Kerching and Katrina

I am absolutely delighted that we’re going to be forming a partnership between Southern Health and Ridgeway. I believe our combined effort is really going to provide superb world class services for people with a learning disability across the whole of the area we cover.

Katrina Percy, Sloven CEO, March 2012 

What Katrina Percy forgot to add to this ‘welcome to my empire’ speech was… and if we cock it up, we’ll flog the Slade House site and other Oxfordshire land for a massive profit and buggar off back down south.

Yep. For some reason [piss up/brewery/Oxfordshire County Council?] there was no penalty type clause in the contract awarding the tender to Sloven. Gifting them land and property worth millions. Rumour is the Slade House site will be used to develop student accommodation.

Astonishing.

Andrew Smith, our bloody brilliant MP, and our equally fab local BBC Oxford news team are all over this. As Andrew Smith said in an interview last week; “This is unacceptable to the public, unacceptable to LB’s family and unacceptable to me. I will fight it.” Good.

Sloven – any thought of providing ‘superb world class services’ for learning disabled people long gone – issued a statement saying ‘We are carefully considering our options. No decision has been made’. ££££££Kerching££££££££. The Department of Health issued a statement saying something like “er, none of our business, piss off and sort out your mess locally.” A teensy bit shortsighted really.

Hmmm.

If Sloven think they are going to profit from LB’s death and parasite this money out of the county, their reputation management indicators will be flashing London bus red for some time. As simple as. It’s just wrong.

Of course they may do the right thing without a fight. That would be priceless.

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LB’s buses at the end of yesterday

 

#107days again… Er, really?

Naive beyond naivety. We were pitched into a completely devastating, toxic, harrowing and obscene space/journey on July 4th 2013 without warning. In an instant. From pretty much nought to a billion with the opening (as kind and sensitive as you can possibly be in the circumstances) words of an A&E consultant. On that baking, baking hot July morning. The snuffing out of a young life and unleashing of horror, devastation, disbelief and pain that defies description.

From thinking about the prom on the bus to work to autopsies, coffins and cremation.

We had no idea then that two years later we’d be locked in a foul, stench ridden, rotten corner with both Sloven and Oxfordshire County Council (OCC) doing their best to extricate themselves from any responsibility for what happened. Sloven by withholding documents, pulling dirty stunts like arguing drowning is a natural way to die, sending bullying letters and consistent obstruction. OCC by conducting a secret and completely biased (non) investigation into what happened. We had no idea that the actions of both (public) bodies (and others who remain shadowy in the background through their non action) would actively add to and increase the intensity of pain and agony.

Bastards.

Naively and even despite the above, we thought that #107days this year (we never expected or wanted to have to revisit the almost spontaneous explosion of goodwill, celebration, solidarity, commitment, awesomeness and magic that unfolded last year) would incorporate the outcome of various ongoing reviews; General Medical Council, Verita and Mazars.

A nonsensical expectation.

Instead, we have no outcomes and an additional ‘thing’ to add to the wait list; the revised OCC ‘investigation’. [This is a ‘might as well wait for the fucking cows to come home’ item supposed to be finished in June.]

So what the fuck are we actually waiting for? And why?

What’s the big mystery?

LB was a fit and healthy young dude with a diagnosis of epilepsy. The STATT unit he was in was clearly crap. It was taken over by a “Trust” based 100 miles away 8 months before his death. OCC and the Oxfordshire Clinical Commissioning Group were apparently happy to shell out £3500 a week for his non care indefinitely. An independent report published 16 months ago established his death was preventable. The unit has since shut and a series of failed CQC inspections across the county have highlighted the maggoty state of provision in Sloven’s “Northern patch”.

As a vague aside, no one seems to be (publicly) going near the question of what happens to the prime chunk of land that the STATT unit was on. If it’s sold, who gets the readies? If the dosh goes to Sloven and into their southern based coffers where does that leave people/kids in Oxfordshire who need support? Ho hum. Awkward questions that won’t disappear but a brief glance at Sloven’s latest Board papers for the meeting tomorrow suggest that property sales form part of their ‘business’.

property disposal

Setting aside the monetary considerations which, along with reputation, seem to be the only thing Sloven and OCC respond to, I keep coming back to the question; what the fuck are we waiting for?

