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.

The victim statement, party and pond re-activity

 

In May, the Health and Safety Executive asked if we wanted to write a Victim Personal Statement that would be shared with the judge in the prosecution against Sloven. They offered support to write it while acknowledging we probably wouldn’t need it. At the time I thought it would be a ‘minor task’. I mean I write, howl and rage on an almost daily basis.

Eight weeks later the statement remains unwritten. Well that’s not strictly true. I circulated a brief draft to Rich, Rosie, Will, Owen and Tom last week. Rosie fed back it was pretty rubbish and contrived (in less brutal words than these).

“Can’t you use an old blog post…?” she asked.

We said we’d talk about it this weekend because we’d all be together for Tom’s 18th party.

The party was on Friday night. It was pretty raucous with a lot of laughter, food and drink. Late evening with the dodgy disco light doing its thing, a Bowie track came on and the room of lively, loud and exuberant 18 year olds became a bit blurry. Rosie was there with a hug. The family grief morse code working as it seems to.

On Saturday morning after a brief party debrief and some groaning about sore heads we talked about the statement and I jotted down notes about what it should contain. This was largely a checklist of Sloven crap actions. We didn’t talk about the impact of Connor’s death on us which is what the statement is supposed to be about.

Later that day, attention turned to the disappeared pond in the front garden. Owen and I dragged the second of two monstrous plants out of the pond and left it sitting upright on the grass overnight. A solid, giant mass of roots, smelly black sludge and detritus with an enormous crown of green fronds that wouldn’t look out of place on a Doctor Who episode.

Rich dug the pond with the kids about 12 years ago now. It was a major operation based on serious pond research. Considerable depth in parts, different levels, shallow shelves for inhabitants to clamber in and out of, grey blankety stuff underneath the rubber sheeting and a couple of plants from an aquatic garden centre in Wheatley. A pond was born.

Life went on. Pond life flourished. We kept the weeds at bay for several years and children from the local primary school visited to see the frog spawn and tadpoles.

The two plants grew. And grew. Life took an unexpected turn. The pond disappeared under the foliage and was largely forgotten about. Apart from a hilarious dog sitting experience a year or so ago when Ned, a husky-cross, went for an unexpected stinky black cool down.

On Sunday morning, I was outside drinking coffee and studying the beached plant which was almost as tall as me and twice as wide. A woman stopped and said primly:

Ah. You’re attacking the jungle. Good! Have you just moved in?
Er, no. We’ve lived here for sixteen years…

She wandered off.

Owen and Tom set up camp in the afternoon for a couple of hours with music, borrowed footwear and gloves, an axe, spade and pair of shears, and the plant eventually disappeared into various bins around the neighbourhood. They later threw themselves into topping up the pond with a hose too short.

It’s incredibly hard to write a ‘personal victim statement’. The impact is unimaginable for each of us in different ways, at different times, in different spaces and with different people.

The fabric of family life continues to be brightly woven with people who didn’t meet LB. Partners, a baby due in November. Life goes on. My camera continues to capture delights. And they are delights.

The moments in between, and occasionally during, remain filled with an unresolvable ache that feels like a rock at the back of my throat or my chest being crushed. I don’t know if people’s hearts actually ache but for me it’s a throat/breathing thing which seems to have a direct line to tear production.

I just miss him.

We all do.

“Breathe before clicking…”

Three possibly related developments in the last week or so. [One] The Sloven annual report published last week included a paragraph about the ex-CEO and her pay off:

‘Independent capability reviews’ had determined Percy was fit to lead. Blimey. That’s  interesting. What do these reviews say?

Well, a capability review was carried out by YSC for a cheeky £116k excluding VAT last year. A report that has never seen the public light of day despite FOI requests by ex-governor Peter Bell. It apparently gave the board a clean bill of health in the summer of 2016.

One year later, not one executive or non-executive director remains in post.

Now I ain’t no mover or groover in senior NHS circles [cue the eye leaking emoji] but I can’t help thinking that purging a Trust board of every executive and non-executive director is a pretty serious move.

Percy is apparently exonerated by this [secret] capability review while two prosecutions for failings under her watch are pending. Just extraordinary. I mean I can only imagine/hope one prosecution against a Trust is a pretty serious and rare gig. While two…?

