Category Archives: Sloven Health

A potpourri* of learning, ‘craftivism’ and fun

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One of those maelstrom twitter/social media type few days where all sorts of stuff cropped up. From different directions. A chunk of stuff about learning. We learned that the Health and Safety Executive are picking up the investigation into LB’s death from the police. [We sort of knew this but it was confirmed which is always good in our post 7/2013 experience]. And the interim board chair of Sloven is now the new board chair.  Mike Petter’s involvement with Katrina Percy pre-dates the creation of Southern Health, going back several years. Mmm. He now chairs a board that has, so far, demonstrated little engagement with what happened to LB (other than allowing continual obstruction and delay). And silence about the potential sale of the Slade House site. The original #107days included fab reflection by Amanda Reynolds on ‘What’s a board to do?’ I wonder if the Sloven Board ever asked themselves any of the questions she poses. Suspect not but they could always do it now.

Ho  hum.

One message I received the other day was for a question/s to challenge social workers/nurses who were going to be shown the Tale of Laughing Boy. The film is being used in several arenas to spark discussion among students/staff/senior teams in both health and social care. This is great. It’s a brilliantly produced film that captures love, humanity, common sense, crap and catastrophe. A lovely mate/legend told me recently it says everything she’s always banged on about person centred care in 15 minutes without any mention of ‘person centred care’.

So. Some suggested questions (relating to adult social care/in no particular order) for frank and open discussion in tandem with watching the film:

  • Do you ever/sometimes/often think parents are a pain in the arse, obstructive and make doing your job more difficult? If yes, what makes you think this? Why do you think they behave like this?
  • Have you/your team tried to find ways to resolve this tension and develop a productive relationship with families? If yes, how? What worked? If not, why not?
  • What would you think if a family member/person was blogging or tweeting about your service? What would you do? Do you think they should be ‘allowed’ to do this? What are your views about social media in the context of your work?
  • How often do you think about the aspirations/potential/value of the learning disabled adults you are involved with? Can you give some examples of how you’ve encouraged/enabled them realise their potential? Or things that have obstructed you doing this. If you don’t think about aspiration/potential why do you think this might be? 
  • How might health and social care work better together to ensure that what happened to LB (Nico Reed, Thomas Rawnsley and the many, many others ) doesn’t happen again?
  • Do you think the response of public bodies towards families after such catastrophic incidents is acceptable or reasonable? Can you identify the moments in which something different could have been done? Why do you think there is little apparent shift towards transparency and candour?

These points are just flung out in the hope of some productive discussion. Please add your own questions or reflections below. At some point, we’ll try to pull together some constructive thinking about what’s happened so the more thoughts the better.

More cheerful biz in the last few days involved the launch of the latest #JusticeforLB crowdsourcing request. New, deliciously creative, action to get involved in (details here).

I’ll sign off with my fave (I think) Chicago photo in this potpourri* of a post. Because it captures light, delight and fun.

 

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*I bloody hate potpourri.

Desperate lady and the four Ds

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L1015447The missing Subject Access Request (SAR) info has pitched up from Oxfordshire County Council (OCC). A glimpse into OCC tower skedaddling after dropping the secret review bomb on us in March. It still makes no sense to me. This whole secret review business. Or OCC’s apparent inability to understand how we feel. One senior person wrote in an email;

“It feels we allow this desperate lady to shake us all…”

Desperate ladies and faux reviews. We clearly need new words to capture these processes. An ‘independent’ consultant brought in (at what expense?) to work with a public sector body to produce… erm, what? Statements like ‘commissioned an independent consultant/organisation’ are trotted out so readily by these organisations, promising so much, so official. Strip em back and it can simply be dosh passing hands to produce pretty much nothing dressed up as something.

OCC continue to describe the review as an ‘internal review’. Rank dishonesty that no body seems prepared to challenge. No one has stepped up to say ‘You shared LB’s records without telling his family, paid someone to conduct an investigation into what happened without involving his family, and circulated a report to various organisations before his family knew the review existed? What the fuck were you thinking? 

Desperate ladies. 

