Some right things and a humility glug

Hoping to head off ‘witch hunt’ commentators and silent but disgruntled medics I sense may be lurking. Valerie Murphy has had numerous opportunities to ‘do the right thing’ over the last four and a half years. Right things and responsibilities. Below is a list of suggested right things based on my observations and experience of the GMC process.

Right things

(a) The early days

  • Say sorry. Your actions may or may not have contributed to what happened but just say sorry. Someone has died. [As a bit of an aside, a key thread running through this interminable process has been the importance of demonstrating remorse and insight. This can only start with with a genuine apology.]
  • Welcome a full and frank investigation into what happened and contribute to it openly and honestly.
  • Scrutinise your professional practice and involve a range of colleagues and others to help think through and understand what happened and why, and how it might be avoided in the future.

(b) Across the investigatory process

  • Avoid trying to cast blame elsewhere.
  • Be transparent, open and honest. Don’t, for example, ‘save’ information like an earlier death to share in a particular setting at a particular time.
  • You have a set of duties to adhere to. Try not to get sucked into shite practices that may be demonstrated by the Trust executive board or others.

(c) Interactions with your counsel

  • Instruct your barrister to treat everyone involved with respect and sensitivity.
  • Take ownership of your position and role in the investigatory process. If, for example, your barrister begins to ask unnecessary or distressing questions of a witness, tap her on the arm and close it down.
  • If something in the evidence upsets you, try and suck it up. The process should enable embellishments and more to be exposed. You don’t need to have your upset recorded.

During the tribunal

  • If particular issues or concerns with your professional practice are highlighted, work out appropriate ways to demonstrate you’ve improved them. Ask for help if you are unsure how to approach this.
  • Try, as much as is humanly possible, to turn up to every day of the hearing.
  • Think carefully about who you ask to be a character witness and make sure they are properly briefed about the importance of this and what is expected of them.

A final reflection is the professional arrogance medics can exhibit. I witnessed this on twitter this week when a discussion effectively ended with non-NHS commentators being dismissed as ‘armchair critics who wouldn’t last 5 minutes in the NHS’. I don’t know at what stage in the education or experience of being a medic this arrogance kicks in (I ain’t a medic). But I do wonder if a glug or two of humility is a good tonic every so often.

 

Reflecting on the GMC hearing

Spent the day, exhausted, dozing on the settee and trying to make sense of the GMC tribunal*. The full determination can be read here. Having waited since August 7 when the tribunal began (and the dread leading up to that date) and limping over the past two weekends of part hearing, hearing that the panel found that Valerie Murphy’s fitness to practice was impaired was both a relief and beyond distressing. I’ve no coherent thoughts, just a set of (overlapping) questions and reflections. Hopefully the process of writing will help.

1. Is Murphy’s ‘medical practice’ common?
The damning determination (worth reading in full to get some idea of the medical ‘care’ learning disabled people can expect to receive) misses some points that made my stomach curdle during the August hearing. Is specialist learning disability health provision so impoverished that it’s OK to prescribe medication before meeting patients? What does this mean and suggest about the treatment of certain patients?

Can it ever be acceptable, knowing you’re going on a two week holiday at the weekend, to not see an 18 year old young man you’ve agreed to be admitted on the previous Tuesday evening? A young man brutally restrained and sectioned that first night [Howl].

Is it common for medical consultants to tout a travelling suitcase with patient records for a colleague to rummage through?

Have these points dropped off the determination because there are bigger issues to pursue or because they aren’t seen as unusual?

2. Was Partridge’s ‘defence’ appropriate? 
A pre-meeting with the GMC earlier this year to go through my evidence left me reeling. It wasn’t a patch on the cross-examination I was subjected to in August by Murphy’s barrister, Richard Partridge. The pre-meeting preparation suggests that the cross-examination I endured wasn’t unusual.

Partridge repeated similar lines to his colleague, Alan Jenkins, who represented Murphy at LB’s inquest. Both focused on my ‘failings’ and the ‘Dr Crapshite’ post. On what they both seemed to view as unacceptable, unreasonable and discrediting action by a feckless mother. Ignoring what that post (and so many others) revealed about the lack of available support. This focus says so much more about them. And/or their client.