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In the same week, I received an email from a journalist scamp with a warning to breathe before clicking. [Two] Percy is back and touting for business  with some toe curling claims. These include inspirational and visionary leadership, creating an open, accessible and energised culture, and successfully delivering a major acquisition of services.

[Three] As the last few Sloven staff transfer over to Oxford Health or limp back to Hampshire, the door is finally closed on the grim and grotesque acquisition process Percy led back in 2012. I think it’s fair and reasonable to say that using the word ‘successful’ in relation to this process and the devastation that followed, is one of those stretches that should never have been a fleeting thought in a careless moment, let alone typed into a Linkedin profile.

I want to flag up here that I have no personal vendetta against Percy. I have no interest in her as an individual outside of what she, her actions and the ‘official responses’ to her actions reveal about the murky of murkiest corners of the NHS.

There are, clearly, serious questions generated by these latest unfoldings which should be of concern to all of us.

Not least, why do the various NHS layers – Jeremy Hunt, the Department of Health, NHS England, NHS Improvement, the CCGs, the Sloven board – allow, enable or facilitate these narratives of delusion and erasure to stand unchallenged, and the continued channelling of scarce dosh into insalubrious pockets and pots?

UPDATE: The PriceWaterhouseCooper audit clearly summarises the failings the bulk of which occurred under Ms Percy’s leadership. Deary, deary me… Something is Stinky Pete around here.

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A Brum based step towards accountability

On a plane to Tenerife last November for a conference I sat next to a woman who had a hush hush job to do with environmental failings. As we chatted, our involvement with the Health and Safety Executive (HSE) cropped up. There were overlaps with whatever she did. She suggested very seriously that I should read the full Alton Towers report. I did when I got home. The key part is here in the HSE press release:

There was a meticulous unpacking of the evidence to show that the failings came from the top rather than the people working that day who were directly involved in the ride that crashed so horrifically.

Rich and I went to Birmingham today to meet the HSE and the barrister they appointed shortly after that trip. It turned out to be the same barrister who represented the HSE in the Alton Towers prosecution. Funny old world.

During the meeting we learned more about the legal process. Hopefully I’ve got this right but it sounds like there will be a hearing at the Magistrates Court in Oxford or Banbury on September 18. At this hearing, the HSE barrister will present a case summary which will distill the complexity of the evidence into a digestible document highlighting links to the wider documentation. I assume (but am a bit hazy on this) Sloven’s legal counsel produce a response to the prosecution’s case.

Then a computer randomly churns out a date for a ‘plea and trial preparation hearing’ which will be held 28-35 days later. This may be heard in a Magistrate Court, Crown Court or High Court.

If Sloven plead guilty on that day no date will be generated. Instead the judge will send the case for sentencing.

So many connections and oddities.

An extract from my book. [As an aside, I’m sure I’m taxing the patience of both the production and copy editor off the planet with my last minute revision attempts – I’m sorry. And I’ve stopped now (yesterday). Sorry.]:

Ten years later we may be back at the Oxford Magistrates Court. For real.

Who knows, it may even be the same magistrate. Unlikely I know, but I wonder if he’d remember the young boy who was bursting with excitement and enthusiasm that Saturday morning. Beyond thrilled with the tour of the court, the cells and the car park where the G4 vans park. A young boy who listened to and took the mocked up case so seriously, demonstrating an unwavering commitment to the process of the British justice system.

I bloody hope so.

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:


Death, dosh and what the CQC knew

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An update to this post.

The CQC knew.

The ‘incident’ referred to here involves a man diagnosed with autism and epilepsy who drowned unsupervised in the bath in April 2016. He drowned. Alone, unsupervised in a bath.

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The CQC re-inspected the ‘home’, found various failings and referred to Elric Eiffert’s death as an ‘incident’. They found inadequate, or no, risk assessments around epilepsy:
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They took no formal action despite identifying risks to life that ended in death.

Instead asking the provider to:

send us a report that says what action they are going to take.

Send us a report…

The CQC knew.

At the same time they knew LB drowned in a hospital bath three years before. A death that should have been, by then, high profile enough to make any provider or NHS Trust pay close attention to bathing risks for [‘”vulnerable”‘] people diagnosed with epilepsy.

