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.

‘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.

Six days in Asturias

A last minute booking to try to escape the stain/strain of GMC tribunal horror. Rich had to stay at home to work. I got a return flight to Asturias for £107. Returning to the land of the Camino. A hotel in Oviedo booked for night one. The rest open to whim [or howl]. The forecast rain and cloud.

Thursday evening

At the airport, waiting for the Oviedo bus, I chatted to D. She was on her way to a Tai Chi course with a Spanish master. After 12 years of practice she was beginning to understand the inner workings involving her core. She also mended clocks.

She asked what I did for a job. 

“My mum told me I was diagnosed with High Functioning Aspergers when I was at school”, she said, when I told her. “I never looked it up or anything, I was just relieved to learn I was normal. I didn’t feel it at the time.”

M joined us. A recently retired economics teacher. She was going to spend a week volunteering on an immense course.

“Immense?” I said. “That sounds pretty important.”

“Immersion. Students of English immerse themselves in the language for a week with no Spanish spoken. It helps to cement learning.”

“I realised I talked all the time and didn’t listen,” said D. “On one of our retreats, someone said I wasn’t to talk for 24 hours. It made me realise that the quiet people, who I’d never even noticed before, spoke the most sense. The noisy ones I’d always engaged with said nothing.”

It was dark and raining in Oviedo. After some help from non English speaking locals, I found my hotel and checked into my room with a view. I felt like shite.

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Friday

The guy on reception enthusiastically scribbled on my map before I left to explore the city (of sculptures). With a final flourish of the biro he marked the Santa Maria de Naranco up on a hillside overlooking the city. I was to catch the A2 bus opposite the Campo de San Fransisco, two minutes from the hotel. The bus turned up straight away. I got on and said my destination. The driver didn’t understand me so I showed him the map. He shook his head and pointed to the bus stand behind me, making his fingers into a shape I think meant a letter rather than a rude gesture.

I got off and pointlessly studied the bus timetable written in Spanish for a few minutes.

Someone shouted. I turned round. Another bus driver asking where I wanted to go in Spanish (I think). 

I got the map out and pointed to the scribble. He nodded. The fare was €1.20. The church spectacular. I stayed a second night in the room with the view.

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Saturday

Early afternoon I was wandering around Cudillero, a dense and beautiful fishing town that tapered down the hillside into a harbour, with Alicia Wood and Henry Iles. Reminiscent of Portofino there were bustling restaurants serving seafood delights around the harbour front. Unlike Portofino, there were no designer shops, masses of tourists or fakery. Just a fishmonger, a vending machine or two, people’s smalls hanging on airers from windows in the narrowest alley ways and an enormous, damp smelling, dusty pink and blue flavoured church.

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We sat up into the early hours of the morning, eating traditional stew, drinking and putting the learning disability world to rights.

Sunday

A day trip to the Somiedo Nature Park with Alicia. A small beer in bear country before driving further into the mountains for a two part adventure. 

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Part One. Clear and detailed info from Alicia about what lay ahead. Eight kms of fairly hairy (pin bends) but doable driving. Passenger advice: don’t look right if you don’t like heights [I don’t]. We reached Valle de Lago, walked further into the mountains and had a picnic from the olden days, chatting about childhood books. Looking for bears.

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Part Two. No advice, just a creeping sense of horror as the road grew steeper and narrower. Small sections of wooden barriers with car sized holes appeared every so often. 

“There’s metal inside the wood. You can see where it’s snapped…” I said, leaning away from the window. As we ‘laughed’ hysterically.

Bend after bend, more broken fencing and the occasional oncoming car. We inched our way up the mountain road to a car park on top of the world. A mountain dog, torrential rain and extraordinary views. 

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After a soaking wet walk to a lake along a pink path worthy of a sci-fi film set we drove back down. With cattle for company.