3. Ted why? 
Twitter discussion has focused on Murphy still practicing in Cork. Earlier, a minor bombshell from Stuart who lives in/near Cork. Murphy’s appointment (which is still unclear) was heralded as a ‘turning point’ in CAMHS service provision. An expert from Britain, leaving her investigation cloud behind her.

Prof Ted Dinan, the Gut Man, was prepared to offer a character witness to a colleague he seemingly barely knew. What were you thinking Ted? Boldly pegging Murphy in the top 10% of Irish psychiatrists [shudder]. He told the travelling suitcase story without faltering. While twitter groaned and buckled with disbelief, a few sharp questions reduced his story to a handful of contact hours – “in an academic year she gave two lectures and approximately 14 hours of tutorials” – and help with 5 patients across two years.

He stated that he regarded Dr Murphy as “extremely competent” and marked her apart from other consultants he had worked with, particularly in respect of her willingness to come in and give her assistance.

In contrast to her apparent unwillingness to see LB for 19 days.

4. What price power and insight?
Power. On April 24 2014 Murphy received a letter from the Sloven Chief Medical Officer stating ‘it was not considered that any further action is required in this matter‘. A clean bill of medical health from the Sloven exec. The various CQC inspections, Verita report, inquest and Mazars review processes led to no further scrutiny of her medical practice. We made the GMC referral (with Charlotte Haworth Hird) in May 2014.

Without this referral Murphy would, I assume, be continuing her practice of ‘implicit risk assessments’ (in her head) and remote prescribing in Oxfordshire, Cork or somewhere else. How can this possibly be?

Insight. Reflexivity or reflectivity is a central task for sociologists. Constantly reflecting on stuff; who we are in terms of our identity and experiences, our assumptions, what we bring to our research, how we interact with research participants and the data generated, and our analysis. I’ve always thought of it as a sound task for life. Like I’ve long thought that ‘easy read’ texts should be the stuff of everyday life, not an added extra when funds or thought permit. Adjustments that make life better for everyone.

Murphy failed on insight. She failed over and over again. Her barrister arguably added to this with his own apparent lack of insight. 

We’ve been brutalised by this process. At the mercy of timescales decided by others, cross-examination, forced to revisit what happened, rehashing blame lines… our lives on hold. John Lish captured the experience of the tribunal perfectly in a tweet.

There must be a better way.

*Am now off ‘sick’ for the week. Wary of the extreme spaces we now inhabit and what these mean. It’s only two weeks until the @HSE hearing to set the date for the HSE hearing…

The waiting game… again

We heard today the GMC tribunal panel will continue their deliberations in camera (privately) on Saturday and have ‘released all parties’ until 2pm on Sunday. The parties are the GMC legal representation, Valerie Murphy and her barrister, Partridge and, I assume, the public. The 2pm deadline doesn’t mean a determination will be given then as to Murphy’s impairment (or otherwise). It means it won’t be before then.

We’ve been warned the hearing may involve further dates yet to be set.

This hearing was originally scheduled for two weeks in the middle of August. Obliterating any summer thoughts or plans. It over ran and involved an inhumane and unnecessary cross examination which has, I suspect, left long lasting mental ill health shite. Harm caused in the process of trying to ‘objectively’ establish whether a person given a special key to count as a ‘medical professional’ is actually worthy of being a key holder. There is no apparent consideration for non key holders.

On Sunday we listened to a ‘defence’ which involved an absent ‘Murphy, a touting of patient records in a travelling suitcase (which sent alarm bells ringing among even the most resistant information governance ears) and a character witness worthy of a Tom and Jerry cartoon. Among copious tears, I felt an odd fondness remembering Butch. Life seemed so simple then.

Connor died in 2013. Murphy denied any wrong doing until the GMC case was well established in 2016. She spent three years denying and deflecting blame. This weekend we heard, via her barrister, about her recent ‘brain child’, her ‘contribution to the profession’; a speedily produced poster published (unusually with her husband) about a yellow card system. 

I think (hope) we ain’t beyond the realm of reasonable in the justice shed. If Murphy had behaved differently at any point in the last 4.5 years, I hope we’d have found it in ourselves to give her ‘a go’. And if we couldn’t, I hope a close mate, relative or colleague would have nudged us to do so. During the train journey to Manchester in August to attend the tribunal, Rich and I reflected at length on the apology we thought I’d been called as a witness to receive from Murphy.

