Explaining #JusticeforLB to a child

IMG_0112-2Well LB was a bit older than you. He was very funny, loving and loved buses and Eddie Stobart lorries. He got upset and a bit low when he was 18 and ended up in hospital. It was a special sort of hospital. It cost more money each week for LB to stay in that hospital than most people earn in a month. It was run by a bit of the NHS called Sloven. The NHS is supposed to look after everyone in this country when they are unwell.

It turned out that Sloven didn’t really care about patients like LB. Or care about some of their staff.  Staff became fed up and some became pretty rubbish at their jobs because of this. They stopped looking after patients properly. LB had a thing called epilepsy which meant he could suddenly pass out. Staff knew this but the doctor in charge told them it wasn’t a problem.

One day LB was in the bath alone (which he shouldn’t have been) and passed out. He went under the water and died. We felt our world had ended. Sloven pretended LB would have died anyway. They said he died of natural causes. But people don’t usually die in the bath (or when they are 18).  Instead of being able to feel sad and think about our beautiful boy we had to fight to get Sloven to admit LB died because they didn’t look after him properly.

Sloven refused to do this and the people, like NHS England or Monitor, who were supposed to make sure Sloven did the right thing didn’t. Nobody who should have sorted this out, did anything. Usually when you work you have a boss who makes sure you do your job properly. And your boss has a boss. It turns out, in the NHS, the bosses of bits of it can do whatever they want. The Sloven boss, called Katrina Percy, and her senior team just carried on behaving badly.

We were worried some other people might have died because they weren’t cared for properly like LB. The boss of NHS England agreed to pay for a review into other deaths that happened in Sloven’s care.

Meanwhile, a lot of other people, all sorts of people, joined in the fight to try and get Sloven to take responsibility for LB’s death. They did all sorts of brilliant stuff. Sports stuff, music stuff, they made films, animations, held cake sales, did embroidery, gardening, drew pictures of buses, flew flags, put LB’s name on buses and trucks and all sorts. Lots of people began to know who LB is. There was lots of fun, love and happiness about LB and people like him.

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The trouble is, all this fab stuff didn’t stop Sloven behaving badly. They lied to us (and others) and tried to stop us finding out what happened to LB. They spent more money than some people earn in a lifetime on lawyers to do this. Money paid for from people’s taxes. Luckily, some brilliant human rights lawyers and barristers helped us. The inquiry into LB’s death, run by someone called a coroner, found that LB died because he wasn’t looked after properly. He should still be alive.

The report into the other deaths also found that Sloven didn’t care about lots of people like LB. When they died suddenly Sloven said they died of natural causes and didn’t try to find out why they’d died. Sloven were furious about this report. They said it was rubbish and tried to stop people reading it. Then they argued that other bits of the NHS were just the same. Allowing certain people to die early and then say it was natural causes.

We think Sloven don’t really think that LB and people like him are proper people. That’s why they didn’t do anything when they died early. Like a lot of things, they’ve got this completely wrong. We just need to work out what to do about it. Because LB’s death has shown us just how badly some people are treated in this country. And how those people whose job it is to actually do something about this, don’t really care either.

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891 days and Sooty tear time

It has taken 891 days to receive a genuine, heartfelt response from a senior level Sloven/Oxfordshire County Council related bod. 891 days..

Serious Sooty tear time.

Dear Dr Ryan

Thank you for sending me a letter to the SHFT Council of Governors about the Mazars review of deaths.The letter has been circulated to all Governors.

I am happy to ensure that the points you make in the letter are shared at the meeting tomorrow but may not be able to provide an immediate response.

On a personal note, I would like to say how sorry I am about Connor’s death. I would be doing exactly what you are doing had he been my son.

Regards

Helen Keats

 

Thank you, Helen Keats.
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2016. Starting as we mean to go on.

I don’t know. I don’t know if it was Chunky Stan’s death this week which was so blinking sad but immensely peaceful. Or the start of a new year. But the Justice shed is cranking up the volume. Enough is enough.

First. A letter to the Southern Health NHS Foundation Trust Council of Governors:gov 1

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Trust(s) and scandal

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No rest for the (lay) self congratulatory. Clearly. A few days after posting about #JusticeforLB related achievements, the Guardian removed their front page story about non-investigated NHS related deaths. Because of complaints (plural). Any naivety we entertained around other NHS Trusts learning from Southern (Sloven) Health NHS Foundation Trusts heavy handed and inappropriate approach to the Mazars review, disappeared. [I know..]

We’ve heard, on the grapevine, that a few Trusts are taking the Mazars/Guardian story findings seriously. And proactively exploring their own practices in relation to deaths of learning disabled patients. This is bloody brilliant.