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Monday

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I left Alicia and Henry and took the single track FEVE rail journey from Las Cabos to Gijon. Alone at first, I was joined along the 30 or so stops by a few Asturian locals. The odd set, perm and elaborately coiffed comb over. No chat. Just travel. Taking in idyllic hamlets, small towns, touching on bits of coast and the back end of industrial Aviles; apocalyptic, smoke belching ironworks and a hinterland of dust covered, unrecognisable landscape.

I was weepy for most of the day. An outcome of the extreme fear therapy we’d endured the day before? Or maybe it was because I was, unusually, able to think about Connor rather than GMC/NMC and other shite. I walked to La Madre del Emigrante (mother of the immigrant) sculpture we’d passed on the CaminoLB.

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Followed by dog and people watching.

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I had a room with two views in Gijon; the second window right above (and facing) this guy’s head. A second set of doors opened out onto the neighbouring square.

Tuesday

The sun shone and I felt brighter. The Gijonese were out in force and I did what they do. A march along the sea edge with my bag, a parade along the front, ice cream and book reading on the beach. 

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Ending the day with a cheerful and delicious final meal with Alicia and Henry. 

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This post is, in part, an unashamed plug for this strip of Northern Spain. An 80 minute flight to a land of delicious food, beautiful and varied scenery, warmth, rich hospitality and a wonderful way of life.

It’s also an account of easing into feeling human again.

Being (in)sane in insane places… in four parts

Part I

Waiting for the GMC tribunal to come back from ‘in camera’ (secret) discussion today. It’s impossible to do anything constructive. Wait. Mope about in bed. Play Candycrush. Clean the floor badly. Answer a few work emails. Pace around the house. Play Candycrush. Poke at weeds for a bit. Mope. Back to bed. Wait.

Agitate.

Part II

We’ve waited four years. But the events of last week make it impossible to concentrate. The cross-examination brutality, the revelation that this blog was causing anxiety among consultants before LB was admitted to the unit and other outlandish arguments by the doctor’s barrister, RP.

Including his bizarre claim he had no computer access to produce submissions for the Friday morning. In central Manchester… sitting next to a colleague with a laptop.

There was incredulity and practical info on twitter.

The next morning RP circulated a set of handwritten bullet points ‘not in narrative form’:

He later argued:

Not all of us are au fait with narrative… You have to find a computer first and then go into free text…

Oh my. Did he handwrite a set of bullet points (a day or so after deftly destroying me as a reliable witness) to demonstrate the point that computers aren’t necessary to do a good job as a consultant?

The day ended with this comment:

Part III

The GMC are keeping us informed about the timetable and process of this hideous process with thoughtfulness and sensitivity.

This is where we are at:

The panel are currently reviewing and considering the evidence given last week and need to agree the position on each charge that has not already been admitted and draft a full decision referring to the evidence, setting out their reasoning for each of the charges.  
 
The hearing will reconvene in public and the determination will be read out. Parties may need time to fully consider the determination then the hearing will move to the second stage. Further evidence can be called and submissions will be made on behalf of the GMC and the doctor in relation to whether the doctor is impaired. At this stage, the Tribunal meet alone again and need to make a decision on two matters: 1. whether the facts found proved are serious misconduct (the meaning of which is set out in various case law) and 2. if so, whether the doctor is impaired by reason of her misconduct.  It is not known how long it will take for the Tribunal to make this decision.
 
Depending on the Tribunal’s determination on impairment, the panel will consider the position of sanction. This would involve further submissions by both parties and another determination by the Tribunal.
Apparently the panel are unlikely to give a determination on the facts tomorrow.  The determination (the next step before the next stage) will likely now happen on Thursday. Coinciding with Tom’s A level results.
Part IV
This hearing has dominated the last few months for us. The Nursing and Midwifery Council (NMC) data sharing breach-too-far is bubbling on in the background. We’re less than four weeks from the Health and Safety Executive prosecution. We managed to polish off the personal impact statement yesterday, thank fuck. In less than a page.

