LB ain’t no Han Solo…

Posted on October 12, 2016 by sarasiobhan

The makers of Star Wars: The Force Awakens have been sentenced after failing to protect the actors and workers while on set during filming at Pinewood Studio, Slough, Buckinghamshire. Harrison Ford suffered a broken leg and deep lacerations when he was knocked off his feet and pinned to the floor of the Millennium Falcon set, as a prop door closed on him. HSE’s investigation found that there was no automatic emergency cut off, to protect those on set, instead relying on the reactions of the prop operator(s) to bring the door to a stop. Aylesbury Crown Court heard how a combination of preventable events, starting with how the door was designed, led to the incident.

In 2013, Southern Health NHS Foundation Trust (Sloven) failed to protect patients in the Short Term Assessment and Treatment Unit, Headington, Oxford. Connor Sparrowhawk lost his life when he was left to bath alone despite a diagnosis of epilepsy.

During dress rehearsals on the 12 June 2014 Harrison Ford walked back towards the entrance ramp of the Millennium Falcon and pressed the prop door button to ‘close’ the door. As the cameras were not rolling he did not expect it to close. The production crew member who was operating the prop believed they were in full rehearsal and closed the door. The door’s steel frame was overlaid with sheets of metal and had a tapered edge. It’s operation moved from ceiling to floor in a sharp downward motion. It did not have any automated safety mechanisms to cut out if a person was unexpectedly under the door.

On 4 July 2013, Connor went to have a bath. He didn’t expect to drown. Staff on duty didn’t think about his safety. There was no leadership from Sloven, both locally and at executive level, which meant the recently taken over unit was unsafe.

The risk of the door causing a serious injury or death had been highlighted by one of the health and safety officers for the production company. Foodles Production (UK) Ltd should have put a system in place to ensure the actors and production workers were protected. A different design with inbuilt safety features or using a different material could have guarded against any possible miscommunication on a busy film set.

The risk of seizure activity had been highlighted by Connor’s mother and wider longstanding health and safety failures by Mike Holder. Sloven should have put systems in place to ensure patients were protected. A different system with robust safety procedures would have guarded against any possible miscommuncation in a small unit.

Foodles Production (UK) Ltd, who had pleaded guilty at a previous hearing to Section 2 and Section 3 (1) of the Health and Safety at Work etc. Act 1974, were today fined £1.6 million and ordered to pay costs of £20,861.22 at Aylesbury Crown Court.

Sloven have consistently tried to wriggle out of any accountability, blame Connor’s mother and ride the waves of executive level corruption over £millions wasted on nonsense training by an organisation led by the then CEO’s mate.

HSE’s Divisional Director Tim Galloway said: “This incident was foreseeable and preventable and could have resulted in more serious injury or even death. The power and speed of the door was such that, had Mr Ford or anyone else had been struck on the head by the door as it closed, they might easily have been killed. It was only the almost instantaneous actions of the prop operator in hitting the emergency stop that prevented the door from continuing to press down on Mr Ford as he lay on the floor. I think everyone would accept that all the people who work in the film industry have a right to know that the risks they take to entertain us, including when making action movies, are properly managed and controlled.

End.

There has been no statement, report or court case about LB’s death. His death. There was no ‘might’ about what happened to him. No over sensationalised, dramatic rehash of what (nearly) happened with photos. He died a year before Harrison Ford’s knee injury.

The HSE, like the GMC and NMC, clearly have no interest in swift, efficient and timely investigations into the death of a young man with his life ahead of him. LB ain’t no Han Solo. Well, he aint human in the eyes of these organisations. But Harrison Ford is more so. As this salacious guff highlights.

There is no whiff of respect, dignity, care or humanity around the deaths of LB, Danny, Edward, Adam, Thomas, Sarah, Nico and others. Along with complete disregard for their families. We are simply ignored, dismissed, bullied, battered and, I suspect, despised.

I’ve given up asking, pleading, demanding, raging or expecting any action. Here’s a selection of words. Please order them in any way you choose. Or don’t bother.

Bunch. Jot. Among. Fuckers. Sad. You. You. Of. Of. Self serving. Integrity. With. Among. No.

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Thank you. From Berlin

Posted on October 10, 2016 by sarasiobhan

Back from a weekend in Berlin with two mates, Ulla and Jorun. Special times. We met when we started working together nearly 10 years ago in January 2007. Ten years. Wow. [Howl]. Two beautiful babies, the death of two dads and one child, moving back to Finland and Norway (before any whiff of Brexit), getting a doctorate, a professorship, a new career in the charity field of women’s work in the Global South.