Dan Goodley and Rebecca Lawthom raised this question as they took the #JusticeforLB flag back to Glastonbury for a second year;

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Without answers, they repeated their remarkable commitment to sharing what happened to LB with Glastonbury revellers. They managed to share LB’s story, keep the flag flying high with no flagpole breakages and hook up with Rosie and Jack. Love em.

Legendary work.

Keeping the hope flickers well and truly fanned. With joyousness, humour, love and dedication. Maybe someone/organisation with any power/influence will step up too. And act. As we continually say, it ain’t rocket science.

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Of moths, pride and Paloma Faith

We’ve got a moth infestation. To the extent that I now wander round obsessively fixated on looking for tiny thin dark/black marks on walls, especially near door frames or down the sides of furniture. And then crush em. We’re going to have to repaint pretty much everywhere. Or extend moth cull to a level in which it resembles some new decorating technique; “papery flakery. In dull grey to blackish.”

Rosie was my fellow moth destroyer. We had some hilarious days a few weeks ago. Systematically searching them out with a spongy baseball bat. But Rosie’s left home now. Gone to moth free pastures [I hope]. I wonder if LB might have taken up the cause. I don’t know. He was a dedicated and committed litter hound and did a cracking number (with constant encouragement/involvement) on weeds in the front garden. I’m not sure if fleeting, flitsy/flaky insects would have rocked his boat.

Rich and I went to London today. Leaving the moths free to do what they do in a day. [Bastards]. We watched a good chunk of London Pride. Loving the brilliance, joy and creativity. A bit bored/frustrated by the (often lengthy) patches of corporate overkill. London buses featured consistently which was ace, though we were staggered by the ‘wheel stewards’. Every bus/vehicle in the parade/procession had dedicated wheel stewards. For each wheel. On a route fenced off from the public and organised to the hilt. L1014426 L1014283 L1014471-2 L1014306 Wheel stewards? LB was in a specialist NHS unit with a ratio of four staff to five patients (plus the wider learning disability specialist team) 24 hours a day. At a cost of £3,500 per week. And he died?

With no accountability, still.

Wow.

How the fuck does that work?

In more positive news, the #JusticeforLB flag has been flying at Glastonbury. Paloma Faith’s set tonight. Action not bullshit. As always.CIhnOmNWsAAl5sG.jpg-large

Running out of titles

Wondering what we can do really. In a bit of a despondent way. The update I posted this week illustrates how public bodies can simply delay. With seemingly unlimited doses of delay powder. A sort of modern wday ‘smoking out’ policy. Earlier today I found out that Oxfordshire County Council (OCC) are delaying their response to my Freedom of Information request about their ‘investigation’ because a Public Interest Test is being carried out.

I don’t know what this means and the FOI dept at OCC were unable to enlighten me beyond the fact it will involve a delay of up to 20 working days. Another month potentially. It would be bloody brilliant if they could soup it up a bit and complete this test (test?) in days rather than weeks but given the weighty blanket of on going delay, I’m not going to anticipate anything. July 22 is the new date.

I don’t have a bar anymore. That was crushed somewhere along the way. When we realised that these public bodies can do whatever they want to devastated parents/families and no one will stop them. I now expect the worse and, so far, that has been spot on.

Another parent, Nic, whose child died a few months before LB posted this on my blog yesterday.

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Nic regularly posted comments in support, in shared grief, rage and despair at the impossibility of trying to get accountability, justice or anything to make sense of the apparently casual and brutal chucking aside of much loved children’s lives. One of the first comments she made included the request ‘More photos please’.

So here’s another pic from that holiday in 2010. When we were walking a completely different path. And, on a more cheery note, the #JusticeforLB flag is returning to Glastonbury this year with the legendary Lawthom Goodley crew. Bloody good timing in the circumstances.

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Updating the update. Of the update.

We’re fast approaching the second anniversary (hate, hate, hate using this word for this) of LB’s death [Howl]. 16 months after an independent report was published stating LB’s death was preventable.

Here’s an update of the latest update (March 2015). As always (and clearly forever) in no particular order:

1. The inquest: A fourth pre-inquest review meeting is being held at 2pm, September 9th, Oxford County Hall. All welcome. It’s a very public affair. The full inquest is scheduled to start on October 5th. Sloven have “unreservedly apologised” for LB’s death (as the curious Tory template (repeatedly) reminds us) but this hasn’t stopped them pulling all sorts of tricks along the pre-inquest journey. Including a bit of desperate back pedalling from that unreserved apology to argue that drowning is a natural cause of death.

2. Disciplinary councils: We referred one clinician to the GMC in May 2014. This investigation continues, slowed by some additional stuff that has cropped up. Apparently Sloven disciplinary processes led to an undisclosed number of undisclosed staff members referred to the (undisclosed) NMC. Who knows?

3. Police: The investigation continues. Staff interviews are underway.

4. Health and Safety Executive: The investigation (apparently) continues in line with 3. above.

5. Oxfordshire County Council: We’ve received legal advice on the “independent” report OCC commissioned into LB’s death without our knowledge. It seems that it is defamatory so there is ongoing legal action relating to this. OCC are sticking to the ‘We did nothing wrong’ line. Chilling really. The consultant is apparently working through the list comments/issues I was forced to identify a few weeks ago to revise the original report. I still say chuck it in the nearest bin but what power do we have? [I’m dreading receiving another version given the methodological approach].

6. Verita 2: This second, broader investigation into what happened to LB remains ongoing.

Mazars death review: The review into deaths in Sloven learning disability and mental health provision since 2011 has been extended by NHS England to allow additional work to be done. Given the announcement this week of a national review into the premature deaths of learning disabled people, this extended work makes sense.

So. That’s it really. When we sadly started #107days again this year, we naively thought some of these investigations would be completed during this time. It’s now clear that this ain’t going to happen.

It’s all a pile of cock rot really.

I’ll leave you with this pic from a holiday we had in July 2010. When life still had colour, beauty and the extraordinary (in a good way).

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Space, place and managing snow

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Just under two days in Tromso this week. Midnight sun land. Well not much sun but spectacular sights. And so much daylight. Which was strangely mesmerising. I learned a lot from colleagues about life in northern Norway. Including snow management techniques. The importance of building capacity to allow space for snow. Built on an understanding that the snow ain’t going anywhere fast and everyday life needs to continue.

Sloven and OCC don’t seem to understand the need for this space when it comes to grief and families. Instead they just shovel, or try to. A process that’s destructive, counter-productive and hugely damaging.

There are policies that try to create space for grief within the NHS. The sensible and straightforward Being Open framework, for example. But policies are just words if they’re ignored. As meaningless as the non-apologies identified by Ally, LB’s cousin, in her recent dissertation on Sloven communications.

There are obvious differences between heavy and sustained snowfall and grief. But I find it hard to understand how the grief stuff, something so agonisingly accessible – most people can, if they can bear to go there, have the beginnings of imagining what such grief feels like – is dismissed or ignored. Intensely human, deeply emotional and gut wrenchingly awful experience is trampled over, ignored or worse, by the public bodies responsible.

How do we get it so blinking wrong?

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Extreme spaces and a touch of Marge Simpson

Another full on week. Thursday morning, the Private Members’ Bill ballot. Thursday afternoon, there was a meeting of the Expert Reference Group for the ongoing Mazars death review. This review, commissioned by the Real David Nicholson before his retirement from NHS England, was viewed as a tick box exercise by some. Sigh.

Friday morning we had an intense and, in places, deeply sad meeting in London talking through legal stuff. There was a bit of swearing, a box of tissues and a shedload of sensitivity.

Tonight we went for some nosh to celebrate Rosie moving to Bristol before starting her first full time job. On the way home, she was chuckling about the time I dipped back into the St Giles fair on my way back from a meeting a few years ago to have another cheeky go on the coin pushing machine. Apparently Tom texted me asking where I was and what was for tea, sending me into a spin about being a rubbish mother.

“You did what?” said Rich. “I didn’t know about that! Marge Simpson is a secret gambler…”

Setting aside what OCC would have made of this story in their craphole review, I just want to say; Good on yer, Rosie. It’s a fab job, brilliant opportunity and you bloody deserve it.

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Blatter, schmatter and candour

I came across Sloven’s 2013/4 Annual Report today in which they make the extraordinary claim that they are 100% compliant with Duty of Candour obligations (p121).

candour100% compliance? Eh? How can claiming LB died from natural causes in July 13, failing to disclose his full medical records until November 14 (via the coroner), accepting that his death was preventable in February 14 and then claiming again he died through natural causes in November 15, fit with duty of candour compliance? How can not sharing how Nico Reed died with his family for nearly two years be candour compliant? Or do learning disability related incidents stand outside this indicator?

Up until the last couple of months, I’d probably have written to the Board chair asking for some clarification on this. Not any more. The OCC report (OCCRAP) and their response to my obvious and fully justified distress about this report, on top of the various brain melt communications we’ve had with the now ex-Sloven Board chair/still-in-post CEO documented on these pages, have demonstrated that they have the power to do what they want. Including telling the most fanciful of lies and sticking them.

It’s simply one fucked up, archaic and sometimes corrupt system.

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Critical questions

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This afternoon, stuck on the Oxford Tube coming out of London, I was reading negative academic related stuff on my twitter timeline. Then my niece forwarded her undergraduate dissertation. She’s just completed a degree in linguistics at Leeds. For her dissertation she did a critical discourse analysis of four documents; Sloven’s public statement on the publication of the Verita report, their briefing document to Monitor, and letters from the CEO and Board Chair to us.

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I still don’t fully understand what transitivity is but non-apologies are pretty straightforward. In a kind of a random shambles; human, mother, (proud) aunt, campaigner, academic, raging woman, Oxford Tube captive and probably other identities, I read this dissertation. Between Hillingdon and Lewknor.

I was struck, in particular, by three things. First, it’s an example of an undergraduate dissertation that’s robust, rigorous, relevant and political. I’m impressed by both Ally’s work/focus and the encouragement and support she was obviously given by Leeds.

Second, (and I won’t say much about the content right now) the conclusions are clear, carefully evidenced and show that Sloven (and probably other NHS Foundation Trusts/local authorities) don’t operate anything approaching a whiff of candour, openness and transparency.

Third, if an undergraduate student can produce a clear, critical and well evidenced piece of research demonstrating this, why is so much meaningless talk still being talked?

OCCRAP, sometime and darkness

Found out today that the investigation into the actions of the unit staff member we referred to their disciplinary council in May 2014 is further delayed because new information* has emerged that will feed into this investigation. Wow. Every aspect of trying get accountability for what happened to LB has been delayed. Interminably.

The two forces of darkness, as I now see Sloven and OCC, are key delay players. Sloven explicitly, through non disclosure of documents, sitting on reports and generally being obstructive. OCC are slightly less obvious but do a cracking number in delay on the quiet. We now have to wait while their ‘independent’ consultant goes through the issues we raised about the ‘independent investigation’ they conducted into LB’s death without informing us. [For the ease of clarity here, I’ll call this report OCCRAP]. Apparently he’ll do this sometime next month.

[NB: In the delay game, there are no deadlines. Just vagueness. The only deadline so far is LB. And he had no say in that. Everyone (other than families) has  flexibility and resources to do what they want. Without remorse, reflection or hint of humanity].

The coroner sensibly said he wouldn’t read OCCRAP until it had been revised. Verita read it and are waiting to hear OCCs response to our response. Their report, (Verita (2) [sorry], has a delayed publication date which is now expected sometime in the next month or so. [Verita (2) officially started September 2014 for six months].

Our response to OCCRAP was, and remains; ‘Bin the fucker. Pile of toxic shite’. But this response is discounted. We have no power (underlined by the absence of challenge from those who could). So we were forced (bullied) into examining OCCRAP line by line and documenting inaccuracies. A process of phenomenal wastefulness, inefficiency and unspeakable distress.

We’re left wondering when did reputation (and vested interest) became the overriding consideration of ‘public’ bodies?

And how can so many in influential positions sleep so apparently contentedly through this? Justicequilt-207 *Thank you to the person/s who came forward with this information.