Category Archives: Sloven Health

Puff the Mackey Dragon…

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It sounds like there’s a dose of musical chairs going on with the Sloven executive. Sigh. Word in the shed is that Sandra Grant, who does summat and goes back to the olden days with Katrina Percy, is off for a six month secondment while Chris Gordon, Chief Operating Officer  (COO) and Director of Patient Safety, is apparently heading to NHS Improvement for 12 months as an improvement director. [I know…]

He, Lesley Stevens and Katrina Percy, are holders of the obscene salary and pension pots exposed a few weeks ago.

In the NHS (unlike much of the commercial sector) it appears when you fail at exec level you simply get moved around in a never ending chess like game. Only one in which the board is so worn the squares are no longer visible and the grubby pieces have been handled so often they’re unrecognisable. And there are no ‘rules’. Just fakery and nonsense played by overly paid, under qualified (in real terms) bods who share a common language, code and cloak of protective armour invisible to the rest of us (who pay their over inflated salaries).

I can remember Tim Smart, the newly, NHS Improvement, appointed interim Sloven chair (the Flash of yesteryear) at the My Life My Choice meeting. Tapping his nose and saying with much gravitas:

Just remember Sharon Shoesmith…

Effectively stopping any discussion about anything.

So, two or three months on from the “action” taken by NHS Improvement in response to repeated evidence of Sloven board failings, where are we exactly? And what did “Remember Sharon Shoesmith…” mean?

Well. Crap all to the Shoesmith question. That was probably part of Smart’s briefing from NHS Improvement… “Just mention Shoesmith when anyone asks a dodgy Q“.

The board got the all clear from (the previously failing) Smart on the basis of fuck knows what. The consistently underwhelming (at best) CEO was removed of operational duties and told to focus on strategy. The COO has gone to NHS Improvement and will only work 2 days a month on Sloven operations. And Grant who, after a quick google, is Director of People and Communications, is off for six months. Blimey. Who is keeping this leaky boat afloat in the land of Solent Lee?

Meanwhile, in addition to the salary/pension scandal, financial irregularities are blasted across the news. Failing, upon failing.

NHS Improvement… I can’t help thinking the question Shaun Picken from My Life My Choice put to Katrina Percy at the January board meeting is relevant here:

Katrina, why didn’t you ask for help? You clearly need it.

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Of mice and (NHS) monstrousness

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A story ‘broke’ yesterday about extortionate NHS interim director costs. Sickening figures of waste, greed and mismanagement. At senior levels. Again.

In another of those ‘you couldn’t make it up’ NHS moments, the highest paid interim Improvement Director named in the report, Steve Leivers, was helicoptered into the trust Tim Smart, now Sloven interim Board Chair, previously ran. Yes. Really. Not Smart in non action. Again.

I read this latest news having been unable to move beyond Chris Hatton’s recent analysis of Sloven’s annual report. Cut and paste Katrina. And extraordinary senior exec salary figures. With Lesley Stevens, Medical Director at the top of the ‘leader’ board. A cool £365-70k per annum including jaw dropping pension contributions. How can she possibly ‘earn’ this sort of dosh? Let’s have a look at her performance during LB’s inquest last October.

Lesley Stevens and LB’s inquest

Reasonably confident while reading out her evidence and then being (sleep) walked through clearly rehearsed questions by the Sloven barrister, she floundered big time when questioned by the six remaining barristers. Her answers so deeply insubstantial (a generous interpretation) it was as if the courtroom had switched to watching CBeebies.

£365-70k per annum…

Some examples:

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LB died in July 2013. The (post Mazars review) CQC inspection in January 2016 found the Sloven epilepsy policy had yet to be signed off. Paul Bowen, QC, carefully questioned each Sloven staff member about their knowledge of epilepsy during LB’s inquest. No one answered in other than the vaguest ‘ain’t got a clue’ terms. There was no up-skilling staff over two years after LB’s death.

[Howl].