A weekend of talk about families, love, work… Laughter, health, life and shopping.

On Friday afternoon, in a coffee shop in Kreuzberg, my phone started to ring. I didn’t think it worked in Europe. And it rarely rings. I missed the first couple of calls. Unknown numbers. Something kicking off. Clearly.

We headed for the East Side Gallery. Later, standing outside the closed to the public, iconic television tower, the Fernsehturm de Berlín, my phone was still ringing. Katrina Percy had stepped down.

Earlier, I’d decided to walk from my hotel to Kreuzberg to hook up with them. A 7km walk apparently. Armed with a cheeky tip from George Julian (for no phone or roaming wifi) I screen grabbed the route in my hotel room and set off early. CaminoLB training. It all went brilliantly until this point (screen grab 4):

I walked in the direction of the blue dots, post canal, for what seemed like miles. I knew I’d missed screen grabbing one section of the route (because it was all the same road) but couldn’t remember which one, so just kept walking. And walking. And walking. Eventually I stopped at a junction, stared at my next screen grab (again) and a passerby asked if I needed help. He didn’t speak much English, my German is non existent. He looked at screen grab 6, pointed a sharp right turn and we started walking together.

We walked and walked. Managing to share, along the way, that he was Lebanese, living in Berlin and owned an Italian restaurant that did takeaways. And that I lived in Oxford and was going to meet mates. We walked in a comfortable silence after those few exchanges. Eventually, we reached the overhead railway. He pointed to the steps up to it and gesticulated one with his thumb. One stop. One stop…

“Can I take your photo?” I asked. He seemed chuffed.

I caught the train, one stop, and met my mates. We chuckled (I’ve an embarrassing history of travel mishaps) and had a fab weekend.

This experience made me wonder, again, about the utter, utter failure of Sloven, NHS England, NHS Improvement, the General Medical Council, the Health and Safety Executive, the Nursing and Midwifery Council, the Care Quality Commission and the Secretary of State, to help bereaved families in any way whatsoever.

As always, it comes down to being human.

Thank you.

An exemplar in how not to

Posted on October 8, 2016 by sarasiobhan

An American sociologist, Harold Garfinkel, famously encouraged his students to go out and deliberately breach social rules (like being very shouty in public) to make visible the strength of these unwritten rules. When I was a student we could do this for one assignment and report how those present responded, or write an essay. I didn’t have the nerve to do the former.

The sacking of Katrina Percy (and the earlier unfoldings leading up to this) has been a kind of breaching exercise. Making visible the deep flaws in the organisation of the NHS. The internet/social media didn’t exist when Garfinkel developed his breaching experiments. These days, the ripples of (public sector) ‘rule breaching’ spread far with an unimagined immediacy. People are rightly outraged about the £200k pay off. How patients denied treatment or operations because of the cost must be feeling about this news is impossible to imagine. It’s simply obscene.

The handling of the Sloven debacle is worse than extraordinarily poor. On December 10 2015, Hunt stood up in the Commons and promised a series of measures in response to the publication of the Mazars review. The CQC so far seem to be sticking to their gig (albeit without using the powers they have effectively). NHS Improvement (NHSI) were tasked with sorting out the rot among the Sloven exec. They have bungled this task spectacularly. The wrong person was appointed to troubleshoot (alarmingly, Tim Smart has always maintained he contacted NHSI offering his help after seeing Tom question the board on BBC News). It was clear NHSI missed an opportunity to appoint a clear headed, sharp thinking, deeply experienced, no nonsense type of person.

Smart, as we know, failed to lift any stones (leaving it to campaigners and journalists to reveal the howlers that were in full view with the sending of the odd FOI request or ten), and decided the board were fit to practice. Etc, etc, etc.

What an almighty fuck up. The NHSI press statement is simply embarrassing. I’m reminded of Shaun Picken, a trustee of My Life My Choice asking Percy: “Katrina, why didn’t you ask for help? You clearly needed it”, at the January board meeting. NHSI. You clearly need help.

I’m a lay person with no experience in public sector management (and currently on leave in Berlin for the weekend…Brilliant timing as always) but it strikes me there are some fairly straightforward things that should happen. Including:

Thorough scrutiny of financial irregularities around the Talentworks contract which, I’m sure, would provide evidence that Percy, supported by a bunch of longstanding exec-mates, has mismanaged public money.
A thorough review of the Sloven exec and removal of the remaining muppetry (Spires, Berryman, Stevens, Gordon, etc).
The appointment of replacement execs with mental health and learning disability expertise.
Full engagement with the public and a clear demonstration of a willingness to be open, transparent, honest and robust.
Stop relying on ‘reassurance’ and demand evidence. A reliance on ‘reassurance’ contributed to LB’s death.

