Housecoats, aprons and mucky labour

Captivated by the women of Galicia along the last section of #CaminoLB.

“Can I take your photo?” I asked pointing at my camera. A few said no. Others stood tall. Looking me in the eye with quiet confidence. There was no artifice or prevarication.

Incredible, beautiful faces.

Lines. Life carvings. Contours of determination, humour, dignity. Resilience. Well earned, authentic resilience.

Glimpses of triumph and more. So many stories.

Housecoats, aprons and mucky labour.

Back to work tomorrow.  It’s been a long five years.


A day in court and some justice sunshine

L1032452-3The sentencing hearing for the Health and Safety Executive (HSE) prosecution took place this week. The #JusticeforLB bus made a surprise appearance at Oxford Crown Court thanks to Alicia Wood who brought it back from Spain where it’s rested since CaminoLB 2016. Rosie, Will, Owen and Tom joined other family members, friends and more for the final day of sentencing yesterday.

Within minutes we heard the judgement would be delayed until 10am next Monday. Disappointing but five days doesn’t register on my delay scale any more given we’ve waited 1825 days to get this far.

A backdrop to the two day hearing was that Sloven had pleaded guilty to the charges before any charges were brought by the HSE. The new CEO Nick Broughton held his hands up to say ‘fair cop’ and accepted systemic failings between 2011-2016.

[Now known as The Percy Years with an ‘HSJ CEO of the Year’ award as a logo.]

Broughton’s statement included open acknowledgement of the way in which we’d had to fight for justice and how wrong this was.

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#JusticeforLB sunshine at last penetrated the black establishment clouds. A position we didn’t anticipate back in the day.

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This welcome development took a bit of a drubbing by the end of the second day but more of that later.

Bernard Thorogood was acting counsel for the HSE. He spent Monday and yesterday morning laying out the case for prosecution.

Roger and TJ

On Monday this involved the death of TJ Colvin in 2012 at a Sloven unit in Hampshire. In 2013 the coroner found no systemic failures in TJ’s care and it was case closed. That is, until the pesky #JusticeforLB kids persuaded David Nicholson to commission a review into the unexpected deaths in Sloven’s mental health/learning disability provision between 2011-2015. This was to become the Mazars report. An extraordinary review which enabled further scrutiny of TJ’s death.

The details were harrowing. Failing after failing after failing in TJ’s care. The HSE case underpinned by one of the quiet heroes on the long road to justice; Mike Holder. Mike, a health and safety expert, had in early 2012 carefully and meticulously provided details of the ligature and other safety risks in the Trust. He resigned when the Exec Board batted these concerns away like a sleepy bluebottle caught up in a boring meeting room on a hot summer’s day.

He identified 21 long telephone wires across Sloven in-patient provision. The replacement cost for each was £55.

“£1100…” spluttered Lord Justice Stuart-Smith. Yes. £1100 to reduce the risk of serious harm to patients and prevent TJ’s death.

As Bernard* spoke Broughton sitting on the Sloven bench looked devastated. This was in contrast to LB’s inquest when the Sloven team gleefully treated the process like a game of  Top Trumps.

Roger Colvin chose to read his victim statement to the court. This isn’t always allowed apparently but Lord J said yes and we heard him describe his family’s devastation at her death and the carelessness that surrounded it.

The packed public gallery was silent.

Connor

Connor’s case began on Monday afternoon and carried over to Tuesday. The same detail we know inside out but with a health and safety focus. It was heartbreaking to again hear how appallingly Connor was failed and how easily preventable his death was. The overlap between his and TJ’s deaths were grotesque.

In an unexpected move Bernard T detailed my interactions with the Trust ending with this:

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I can’t describe how – I don’t have the words here… powerful? Moving? – it was to hear this said in court. Bernard effectively produced a balm for the raw guilt I continue to drag around.  I hadn’t realised what having ‘your day in court’ could mean.

The defence and dirty dealings

The Trust accepted pretty much the whole of the HSE case. The defence won’t take long I naively thought. We’d been prepared that this section would be pretty unsavoury and it was. It was basically about dosh and reducing how much the trust would be fined.

“Every pound fined is a pound less available for future patient care…”

Of course.

There’s a one third ‘discount’ (I know) in place because it’s a public sector body. Fair enough. But given the thousands racked up by Sloven on legal fees to destroy families, paying mates £3m for shonky viral training and rewarding Percy with a £200k + pay off, the arguments presented were foul to sit through.

The defence barrister proceeded to do a ‘I’m sorry but…’ type number as he undermined Broughton’s ‘fair cop’ position with some dirty little dealings. These included the argument that the coroner had found no systemic failings at TJ’s inquest.

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We saw in the earlier link to TJ’s inquest coverage that her family were deeply disappointed with the coroner’s lacklustre engagement with what happened. The same coroner presided over numerous inquests relating to Sloven without, ironically, finding any systemic failings. A cracking example of how coroners may be ‘best placed’ but may still do a crap job.

The barrister also seemed to suggest that the observation levels for TJ were adequate and the Judge should differentiate between her case and Connor’s in his decision on fine amount. The HSE case was a careful compilation of layers of failings with pivotal chronological points at which the Trust should have acted and didn’t. Trying to pick away at what happened to TJ was unnecessary and cruel for her family to listen to. The point had earlier been made that criminal prosecutions are a very last step for the HSE.

The barrister moved onto the individual responsibility of staff members again trying to  introduce some wriggle room into the hitherto accepted systemic failings pot. Then in an unexpected move mother blame was back on the table.

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Setting aside the fact Murphy’s performance was found to be woeful rather than ‘wanting’ there was no reflection that Sloven’s failure to refer Murphy was further evidence of how shite they were. Instead he tried to weave a further vexatious mother thread taking the shine off the apparently heartfelt declarations in Broughton’s statement.

That’s where we’re at really. Evidence is now done. No more nasties for us to hear (I hope). Sentencing judgement on Monday.

Finally a few thanks…

We’re in awe of Bernard and the HSE team who were meticulous and thorough in their investigation and case building. They were also kind, humane and sensitive throughout.

Thanks to everyone who pitched up from all over (and those who followed the hearing on twitter). The judge could not have failed to be moved by such a strong collective showing on both days demonstrating that TJ, Connor and all the other people who have died preventable deaths in careless, inhumane settings count.

Finally thanks to the Witness service at Oxford Crown Court. I was a bit bowled over having a bespoke person take good care of us during the hearing.

*Apologies if first name is not appropriate here.

Light and the fatberg ingredients

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Crumbs. I’m feeling brighter. I’d anticipated a plummet to rock bottom land in the lead up to the Health and Safety Executive (HSE) sentencing hearing next Monday and Tuesday. A month after the MPTS sanction decision for Valerie Murphy. Two years after LB’s two week inquest. Five years to the day we took him to the STATT unit that cold, dark Tuesday evening on March 19 2013 [howl].

Other than the odd trip to London or Oxford I’ve been hanging out in the Justice shed for weeks. Crocheting.

A recognisable blanket of brightly coloured granny squares has emerged (will add a picture in the morning when it’s daylight). Griefcast has become my (late to the party) go to soundtrack. The (sometimes) humorous reflections of death and grief by comedians has been a gentle and soothing backdrop to the wool action.

I feel brighter.

Tom and I did a news interview this morning in advance of next weeks hearing. In our kitchen. The setting for numerous recordings over the last five years.

Doors have since fallen off cupboards and and half arsed drawer fronts carefully propped up. In preparation for the visit I did a bit of cleaning this morning.

“Mum! It smells really funny down here!” shouted Tom while I was upstairs getting out of my crochet uniform of grey tracky bottoms and a worn out old woolly red jumper.

“Ah I chucked a load of bleach down the sink. It might be that!” I replied. Visions of some right old ripe and until now undisturbed fatberg ingredients fighting back in the u-bend.

We ended up talking about five years of campaigning. Five years. Five of Tom’s seven teenage years. Pretty much the first five of Rosie, Will and Owen’s adult years. Half a decade. Half a decade of repeatedly poring over the hideous and distressing details surrounding LB’s death. Over and over and over again.

