriate approach to the Mazars review, disappeared. [I know..]

We’ve heard, on the grapevine, that a few Trusts are taking the Mazars/Guardian story findings seriously. And proactively exploring their own practices in relation to deaths of learning disabled patients. This is bloody brilliant.

The challenge to the Guardian story is deeply depressing though. Headline figures of the number of deaths investigated compared to number of (allegedly) unexpected deaths (from the now removed Guardian story) remain harrowing:

Somerset Partnership NHSFT 0/146
Northamptonshire NHSFT 0/63
Rotherham, Doncaster and South Humber NHSFT 0/28
Leicestershire Partnership NHSFT 1/116
Dorset Healthcare University NHSFT 2/97
Derbyshire Healthcare NHSFT 1/23
Sheffield Health and Social Care NHSFT 1/23
Leicestershire Partnership NHSFT 1/13
Penine Care NHSFT 1/10

These figures are from a Freedom of Information (FOI) request by the Guardian that asks different questions to the Mazars review. The latter found that Sloven investigated less than 1% of the total deaths of learning disabled people under their care. Less than 1%... We don’t know the exact questions the Guardian asked but whatever questions, it’s blooming clear there’s an almighty stench here. With a range of whiffs.

Some published challenges to the Guardian piece;

Somerset: these deaths were expected not unexpected.
Northamptonshire: these deaths were expected not unexpected.
Penine: the figures provided related to community and not inpatient provision.

Wow. What (particularly) stinks here is that the Mazars review, subject as it was to unprecedented (and, at times, offensive) levels of scrutiny, contains the answers to pretty much any challenge offered by Somerset, Northants and the like to their death practices. It clearly states that Initial Management Assessment (or whatever these tick box exercises, completed within a day or so of death, are called across different trusts) are not ‘an investigation’.

There is a circularity here of course. The filling in of this initial paperwork flags up that there is some level of unexpectedness, that ‘an incident’ has occured. That this is the only step taken is further evidence of the scandal gradually being uncovered.

The Mazars review underlines how there is no clear definition around what constitutes an ‘unexpected death’. A chilling position for learning disabled people who, all too often, are perceived to be of ‘inferior stock’ by health and social care professionals. Mazars used the Sloven policy which states that unexpected deaths are those that occur without anticipation or prediction, or where there is ‘a similarly unexpected collapse leading to or precipitating the event that lead to the death’. Sloven, as always, exemplary in the production of policies here (while their practice kicks back to the very edges of care, interest or humanity).

The problem is, if your death is perceived to be expected whenever (or wherever) it happens (including if you’d just got into a bath, in an NHS unit, with four ‘specialist’ staff members and five patients, in anticipation of a trip to a much loved bus company, aged just 18) then you ain’t got much of a chance. [And really, Somerset and Northants.. can you seriously argue that not one of those 209 deaths were unexpected? Not one…?]

What both the Mazars review and Guardian story (and the earlier Confidential Inquiry published in 2013 …) demonstrate (in addition to the arrogant, short sighted and bullying actions of some Trusts) is:

  1. People labelled ‘learning disabled’ die considerably earlier than people who ain’t considered ‘learning disabled’.
  2. These deaths are typically expected and are, therefore, rarely categorised as unexpected.
  3. It is all too easy to label these deaths as ‘natural causes’.
  4. Existing NHS ‘death’ processes are unfit for purpose because of 1-3 above
  5. Recent reviews/newspaper reports and the associated responses by various Trusts to these should raise unmissable red flags to NHS England, the CQC, Monitor and the Department of Health… but we know they won’t.

The lives of certain people, like LB, simply don’t count. The extraordinary resistance to the publication of the Mazars review and post publication challenge to the Guardian story underlines both the existence of scandalous practices in the NHS and, as importantly, a refusal by those entrusted with the wellbeing of patients, to recognise what they are actually doing.

Here’s to 2016 being the year in which these practices are rootled out and stamped on. Surely.