Jim Mackey, Jeremy Hunt and others, you should feel ashamed at the handling of this. It’s an exemplar in how not to.

Weepage, seepage and who cares?

Posted on October 6, 2016 by sarasiobhan

Dunno why, maybe the anniversary of LB’s inquest, but I’ve been having a weep fest over the past few days. I think about LB all the time. He’s never more than seconds, occasionally minutes and very rarely an hour or so, from my waking mind. I’d got to a state (hate to stage this grief stuff) where I could think about him in different ways. With the occasional, typically left field, gut punching moment. Sparked by a word, a smell, a thought, sound or memory. Moments of near meltdown (I know, the irony), fright, (at the) sheer horror, brutality and worse.

This week I’m back to just crying. Or weeping. Or something else. I don’t know what to call this thing. Maybe weepage. A sheet of tears. There’s no movement. No sort of sobbing and dabbing with a tissue action. No drama. Just moving wetness.

I cried last night re-reading my older sister’s handwritten letter to each Sloven board member. In 2014. Two years ago. Can you imagine?

I cried looking through another pile of photos that have shifted to the surface of home clutter this morning.

I cried sitting at the back of the Oxford to Heathrow coach this afternoon. For pretty much the whole journey. Watching a stream of heavy haulage lorries and coaches. After receiving an update from the General Medical Council. The supplementary expert report is now with Dr M (again). She has two weeks to respond before it goes back to the Case Examiners. Another never ending story.

The Nursing and Midwifery Council investigations? Who knows. Tumbleweed.

We were told, months back, during a meeting with Norman Lamb and the Health and Safety Executive, that some report was with some panel and we would hear something in October. No doubt we will have to chase up any (non) news ourselves.

I think my new tear configuration has (re) emerged because of the utterly shameful banality of the public sector response to what has happened. A year ago an inquest jury determined that LB died from neglect. He should not have died. He was effectively killed. And nothing has happened. And a recognition that this sustained cruelty can’t continue indefinitely. We (a collective #JusticeforLB we) could not have done more to counter the darkness of the #NHS and social care at its worse, with light. And brilliance. And there is still no accountability.

I wonder where, in the structure of the NHS, effective support and attention exists for brutalised families. Who should know the answer to this. And why the fuck I’m having to ask.

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The Shaw Report

Posted on October 4, 2016 by sarasiobhan

Start writing a book with determination. A new evening activity. This means digging out all the FOI stuff, documents, reports and paperwork. It feels like the right timing given LB’s inquest started a year ago today. Two harrowing weeks, a jury determination of neglect and no action. Still.

Revisiting these documents (post LB’s death, I can’t bear to return to the earlier stuff yet), in the light of what has unfolded is pretty revelatory. I just wanted to single out one of the many individuals who have stuck with the campaign from the start here. Graham Shaw. Graham, the CEO of the DIPEx Charity until a couple of years ago, has consistently written letters about what’s happened. To all those implicated. Incredibly sharp and dripping in sense, his letters generate responses.

This one, written to Jeremy Hunt in April 2014 was prophetic really.

The Sloven Head of External Communications responded in a tawdry and deeply inappropriate way asking [redacted] to “support the drafting of any response to Mr Shaw” [16.4.4 13:46]. Extraordinary evidence of the blurring of boundaries and positioning of NHS trusts as above questioning.

Here is the unfolding exchange. About as Stinky McStink as you get really, particularly given the timing of the responses and redactions. Emails 3 and 4 probably hold some significant clues to the continued lack of action against Percy and the board.

Two and a half years ago.

A year and a half before LB’s inquest.

No words really. Other than Graham Shaw, we salute you. Keep writing the letters matey.

Talentworks, buses and the Oxford Bishop

Posted on September 30, 2016 by sarasiobhan

So the Talentworks contract with Sloven is over. £5.5m of public money flushed down the toilet but at least that particular leak is plugged. Hopefully the National Audit Office will scrutinise the whole, grubby process and take action. £300k to £5.8m is simply scandalous. As is an ex-CEO doing a made up, very part time, job for nearly £250k.

Jim Mackey must be feeling a little bit hot around the collar given everything that’s unfolded. We couldn’t have clearer evidence that NHS Improvement are a waste of space. Appointing Tim Smart who bizarrely refused to engage with what was under his nose (or families), gave an ailing and flailing board a clean bill of health then resigned without notice, was not a good move.