LS3Here Paul Bowen seeks clarification of Stevens outlandish statement that all learning disabled patients with epilepsy were reviewed before the CQC inspection in September 2013. At that point, Sloven were still spinning the line that LB died of natural causes. They did nothing to check the provision in STATT (it failed on all 10 domains inspected 6-8 weeks after he died) let alone review patients with epilepsy in their wider provision/outposts.

A blatant and contemptible lie. Perjury to us herbs outside of senior NHS circles.

LS2Paul Bowen tries to drawn Stevens on the failure of the RiO system. A failure that persists to this day. She resorts to her default response. A murmur/mutter noise reminiscent of the dog ate my homework type responses from school. Not the sharp, authoritative, informed, engaged response you’d expect from a senior exec at an inquest over two years in preparation, with nearly £300k squandered on ‘defence’ costs.

When questioned by Adam Samuels, another barrister, about the reduction in Band 6 and 7 staffing reductions in STATT (and the next door John Sharich House), Stevens says:

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‘We make savings where we have to make them…’ On frontline staff. While you continue to draw an obscene salary

Monstrous. And remorseless. Just one, among so many.

When did the NHS we grew up with, took for granted and loved, become so riddled with greed and rot… with complacency and arrogance, with inaction and protection. At senior levels?

Cut and paste leadership and the pro-Percy HQ

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Sloven financial irregularities (that is, bunging apparently endless amounts of public dosh to mates for little or no return) hit the news on Friday, via Michael Buchanan. Today Chris Hatton published his analysis of the Sloven (or Sudden Wealth) 2015/16 Annual Report. I can’t recommend reading this post enough. Just one titbit (and there are so many) is that KP simply cut and pasted the last paragraph of her closing statement from the previous Annual Report. Unbelievable action in any annual report, but breathtaking given the content and context. The end of the paragraph states:

Notwithstanding this, my review confirms that the Trust is taking appropriate actions to deliver the agreed undertakings and ensure compliance with the Trust’s provider licence and to address any weaknesses in the system of internal control.

Those failings and enforcement notices clearly just roll over yearly. Sickening demonstration of the contempt the Sloven board have for patients, staff, regulators and the wider NHS, and the public. And further indication the Sloves (or Suddens) are not capable of improvement.

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What is actually going on here?

Let’s have a little look see at what’s happened since the Mazars review was published:

  • In December 2015 Jeremy Hunt announced the CQC would go in and inspect Sloven again with a focus on death reporting.
  • In April, the CQC announced serious (continuing) failings.
  • Ball over to NHS Improvement who send in Clive Bell as Improvement Director and, subsequently, Tim Smart as Interim Board Chair.
  • Tim Smart did a tinpot investigation (no family involvement), Katrina Percy was subjected to six hours of psychometric tests and he gave the board a clean bill of health. A week ago he commended the performance of the board to the Council of Governors (audio from 17.10 here…)

 

So blinking awkward. In the light of the Buch-Hatt findings this is a serious egg on the face situation for Smart (who signed off the Annual Report) and Jim Mackey (CEO of NHS Improvement). It also offers some chunky old clues about where pro-Percy HQ is based. [And believe me, many people are asking this question…] Jezza took action, the CQC took action, things get snarled up in an NHS Improvement pretend party. Interestingly, a Sloven staff fairy heard that Sloven exec, Paul Streat (who worked at, er, NHS Improvement before joining the trust) was arrogant and dismissive about #JusticeforLB in a Senior Viral training day.

Mmm…

We heard yesterday a rumour that KP won’t be returning from her holiday after pressure from the Department of Health. Jezza now has Alistair Burt’s (love him) portfolio for mental health/learning disability issues. He has the ball firmly back in his court. Here’s hoping he takes action (or further action if Percy has been pushed) and removes other culpable board members. The rot in that room is extensive.

He should then perhaps ask questions of Mackey and his merry band. It really ain’t the job of campaigners and journalists to reveal what is in full sight of NHS Improvement, NHS England and the Department of Health.

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Woman on all fours

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In honour of the £5.365m of our money spent on this shite. Here is the woman on all fours. Who called it for what it was.