There was no apology. Just a no show. Like she didn’t turn up for her second day of giving evidence at Connor’s inquest, instead appearing by video link and expressing disgruntlement at having to return after a lunch break.

George Julian live tweeted the tribunal parts that were public this weekend. She felt it went too fast to catch the comprehensiveness of the GMC case presented. She wasn’t able to convey how the overarching objective of the GMC was failed individually and cumulatively.

There are no words to describe, explain, capture what this slow drip drip feed of the ‘processes’ around the preventable death of your beautiful and beyond loved child by a combination of something described as ‘health and social care’ is like to experience.

The GMC have kept us consistently kept us informed which is good. Dunno what else to say really. Other than what a pile of shitfuckerywankmarbles.

Prof Ted the Gut Man and the travelling suitcase

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Exhausted. A terrible, terrible day following George Julian’s live tweeting of the General Medical Council (GMC) tribunal examining the conduct of LB’s ‘responsible’ clinician, Valerie Murphy. A tribunal that began back in August and is now spread across the next weekend or so.

Todays offering included a tangential figure – Prof Ted (a gut expert) on the phone to provide a character reference for Murphy – and an account of a travelling suitcase full of patient records. Murphy apparently asked Prof Ted to pluck records out of her suitcase, like drawing raffle numbers, to comment on her record writing skills. These are apparently top notch now. She’s learned not to keep them in her head.

Twitter commentators went into free fall. Eh? Audit? What records? With patient consent? Were they redacted? What price ethics?  Murphy was unable to attend for undisclosed health reasons. She seemed to be following the @JusticeforLBgmc twitter feed as, late afternoon when her barrister phoned to ask how this ‘audit’ was conducted, she tried to re-shape the suitcase story into something slightly more robust. Apparently she selected the first fourteen patient records (whose?) alphabetically and stuffed them in her travelling suitcase. Prof Ted randomly selected eight records from these 14.

He unwittingly generated criteria for what to look for when choosing a character witness who doesn’t really know you. Not a big demand for such a role possibly but useful to a few maybe:

  • Choose someone who barely knows you but is prepared to stick their hand into a dodgy travelling suitcase of patient records and describe this process under oath.
  • Make sure they are so tangential in your life that you spend around 14 hours a year in situations in which your paths could cross.
  • Make sure they are prepared to make outlandish statements about how good you are. For example, that you’re in the top 10% of consultants they’ve ever come across.
  • And when pushed on this claim, they’re willing to state rubbish like having a PhD and ‘being helpful and willing to offer an opinion’ is evidence of being brilliant at your job.

Around late morning the GMC presented their submission. We were suddenly thrown into a space of rare sense. Suitcases and gut stuff ditched. The GMC arguments can be read on the @JusticeforLBgmc twitter feed. The statements that made me weep were around how it was not unreasonable for us to expect LB would be looked after in the unit. Chloe Fairley, the GMC barrister, made the point that Partridge’s cross-examination of me in August was an example of Murphy’s more general blame-casting which included nurses and support workers.

Rich and I broke off to eat our weight in takeaway nosh. Returning to twitter an hour later Partridge was presenting his submission. Right back to Gut Man and the suitcase. And Murphy’s ‘brainchild’ the ‘yellow card’.  A shameless rip off of a well known government scheme on a pilot scale. The ‘yellow card’ was presented as Murphy’s contribution ‘to the profession’ to make sure no one ever died again.

Her entry back…

The fakery, sham and offensiveness of this redemption narrative, generated once the  tribunal process was put in motion and not as an outcome of LB’s death, was difficult to sit through. The dripping of ‘madam’, ‘in my respectful submission’ and ‘very painful for her’ statements by Partridge were grotesque.

Tears and more tears.

The day ended around 5pm. It starts again tomorrow at 9.30am with a private hearing.

Writing about an ongoing tribunal (or inquest) process is something we’ve thought about. We concluded today the process is so flawed and stacked in favour of the ‘professionals’ it can’t matter.

The deep sadness I feel. For LB. For the callous and continued disregard of his life (and so many other lives) – presented today as a ‘single patient episode in 2013’ – is matched by the obscene acceptance of the clearly wrong by tribunal panels. By senior NHS officials, by Jeremy Hunt and so many others.