In other news, it was the inauguration ceremony of the new Bishop of Oxford earlier. The buses were pretty much backed up to the ring road but there was a real buzz among strangers on the High Street who wanted to know what was going on. I suspect there was a similar buzz among Sloven staff this afternoon. And a huge sense of relief that they would no longer have to endure mandatory Going Viral nonsense.

Onwards and (hopefully) upwards.

Antelope House and those old tear waterfalls

Posted on September 29, 2016 by sarasiobhan

I’m stripping this post back to the minimum in an attempt to try to help Jim Mackey, Jeremy Hunt and others understand the gravity of what was/is happening here. Screen grabs, minimal text and links.

Going back to 2011 when the CQC found major concerns at a Sloven run mental health unit, Antelope House, after the death of Michelle Connor.

In response to this inspection, Percy pitched up to a Hampshire and Southampton Health Overview and Scrutiny Committee Joint Meeting to answer concerns. She typically dismissed the seriousness of the inspection report. The deeply inappropriate ‘we’re no worse’ excuse dragged out five years later when the Mazars review was published:

And went on to state:

Overall, a shift in the culture of the organisation was needed, and bad practices of the past needed to be left behind.

Bad practices of the past, eh? A set of responses were presented, summarised here (worth reading in full if you can bear to):

Internal inspections were currently going on across the whole trust.
An audit and completion of all care records was completed within 12 hours of receipt of the CQC draft report.
Care plans are now subject to regular, unannounced spot checks.
Implementation of immediate training and training scheduled for the near future.
The locked door policy was not being fully implemented.
Patient experience is important. Sloven want to return the trust and confidence of the public.
And a load of other utter bollox. Including training is embedded into practice, “a very senior nurse”has been brought in to provide the clinical leadership needed. Oh, and “The CQC unfortunately did not speak with service users whilst undertaking their inspection.”

Recommendations that have been regularly and repeatedly ringing ever since. With each death and inquest. Oh, and there was the usual evidence of the (Percy) Sloven way. A focus on ‘awards’ and glitziness to distract from the serious issues.

The meeting ended with blankety blank type shite.

A year later Hannah Groves died…

And other unfoldings…

In the meantime, Sloven took over the Ridgeway provision in Oxfordshire. Apparently experts in mental health and learning disability provision (despite all these experts having left in the previous year or so). Ms Percy was huffing her puff and stuff online, regardless.

Once the lucrative contract was signed, Sloven withdrew from pretty much any engagement with the Oxon services. The white noise they talked about in the 2011 meeting didn’t translate into action. Just words to appease vaguely interested audiences. The 12 hour urgency type stuff was fakery. The exec never took the very obvious health and safety failings seriously. And haven’t since.

Here we are. Five years on. Deaths. More deaths. And closure.

However, Southern Health did not believe that the areas requiring improvement were of a serious nature, and were not of the scale seen on recent documentary programmes (e.g. Panorama programme on Castlebeck). [2011]

Our beautiful, beautiful boy. A life (one of many) snuffed out because the Sloven exec (and those who should have been keeping watch from above) simply didn’t.

There was a ruling yesterday by the judge in the horrific Alton Towers crash case. So much resonates here.

Sloven’s catastrophic failure to assess risk, woefully inadequate safety procedures, failure to communicate and being a shambles explains why LB, and so many others, died. Well, with a hefty dose of arrogance, an obsession with reputation and awards, and stupidity. Typing this through a now familiar waterfall of tears and rage, I don’t understand why we are still fighting. Why people are spending their time digging through this shite, committed to exposing the grubbiness that is publicly available, when so many are paid to do so and don’t.

If anyone from NHS Improvement, NHS England, the Health and Safety Executive or Department of Health (well anyone, really) could explain why we still have no answers or accountability over three years after LB’s death, please do.

This is state sanctioned cruelty.

Candour, what candour and the Camino training

Posted on September 26, 2016 by sarasiobhan

Back in March 2016, the Sloven CEO included this section in her report to the board.

percy-report

Today this family received the response to the complaint they made about their treatment by Sloven, and Chris Gordon. There was no ‘contact with the family throughout this very difficult period‘. Instead, Sloven, true to form, continue to make something so agonisingly painful, nightmarish and brutal, even worse.

Just a few lowlights from the report:

The complaint was investigated by Capsticks who regularly work with Sloven and other NHS trusts.
Complaints about inappropriate comments made by Chris Gordon were dismissed because he said he didn’t make them.
The investigators couldn’t read board meeting notes relating to the death of this person because discussions were during the ‘private’ part of the meeting.
The delay of two months between Tim Smart receiving this report and the family receiving it today was because it was with Chris Gordon for reviewing. [Even though the complaint was in part about him and despite his current secondment to NHS Improvement.]