The challenge to the Guardian story is deeply depressing though. Headline figures of the number of deaths investigated compared to number of (allegedly) unexpected deaths (from the now removed Guardian story) remain harrowing:

Somerset Partnership NHSFT 0/146
Northamptonshire NHSFT 0/63
Rotherham, Doncaster and South Humber NHSFT 0/28
Leicestershire Partnership NHSFT 1/116
Dorset Healthcare University NHSFT 2/97
Derbyshire Healthcare NHSFT 1/23
Sheffield Health and Social Care NHSFT 1/23
Leicestershire Partnership NHSFT 1/13
Penine Care NHSFT 1/10

These figures are from a Freedom of Information (FOI) request by the Guardian that asks different questions to the Mazars review. The latter found that Sloven investigated less than 1% of the total deaths of learning disabled people under their care. Less than 1%... We don’t know the exact questions the Guardian asked but whatever questions, it’s blooming clear there’s an almighty stench here. With a range of whiffs.

Some published challenges to the Guardian piece;

Somerset: these deaths were expected not unexpected.
Northamptonshire: these deaths were expected not unexpected.
Penine: the figures provided related to community and not inpatient provision.

Wow. What (particularly) stinks here is that the Mazars review, subject as it was to unprecedented (and, at times, offensive) levels of scrutiny, contains the answers to pretty much any challenge offered by Somerset, Northants and the like to their death practices. It clearly states that Initial Management Assessment (or whatever these tick box exercises, completed within a day or so of death, are called across different trusts) are not ‘an investigation’.

There is a circularity here of course. The filling in of this initial paperwork flags up that there is some level of unexpectedness, that ‘an incident’ has occured. That this is the only step taken is further evidence of the scandal gradually being uncovered.

The Mazars review underlines how there is no clear definition around what constitutes an ‘unexpected death’. A chilling position for learning disabled people who, all too often, are perceived to be of ‘inferior stock’ by health and social care professionals. Mazars used the Sloven policy which states that unexpected deaths are those that occur without anticipation or prediction, or where there is ‘a similarly unexpected collapse leading to or precipitating the event that lead to the death’. Sloven, as always, exemplary in the production of policies here (while their practice kicks back to the very edges of care, interest or humanity).

The problem is, if your death is perceived to be expected whenever (or wherever) it happens (including if you’d just got into a bath, in an NHS unit, with four ‘specialist’ staff members and five patients, in anticipation of a trip to a much loved bus company, aged just 18) then you ain’t got much of a chance. [And really, Somerset and Northants.. can you seriously argue that not one of those 209 deaths were unexpected? Not one…?]

What both the Mazars review and Guardian story (and the earlier Confidential Inquiry published in 2013 …) demonstrate (in addition to the arrogant, short sighted and bullying actions of some Trusts) is:

  1. People labelled ‘learning disabled’ die considerably earlier than people who ain’t considered ‘learning disabled’.
  2. These deaths are typically expected and are, therefore, rarely categorised as unexpected.
  3. It is all too easy to label these deaths as ‘natural causes’.
  4. Existing NHS ‘death’ processes are unfit for purpose because of 1-3 above
  5. Recent reviews/newspaper reports and the associated responses by various Trusts to these should raise unmissable red flags to NHS England, the CQC, Monitor and the Department of Health… but we know they won’t.

The lives of certain people, like LB, simply don’t count. The extraordinary resistance to the publication of the Mazars review and post publication challenge to the Guardian story underlines both the existence of scandalous practices in the NHS and, as importantly, a refusal by those entrusted with the wellbeing of patients, to recognise what they are actually doing.

Here’s to 2016 being the year in which these practices are rootled out and stamped on. Surely.

 

A bunch of pests… and humanity

Chatting with Rosie earlier. She reflected on how, after 2.5 years of (relentless) campaigning, things had really started happening over the last two or three weeks. Various people also sent emails/messages to the Justice shed today, including Andy who wrote…

What a bloody brilliant thing to see front page of The Guardian. So just to reflect – in the space of about 10 days you made front page of The Guardian and The Mirror, loads of lead stories on all the big BBC hitters (and the ITV ones), triggered an urgent parliamentary debate and, most importantly, brought together 337 hand-crafted colourful, brilliant gingerbread men to remind everyone that this is lives we’re talking about, not statistics.
Not too bad for a bunch of pests eh?

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Yep. It is bloody brilliant. And we have been relentless. It has been a relentless campaign. Luckily dotted with laughter, spectacular contributions, solidarity, magic and more. At the same time, instead of (hideously, over complicated, inefficient and costly layers of) quality assurance/regulatory processes uncovering this scandal, it took ordinary people to just say ‘Eh. There’s a strong whiff of something wrong here. It needs investigation.’