We’ll keep writing justice. As simple as. And not be bullied by the processes seem to be designed to silence. That’s all we can do.

[Thanks to @RoseAnnieFlo for the title of this post.]

‘It was found that…’ A reflection on grief spaces

The General Medical Council (GMC) tribunal examining Valerie Murphy’s fitness to practice starts again tomorrow. Monday. And next weekend. Next Saturday and Sunday. And two more days possibly still to schedule. The findings so far are summarised here:

During the August hearing I was cross-examined by Murphy’s barrister. He said the way I described her in my witness statement upset her. We aren’t allowed to read her statement. We’ve no idea what she’s said. About LB. About what happened. About anything.

I was unwell after that hearing. Having just about managed to duck and dive the  traumatic, unexpected and preventable death cloak over four years, the calculated and deliberate questioning/non-questioning (and giant arch lever file action) by the barrister floored me.

Anxiety, panic attacks. Distraction, agitation, worry and more anxiety.

I worked today. I often work weekends but this was in anticipation of possibly becoming unwell again. And the late realisation it will be impossible to work on Monday (possibly Tuesday, Wednesday, Thursday…)

I was talking to someone recently about how NHS investigatory processes interfere with or even obliterate grief spaces. Spaces people have a right to inhabit after the death of a loved one. About how the ‘National Health Service’ generates further harm with little apparent thought. Even glee. [The slightly hysterical briefing to the then CEO of NHS England about how #JusticeforLB campaigners were hacking into Sloven staff Twitter accounts springs to mind…]

I thought about these spaces during my recent trip to Canada and the US when I experienced unexpected and breathtaking waves of intense and deep sadness. I don’t know if the lengthy bus and train journeys were a mechanism to re-enable grief thoughts. Or the space itself.

The determination of facts can be read here. George Julian will be live-tweeting tomorrow and Monday. A remarkable open justice service you can follow here.

Here’s to ‘finding’ sense. And space.

The Percy Problem?

Oh my. A piece in the Mail on Sunday* today about Katrina Percy, former Sloven CEO, touting leadership expertise on LinkedIn.  During twitter exchanges across the day I was bounced back to exchanges around our referral of Percy to the Care Quality Commission (CQC) for investigation under the Fit and Proper Person Regulation (FPPR) back in the day.

A right old dogs dinner that spanned more than 18 months. Littered with a remarkable number of non-responses. Demonstration of the disregard and disrespect bereaved families can expect from the NHS and wider bodies. Brutal non-responses…

2015
17 March 15 We refer Katrina Percy for investigation.
[No response.] Please reply even if only to say you’ve received the email. Families are in a terrible, brutalised position. To ignore is to simply add a size 10 Doc Marten kick in the gut to the experience.
27 May 15 I tweet about this non-response. Andrea Sutcliffe steps in to mediate. Good for Andrea but it shouldn’t take a tweet and the potential for reputational damage to generate action.
29 May 15 An apology from Mike Richards, then Head of Inspection, for the delay in response.
1 June 15 A letter from Richards with the panel decision:
Richards bollox

No words.

2016
3 Jan 16 After publication of the Mazars review we ask the CQC to reconsider their decision.
[No response.] As above. I tweet and Andrea Sutcliffe again steps in to mediate This flags up some communication type issues that really need addressing.
1 Mar 16 Email from Mike Richards’ executive PA to say our referral is tabled for the FPPR management review meeting on 11 Mar 16 and we’ll hear after that.
‘Thank you’ I reply. The differential in power laid starkly by the ‘thank you’ emails.
31 Mar 16  Hello, I email… Again.  Is there any news? As above.
1 Apr 16  Email from Paul Lelliot (Deputy Chief Inspector for Mental Health) to say the Chair, PA and Mike Richards are on annual leave. We should hear soon. A holding email takes about 1 minute to write and send. There is no excuse to piss off on leave and not reply. 
4 Apr 16 The Chair replies:

The panel concluded that any further action should be considered once CQC had concluded our most recent review and have an understanding of the position of NHS Improvement in relation to the trust.