Of being blamed and vilified. Of persistent fat berg ingredients.

The interview was unexpectedly positive. There are no more nasties to come. No more bundle pages to turn over and ‘go to’.  No more oaths to swear. No more vicious counsels to face. We’re part of the audience for the hearing next week. And Sloven have pleaded guilty.

Tom made a comment at the end of the interview about the style of the campaign; the humour, creativity and fun. He was spot on.We’ve collectively written, blogged, spoken, tweeted, live-tweeted, presented, met, challenged, shouted, scrutinised, counted, drawn, produced, filmed, sung, shared, kayaked, run, walked, danced, travelled, stitched, photographed, baked, drunk, laughed, cried, wept, hugged, raged and laughed more.

Whatever happens next week we’ve done LB and all the other dudes proud.

Light.

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A missing ‘apology’ in five parts

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Part I.

Michael Buchanan (who I suspect bereaved families across the country are developing serious love for) continues to fight the good fight of uncovering and shedding light on brutal NHS practices. He did a piece about the decision of the Health and Safety Executive (HSE) to prosecute Sloven for BBC News on Tuesday.

At one point, Huw Edwards, introducing the story, said:

“The Trust earlier apologised to the family…”

I nearly dropped my glass of cheeky and chilled vino.

“Eh? Did you hear from Sloven today, Rich?”
“No.”
“Neither did I. What apology?

The next morning, a local journalist rang and mentioned the apology.

We ain’t received an apology, mate.

I looked on the Sloven website. Maybe they’d issued a statement. [Putting an apology in a statement is not the way to apologise to a family, mind. I was curious about where this ‘apology’ was].

Nothing.

I continued to hear about ‘the apology’ as the day wore on. With no sign of it. Then bingo. This, on twitter:

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Ah. The apology was part of a statement the Trust were sending to journalists. A fake apology extraordinaire.

Part II.

In the same way that the Trust response to LB’s death was to write and circulate a briefing document about my blog to protect their reputation, their response (and this needs to be read within the context that three board chairs, a CEO and a complete set of non-executive directors have now been replaced)  to the HSE decision was to tell the British public, via the press, that they have, once again, offered their ‘unreserved apologies’ to us.

Now Julie Dawes, and your merry band of (shit and/or remaining) executives, here’s the rub:  this is no apology. It is nothing resembling an apology. It is so much worse.

What you have done is:

  • compound the barbaric treatment you have relentlessly dished out to us (and many other families).
  • Make visible the insincere, formulaic and performative ingredients of an NHS ‘apology’.
  • demonstrate you have learned nothing despite saying you have.
  • treat us with further contempt and disrespect I didn’t think possible.
  • show us you remain incapable, either wilfully or otherwise, of understanding basic humanity and decency.

Part III.

The statement is pure spin. A closer look at the wording:

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The HSE has “informed the Trust of its intention to prosecute in relation…” [Prosecute who?] “Connor’s death whilst in our care…” [It could have happened to anyone, we just happened to be holding the parcel when the music stopped.] “Could have been prevented…” [Introducing uncertainty into the findings of the independent investigation and the inquest.] “We would like to…” [But we ain’t going to.] “Once again…” [We have apologised to this vexatious mother relentlessly.] “Offer our unreserved apologies…” [A prize for us to take with grateful hands.]  “To his family.” [Family for PR purposes, ‘the Mother’ for every strategic opportunity to stick the boot in.] “Continues to do everything it can…” [Apart from actually say sorry].

Part IV.

You didn’t get in touch with us to say sorry. You got in touch with the press.

Minutes after finding the ‘apology’ on twitter, I received an email from your administrator. On behalf of you and the Board Chair, Alan Yates, about meeting up with the group of families you have treated like utter crap.

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You can email me about a meeting (to benefit you) but you can’t say sorry.

You didn’t get in touch with us to say sorry. You got in touch with the press.

I find this unforgivable.

Part V.