 

Update: September 25 2016

A day or so after posting this in July, our solicitor got in touch to say a Sloven solicitor had been in touch:

She said that there is a video which has been posted on your blog which contains a female member of staff […]. Apparently that member of staff withdrew consent in relation to that video some time ago and so the Trust has not been using it and she has reported that the republishing of the video is causing her a lot of upset and therefore wondered if it could be taken down.

At the time we took it down immediately.

Today, we found out that the current total paid to Talentworks (who are behind the Going Viral programme talked about in the short film) is now £5,861,424.03. Another £500k since Michael Buchanan’s original expose?

I’m reposting the film. I’m sorry to the staff member if this causes upset (and please contact me directly if it does – posting a comment below for the first time is private) but the full extent of the rubbishness of the training needs to be seen.

Going viral. At nearly £6m of NHS money.  Talentworks? Gone to ground…

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When trusts go bad

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Walked into Oxford earlier with Rich. One of those days when there were no end of brilliant photos to take. Including a cheeky bee.

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Got home to find out one of the rebel governors, Peter Bell is under formal investigation by Sloven. Yep. Sloven are formally investigating the actions of a (rare) governor.

Sloven who:

  • initially said LB died of natural causes and all due process was followed.
  • tried to stop the publication of the first Verita investigation which found LB’s death was preventable.
  • spent nearly £300,000 on legal expenses at LB’s inquest to try to avoid accountability.
  • spent nearly £50,000 to try to sink the Mazars review into their death reporting.
  • have been found to be failing by numerous coroners over the past five years
  • etc, etc, etc…

Blimey. A formal investigation…
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‘Seriously derogatory remarks’…. Not sure where, in the guvs’ code of practice, it states ‘thou shalt not say owt negative against the hallowed trust’. What a load of bullying bullshite. Those of you following this deeply harrowing tale of a trust gone bad will know that an extraordinary meeting to discuss a vote of no confidence in the Sloven leadership was stopped on May 17 by interim chair, Tim Smart. He got the Capstick heavies involved. The discussion remains to be had. Now this.

Truly, truly extraordinary.

Extraordinary timescales too. An ‘investigation’ into the actions of a governor with such priority it can be sorted in a month. We’re into the fourth year of investigations into LB’s death. GMC, NMC, HSE.. Every one of them drawn out because of Sloven slovenliness. Delay and obfuscation.

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LB died. He died. Without any accountability. But the investigation into the actions of a governor is racing on. Interviews, evidence collecting and all. By an organisation who failed to investigate 100s of unexpected deaths in their care. I almost think I’ll wake up in a mo. Surely this can’t be happening in full view of NHS Improvement, NHS England, the CQC and Jeremy Hunt?

Surely…

In a final piece of [no words left] the Sloven annual report has been signed off.

smart and percy

My incredulity monitor has finally broken.

Another sordid little tale of failure

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Sloven have shut the psychiatric intensive care unit at Antelope House for 8 months. Reported in the media last week. The board papers published yesterday provide more detail (around p72).

The closing of these beds mean patients who really should not be, will be shipped to a unit in London. To a unit that ‘needs improvement’ according to the latest CQC inspection. Yep. Closing shite provision and shipping seriously unwell patients to sub-standard provision. Extraordinary.

The board papers describe how a ‘tipping point’ was reached:

tipping

To the extent the Deanery raised concerns about the quality of Antelope House as a training place for Junior Doctors…. Deep breath. Hold on to something solid.

Sloven run a unit that isn’t a fit space to train doctors.

How can any NHS Foundation Trust run a unit that is not considered a fit space to train doctors?

What about the safety and wellbeing of the patients?

I suspect Deanery concerns led to the sudden closure of the ward at Antelope House. The CEO/Board could clearly ignore the 4/5 year of failings publicly documented over the past 3/4 years. Lives lost. Non lessons learned. Inquest after inquest after inquest, failed CQC inspection after failed inspection and the Mazars review.

Deanery rumblings and concerns around junior doctor training (with implications for Vanguard membership) generates ‘action’.