6 Apr 16 A warning notice (and no action) from the CQC is announced.
7 Apr 16 I email to ask what the CQC are going to do about Katrina Percy.
14 May 16 I chase up my email.
15 May 16 Apologies for not updating I’m told. We will provide an update shortly.
29 July 16 I email for an update. [Note we’re leaving gaps of 5/6 weeks before recontacting. The spectre of the vexatious family/mother ever present. This consideration is not even a whiff among CQC business. Kind of reminding me of a paper we wrote about the ringside seat autistic people can have to mainstream life with little or no reciprocated thought from mainstream society.]
29 July 16 An email response: they are waiting for Tim Smart’s review of board capability and governance.
22 Aug 16 I email to ask if there is any decision about FPPR.

No reply. They didn’t bother to reply. As above. With bells on.

Katrina Percy ‘stepped down’ at the end of September 2016.

2017

There are three criminal prosecutions against the Trust in 2017. All cover Percy’s period of ‘leadership’. The Health Service Journal awarded her a ‘CEO of the Year Award’ back in the day which features on her LinkedIn profile. This was, according to a HSJ journalist, awarded by an independent (non-HSJ) panel, nothing to do with the HSJ and ‘before the issues were known‘.

We all know the issues now. Many of us recognised them before weighty (bloated, worn out and toxic seeped and steeped) senior NHS (Improvement/England/CQC/Dept of Health figures) eventually stopped slumbering. We all now know.

There is no more pretence. No more shonky little (and big) practices covering up, denying, bullying, bouncing and battering blame onto bereaved families.

The questions that whizzle around our brains/discussion relentlessly (raised by all sorts of people we meet, bump into or who even pull over to talk to us on the street)… Questions any sensible, non-NHS befuddled (at best) person asks and continues to ask remain unanswered. Not least how the hell could any of this happen? 

I don’t know if I want to ever know the answer/s to this. I just hope that those senior bods who were, and continue to be implicated, take a long hard look at themselves. That they start to polish their murky and corrupt stained goggles. Set aside the lure of the rewards for not seeing, not listening and denying and breath in some fresh air.

You’ve been arsewipes of fuckwhattery proportions. There’s no doubt about this. There is also time to change.

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*Our experience of sensitive and thoughtful exchanges with journalists continued with Jonathan Bucks. Thank you.

The afternoon before the hearing

 

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I spent the afternoon with Tom trying to get photos from an old mac that’s been gathering dust and more upstairs. Eventually, after exemplary focus and persistence by Tom, and a few chuckles along the way (yep, yep, my computer smarts are shite, I’ve a desktop that demands a cone of shame and I’ve not updated anything since about 1749), 451 pics from the (g)olden days are now on my desktop. (A fair few have an alarming luke white question mark but we can save that battle/puzzle for another day).

Above is LB ploughing his own path up a hillside holding tightly onto to his i-summat music player. The gadget he produced myriad playlists on, back in the day. Each with one song on.

It was our last family holiday in 2010. He did what he typically did; stuff (the day out in the Black Mountains with a makeshift picnic) in his own way, own time while breaking nonsensical and meaningless rules along the way. So what if he was far behind? He got there in the end.

Before we got stuck into this task Rich and I walked into town to get a hard drive. On the bus home Julie Dawes, Sloven CEO, rang in response to my email from Friday. Good for her for calling back. I want to present the gist of our conversation here because I think it contains or flags up important elements/ingredients for the relationship between Trust staff and bereaved or harmed families.

The Sloven board apparently made the decision that no board member would attend the Health and Safety Executive hearing at Banbury Magistrates court tomorrow for ‘various reasons’. This was because they decided it would cause us further distress and it was ‘usual’ to send the communications manager to such hearings.

Julie Dawes rang me out of the blue on Friday because she was worried about the distress their planned press release would cause us. We weren’t asked whether the attendance (or non-attendance) of a senior exec at the hearing would cause us distress. This suggests that baby steps of improvement (concern about press release distress) remain coated in relentlessly longstanding concern about Trust reputation. And an accompanying lack of really understanding what is important to families.

You can’t assume distress in one area (attendance at the hearing) while checking it in another (press release content) without raising questions about what is actually ‘important’ here. Our feelings as a family or Sloven comms/reputation.

And when you’ve endured the extraordinary through Trust actions like we, and so many other families, have the ‘usual’ is irrelevant and obscene.