You should include the fact you haven’t had a bath since LB died.” said Rosie. “And you loved them. I remember when we were little and we used to come in and chat to you. Sitting on the toilet…”

My definition of crap has taken such a battering I no longer have words for what we’re enduring.

We’ve been pushed into such an extreme space now that daily interaction with people is becoming difficult. Throwaway conversations in the street about the weather, summer holidays, dogs are hard to engage with. You can’t lay the shit storm we’ve been subjected to on any passerby or acquaintance. At the same time, saying, vacuously “Yeah, fine” is harder to say.

This led me to think about another layer to the campaign and social media activity; the sharing of rage, distress, incredulity and bafflement. The discussion and commentary. We know we wouldn’t have got ‘this far’ without social media. I hadn’t thought about how we would have personally been derailed months or years ago if we were experiencing this in isolation.

An hour into Mr P’s interrogation last Tuesday I was doubting myself.

It’s harder to doubt when so many others express sense, offer expertise (in any shape or form) and solidarity. And genuinely care.

 

The bleat action continuum

Over two years ago now I was writing about ground elder and the #LBBill. I’ve moved into the front garden recently, leaving the elder battle in kind of easy truce [I failed]. The front garden has tall ‘weeds’ with yellow tops which grow to middling head height every summer, leaving columns of snappable woody stems in the autumn.

Turns out these fuckers are worse than the ground elder. They have incredibly dense interconnected knotted lumps of a main root with shaggy swathes of stringy roots. Each one involves a hefty dig, more digging and almost full body wrestle to remove it from the ground. I can almost hear the earth breathing as they are lobbed into the brown bin.

Today we were due to hear the outcome of the Nursing and Midwifery Council (NMC) investigation into how they could possibly have shared personal details to the six nurses under investigation and their counsel.

Given the General Medical Council (GMC)* tribunal into Dr M’s fitness to practice starts on Monday in Manchester for two weeks and Rich and I are on extreme stress settings, I naively hoped that the NMC would be in touch early on in the day to limit the stress. We’ve had way too many 5-5.30pm Friday disclosures over the last four years.

The day dragged on. I punctuated work tasks with patches of root wrestling. Still nothing from the NMC. By 4pm I drifted onto twitter. It was impossible to concentrate. There was some discussion around what time we might expect to hear from the NMC and recognition that the Friday afternoon ‘disclosure dump’ is clearly modus operandi for public sector organisations with no heart or feeling. I resorted to tweeting the CEO about the cruelty of this delay.

The email pinged into my inbox. At the very outer edges of the allocated time.

Tip: Because you say an investigation is going to take x amount of days doesn’t mean the investigation has to take x amount of days. Focusing more attention on a complete balls-up to reduce the time the investigation takes and the accompanying stress for the family is the least you can do in a situation like this. Particularly if

  1. you had an additional 15 days between discovering the data breach and bothering to contact one of the four people affected.
  2. you have previously and publicly spent £250k redacting documents requested by another bereaved family in a breathtaking self protective act.

One of the numerous shite practices we’ve noticed over the past four years is the tendency for senior public sector staff to bleat ‘It was not our intention to do x, y or z’ despite doing it. Or ‘On reflection we should have done…’ when they didn’t.

What this really means is senior staff act with intent (and speed) when it involves their (organisational or own) reputation/skin and don’t when it doesn’t. The briefing on my blog circulated the day after LB died is an exemplar of this bleat action continuum.

The NMC letter outlined how sorting out the return of our personal data (first shared in November 2016) is shambolic. A mix of returned data, alleged destruction of data and outstanding information about copies made.

About as unreassuring as you could get.

And then, in a move not worthy of being written into a cheesy, made for tv movie, it turns out that after discovering the data breach in July 2017, they re- shared my personal details with three of the nurses. Yes, you read that correctly. Re-shared. Nine months after first carelessly tossing them around. But only [bleat] the same information (minus my bank details) to the same people…

There is nothing like heavy handed, dosh drenched redaction when it ain’t your reputation under threat. Nope. Nothing like it.

