Category Archives: Sloven Health

A letter to the Ministry of Justice

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Dear Ministry of Justice,

I’m writing because I’m pretty concerned about this statement you issued to BBC Radio Oxford a couple of weeks ago when asked why there was no legal aid for families to cover representation at inquests:

An inquest is aimed at helping families find out the circumstances behind the death of their loved one. Lawyers are not usually required as the hearings are specifically designed so people without legal knowledge can easily participate and understand what is happening.The coroner is there to investigate the death and can put questions on behalf of the family during proceedings.

This has a touch of the In the Night Garden about it. Naive, meaningless fluff. You present a version of the inquest coated with parma violets, butterscotch and cream soda. Devoid of context. You suggest that families put their trust in the coroner. Yes. Maybe. But they should also be aware that other interested parties (such as the NHS, the prison service, police, local authority) may well turn up mob handed with barristers and the like. Determined to close down questions and limit the investigatory process.

And it ain’t just about what happens at ‘the inquest’. The inquest is a process not an event that happens within a set space at a particular time, as I’m sure you know. It’s a process that involves evidence gathering and submissions. Without legal representation, how can families be sure that the questions they want answered are going to be asked? I ain’t being funny, but coroners are only human and can’t go through the mountains of paperwork associated with a particular death in the level of detail necessary. And a family who are experiencing the gut wrenching and devastating despair associated with bereavement aren’t best placed to (and shouldn’t have to) trawl through records and documents.

If, as you also suggest, the inquest is inquisitorial and not adversarial, why have Sloven Health been arguing for the narrowing of our son’s inquest to one with no jury and no Article 2 engagement? In your sunshine version surely the Slovens would be there cheering on in the sidelines for an inquest best placed to answer questions? With openness, candour and transparency. Not fighting the toss on these points. With spurious, insensitive and offensive arguments that include death by drowning is neither unnatural or non-violent.

Their choice of barrister, Gerard Boyle, also speaks to a fairly weighty adversarial inclination:
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Gerry is in huge demand by the police and medical defence organisations to appear at Article 2 inquests? In huge demand?? How does this fit with your bland statement that families need no legal representation? It makes no sense at all. You must be completely distanced from the reality of the process, or worse.

I don’t know how to convey to you how we felt on the morning of LB’s pre-inquest review meeting. Back in November. When, three hours before the meeting, we found out who was representing the Trust. Such a blatant sign of their determination to fight. To fight about the circumstances of the death of our son they’d previously accepted was preventable. I really don’t know how an NHS Trust can possibly defend the death of a patient with epilepsy in the bath but that’s clearly not stopping them. I’m just relieved we have a legal team that shine a fierce light on human rights issues. A team drenched in integrity. And no whiff of parma violet pong.

Advising families they don’t need legal representation at inquests is simply wrong. Each situation is different. And clearly in some contexts legal representation is a necessity. I can’t imagine what it’s like to end up with an unsatisfactory inquest outcome. Other than making the worst thing you could ever imagine so much worse. This is unforgivable. And who funds this representation needs examination and reform. It isn’t fair that families have to pay.

It strikes me it might be helpful to send a few of your bods out to attend some inquests involving deaths in NHS Trusts. To get an idea of how it works in practice. Our next pre-inquest review meeting is on January 13th in Oxford if that’s any help.

Yours,

Sara

Peace, doves and pigeons, again

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A few reflections as 2014 draws to a close. The #justiceforLB campaign continues to grow. We have collectively generated some noise, discomfort and disquiet around the provision of services for learning disabled people, as well as encouraging joyful contributions, actions and activities from a diverse group of individuals, families and organisations. Heartwarming doesn’t begin to capture the experience of #107days of action and it remains thrilling to look back at those months and re-absorb the enormity of what people did. Seriously. Just legendary commitment and spontaneity.

I won’t rehash the things we have managed to achieve here as they are detailed on these pages and over at #107days, theJusticeforLB advent calendar and LBBill pages but it has been remarkable. (I get despondent about the lack of change but am reminded by Rich regularly that change takes time and we’re taking on an area which has been historically, socially and politically consistently shat upon.) So yeah, we’ve done good.