It’s obscene that  we’ve had to fight so hard to get this far. It ain’t our job to do this. Far from it. We should never have had to have spent the countless (countless) hours we have working to get some sort of accountability and justice. None of us. I can’t imagine what the collective salary is of staff in Sloven (and other Trusts), NHS England, the CQC, Monitor and the Department of Health who should have spotted that people were dying way too early, with no investigation into the cause of their deaths. [Howl].

Why didn’t they? The findings of the Confidential Inquiry into the Premature Deaths of Learning Disabled People (CIPOLD) was a pretty big red flag in 2013. The government decided to ignore the key CIPOLD recommendation and didn’t set up a national body to examine these deaths. A cracking decision. Leading to the eggy faces we’ve seen in the last week or so. With plenty more eggs lined up. 

Mmm. This was after the public outcry about Winterbourne View and that embarrassingly expensive and ultimately pointless work programme that unfolded, painfully across a few years and then disappeared digitally after the election this year. Ouch. So many organisations/charities signing up to the ‘glory’ back in the day. And little or no public reflection on this collective failure… Astonishing. Meanwhile, people continue to live non lives (or worse) in these hell hole units.

Here in the J-shed we’re pretty battle weary, scarred and totally fucked off by the combination of a lack of integrity and guts, arrogance, dismissal, closing of ranks and suffocating overriding superiority that seems to circulate around the senior levels of the various public sector organisations and government*. The battle to publish the Mazars review just one example of this. Detailed at length on these pages.

For any of these salaried staff, particular those at senior levels, [excluding Katrina Percy and the Sloven Board who clearly ain’t human] there is no mystery here. As Tommy said in The Tale of Laughing Boy, it’s not rocket science. There’s a lack of understanding and recognition that people are just people. And that certain people shouldn’t die (conveniently?) years before other people. Stripped of humanity, dignity, love, respect and value. In both life and death.

The answer? I dunno. A good starting point may be to get over yourselves. Go and hang out with people who ain’t the same as you, your family and your mates. And start to recognise colour, diversity and difference.

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*There are clearly some brilliant people in these roles. Just many more who ain’t.

 

 

Berry berry serious and another board failing

A minor Mazars related scandal emerged last night on twitter. Most of the doubters and deniers of the Mazars review have faded away in the light of the clear evidence the review outlines. The belieSHers have disappeared. Hard to really keep believing in a Trust with such serious failings at board level. Sigh.

Turns out an apparently random denier was still spluttering about the rubbishness of the review in a convo involving Alexa Wilson, Gallus Effie and Mark Neary last night. Super sharp sleuth Alexa worked out this laddy was the son of a Sloven Board Member, Malcolm Berryman. Adding in a good dose of comedy. (One of the reasons why I love twitter).

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I was reminded of the story of LB on the bus with my dad… Berry Berry serious indeedy. This morning I tweeted about the connection and got the following response:

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Oof.

After a few more tweets, he said sorry (a bigger surprise than the original tweet) but kept up a bit of anti Mazars banter. Of course twitter allows no stone unturned and it soon emerged that baby Bezza had been challenging the content of the review before it was in the public domain. Ouch. Once that detail started to spread, he locked his account so his tweets were no longer public. When Rupert Evelyn, from ITN, joined in, the account was deleted.

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Looks like the Sloven surveillance team put in an urgent call to Papa Berryman alerting him to his son’s actions.

Joking aside, this tale captures so much of the problems we’ve seen over and over again with the Sloven muppets:

Poor governance, poor communication, poor judgement and consistent social media failure. Arrogance, contempt for families (other than their own), rudeness and an inability to understand, at any level, what is actually important here. [Howl].

Board members’ children or other relatives should not be given sight of confidential draft reports and discuss the content on social media. [A small part of my brain is thudding as I type this… I almost, still, cannot believe the crap I continually recount on these pages.]

The board, and Katrina Percy, need to go. Jeremy Hunt needs to put his money where his mouth is and sort this shambles out. People’s lives are at stake.

Mazars, the pop up display and lives

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For the last few months, people have been sending in gingerbread figures. We wanted to find some way of representing the learning disabled people who died in Sloven’s non care [howl], uncovered by the Mazars review, visually. George hit on the gingerbread idea and we were off. Envelopes started stacking up in the My Life My Choice office.

Over the past few weeks, while we’ve been waiting (and waiting) for publication of the report, gingerbread fairies have been working behind the scenes mounting these (337*) colourful, vibrant and quirky figures on large boards. A lot of velcro and eventually a staple gun.