As my brain, again, slowly, slowly melts, I (easily) stumble upon a news report about Antelope House from September 2011. Yep. Really.

A report on failings identified during the inquest of a patient in 2008 and a recent (2011) failing CQC inspection report. Risk assessments not updated,                                                                                                                                                inadequate records, lack of training, etc etc. The same old same old failings. Identified over and over and over again. The then Medical Director, Huw Stone, long gone (sensible guy), did the old learning lessons spiel:

huw

Mr Stone, back in the day, 14 months before Sloven took over the STATT unit LB died in, said all care plans and risk assessments were now reviewed. Extra checks were conducted on standards of care. And further made up blarney. How any NHS exec can stand in front of the press/coroner and say these empty words when the lives of patients are at stake is beyond me.

No other words really.

I just wonder.

  1. How those who should be doing something about this continue to look the other way/slumber despite documented failings.
  2. How those around those who should be doing something about this, allow their colleagues, family or friends, to continue look the other way/slumber despite documented failings.
  3. How those directly implicated look the other way/slumber.
  4. When any of the the above will realise that we will continue to document this shite for as long as it takes.

 

 

I start walking…

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Started walking to work this week. Prompted by consistently destructive levels of rage generated by the continued non action around the Sloven senior team.  (Despite an extraordinary evidence base of failings.) About 3-4 miles depending on the route. Monday was day 1. Bit spooky walking along a long, isolated stretch of footpath by the river to University Parks. Rich came with me the next day, love him. We found a spooked dog. Pippa. I got to work later than planned. I changed my route to High Street/George Street/St Giles…

Then went to Staffordshire, via Birmingham New Street, on Wednesday so walking was shelved. London on Thursday. Watching walking instead.

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Yesterday we walked to town. Raging slightly muted by pounding the streets. Absorbed by watching/snapping everyday life. Back on the High Street, a vaguely familiar couple were snugged up on the bench by the bus stop.

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I photographed them before. Four long years ago. In the life that was. As snug. Just mobile.

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George Street, Oxford. August 2 2012

Today I didn’t leave the house. Among working and hoovering I started reading Victim and Victimhood by Trudy Govier. Unpacking what and who a ‘victim’ is, what being a victim means and different ways of making sense of victim and victimhood. Silence, blame, deference and restoration. Hmm. I’ll keep reading. And walking.

And get a print of the photo to drop off to the couple who apparently sit on the same bench most days. And, I suspect, have a story or two to tell.

And wait. Still.

Updating LB

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Hello matey,

Three years now. Well we’re into the fourth year really. I thought I’d update you on where we’re at in terms of justice and accountability. Not far really. [Sorry]. Various investigations limp on. The General Medical Council (GMC) has spent over two years collecting evidence about the clinician who was kind of in charge of you. You know. That woman who spoke to you for about 15 minutes across your whole time in STATT from what I can tell from the records. And gave you Bonjela after you had that seizure. She’s got about a week left to respond to the allegations the GMC have put to her. We’ve no idea what these allegations are because it’s all secret squirrel stuff. She’s working in the Emerald Isle now. Still responsible for patients.

She pitched up at your inquest in October with a barrister who was like the worst of worst baddies in a Simon Pegg film. He, like Sloven peeps, questioned whether we wanted you home. We did. I’m so sorry if that got lost over those hideous weeks in the unit. We stupidly, stupidly thought you were in a safe space while support was being sorted. Turns out all the failings in the unit were written in a report the summer before you went there. But nothing was done. [Howl…]

Your inquest went as it should have done. Superb legal representation (as you’d have expected) and a jury of nine members of the public who listened and understood how deeply you were failed by Sloven.

Other investigations are going on. Still. We met three people from the Health and Safety Executive (HSE) on Thursday with Norman Lamb. The meeting was in Portcullis House which you’d have loved. Heavy weaponery, police presence and security… The meeting was disappointing. Not the objective, razor sharp, robust, investigative scrutiny I imagined. Mind you, the writing was on the wall given the speed in which they slapped a charge against a production company for Harrison Ford’s leg injury in June 2014. 