It’s really time to start walking up hills using the example of LB (and others) if you mean business around changing practice. Chuck out the grotesque, the turgid, the meaningless, the offensive and step up. Demonstrate the ‘impact’ a patient’s death has had on your organisation with actions. Not talk. [As an aside, and a frankly unapologetic plug for my book, one of the things I learned from early readers was ‘show don’t tell’.]

Think about the thin arguments you’re making and challenge them yourself. Instead of sending the comms manager ‘as usual’ (I struggle here with what ‘usual’ is in such circumstances), make sure a board member pitches up, even if you anticipate a five minute hearing. LB wasn’t given the chance to live. Don’t show further disrespect or worse by thinking it’s only a ‘five minute hearing’, or because you want to downplay the importance of the hearing.

Stand up publicly and show you fully understand and recognise that your organisation is responsible for the preventable death of a patient. Until you do this, no other fucker is going to.

Julie Dawes said on Friday she wanted to offer any personal help she could. It turns out this was distinct from arrangements around the hearing tomorrow and board decisions about attendance. A revealing comment (which is not to knock the offer of help which we appreciate). For families ‘the personal’ is too often the process. And the obliteration of humanity through that process.

By the end of the conversation I think we were sort of on the same page. I appreciate her sticking her neck out by ringing earlier. I hope productive discussion followed our fraught conversation. And I hope some respect will be shown to our beautiful boy who died in the cross hairs of a greedy, arrogant and failing Trust, local authority and CCG, tomorrow.

He deserved so much more.

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Imagining a guilty plea

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The Health and Safety Executive (HSE) prosecution against Sloven is scheduled for 2pm Monday at Banbury Magistrates Court. If the Trust plead guilty it will be a short hearing adjourned until a sentencing date in the next few months. This is a criminal prosecution. A guilty plea is pleading guilty to a crime. A crime that caused LB’s death.

Katrina Percy, then CEO, consistently distanced herself from the dire happenings she presided over between 2011-2016 with the apparent blessing of those who should know better.  Even after the jury at LB’s inquest found serious failings:

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An ‘absolutely tragic failure’. I don’t know what these words mean. Other than it was nothing to do with me guv. But no one (no one) who should have, challenged them. For Percy, the unit and not her leadership was to blame. Before and during LB’s inquest, the argument was LB died of natural causes and it was my fault. The difficult mother and the pesky blog.

Sloven smeared here and they smeared there. Across the years. Embarrassing briefings outlining the wrongdoing of #JusticeforLB campaigners. Hacking, trolling and persecuting hapless staff members. And more. Blaming staff. Blaming everyone but themselves. There was no looking glass among the Sloven senior exec. Or Oxfordshire County Council and the Clinical Commissioning Group. No reflection whatsoever.

A tawdry soup of typically self-serving, smug, arrogant and sometimes nasty individuals. With inflated salaries and no understanding of what it is to be human.

Percy took her massive pay off, disappearing in to the early winter sunset last October. Waiting in the wings to re-launch herself as a leadership consultant on Linkedin.

Meanwhile, the new and remaining board members took it upon themselves to exonerate her in the recently published (and now suddenly removed from their website) 2016/7 annual review. She displayed neither “negligence or incompetence” apparently “during her time with the Trust to the extent that would warrant her dismissal”.  Despite two prosecutions underway.

Psst… board members – past and present – do you really not understand that patients have experienced serious harm or died under Percy’s leaky leadership?

Really?

Imagining a guilty plea

Just imagine. A guilty plea from a Trust who have forced us to fight every step of the beyond distressing way for accountability. Full pages of black redacted pages while other people leaked key quality reviews, briefings and more. Lies, more damn lies and non-disclosure across 51 months to us, to the coroner, and I assume to the police… Smears, delay and prevarication. Desperate attempts to prevent an Article 2 inquest and jury.

Valerie Murphy recently sharply shifted from a four year blanket denial of failings to partial admittance at her tribunal. Will Sloven, having steadfastly trawled through the darkest of dark practices, suddenly shift to a guilty plea?

If they plead guilty what does it mean? Can we can expect an apology for everything we’ve endured since LB died? The mother-blame shite. The staff witness statements with their ‘my relationship with Dr Ryan’ sections. The #fuckingpest commentary from the Berryman board member’s son. Will the abusive caller acknowledge I wasn’t a vindictive cow…?