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We heard this week that a meeting was being held at Jubilee House today with attendees from Sloven [who were subsequently uninvited], Oxfordshire County Council and NHS England (NHSE), among others. Sounded just the place for a pop up display of the Justice gingerbreads. We would invite the meeting attendees to come out and view them.

Local press pitched up. Along with a security guard who tried to get shot of us. Private space and all. We stayed. He hovered taking phone shots of us. An NHSE comms woman appeared, shrugging her shoulders nervously and went between the meeting and the display, several times. The My Life My Choice minibus appeared with a gang of champs, solidly supportive as always.

L1017160It was a striking display of brilliance really. But weirdly, pretty much every employee who left Jubilee House during that hour, walked the long way round to avoid it. The couple of people who took the path we were lined up along studiously stared at the floor. Fran, love her, started to invite people to view the display ‘They won’t jump out at you..’, she said to a couple of retreating backs.

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L1017079-2Eventually, a few meeting attendees started to appear. Jan Fowler, from NHSE, and a commissioner came first, chatted with various people and with BBC Oxford. Then a few more attendees came and viewed the figures, took some photos and chatted. It was an odd experience really. Such intensity. Of horror and inhumanity, of colour and individuality, and of (some) avoidance. The meeting chair said ‘I will remember this’ as he left.

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As we were about to leave, and the gingers were safely packed in the car, one employee who’d avoided looking on his way out, came back and asked what it was all about.

Just lives, really. And chilling inhumanity.

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*There were so many more deaths than this, but here we focus on these.

Sloven briefings and bleatings

Blimey. Sloven don’t half love a briefing. Their briefing to NHS England about the Mazars review found its way to us earlier this week. They commissioned an independent review into (specific bits of) the Mazars review of their own practices of responding to particular deaths. Paid for by public money.

To distract myself from debilitating incredulity, I googled ‘what (the fuck) is a ‘briefing?’ A briefing basically identifies a problem and offers a rationale for a solution. Not rocket science.

Sloven’s ‘briefings’ are pretty disturbing and flaky. The now infamous Background briefing on mother’s blog circulated the day after LB died. [Howl]. Still packing a punch spiked with scotch bonnet chillies and rusty nails over two years on. [He died… He drowned in a bath. In ‘specialist’ NHS provision…?] The problem: a publicly documented account of love, health and social care failures and worse. The solution? The briefing ‘may help in shaping a tailored media response to the incident’.

An erasure of LB as a person. And so much more.

Then there was the David Nicholson/Monitor briefing (March 2014). The problem: that bloody mother (again), pesky #JusticeforLB campaigners and social media high jinks causing reputational damage. The solution? Discredit, bleat and block.

This latest briefing. The problem: an independent [yep, independent] review uncovering scandalous findings and clear evidence of eugenic/dehumanising practices. The solution? Discredit the review.

Chris Hatton has written about the Sloven attempts to discredit the Mazars review here. This morning we flagged up that the helpline on Sloven’s website for families who may be affected by the review no longer existed. As ever, their energies and attention focused solely on their reputation. Families? Forget it.

A clunky and late revision of their statement eventually appeared later today:

Untitled 3NHS England continue to delay publication. Relentlessly. It’s looking likely it will be pushed beyond  the closing of the House of Commons on Thursday as ‘it needs to be clear about its messages as possible’. Wow. Quite some jostling for the winner of the scumfuckery public sector bastard of the year award going on here.

Here’s the latest briefing in full.

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briefing 6

 

 

 

Doubters, deniers and belieSHers

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Helter skelter times. With the emergence of the key findings of the Mazars review via the BBC this week. Having banged on relentlessly for over two years now, we feel some relief that a wider set of people may be gaining insight into the improbably inappropriate, incompetent and deeply arrogant actions of Katrina Percy (KP), the CEO of Southern Health NHS Foundation Trust (Sloven), and her merry (board of) wo/men.

Sloven have demonstrated tooth enamel removing disregard for the content of one of the most scandalous reviews to be (almost) published this century. A review that has generated what Graham Shaw has rightly described as ‘a deeply-troubling episode in the history of the NHS’.

As we followed the painfully slow unravelling of the top layers of Sloven ‘leadership’ in the last few days, including a late night statement from KP that made me wonder if some cheeky chapster had hacked the ITV website, doubters and deniers started to appear on twitter. [And in person, as Mark Neary experienced.]