We’re increasingly disturbed by the ease in which conjecture, subjective judgement and sweeping statements are made and presented as incontrovertible ‘facts’ by reviewers/public bodies. Untouchable bodies. Untouchable processes. Meanwhile, what families say or do is dismissed or discounted. Individuals derided and discredited. The four Ds. I was given the opportunity to comment on the review so we should stop bleating about it or make an official complaint. Public bodies protected by a veneer of respectability that bears little scrutiny but remains remarkably enduring.

What a old shitty business.

While OCC were posting this latest, late, info, Rich and I were in Chicago. Attending a session dedicated to LB at the Society for the Study of Social Problems annual conference*. Last year, a motion proposed by Mark Sherry was unanimously passed demonstrating SSSP support for how simply wrong what happened to LB was. Sitting in that session, on the other side of the Atlantic, I couldn’t help reflecting on how most people just get this wrongness. People in the audience who knew nothing about LB gasped when they heard what happened. And yet we’ve had over two years of crap thrown at us by public bodies. Crap that has, ironically, according to Mark Sherry in his presentation, contributed to the strength of support for the #JusticeforLB campaign.

Plenty of learning in this. If Sloven and OCC can ever get beyond their positions of prickly defensiveness and refusal to listen and reflect.

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*More on this to follow.

True detectives, (in)justice and the law

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[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 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

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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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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

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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. 

 

Thanks (it was his tongue btw), Sara

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We went on holiday last week. Starting from the battered position of getting the ‘updated’ version of the OCC ree (I refuse to call this a report as it bears no resemblance to anything I’d call a report) at 5pm, the day before we left. The issue of records cropped up again when we were away. Relating to whether LB bit his tongue or his lip in the unit.

This is a nonsensical question that underlines the importance of families documenting interactions with health and social care professionals meticulously. And even then, how their records are not really records.

In a complete panic, back in May 2013, I emailed the STATT manager to say that LB had had a seizure and accidentally typed lip instead of tongue. This typo has become part of the official record and has seeped into both the original Verita report (extract below) and the documents for the coroner.

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It was a typo. One I realised and corrected the following morning, first thing, in a follow up email to the manager who’d replied to say he had contacted the consultant.

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This email didn’t make it to the ‘official record’.

The lip/tongue question remains an issue. A confounder in getting accountability for LB’s death. [Yes, he died. He drowned. You fuckers].

This raises so many questions about what families can do to make sure their records, their version of events, are treated with respect and fully engaged with. To avoid being dismissed, misrepresented or ignored.

I typed lip instead of tongue that evening because I was so intensely distressed by the thought LB had an unwitnessed (unwitnessed??) seizure in that place. It was a simple typo.

Back from holiday. Sitting at the computer on a sunny Sunday afternoon to gather more evidence that fell outside the official Sloven/OCC record, I can’t help asking;

Really? Are you really making us go through these hoops?

Why?

Records and the internet web log

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In a superlative moment of classiness, the OCC Director of Social Care sent me a red flagged email at 5pm this evening with a revised version of his shoddy little review. And responses to my concerns.

Yep. 5pm on a Friday evening. I hadn’t had a bad day up to then really. I had an emergency appointment at the dentist because my tooth cracked the other day. No big deal in the toxic world of trying to get accountability from public bodies. I then worked at home reading a thesis and catching up on other tasks. Halfway through reviewing a book chapter (deadline today/ironically about social media use) the email pinged in. End of that review. Instead the typical and now familiar deeply intense rage, frustration, bewilderment and distress.

LB died. He’s dead.

Why the fuck are we dealing with shite still?

[Brief background to the review; OCC commissioned an external consultant without telling us. They sent the review to Verita. Verita said we should see it. OCC emailed it without warning back in March. Under duress I identified the inaccuracies.]

The only good thing I can say about this latest documentation is that a potential PhD student now has more ‘riches’ to pore through and analyse in trying to understand the workings of public bodies under challenge.

The revisions to the original report? Extraordinary.