Will there be recognition that we were collectively trying to get accountability for LB’s death?

Will Oxfordshire County Council and the Oxfordshire Clinical Commissioning Group hold up their hands and finally admit their role in commissioning and enabling crap care on their watch?

Will people/organisations actually take responsibility for LB’s death and their subsequent actions?

An unexpected call

On the bus to work this morning, my phone rang. It rarely rings. Sloven CEO, Julie Dawes. Ringing to update me about Monday. She wanted to run her statement by me, given we’ve been upset about earlier Sloven statements. Reflecting on our upset over previous statements is good. The statement she read out was an improvement on previous Sloven statements. More heartfelt and human.

It was missing any reference to the impact of Sloven’s actions on us since LB died though. What they forced us to endure. Walking through Cornmarket I tried to explain to Julie what it was like to listen to the Sloven barrister argue that drowning was a natural cause of death during LB’s inquest. Just one example of the slippery dishonesty the Trust demonstrated. I tried to explain how damaging this process has been.

Julie listened and said she’d try to reflect this in the statement. She said she wouldn’t attend the hearing on Monday ‘for various reasons’, she recognised how distressing Monday will be be and said if there was anything she could do to help I should get in touch. She reiterated this a couple of times. She asked if I was going to read out my witness impact statement on Monday. No, I said.

I thanked her, hung up and an hour or so later wondered why she, or the board chair, weren’t going to attend the hearing. It’s a criminal prosecution and most people don’t get to not attend ‘for various reasons’. If nothing else, it’s a simple sign of respect.

Given the earlier offer of ‘anything she could do…’ I thought I’d call her back to ask her. Number withheld. She could phone me, generating distress, but I couldn’t call her back.

I’m left wondering how much of the call this morning was driven by an underlying concern about reputation and managing comms. I mean if the Trust seriously wanted to demonstrate evidence of change the CEO or Board Chair would attend the hearing on Monday. And I wouldn’t be asked if I’m going to read out our victim impact statement.

The day after LB died Sloven wrote ‘Mother’s blog may cause a risk to the reputation of the organisation’. Over four long years later the only risk to this organisation remains themselves. And their actions.

 

Trivialising trauma

I revisited the letter from the Oxfordshire County Council commissioner this week. Christallbloodymighty. The 9 page letter sent to a disability rights activist a year or so after LB died and passed on to us just before his inquest in October 2015.

With increased incredulity, rage and distress, I googled her. Blimey. A more recent local news story. Mrs Cross of Oxford. Sent a free lesson at a now closed leisure centre. She seems more outraged by this than what happened to LB.

The first part of section 10 of the letter begins:

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So much so fucking wrong.

  • The erasure of LB.
  • The diminishing of what happened to one ‘frustration’ (of many?)
  • The removal of agency; I’m out of control, irrational, hysterical.
  • Blaming the blog
  • Checking people are still alive [howl]
  • Blaming admin
  • Prioritising the absence of a particular colleague
  • Erasing LB.

Sending a letter to a patient who died a preventable death on your watch is more than ‘crass’, ‘upsetting’ or ‘unfortunate’.

Writing this letter and bleating about a random promotional freebie exercise class to a local paper screams so much so wrong with values.

Has (the audacity of) publicly documenting poor provision on ‘the blog’ and the light shone by #JusticeforLB turned senior public officials into monsters?

Or just exposed reams of rubbish wrapped up in ‘No one will ever know about or expose our inadequacies’ complacency parcels?

‘Upsetting’

I’m struck by the use of the word ‘upsetting’. In Josh Halliday’s Guardian piece about the tribunal, the MPTS responded

We are sorry to hear how upsetting Dr Ryan found the process of giving evidence to the tribunal.

An extraordinary trivialising of trauma.

‘Upsetting’. They heard how upsetting I found it? How? Through Josh’s questions? From MPTS staff present? From jibber jabber by the coffee machine?

From the clearly upset clerk who led me into that vicious den, removed me from it for a few minutes and then returned me to it?

Upsetting. What is ‘upsetting’?