For some reason the Health Service Journal (HSJ) led a paternalistic backlash. Cautioning against anyone paying too much attention to this half baked and strongly challenged review. This may be because the HSJ, like us, had been leaked a copy of the independent review Sloven had commissioned to examine the methodology of the (independent) review into their practices.

[At this stage, you may need a moment or two to;

  1. Scratch your head with incredulity
  2. Laugh hysterically
  3. Get a cold beer from the fridge to cool down your forehead
  4. Weep at the bottomless pit of money Sloven can seemingly throw at wriggling out of ‘tricky situations’
  5. Perform some other action to make this completely inappropriate action somehow digestible…]

Sloven commissioned Professor Mohammed* to do a review focusing largely on the ‘outlier’ question.  He strongly critiqued the Mazars ‘at best unsatisfactory and, at worst, incompetent’ analysis. Cripes. NHS England had already commissioned an academic to review the full methodology. Their review (of the review) asked for a fuller account of the methods used but otherwise gave it a clean bill of health.

The second group, the belieSHers, without knowing the content of Prof M’s review, believe so strongly in Sloven’s credibility (as an NHS Foundation Trust?) that the ITV statement was all they needed. Sloven said the findings were wrong. There. Sorted. And stop this sensationalist reporting without foundation. Tsk.

Overlapping this group were the disbelievers, including Roy Lilley who drew on his own ‘intelligence’ to suggest strongly that only sections of the half finished review had been leaked by a disaffected Sloven employee. Incredulity was also expressed at the commissioning of Mazars by NHS England. An audit company, FFS. I mean why not commission an independent outfit who understand the healthcare world. Like, er, Verita, I assume… The disbelievers were distinct from the belieSHers as they snarled at us to publish the review. They at least seemed prepared to accept that a robust review existed.

Finally, there were the conspiracists. Jezza Hunt had orchestrated the leaking of this review as part of his wider privatisation plot. How could there possibly be so much news coverage and an Urgent Question in the Commons on such an issue, in such a short space of time? Wow. Like Sloven, a complete disregard for the content of the report.

These positions were contradictory, sometimes extreme and ill informed. For once we were able to step back and (almost) park the swearing, rage and frustration we’ve experienced and articulated for over two years since LB died. [Howl]. And calmly reply, over and over and over again;

The review is robust. It is complete. We have a final copy. We don’t know why it still isn’t published.
 

The trouble is, the responses above (including Sloven’s position) make visible the typical excusing and acceptance, even expectation, of shortened lives for some people. They point to accepted processes and practices of a publicly funded health and social care system that consistently discriminates against and excludes certain ‘types’ of people. And when these people die ‘unexpectedly’, a discounting of their deaths.

That there were three days of headline news and sessions in both the House of Commons and Lords on the back of the headline findings of a leaked report, suggests that that the findings of this review are hugely important to the wider public. Outside of the doubters, deniers and belieSHers who, well what do you know… are all firmly embedded within the healthcare world.

The review will be published this week.

*Of Mid Staffs fameimage

 

What a difference a day makes…

Blimey. A right old trudge across pain filled terrain. Dotted with regular state sanctioned batterings. For over two years. Patches, drops and buckets of brilliance along the way in the shape of #JusticeforLB. Thank goodness.

And then yesterday. The Mazars death review leaked to the BBC. Less than 24 hours later a 35 minute debate in the House of Commons. Heidi Alexander, Shadow Health Minister, putting an Urgent Question to Jeremy Hunt. Love her. He ducked some answers and answered some unasked questions. The review methodology was sorted.

Sloven trended on twitter. Katrina Percy and senior colleagues went into hiding. NHS England left an out of office ‘publication by Christmas’ message. More than a 1000 families left hanging.

We’ve lived with the Mazars findings for a few months now. A report that, once read, leaves you in a space in which sense making is impossible. This is clear from the response to the tiny slice of it offered by Michael Buchanan’s excellent coverage. Debates in both the Commons and Lords earlier today demonstrate remarkable and unusual cross party concern, horror and engagement.

Sloven’s entrenched and ludicrous ‘it wasn’t us guv’ position compounds the seriousness of the findings.

BBC Breakfast coverage this morning included a video clip of LB, aged around 6, tangled up in his duvet. Peeking, cheeking and oozing happiness.

We’ve chatted a lot about what he would think about these latest developments. As we do. He’d have probably found the media coverage and parliamentary debates fascinating and important. Repeatedly (and I mean repeatedly) asking ‘Has the Mazars review been published, mum?’ and ‘Why not, mum?’

I don’t know what I’d have said to him, back in the day. I’d have probably dredged up some explanation/excuse and fobbed him off. Explained the delay away.

Now I’d say ‘Because they can and they do.’

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