In contrast to the joy and celebration, Sloven and their merry band of solicitors, Bevan Brittan, continue to occupy the dark side. A (publicly funded) festering, stench ridden space in which they hatch nasty little plans that appear to be designed to try and crush us. Drawing on deceit, delay, non disclosure and offensive arguments. (It could be so, so different…)

The then head of NHS England, David Nicholson (love him) said to us back in March that Sloven would be advised not to contest the inquest. I mean leaving a young dude with known increasing seizure activity to bath without supervision in hospital is so off the scale of wrong I still can’t comprehend it. But nah. Sloven and the BB’s (or the Slevan B’s) submission to the coroner a few weeks ago included the argument that LB shouldn’t have a jury inquest because drowning in the bath is natural and non violent. Not only is this argument beyond distressing but c’mon weasels, you can’t possibly publicly accept that LB’s death was preventable and then argue that it was natural. Why? Just why?

Anyway, leaving that miserable happening on the pile of numerous other Sloven related miserable happenings, I’ve been thinking quite a lot about the campaign recently. Partly because of the #hairhack workshop George Julian and I did in Liverpool a few weeks ago. We tracked back through old emails to work out how the campaign got off the ground and had a right old chuckle at the ad hoc, almost random way things unfolded and developed. But underpinning this chaos were some core ingredients that may be necessary for a cracking social media campaign: commitment, energy, passion, creativity, humour, a range of varied skills to draw upon/crowd source, cheek, fearlessness, and no vested interests.

This list is up for discussion but I can’t help thinking the latter is possibly key. And what stymies the chance for actual change too often. Once you’re sucked into, or part of the system, it’s game over really. I can imagine that we’ve been a real irritant to various people/organisations over the past year. Pretty irrepressible, annoyingly and relentlessly buoyant in the face of some shite knocks (and I ain’t talking about LB’s death here), continually shining a light at little known practices, structures and processes, and not for buying off, distracting or deflecting.

And that brings me back to George Julian. While the campaign is and always has been a collective endeavour, George’s involvement deserves particular recognition here.

After a bizarre, work related, unremarked upon twitter thing about five years ago, George and I hooked up on twitter after LB died. And she became the central force in the campaign. I can’t (and almost don’t want to) imagine how many hours she has devoted to campaign activities from various parts of the world, with dodgy internet connections or exhaustion creating time differences. She has been consistently encouraging, thoughtful, creative, organising, planning and chivvying. With cheerfulness, enthusiasm and sensitivity. George has a legendary capacity to both deliver and keep things moving, even in pretty intense situations. She has added a level of sense checking, realism and balance to the campaign (while at no point suggesting a toning down of howling, desperate rage/swearing). As Mark Sherry commented on facebook yesterday; ‘I’m so impressed by her kindness, solidarity, principles and commitment.’

This, together with a cheerful readiness to break rules where necessary, make her the ideal type informal, radical, campaign manager. And she does it all, as the campaign has been from the start, for free.

So here’s to George Julian (sorry, you will always be George Julian in our gaff). And here’s to a new year. To changing the law and challenging the complete shiteness that continues to coat so many lives. And to getting justice for our beautiful dude who was let down in such a horrific and catastrophic way.

I took my camera into town today to snap a pic for this post. Pigeons featured again. And more guerilla knitting…

Patterns. There are always patterns. 

Justicequilt

The dream

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JusticequiltLast night I dreamed that Sloven Health pitched up at LB’s pre-inquest review meeting and argued that his death wasn’t unnatural or violent to avoid there being a jury at the inquest.

That they still hadn’t disciplined staff 18 months on. I dreamed that they had been surveilling my social media activity from the time LB went into the unit. And written and circulated a briefing about my blog, the day after he died. I dreamed that they didn’t pay attention to the content of the blog, other than scanning for defamation nobbling opportunities. So they completely ignored the warnings I was providing around his seizure activity.

I was kind of momentarily relieved when I woke up.  I’d been dreaming. I mean we’re talking about the NHS here. The National Health Service. A publicly funded body built on the premise of equality of healthcare for all. Not some grubby, two bit, private organisation that couldn’t give a flying fuck about people.