Rich and I have felt pretty low since the HSE news. People have been saying it’s remarkable that the campaign has achieved so much. It is. Bryan, from My Life My Choice, earlier reminded me of the time I sat in his office a year or so ago, dejectedly saying we didn’t have a craphole chance of achieving our aims… particularly around making sure Sloven didn’t profit from the sale of the Slade House site and a prosecution against the Trust.

The trouble is, of course, LB remains dead; our beautiful son, brother, grandson, nephew, cousin and friend, is forever absent and, within a shifting family landscape, newer family members will never meet their quirky uncle LB, brother in law, second cousin or potential godfather. We know this. Any bereaved family knows this.

What your latest ‘unreserved’ non-apology beyond shiteness this week has shown, is that you have zip all understanding of this, and that you couldn’t give a flying fuck. You have been beaten into a corner by a remarkable, and unprecedented, collective brilliance, and you’ve learned nothing.

Still.

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Jeremy ‘witch Hunt’ and the mother blame

Was reminded all week about the terrible mother blame that went on across LB’s inquest which was held a year ago. Just a few tasters:

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Unspeakably awful. Again my brain weeps This is the NHS…

Sadly, blaming us has been a consistent theme since LB died. Sloven have sent extraordinary briefing reports to all and sundry blaming us for hacking into staff twitter accounts and trolling. Oxfordshire County did a corporate number with their sordid secret review of me, while one of their commissioners wrote a terrible letter tearing me to shreds (I’ve never met the woman who is apparently deeply christian).

Jeremy Hunt seems to have joined the blame brigade now. He was interviewed by David Fenton in a bizarre piece on BBC South last night. Between them, pushing a ‘witch hunt’ version of events. Fenton even described how Sloven staff are too scared to go out with their Sloven lanyards on for fear of reprisal.

Wow. A witch hunt. An unfounded persecution?

For the record.

  1. There was no ‘witch hunt’ after Percy. 
  2. She didn’t form part of our Connor Manifesto.
  3. We have consistently called for the resignation of several exec/non exec members (Gordon, Spires, Grant, Berryman, Stevens…)
  4. Percy, and the above, should have gone a long time ago.
  5. Our campaign has always focused on the executive board (and LB’s responsible clinician) and not the 9000 or so staff members, many of whom I’m sure do a brilliant job.

I wonder why we are blamed. It’s fucking outrageous. We’ve (collectively) done more to generate awareness of learning disability issues than major charities with enormous budgets. For free. #JusticeforLB has been like a second, full time job over the past 2.5 years. We’ve worked our socks off. We’ve been told we’ve encouraged other families to campaign, and fight for accountability for catastrophic events harming their loved ones. What happened to LB is taught on various undergraduate and post-graduate courses across the UK. School kids have written about him for homework. We’ve generated a shedload of brilliant resources (a justice quilt and other art, blogs, lectures, songs, short films, animations, the LBBill, the first ever inquest tweet archive and loads more… see below). We’ve been consistently reasonable in the circumstances (with liberal swears).

The families and ex-Sloven governors have shown remarkable restraint given everything they’ve endured. Peter Bell is under investigation by the trust (I know) and has declined to sign a gagging order in order to see the draft report of evidence against him (I know). (There was no investigation of Malcolm Berryman’s actions in sharing the Mazars review with his son before publication). John Green has been a model of reasoned, informed, restraint in trying to highlight failures in both Sloven and the wider organisation of the NHS [click here for the abridged version of his report]. Repeated appearances on national and local news by Richard West, Maureen Hickman, the Hartleys, Angie Mote and others have been remarkable for the consistently careful, considered and, again, restrained commentary in the face of such (continued) horror. The behind the scenes email exchanges are reflective and respectful.

It’s a very dangerous precedent if any member of the public who asks questions or seeks lines of accountability from those in power is dismissed as a witch hunter.  Cheap and lazy journalism by the likes of David Fenton, who has failed to have even analysed that which has been put in the public domain by campaigners, is simply wrong. The serial failings that we, and other campaigners and journalists have largely unearthed sit well and truly on the doorsteps of the Sloven board (and some governors), Jim Mackey and the NHS Improvement gang, and, er, Jeremy Hunt.

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An antidote to the above; some #JusticeforLB magic. The middle pouch is an Arabic justice pouch, the bus ipad holder is made from material used to decorate a lorry driver’s cab and the third pouch holds the complete music for Tippett’s ‘A Child of our Time’ to celebrate the performance in memory of LB at Warwick University in June. Brilliance.

When troubleshooting goes bad…

Blimey. More documents pinging mysteriously into the Justice shed. Including a letter written by the then Sloven board chair to Monitor (now NSH Improvement) raising serious governance concerns in 2011. [Yes. Really]. At first graze, a dense, detailed, informed, harrowing and enraging addition to an apparently unlimited evidence pile highlighting Sloven governance failing.

I’m typing this post listening to Laura Veirs. A vague balm. Rich and I have spent the last three days since the faux announcement of Katrina Percy’s (yet to be properly confirmed) ‘resignation’ in a harsh and agitated space. It’s not about her, as a person. It was never about her as a person. Blimey. She didn’t make it to the Connor Manifesto. But it’s becoming more and more about her

Percy failed to lead effectively. We all know that. The board failed, and continues to fail, as an executive board. The Council of Governors remain split between an enlightened minority and the waste of space rest. There remains a consistent and shocking lack of competence, authority, knowledge and sense among both the board and council. Backfilled with a frenzied focus on reputation and apparently unlimited funds to buy in whatever spurious consultancy or legal support they think will magic away the disorder that surrounds them.

Deeply depressingly, the documents leaked to us today were shared with Tim Smart to provide context to his review of the board. Now we don’t know (I don’t think anyone really knows) what Smart based his (30 June) judgement of the board on. We do know he scathingly dismissed the Mazars review during the meeting with My Life My Choice and we now know he must have dismissed the serious concerns raised by the board chair back in 2011.

We also know he agreed to the very recent secondment of Sandra Grant and Flash Gordon to new pastures (as well as gifting Percy a substantially reduced role on a CEO salary). Why you would give a board under serious scrutiny a clean bill of governance health and then start seconding execs five minutes later is a mystery. Oh. Unless you finally, and belatedly, realise the board is as grubby as they come.

Indeedy, it’s probably about time some of the spotlight shifts to Smart and Jim Mackey (the CEO of NHS Improvement My Arse). What this pair of muppets are doing is beyond me. Did they really not anticipate the inevitable backlash against such offensive and scandalous news? Did Smart not realise erasing all whiff of failure in Percy’s leaving statement, blaming press interest, would simply enrage and inflame? What an almighty pigs ear of executive and regulatory ‘action’.

Ironically, one of the biggest failings here is candour and transparency. From where we’re sitting, it appears Smart made the wrong judgement on June 30 because he is incapable of listening. Days later Michael Buchanan broke the news about dodgy contracts. Patient deaths are clearly nothing compared to doshing your mates £millions for going viral nonsense. Once Roy Lilley was on Radio 4 condemning the spiralling of a £300k contract to £5m, the writing was on the wall. Failing governance a go go.

Instead of a clean sweep, an acknowledgement of failings – of letting down hundreds of patients and their families, of a board gone bad – Smart, Mackey (and Hunt?) ballsed it up. Big time. Generating more media attention and public outrage than the publication of the report revealing that Sloven investigated less than 1% of the unexpected deaths of learning disabled people over four years. A report that led to the appointment of Smart as the troubleshooting interim chair.

What a stinking mess. Do the right thing someone. Please.

In search of rights and colour…

Came across some serious craftivism this evening. Mind and the Drunken Knitwits (among others) set too on the Radcliffe Camera. A welcome distraction from the continuing non action by those who should.

Left me thinking about plans for a bit of a #JusticeforLB shindig later this year (not quite confirmed) called In Search of Rights and Colour. Involving people, human rights, commitment, explosions of colour, love, brilliance, enthusiasm, stitching, passion, double decker buses and a pilgrim path.

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Drops of brilliance.

The settlement

Yesterday was mediation day. As part of an action against Sloven about LB’s right to life being breached under the Human Rights Act*. The date was agreed a while back and papers were to be submitted to the mediator seven days before. Sloven submitted nothing. We got more tense the closer it got and by Tuesday night, Rich and I were pretty much in pieces, firing off random, belligerent emails to our (wonderfully calm) solicitor and pacing round the house. Necking wine.

I can barely remember the journey to London first thing in the morning. My rage at what happened to LB, what we’d been put through by Sloven and dread of the day ahead consumed me. Rich listened to music.

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The meeting was held in Doughty Street Chambers and there were three rooms. One for us and our legal team, one for the mediator and one for Sloven and their group (of several people). For the rest of the day, we sat in a big, very warm meeting room with a view, tea, coffee, water and wifi. The mediator came in and out. Our legal team went out and came back in. The sun went in and we waited.

 

At 2.30pm, the Sloven debate started at Westminster Hall. We watched parts of it in between discussions. I half watched the rest of it with the sound off. Following the tweets and texts from a mate. Sloven were getting a deservedly intense and critical panning. On the floor below and over to the left of us, their Chief Operating Officer, another staff member, their solicitors, a partner from their solicitors firm, a barrister, and a NHS Litigation Authority bod sat.

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Mid afternoon there was an enormous downpour. A get people off the streets type downpour. No umbrella could withstand the ferocity and that amount of rain. The atmosphere in the room pretty tense as deliberating and discussion continued. Andrew Smith, MP, was clearly articulating the depth of Sloven failings on the muted screen.

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Eventually, agreement was reached. Seven hours after arriving we left the chambers and went for a drink in the pub across the road. In sunshine. It was hard to make any sense of what was agreed. A good outcome apparently. I just felt deeply sad and a bit odd.

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There are two parts to the settlement.

I’ve woken up feeling as sad and odd as I felt yesterday (with a layer of new exhaustion). The statement is very clear and, given everything that’s happened [he died...] is a form of ‘vindication’, if that’s the right word, without meaningless apology. The money? It was never about money. We’ll talk about that when the kids are all here together in July.

One of our lovely nieces, Clare, messaged earlier asking ‘What does it mean for the campaign?’

Nothing really. This human rights part was never part of the Connor Manifesto so it’s business as usual. Just one horrible, ‘gruesome’ as someone put it yesterday, process done. None of this should have happened.

*We had to make sure the judge could not look back, if the ‘case’ reached court, and say we had turned down any reasonable ‘offer’. If s/he thought we had, we ran the risk of having to pay Sloven’s costs and (I think) being fined.

Non action and a ‘Licence to kill’

During a departmental meeting today, a colleague gave a talk about a project he is involved with; Human Resources for Healthcare in Africa. Part of this work is focusing on how to reduce the shocking mortality rates of children under 5 in Mali and Uganda.

He talked about the drop in mortality rates that emerged as an outcome of the setting up of the Confidential Enquiry into Maternal Deaths in the UK in 1952. Setting up an enquiry into deaths in Mali and Uganda seems to have, similarly, led to a drop in mortality rates. One reason being that once healthcare professionals knew that these deaths would be investigated, they started paying more attention to the care they provided.

Leaping to this talk from mundane discussion around office moves and desk space left my head spinning.

…once healthcare professionals knew that these deaths would be investigated, they started paying more attention to the care they provided.

As simple as.

Meanwhile, in the UK, talk of setting up national board to look at the premature deaths of learning disabled people after the shocking mortality rates identified by CIPOLD was watered down into a mortality review programme. Seemingly serving a ‘pointing to’ function. ‘Look… Bristol University are doing this.’

…once healthcare professionals knew that these deaths would be investigated, they started paying more attention to the care they provided….

And once health and social care professionals/organisations witnessed the abject lack of any substantive action by the government response to the Mazars findings they all got a symbolic ‘get out of jail free’ card.

No reason to pay any more attention to the care provided.

Business/death as usual.

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Experiencing Mazars, fuzzy boundaries and rank closing

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

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

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

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

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

Fabrication. Fabrication. Fabrication.

Reputation. Reputation. Reputation.

The Mazars review

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

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

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

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

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

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

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

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

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

Or fucking do something about it.