There seems to be a fog engulfing and dispersing any critical challenge by public bodies of public bodies. And when you stupidly ain’t considered to be fully human, that fog just thickens. 

We managed to get a review commissioned by NHS England into deaths in Sloven ‘care’. This found a scandalous lack of interest or engagement in investigating unexpected deaths. We thought this report would lead to sharp and immediate action. But nah. Seems like this is ok.There’s a bit of tweaking going on round the edges but no commitment to really looking at these deaths or to act with any conviction. You’ve been mentioned a few times in the House of Commons though which would make you smile. 

Meanwhile, Sloven failings continue to pile up. They are seriously shite. NHS Improvement sent in a troubled shooter, Tim Smart, to look at leadership failings. He spent a few weeks there, avoided speaking with families, got some psychometric testing organised and decided there were no leadership probs.

I can hear you saying ‘Mum? Why mum?’ into infinity and beyond.

I dunno. I was waiting for the Scooby Doo gang to pitch up and unmask him as Mr Crawls or one of the other villains in the end. Such a nonsensical, cartoonish judgement. Apparently Alistair Burt, the social care minister, is still looking into it but for some reason, that rag bag bunch of muppets remain in post. 

These systems we loosely brought you up thinking were good, right and just, simply and sadly ain’t fit for purpose. While the public have stepped up and created an explosion of brilliance around you, your life and the lives of so many other people, you were and continue to be well and truly fucked over by those you always firmly believed in. 

There was a story in the Guardian mag about you a few months ago. A very funny journalist, Simon, came round and later a photographer. You’d have liked them both. Joel souped up some of our old photos. Like this one. No orange binoculars but the old shower cap and goggles. Rocking life as you always did. Your way.

Connor

Connor

xxx

State sanctioned cruelty

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L1020557Rich and I were back on the bus to London at lunchtime to meet with Norman Lamb and the Health and Safety Executive (HSE). Brilliant sunshine on the walk from Victoria to Westminster. People going about their daily biz. Three years and three days after LB died a preventable death in the care of Sloven Health. 266 days after a jury determined LB died through neglect. And still no accountability.

The meeting, at Portcullis House, largely involved discussion around the length of time the HSE investigation has taken so far as detail couldn’t be discussed.

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Our love for Norman Lamb has been a constant since the curry night when we first met him. He was instrumental in getting the HSE to investigate LB’s death. Writing to the CEO after the HSE originally decided not to investigate. I’ve not seen him in action up close before today. He was deeply impressive, carefully questioning the HSE trio throughout the meeting.  Sense, clarity, knowledge and sensitivity. Pinning down timings, process and progress.

Why did the HSE decide not to investigate originally?

I assumed when I was informed there would be an investigation it would happen straightaway.

Why is it taking so long?

Why did you not work in tandem with the police?

This is not being given the seriousness it deserves. I can only conclude it’s an indication of how learning disabled people are seen as less than human…

It amounts to cruelty to take this long. It isn’t complicated what happened.

I don’t understand why it is taking so long. 

Where does the failure lie?

There were mixed answers, some contradiction and non answers. The back story is that the HSE originally decided not to investigate because they decided (no idea why) that LB died as an outcome of a clinical decision. [Howl]. After Norman Lamb’s intervention five HSE people reviewed the decision and, with particular focus on the Verita report, decided to investigate. Apparently there was some blurring over investigative responsibility while the police were still involved and the HSE took primacy for the investigation after LB’s inquest in October 2015.

The HSE inspector finished her report in February and it then got stuck in some interminably slow process of internal checking for around five months until this week. It’s now been sent to legal advisors and next steps are expected to be announced at the end of October…

It’s taking so long because these things can do, it depends on the complexity of the particular case, because there was a lack of clarity over responsibility. It most definitely is not related to LB being learning disabled or (slightly less emphatically) because an NHS Foundation Trust is involved.

On the bus home, I had a look through recent HSE press releases. Three bath related investigations since December 2015.