Sloven and the CCGs

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So here’s a mid-week quizette for you. The review into deaths in Sloven provision is going to have an expert panel to “review all the information and make recommendations on any further action required”.

Do you think this expert panel will include:

(a) Experts in reviewing deaths, particularly those occurring in mental health and learning disability provision?

or

(b) Representatives from Sloven and the two sets of commissioners on their patch (Oxon and Hants)?

Yep.

(b) Sloven and the CCGs. Sounds like a craphole Christmas No. 1.

Needless to say Meeting the Mazars was duly logged in The Little Book of Crap Meetings, under ‘Drenched with Incredulity’.

Rich walked out. After saying exactly what he thought of the death review so far. I caught the train to Glasgow.

Where it pissed down.
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The Sloven Book of Dirty Tricks

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Pre-Inquest Hearing yesterday. And Sloven added a new chapter to their Book of Dirty Tricks. Delay, as always, was a Sloven feature. They circulated their submission 3.5 hours before the meeting started. Classy little technique. Reading it at home, and weeping, I thought back to the meeting we had with David Nicholson where he said something about the Trust not contesting LB’s death (I mean how can you, really?)

How can you? Well Sloven, turning up en masse with a barrister, a solicitor, their in house legal person and the now too familiar medical director, gave it a go. In an obscenely offensive move. They argued that there should not be a jury at the inquest because LB’s death wasn’t – wait for it – violent or unnatural.

Yep. I ain’t joking.

It’s indescribable how awful it is to read such dirty little, lying, contradictory, game playing, rubbish about the death of your child. This is the NHS?

Note to Sloven and team. If you fully accept the findings of a report stating that a patient died a preventable death, don’t pitch up in a courtroom setting six months later and claim he died of natural causes.

Complete scum of the earth stuff.

The coroner dismissed it straightaway.

The Pre-Inquest Review

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Seventeen months after LB’s death, the pre-inquest review hearing is taking place tomorrow afternoon. In a room in County Hall, Oxford. The building where I used to attend meetings about provision for disabled kids in Oxford. Transport issues and cuts. The Parents Advisory Group.

There’s not much to say at this point. I’ve said it all on these pages. In various ways. Pretty relentlessly.

A tiny part of me still thinks ‘Really? The NHS? Behaving like a bunch of bullyboy thugs? Nah. Our beautiful dude died. He was young, fit and had his adult life ahead of him… Such a terrible, terrible preventable death would lead to care and concern, not cover up, delay, crap and deceit. Surely?’

A tiny part the size of a pin head now.

Tonight, we’ll be thinking about LB. In all his legendary awesomeness. And the comfort he felt in doing things his own way. Before he grew older and stuck his toe in a new and empty world of ‘adult services’. Where one size fits all and he wasn’t allowed to be.

Like so many young people like him.

old pics (8)

I bloody love and miss you. xxxxxxxx

“Errors, omissions, distortions and false claims”

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Sloven board meeting papers were published this week. Ahead of the next meeting on November 25th. (Same day as our pre-inquest review meeting). Jaw dropping nuggets. As ever. This bunch of festering toe rags never fail to deliver.

First, the off the scale of inappropriate powerpoint that surfaced a few weeks ago – Could it happen here – is actually a quality improvement toolkit. Developed in response to ‘the risk of not learning from incidents’. Yes. I know. Personally this would be enough for me to whip their licence to kill operate away right now but we know there is no straightforward route to accountability.

crap

The ‘owner’ of this risk in Sloven Towers is the aptly named Medical Director (Quality), Martyn Diaper. The ‘toolkit’ uses what happened to LB in a tasteless and completely pointless way (there ain’t an awful lot to learn about people with epilepsy and the dangers of bathing after all) and is crap throughout. But hey ho. It’s going to be launched at the Sloven quality conference in December….

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(Bit of an aside really, but judging from the programme and title, you’re doing pretty shit really. Not sure you need to set aside a day to discuss it.)

I assume Could it happen here is being ‘launched’ in the learning disability service user story session. Howl… how fucking dare you??? How fucking dare you?????? Sickening to think someone will stand up in front of an audience and present this pile of offensive crap. For so many reasons. Not least because LB wasn’t a ‘learning disability service user’. He was dearly loved young man with his whole life ahead of him.  And nothing went fucking well. How could you even begin to suggest it did?