The CQC knew.

At the same time they were conducting an investigation into the way in which NHS Trusts respond to unexpected deaths. The irony. The wanton, careless, unjoining of dots that demand to be joined. That scream to be joined. How much money is wasted on this shite? While people continue to lead impoverished lives or worse?

The CQC knew.

Today #7daysofaction launched a campaign focusing on the profit made from the incarceration of learning disabled people in assessment and treatment units.

Dosh or death. Death and dosh.

The CQC knew someone had drowned in the bath when they inspected that place on April 28 2016.

The Mystery of Loring Hall and the CQC

Ok. This is hugely important. And devastating. I’m going to go through it in some detail because it is so fucking important. And devastating.

Here’s the rub. In November 2015, the CQC inspect Loring Hall, a care home for up to 16 learning disabled adults, run by Oakfields Care. ‘Good’, ‘good’, ‘good’, ‘good’ and ‘good’ on all five domains inspected. A clean bill of health.

The CQC then received concerns around the management of risk to people living at Loring Hall.

On April 28 2016 they reinspect the home focusing on how safe and effective the service was. This produced a remarkably different picture to the November inspection. The re-inspection was conducted by an inspector and specialist advisor with epilepsy expertise. The key findings:

The inspection report reads eerily like the September 2013 inspection report of the unit LB died in. Medicines not stored properly, untrained staff and inadequate risk assessments…

Despite the list of failings identified during this new inspection (including a striking lack of training)…

… the CQC decided not issue any enforcement action:

A last bit of detail on the process of the April 2016 inspection:

On April 13 2016 Elric Eiffert drowned in the bath in Loring Hall. He was 34 and diagnosed with epilepsy and autism.

His family were told about his death on April 30 2016.

Just a few scrambled questions and comments (I can’t make much sense of any of this) largely for the CQC:elric 7

Our son drowned in a bath in a craphole unit, six years after another patient drowned in the same bath.

The first patient’s death was covered up until October 2015 when it was used as a nasty little ‘weapon’ at LB’s inquest.

Nearly three years after LB’s death (and after a Prevention of Future Deaths report was issued by the Coroner), Elric Eiffert  drowned in a bath in a craphole ‘care’ home that five months earlier had received a ‘good’ CQC rating.

No one should drown in a hospital or care home bath in the 21st century. Or die unsupervised of a seizure in a ‘care’ setting. LB, Elric, Edward Hartley, Danny Tozer and countless other people, would all be alive if they had received appropriate care.

This is beginning to look a tiny bit like state supported eugenics. And no one who should appears to give a fucking shit. Still.

Tribunal torture

This post builds on Five tribunals and a dress code. Sadly.  A few weeks ago I had a three hour (yes, three hour) interview with General Medical Council lawyers. This grilling (they warned me in advance it would be) involved a barrage of questions in tortuous, micro detail.

It was grim. Documentation (and this blog) had been mined for any inconsistencies.

As I’ve banged on before, staff have legal representation at these tribunals and these barristers can ask anything they want of witnesses. Witnesses (including bereaved families) are not allowed representation. During the interrogation, in a hotel meeting room in North Oxford, I scrawled this:

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I went home afterwards, instead of to the work meeting I was supposed to attend.

This morning the Nursing and Midwifery Council (NMC) called to update me on the six nursing tribunals due to be held this summer/autumn. A preliminary meeting was held last week apparently and the independent chair agreed to:

  1. Lump the tribunals together to make one long one hearing.
  2. Postpone this until May 2018.

Apparently the NMC opposed this delay but staff representatives disagreed with a possible January 2018 date.

So, another year and another tribunal to dread. The brutality of forcing us to revisit what happened for at least another 12 months.

We had no one at the meeting to draw to the chair’s attention the utter inhumanity intricately woven into this process.

We simply don’t count.

 

A missing ‘apology’ in five parts

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Part I.

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

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

“The Trust earlier apologised to the family…”

I nearly dropped my glass of cheeky and chilled vino.

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

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

We ain’t received an apology, mate.

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

Nothing.

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

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

Part II.

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

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

What you have done is:

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

Part III.

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

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

Part IV.

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

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

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

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

I find this unforgivable.

Part V.

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

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

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

Still.

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