Fuckers.

*The GMC have been exemplary in the approach to this: clear, detailed information, communication and organisation.

A breach too far

I’ve spent the day since talking to the Nursing and Midwifery Council (NMC) at lunchtime shaking uncontrollably, swearing and raging, laying on the settee in silent tears and, for the last two hours, drinking beer and now wine. ‘Luckily’ we are on annual leave so I can do all these things.

I think it’s fair to say that since Connor died we have been treated in a remarkably consistent and appalling way. We’ve had no equivalent of a police liaison officer to help us pick our way through the wreckage of his death and our shattered lives. We’ve had no support, kindness or understanding from any of the organisations implicated in his death (the Trust, the county council, the clinical commissioning group, NHS England or NHS Improvement).

Instead we’ve been smeared, pissed and shat on in extraordinary ways.

In addition, we’ve been expected to attend numerous meetings with the ‘great’, good and mediocre to try to improve practice. All at our own expense, all in our own time and not one single meeting held in Oxford where we live. We have been chewed over, sucked dry and spat out.

I think we’ve behaved pretty well in the circumstances. I’ve only started using the word cunt regularly in the last few months or so. It trips off my tongue now. Rich has stormed out of the odd meeting or raged down the phone to the odd Chief Inspector or two, but in the circumstances small fry really.

We’re a family, like so many others, who have experienced the worst possible happening; the preventable and brutal death of a beyond beloved son, brother, grandson, nephew, cousin and friend within the hallowed walls of the NHS. A young man with his whole life ahead of him, discounted as human because he was labelled as learning disabled.

We’ve sucked up delay after delay, obstruction, deceit, denial and mother-blame on a scale that is more than enough to generate long term mental ill health. We’ve battled on with remarkable support from many people. Dealing with the death of a child is horrific. Dealing with the accompanying shite and recriminations that come with the bullying, defensive and self obsessed practices of public sector organisations (and individuals therein) which have failed, is simply brutal.

Today I was told, after an opening filler of no substance whatsoever, that the NMC had ‘accidentally’ shared our personal details with the six nurses under investigation back in November 2016.

There was no whiff of an apology until I asked for it.

A couple of hours later, when I was able to speak, I found out that this data breach involves:

Our home address, my mobile number, email and bank details, my mum’s name and phone number, Connor’s date of birth, NHS number and his dad’s name and phone number.

 

The redaction policy of redacting personal information had been ignored when it came to our personal information. There were other redactions. From this, we can only infer that we, like Connor, were discounted as human. How else can you redact some personal information and not others?

This apparently came to light on June 26 2017. Over two weeks ago. Five out of the six nursing staff (or their counsel) were contacted by email on Monday with a request to destroy or return the disc containing this information. Four out of the five have apparently acknowledged receipt of the email with no accompanying action. The sixth staff member who only has a postal address hasn’t been contacted yet. The NMC haven’t bothered sending a letter.

Our personal information is still out there live and kicking.

The senior member of the fitness to practice team I spoke to after the first call spouted root cause analysis and learning shite after a delay of an hour between calls while she bothered to get the relevant information to hand to answer my questions.

I can’t articulate this violation other than in tears. A flood. The level of contempt and disrespect is generating weeping in a way I thought we’d kind of crawled beyond. A return to the Sooty tears. Almost worse in some ways because it is so fucking wanton.

The basics here – like don’t leave a patient with epilepsy to bath alone in a locked room and redact the personal details of the dead patient and their family when sharing information –  don’t need investigation or root cause analysis.

And the tears kick in again.

 

 

A phone call from the NMC

“Hello Dr Ryan,

I just wanted to update you with where we are at with the tribunals. Since we last spoke we’ve held case conferences with the HSE and GMC and established a good working relationship.

One other thing that’s come to light is that back in November 2016 we sent out your personal details to all six registrants [nurses] and their counsel. We’ve asked them to send the hard disks with the details on it and to destroy any copies they may have made.”

No words.

Update: