Back to the Oxfordshire County Council report this evening. I was struck by things I hadn’t noticed or noted in the list of factual inaccuracies I was forced to produce the other weekend.  

Reading the Methodology section alone makes me feel like a nest (nest?) of spiders eggs are about to hatch and burst through my skin. Interviews were apparently conducted with the;

Area Service Manager

Operations Manager

Team Manager

Senior Practitioner

Care Manager

Clinical Specialist Occupational Therapist

Service Manager, Children with Disabilities

Team Manager, Children with Disabilities

LB’s teacher

LB’s teacher obviously knew him well. The Care Manager met LB and me a handful of times (3?) across ten months or so.  I met the Operations Manager once after LB was admitted to STATT. The rest? I dunno. Just job titles. That give certain people the power to produce words/claims about what happened. Some personally named, some not.

I wonder how long these ‘interviews’ were. What was asked? How much careful probing was done? Were they recorded or were notes jotted down? Were they face to face or over the phone/email? What could so many of these people contribute to any understanding of what happened to LB? Why weren’t we involved at any point?

As if this flimsy engagement wasn’t enough for someone (anyone) with any sense at OCC to recognise that this ‘independent review’ was clearly, seriously flawed, there’s also a handy list of ‘Other staff noted in this report but not interviewed‘. This includes the psychiatrist who was apparently contacted by the Team Manager (who?) on behalf of the Independent Consultant. And various other staff members who had either left OCC or were not available for interview (in the eight months the review took to produce).

What a dogs dinner of a report.

And how often are sneaky little investigations like this conducted and circulated within and beyond local authorities/NHS Foundation Trusts without families’ knowledge?

Just chilling.

Two years ago today I wrote this; The Unit. Day 63.

24 days earlier I made a complaint to Sloven/OCC. My main point about not being listened to and a lack of recognition about the seriousness of the situation was ignored.

What exactly are we fighting about still? And why?

Anyone?

[An old friend, Bob, died on that same day, unexpectedly. This post is (hopefully appropriately) dedicated to him].

Years ago, after chucking in university and rambling off to explore other spaces, I came home and landed a job as an editorial assistant for a little publication called ‘The Pro Shop’. It was a monthly magazine linked somehow with the Professional Golfers Association. It went to all professional golfers in the UK. Now I ain’t no golfer but we (staff of two) had a chuckle or two in the tiny office off the high street… typesetting, spray mount and daily pub lunches. At one editorial meeting around November we came up with an annual ‘Shopfitter of the Year’ competition. We thought we were on fire. We’d invite pros to send in pics of their creative shopfitting efforts. One of the golfing equipment companies stumped up a good prize (a Titleist? set of golf clubs or summat like that) and four other prizes were pledged. Wowsers. We were excited.

We did the blurb, designed the application form (postal) and looked forward to receiving the (polaroid) pics in the post.

The first entry arrived within days. With “Shopfitter of the Year Competition” obediently written in caps across the envelope. We couldn’t wait to see it, envisaging the sackloads of entries that would follow. Already buffing our judging hats. We ripped open the envelope and out dropped a picture of a branch, stuck in a pot with a couple of golf shoes tied by the laces hanging from it. Wonkily.

We chucked it to one side.

About two weeks later no other entries had arrived and the closing date was looming. A hastily convened editorial meeting was held. We’d have to extend the closing date and big up the blurb. This generated three more pretty mediocre entries. We extended it again. Photographing the clubs (which by now were acting as a coat hanger, Christmas tree and target for angst ridden, screwed up bits of paper) in the office and outside the office door in the alleyway (better light).

A fifth entry arrived by spring. Almost lost in the amount of angry post from entry 1 demanding to know who had won first prize.

Thank fuck for that. We could announce a winner and the four runner ups.

The reason I’m remembering this story today is because the Health Service Journal announced their ‘Top Chief Executives’ list. ‘Recognising the outstanding leaders of NHS provider organisations’. It included Katrina Percy.

I can only hope think the editorial team were in a similar ‘extend the deadline for nominations’ situ of desperation. Gnawing on their fists over a greasy but delicious shepherd pie and couple of pints.

We never ran the competition again.

I deleted this post I wrote in the middle of the night because I hadn’t noticed the date. Careless.

Imagine that pretty much straight after LB died, Southern Health deftly kick away the stale, overused ‘learning disability=natural causes’ cloak lying, as ever, in the lobby of Southern Health Towers.  With a yellowing ‘use me’ sign attached. Commonly found in most Trusts/social care HQs.

They instead turn turn a critical lens on how a fit and healthy 18 year old young man could die in their care. They contact the family and say how desperately sorry they are that this has happened. They’ll do everything they possibly can to find out how it happened and make sure it will never happen again. They will work with the family and keep them informed of all developments.

A key person is designated to make sure this happens (the Southern Caped Crusader in this instance). S/he knocks up a newly designated work station (with clear plastic ER type ‘white’ boards and brightly coloured whiteboard pens) and knuckles down. With resources. The police are investigating but that doesn’t stop the planning and organising of the investigation team. The caped one pulls together a robust investigation team and provides them with the records to start doing meticulous preparatory work. An external advisory set of experts, including an epilepsy expert, is created.

As soon as the police pass the baton, the investigation team are off. Leaving no stone unturned in their quest to establish how such a catastrophic incident could have happened. At the centre of their investigation, always, is LB. The dude. Not a hollow set of initials. Disconnected from anything other than NHS speak. The team regularly update the family with their progress (checking, of course, in advance how regularly they want to be updated). The investigation is timetabled to take 60 days.

There are some confounders along the way. The CQC do an unannounced investigation and the unit fails on everything. Really? That adds fuel to the fire for our team. The caped one contacts the family to say how deeply sorry s/he is that this will clearly compound to the distress they must be experiencing. Adding further reassurances that the Trust are committed to making sure that this could never happen again. S/he underlines this by outlining radical and innovative steps the Trust are already taking to make sure their learning disability provision is as good as it could be. Steps that draw in learning disabled people and family members as core movers in the creation of good care.

Monitor step in. And start to examine whether Southern Health should hold a licence. Whoah. Cripesy. Serious stuff. But no. Bring it on. Southern Health are determined to make sure any failings on their watch are identified, made accountable, transparent and act on changes identified.

Sixty days later the report is finished (bang on time). It doesn’t look good for Southern Health (obviously). But that’s cool. They’re willing to hold their hands up, admit appalling practice, operate the shiny, new duty of candour and spell out how they are going to change. Slamming and locking the door on the traditional/historic ‘sweep it under the carpet brigade’ is a bit niggling/challenging but no, the Caped Crusader is firm. It’s time to face the public. And the family.

“We got it so completely wrong. We are so sorry. LB should never have died.”

LB’s funeral is today.

Yep.

LB’s funeral is today.

In the last ten days, I’ve said new things like “The coffin looks great, thank you” (which it does) and “Yes, let’s do the ‘scattering’ after the committal, during the song”. We’ve agreed ‘order of service’, no limousines, an outside, rather than chapel, service. I’ve remembered how to spell cemetery (after googling it). We’ve sat with LB in the ‘chapel of rest’, handed over things we’d like to be buried with him (bus timetables, his first aid book, die cast bus/truck models, a photo of (just you and …) me, the Sweaty Betty catalogue, his bling), checked out his woodland ‘plot’, and wept.

Friends and family have taken over necessary tasks in almost invisible ways, doing their absolute best to reduce the hideousness of what’s happened.  The collective feeling, commitment and action is remarkable. Makes me think that change is possible.

We’re grubbing around trying to find new ways of being a family, trying to incorporate the devastation into what we had. I’m not sure how this will work, or what we should be doing really. We all just miss him too much. Too fucking much.

I don’t want to go today. I want to hang out with LB and chat about where Steve Wright was born, about Irish lorries and County Mayo. I want to help him draw up his plans for his depot and have a chuckle about what the girl he took a shine to on the speed ferry a few years ago might be doing now. I want to answer every one of his questions until he’s finished asking them without getting exasperated. I want to give him the biggest hug ever and not let go, but I know he hates that. High five and bit of a bounce. Coffee cake and ginger beer.

It’s going to be a very long day.

Written by someone else today. Perfectly.

http://thesmallplaces.blogspot.ie/2013/07/lb.html

I’m a bit worried as I feel as though my heart is locked away in a small box. Like a tiny one of those old packing chests they used to use in house moves. I’m crying but the tears ain’t reaching anymore. They feel meaningless.

It started at the funeral place yesterday afternoon. The room overlooked the London Road. While we discussed coffins, in a strangely quiet, cream coloured haven of sorts, and I watched the number 8, 9, 400, U1, 280, X90 and Oxford Tube buses drive past.