Please don’t reduce him to some sub-standard, sloppy case study in a pretend learning exercise, in a shonky little day, top and tailed with yoga and footprints. 

Deep breath.

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Yep. The fuckers are actually thinking of putting in for a BMJ Award.

Setting to one side the seedy, commercial angle to the whole NHS award scam/industry, brilliantly captured this week by George Julian, how.the.hell can a Trust who allowed a fit and healthy young man to, er, die, and who continue to be the subject of a police investigation, even begin to think about awards?

Truly sickening.

Oh, and one last thing… The Patient Association published a cracking report about the role of the ombudsman andNHS complaints this week. And there, on page 17, (thanks @Minh Alexander) is a terrible story about a young woman let down by Sloven in 2011.

The account could be a word by word account of what we’ve experienced; insensitive and unsafe care, not listening to the family’s concerns and a response from Sloven containing ‘significant errors, omissions, distortions and false claims’.

More evidence of Sloven form. So much evidence of Sloven form. How they learn fuck all, cover up at any cost and crush families along the way.

Could it happen here, they ask.  Why wouldn’t it? Why wouldn’t it?

NH-Kafka-S and smoking mirrors

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A response to our question about staff disciplinary actions. From NHS England. At long last. We’ve pressed for information about this endlessly. I’ve lost count of how many tweets, bleats and rants I’ve done/produced. Sorry to be so relentlessly tedious. I’ve bored myself.But hey. What a response.

“1 member of staff has left the trust and has been formally referred to the NMC.

Disciplinary hearings for 3 members of staff will be held in December. This has been delayed as we previously understood that these would take place in October.

2 junior staff have been investigated and have returned to work under supervision, following additional training.

The doctor involved has left the trust, as you are aware. We believe that they are no longer registered in the UK. We understand that the GMC are carrying out their own process in regard to this doctor. I believe that Sara Ryan is aware of this.

The duration of time that this is all taking to conclude is very regrettable. The Trust have acknowledged this and apologise for it. They have explained that some of the staff involved have had periods of sickness, which has resulted in their cases being unable to be progressed. There was also an issue of staff being subject to Ridgeway policies, which were not wholly fit for purpose and subsequent negotiation with the staff representatives to agree a way forward.”

What the fuck is going on? Have Sloven got some sort of royal family type force field around them? How can the response to ‘Can you let us know where the HR investigations are after 16 months’ come back framed in complete fuckwattery;  ‘We previously understood’, ‘we believe’, ‘the duration of time that this is taking to conclude is very regrettable’This is the sort of language used when people complain about crap food, uncooked chicken, buying mouldy veg and flakey 3G coverage. LB was a fit and healthy young man with his life ahead of him. Please don’t reduce his death to the equivalent of a consumer complaint. 

So. As ever. Questions/comments. Questions we shouldn’t be asking.

Why has it taken so long to get an update on the above?
Why do the numbers of staff involved change on every iteration?
Why are the disciplinary hearings to be held in December? LB died 19 months before this. How can this process possibly take this long?
You know I’m aware that the GMC are carrying out their own process about the doctor because I fucking referred him/her. Because no one else would.
The time taken isn’t ‘regrettable’. It’s barbaric.
We haven’t had the luxury of taking ‘periods of sickness’ because of what we’re up against.
Don’t pull the ‘Ridgeway policy’ card. You took over this organisation knowing the issues involved.
Given crap all has happened in over 16 months, what a meaningless statement from NHS England about pressing for progress.

And, as ever, you absolute fucking bastards. Typical bastardry by Sloven, half arsed, lily livered NHS England response, complete duck out by Monitor, behind the fence shivering from the local authority/clinical commissioning group and some action by the CCQ.

What an absolute shambles.

A counter powerpoint

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The Slovens compounded distress with even more distress this week. A staff training powerpoint off the scale of appropriate.

A (bad) taste of the document, now hidden behind the Sloven firewall:
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Here in the Justice Shed we kind of try to stay positive (determined not to let these bastards destroy us). So here is a counter powerpoint which is hopefully more useful.

(I’ve pulled this together quite speedily and may revise over time).