Joseph Hobbin died in June 2013. Ark Housing Association pleaded guilty and were fined £75,000. [December 2015]

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A patient died in April 2008. NHS Kent and Medway Social Care NHS Partnership Trust pleaded guilty and were fined £107,000 plus £25,000 costs. [January 2016]

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A patient died in August 2011. The European Healthcare Group pleaded guilty and were fined £100,000 plus £50,000 costs. [June 2016].

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Blimey. Should never have happened. Well documented risks. Legal duties…

Same old same old. An alternative re-run of Sloven related inquests over the past five years. Lesley Steven, Medical Director, popping up to say lessons learned/changes made and the CEO in hiding. A grotesque and macabre dance around death. Dripping in (meaningless) and lengthy bureaucratic processes. A fine and a non rap over the knuckles. Disconnecting and siloing. No linking between instances of shit care. To enable the wheels to keep turning.

Meanwhile families continue to be brutalised.

We know LB should never have died. We knew before we walked out of the John Radcliffe A&E into blistering sunshine that July morning. He was completely failed by the state who had a duty to care for him. Since then, evidence of Sloven failings have been unprecedented. Both in volume and the extent to which they have led to no action.

Norman was spot on when he said this is a form of cruelty. State sanctioned cruelty. With no end in sight.

 

Tears, rage, disbelief, frustration and utter bafflement

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Tim Smart made his judgement about the Sloven board on Thursday morning:

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Graham Shaw managed to summarise this statement in less than 140 characters shortly after it was published.

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Needless to say there have been tears, rage, disbelief, frustration and utter bafflement in the Justice shed. Richard West produced a powerful statement on behalf of families and patients (drafted in the early hours of Thursday after we’d pretty much worked out that KP was not going) summarising key failings and articulating our collective incredulity. [The decision to transfer Oxfordshire provision to Oxford Health was made months ago…]

In a (farcical?) twist, Smart arranged to meet some families with Alistair Burt just before his statement was published on Thursday. Their response (with evidence of contemptuous Sloven behaviour) surprised him and he said he needed to think further/hear more. This explains Alistair Burt’s statement on local news that the issue of Sloven governance wasn’t concluded.

I’ve got a lot of time for Alistair Burt (and never thought I’d say that about a Tory MP). Here he is, a few weeks ago, at the extraordinary Sloven debate at Westminster House:

Burt tweets

On Wednesday, the day before Smart’s announcement, the inquest into the death of another young woman in Sloven’s care was held. The coroner reinforced Alistair Burt’s concerns as lack of communication, ignored care plans and records changed retrospectively were revealed. Again. Lesley Stevens, in her full time role of attending inquests and producing worn out platitudes dropped the ‘lessons learned’ crap this time. That ship has well and truly sailed. Sadly, and incomprehensibly, the Sloven CEO was not on it.

It’s worth revisiting Alistair Burt’s words about Tim Smart and NHS Improvement from the Westminster Hall debate here:

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I think many of us disagree that ‘the right person is (was?) in place’. Smart, for whatever reasons, failed inexorably to cut effectively through Sloven murkiness. Despite the clear evidence trail laid out for him online. An example of the dangers of crusty (and arrogant?) senior bods dismissing social media without having more tech savvy colleagues provide them with a summary of what has gone before. Or perhaps Smart knew and chose to ignore this beyond damning evidence. After all, he pulled me up on the language I use on this blog when I met him.

I can tell you, Mr Burt, (and I know you heard this in the meeting on Thursday morning) the (non) actions taken by Tim Smart have not gained the confidence of people. Quite the opposite. And there seems to be little quality in the actions he’s taken. We’re left asking how and why the person ‘leading’ an organisation that cannot keep certain patients safe (while her focus has apparently been overly focused on operations) remains in post? Despite demonstrating no understanding of patient care, humanity and appallingly little competence stretching back over four years (and possibly longer).

I could pepper this post with swears. My brain has swears careening around it at the speed of sound. Rich and I have become even more randomly sweary since Thursday morning. If that’s possible. But I won’t. Instead I’ll leave you with a photo of a Playmobile figure I dug up in the garden earlier. LB died three years ago on Monday.

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