LB missing his beloved Olympia Horse of the Year Show because of whooping cough. [We both had whooping cough, as did Fran’s son, James. I have a tear inducing fondness/nostalgia remembering those whooping cough weeks]. I was upset that LB missed the horse show.

Upset seems to relate to missing things. An event, a job, an exam pass, a promotion, a ticket, an opening, a closing, a dying plant, a building, a pub, a writer, an actor.

But it ain’t receiving a letter addressed to your dead son telling him how well the hospital he died in is going to care for him in the coming year.

Or being forced to answer a battery of nasty, credibility shredding non-questions for two hours in front of a tribunal panel and the clinician responsible for your child’s care.

As time drags on, space emerges to reflect more clearly on what happened. To make reflections, sense or no sense. There are clear similarities between the responses of the commissioner, Murphy, Percy and others.

Cut from the same cloth. Cloth woven with a thread that obliterates humanity, reflection and recognition of people and their families. No remorse, no genuine sorry, no regret, no nothing. Just blame. The mother, the blog, the frontline staff.  [Dip into the Katrina Percy reply for an extraordinary letter with 40 or so mentions of ‘I’, ‘me’ and ‘mine’ in just over two two pages.]

I’m wondering how far the stain of this model of ‘leadership’/senior NHS staff spreads. Are commissioners, learning disability psychiatrists, Trust CEO’s typically petty minded, self obsessed and ignorant of the lives and love of the families they are supposed to be serving? Is this unchecked or even encouraged by their peers/the culture of the senior tier?

And to those of you still monitoring this blog with a defamation lens. In case you still ain’t got it. Our beautiful boy died. He died.

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A levels, love and waiting for the tribunal

A ‘day off’ from the GMC tribunal which continued in private today. Day three of deliberations to determine the facts.

A level day.  Early morning jitters (and humour) from Tom:
Tom
He stormed it. We could not be prouder.

Funnily enough, a photo of Tom and Owen from 2012 popped up on Facebook. A day out in London months before Tom’s childhood was to change irrevocably. Owen, then 17, turned turned 18 the day before LB died. [I know].

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A friend messaged earlier saying congratulations and Tom has ‘done his part in saying ‘fuck you’ to the system and not allowing it to control’. Rosie, Will and Owen have also done their part in doing this. They have, in addition to the death of their beyond loved brother, endured home becoming a site of activism, anger, rage, despair, distraction, tears and more tears.

About a year ago now, at some particularly low point, Rich and I decided during an unusual weekend home alone that we would chuck in the towel on the fighting front. It was too much. It wasn’t fair on the kids. We were trying to climb a super smooth glass NHS mountain coated with a combo of pig grease, melted butter and olive oil.

We told Tom on his return expecting relief. A levels looming and all. He was shocked we’d even consider it. The love, concern, steadfast and unquestioning support and humour they have demonstrated over the last four years, mirrored in the actions and support of their partners and friends, is something we treasure beyond words.

These last few weeks have been particularly unpleasant. We’ve been shoehorned into even more extreme spaces by the careless fuckwaddery actions of the Nursing and Midwifery Council sharing our personal details and Mr P’s brutal and unnecessary cross-examination last Tuesday.

Wilful attempts to discredit without any relevance to the allegations under examination.

paramedic

On Wednesday we waited for the tribunal to begin again in public. A inhumane waiting even without the unchecked, salacious and unnecessary savaging. I lay on the settee, under my Routemaster blanket, refreshing twitter repeatedly. Bess dozed on the chair opposite. I took a pic of her on my ipad and tweeted it.

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#Waitingforthetribunal

This generated an unexpected and hilariously heartwarming set of photos; the pets of twitter. Waiting in solidarity for the tribunal. Including a plant (a groot?) which I can’t find now (sorry).

Names, spaces, commentary and love.

I’ve written about pets and health, we’re currently putting together a funding proposal with vet colleagues to further explore this area and yet I didn’t expect to find such solace in the sharing of photos of much loved animals on twitter. It made me chuckle. It was grounding. It was kind of reassuring.

Yep, I thought. These non humans could teach us a lesson or ten. If we would only start listening.

Late morning tomorrow (Friday) the panel are due to announce their determination on the facts (whether the doctor is guilty of the remaining charges she has not admitted to). The tribunal will then be rescheduled to continue at some point in the future.

We will continue waiting. Four years and six weeks on.