Candour and transparency clearly ain’t reached the southern regions yet. And another family left complaining about complaint handling and facing the dire Ombudsman route.

It shouldn’t be like this.

In more cheerful news, the #JusticeforLB cardboard bus has been expertly revamped by LB’s grandad and the My Life My Choice trustees began training for the #CaminoLB today.

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This film of their first walk is blooming brilliant. Keeping it real, funny, passionate and determined.

In search of rights and colour…

We must be getting closer. Surely.

An exemplar in absurdity (and conkers)

Posted on September 25, 2016 by sarasiobhan

A sort of follow on from the (updated) The Talented Mr Martin and viral impact post. Underpinned by continuing incredulity at the removal of the Talentworks website. A ‘leadership’ consultancy with the tagline:

Meet the Talentworks team… hired for our large brains, love of psychology and impeccable dress sense.

Yes. Really. Well, and at least £5m of public money.

In the continued absence of any apparent scrutiny from NHS Improvement and others who should, we’re left digging deeper into shit we should never have to go near.

Talentworks. A virtual collective of people with large brains… etc have not only been getting obscene amounts of dosh from Sloven. They’ve also been working closely with Thames Valley and Wessex Leadership Academy (TVWLA). An academy led until last year by Katrina Percy.

I’m rubbish with figures but the Talentworks ‘blah blah’ work with the Thames Valley bunch (Financial Summaries available here) seems to involve a shedload of dosh for the two years Percy led the academy (around £500k and £370k) dropping to around £20k after she stepped down. [As an aside, how could Percy dismiss Mike Holder’s safety concerns while championing Chris Martin and his jibber jabber? [howl]]

A brief browse of the Talent Management pages on the Thames Valley Leadership Academy pages:

tw-shite-1

A teeth achingly meaningless statement. Just noise. How the Wessex leadership gang allowed this to be published on their website makes me want to weep. I’m left wondering (again) is this about stupidity, incompetence, fear, corruption, bullying, greed, narcissism or simple slumbering? The focus on this hocus pocus crap, while staff were left without leadership, untrained and unsupported to provide the most basic care to keep LB and so many other patients alive [alive], is haunting.

More bollocks…

Greater pipeline intelligence? A driver of culture change? It’s like the Stepford Wives meet NHS England.

I’ve not read this blinky blonky table yet. The headings alone suggest nonsense. I just want to know who authorised payments for this ‘work’? Where were the internal (and external) audit processes? Did no one ask what is this about and is it effective?

Did Talentworks really have a blank cheque to do whatever?

What are the links between Chris Martin, Katrina/Iain Percy and others?

What does it mean that Talentworks have withdrawn their website?

What the actual fuck?

Here’s a photo of conkers we collected in the park earlier. I bloody love this photo. These are conkers. As simple and uncomplicated as.

A bit of a #CaminoLB update

Posted on September 22, 2016 by sarasiobhan

Planning for the #CaminoLB is crackling along. We will be walking for eight days, with the long walks (around 20 miles a day) in the first five days, dropping to 10 miles maximum for the last three. [25 Oct-3 Nov].

The Life My Choice crew have been busy organising or renewing passports today. It looks like there will be 3 (possibly 4) members with two supporters tipping up for the last three days. Excitement is bubbling apparently. My sis, Tracey, is coming for the second week. Rosie Tozer is joining us for the last three days, walking in memory of her son Danny. John Williams will be doing the chunk in the middle. And a few other people are thinking about pitching up at different points. [None of us are big walkers… well yet.]

This whole, random, walking the #JusticeforLB bus across the Camino de Santiago to an exhibition centre in Aviles, has been oiled by the enthusiasm and simply can do attitude of the Learning Disability England team (with Spanish support). They not only organised the Justice exhibition, on December 2 in Aviles, which kicked off the whole thing but have stepped up to offer lifts, blister mopping, scouting the route for possible hazards, and the lovely Mariana (and her dog and possibly daughter) to ease our non Spanish speaking way. The bus, for those of you worried about us getting it from Santander to Aviles in one piece, has been carefully and lovingly strengthened by LB’s grandad and now has a nifty tarpaulin bag for those rainy days.

We will be a right old ragbag collective walking along the trail, in search of rights and colour. Remembering LB, Danny and the others. Carrying a cardboard bus. And hopefully having a bloody good laugh.