A few examples…; SR says x, y or z but “there is no record on file to this effect”. “There is no file record of that contact. SR advises that it took place.” “The Care Manager arranged a further visit on 31st August to meet CS, but 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.” He even states there must have been two meetings on one day because I said the care manager wasn’t present and the record says she was.

What is actually happening here? Why do ‘records’ trump what happened? Apparently there is no ‘record’ that I waited in all day for a visit from the care manager who was a no show. Parents/families now responsible for making sure social services keep accurate records…

What makes these partial, half arsed and biased ‘records’ the ‘truth’?  I asked OCC to look at the different interpretations of one afternoon where the OCC ‘recorded’ version was sanitised off the planet. My blog presented an alternative description of an afternoon etched in my brain.

Completely misunderstanding my point, the response today was;

SR has recorded a different perspective on her internet web log. Having reflected on the implications of this comment, I have added a recommendation to my report that OCC provide guidelines to staff, service users and the public that postings on web based social media are not part of the case management or complaints and comments procedures. I do not consider it appropriate to comment on a social media posting.

There is a clear issue here that public bodies don’t get social media and see it as something threatening. Which it isn’t and shouldn’t be. [This was in evidence earlier today. Sloven while hosting a shindig for their learning disability/mental health staff started blocking campaigners on twitter when challenged about inaccuracies (or simply asked questions)].

I’m not claiming my version of what happened that afternoon is more ‘truthful’ or that local authorities/NHS Trusts should be looking for clues about their patient care on blogs or social media. I’m saying that ‘official records’ are not infallible. They are created by people. Like this blog is. Or any other account of something. It’s ludicrous, short sighted and problematic to only accept what is written in a particular space, by a particular ‘professional’, as ‘truth’. As the revisions of this craphole report demonstrate.

I suspect part of the (sustained/tooth shattering) battering we are getting from Sloven and OCC is due to our use of social media. The ‘records’ are under threat. Emails/tweets/posts contradict and challenge official versions. We’re shining an unwelcome light on stuff that has probably gone on in darkness for years. And doing things the ‘wrong way’.

You can’t shout down, bully, deny or try to ignore what is perfectly legitimate challenge to a system that is steeped in wrongness. A wrongness recognised by those beyond LB’s family or friends. To try to do so is to show contempt for democratic processes. For basic human rights.

The only way there will be any resolution – not for us because that clearly ain’t going to happen – is for NHS Trusts, local authorities, regulators, the Department of Health, government, etc, to embrace the use of social media. To engage with patients, people, constituents and use these interactions as a resource. Something valuable and insightful, not something to be feared. Something to build on, work together and thrash through challenges, obstacles, difficulties…

As much as OCC, Sloven and others may resist or dislike it, the future is the internet web log.

The Tale of Laughing Boy

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This year #107days ended with the launch of The Tale of Laughing Boy produced by My Life My Choice and Oxford Digital Media with funding from Oxford City Council. Tommy, Tyrone and Shane from MLMC worked with Oxford Digital Media (who gave their time – blooming shedloads of it – for free). Saba Salman has written a review of the film here. Since the online launch there has been a remarkable response to the film.

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It’s being shared widely as it should be by a range of people and organisations; CQC, providers, commissioners, charities and other third sector organisations and people. Even Mencap.

A screening was held last Thursday evening at the Old Fire Station in Oxford to a full house. Including our MP, Andrew Smith, BBC Oxford news (tv and radio) and the Oxford Mail. Andrew Smith, love him, was all over Sloven’s potential ‘land grab‘. Absent were representatives from Oxford City Council, Oxfordshire County Council, Oxford Healthwatch and the Oxford Clinical Commissioning Group. Typically staunch supporters of the work of My Life My Choice.

I was chatting on Skype with a colleague yesterday. He’s arranging a screening of the film at his university over a lunchtime. He was shocked when I mentioned the Oxon screening boycott. He couldn’t understand how people (ordinary, decent people) can seemingly so easily ditch their humanity and act as state agents.

I gave him the briefest outline of the early, and as yet unpublished, findings from the Mazars death review.

He visibly froze.