Running out of titles

Wondering what we can do really. In a bit of a despondent way. The update I posted this week illustrates how public bodies can simply delay. With seemingly unlimited doses of delay powder. A sort of modern wday ‘smoking out’ policy. Earlier today I found out that Oxfordshire County Council (OCC) are delaying their response to my Freedom of Information request about their ‘investigation’ because a Public Interest Test is being carried out.

I don’t know what this means and the FOI dept at OCC were unable to enlighten me beyond the fact it will involve a delay of up to 20 working days. Another month potentially. It would be bloody brilliant if they could soup it up a bit and complete this test (test?) in days rather than weeks but given the weighty blanket of on going delay, I’m not going to anticipate anything. July 22 is the new date.

I don’t have a bar anymore. That was crushed somewhere along the way. When we realised that these public bodies can do whatever they want to devastated parents/families and no one will stop them. I now expect the worse and, so far, that has been spot on.

Another parent, Nic, whose child died a few months before LB posted this on my blog yesterday.

nic

Nic regularly posted comments in support, in shared grief, rage and despair at the impossibility of trying to get accountability, justice or anything to make sense of the apparently casual and brutal chucking aside of much loved children’s lives. One of the first comments she made included the request ‘More photos please’.

So here’s another pic from that holiday in 2010. When we were walking a completely different path. And, on a more cheery note, the #JusticeforLB flag is returning to Glastonbury this year with the legendary Lawthom Goodley crew. Bloody good timing in the circumstances.

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Updating the update. Of the update.

We’re fast approaching the second anniversary (hate, hate, hate using this word for this) of LB’s death [Howl]. 16 months after an independent report was published stating LB’s death was preventable.

Here’s an update of the latest update (March 2015). As always (and clearly forever) in no particular order:

1. The inquest: A fourth pre-inquest review meeting is being held at 2pm, September 9th, Oxford County Hall. All welcome. It’s a very public affair. The full inquest is scheduled to start on October 5th. Sloven have “unreservedly apologised” for LB’s death (as the curious Tory template (repeatedly) reminds us) but this hasn’t stopped them pulling all sorts of tricks along the pre-inquest journey. Including a bit of desperate back pedalling from that unreserved apology to argue that drowning is a natural cause of death.

2. Disciplinary councils: We referred one clinician to the GMC in May 2014. This investigation continues, slowed by some additional stuff that has cropped up. Apparently Sloven disciplinary processes led to an undisclosed number of undisclosed staff members referred to the (undisclosed) NMC. Who knows?

3. Police: The investigation continues. Staff interviews are underway.

4. Health and Safety Executive: The investigation (apparently) continues in line with 3. above.

5. Oxfordshire County Council: We’ve received legal advice on the “independent” report OCC commissioned into LB’s death without our knowledge. It seems that it is defamatory so there is ongoing legal action relating to this. OCC are sticking to the ‘We did nothing wrong’ line. Chilling really. The consultant is apparently working through the list comments/issues I was forced to identify a few weeks ago to revise the original report. I still say chuck it in the nearest bin but what power do we have? [I’m dreading receiving another version given the methodological approach].

6. Verita 2: This second, broader investigation into what happened to LB remains ongoing.

Mazars death review: The review into deaths in Sloven learning disability and mental health provision since 2011 has been extended by NHS England to allow additional work to be done. Given the announcement this week of a national review into the premature deaths of learning disabled people, this extended work makes sense.

So. That’s it really. When we sadly started #107days again this year, we naively thought some of these investigations would be completed during this time. It’s now clear that this ain’t going to happen.

It’s all a pile of cock rot really.

I’ll leave you with this pic from a holiday we had in July 2010. When life still had colour, beauty and the extraordinary (in a good way).

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Cut and paste society and template life

template

Still a bit baffled by the Tory template [copy below] being pinged out by MPs in response to requests from constituents to support the #LBBill. Some people see this as a sign that the campaign is weighty and demands a response. That it’s referencing the Green Paper, keeping it out there. Yep, I can see that. I also find it pretty offensive to see cut and paste jobbies stating how “deeply saddened” MPs are by LB’s death.

“No you ain’t”, I want to snarl at them. “If you were you wouldn’t blooming well template it…”

Maybe there are bereavement templates in Tory HQ. Who knows. Maybe there’s a whole filing cabinet of templates. One for every occasion. Bit like LB used to say he had a girlfriend for every occasion; camping and funerals.

I’m interested in who produced the template and on whose say. It’s a masterpiece in saying nothing, while saying so much.

I was greatly saddened to learn about the case of Connor Sparrowhawk. I understand that past-mortem findings have shown that that he died as a result of drowning, likely to have been caused by an epileptic seizure.

I am deeply sorry that Connor died whilst in the care of Southern Health NHS Trust who I understand have acknowledged that they failed to undertake the necessary actions required to keep him safe. I think it is quite right that the hospital has now apologised unreservedly to Connor’s family.

I read the proposed Private Member Bill with great interest. I think it is an important contribution to the ongoing debate about how we best improve care for people with learning disabilities. You may be interested to know that during the last Parliament, the Department of Health held a consultation called ‘No voice unheard, no right ignored’ which looked into precisely this issue. In particular it included a section called ‘My right to be independent, to be part of a community and to live in a home I have chosen’.

I hope this is an area that the newly elected Government will choose to examine carefully before deciding how best to support and care for patients.

Thank you again for taking the time to contact me.

The expert witness report

Blimey. In the topsy turvy world we’ve been pitched into, I found out today I’m in Manchester tomorrow and not not Birmingham. The Birmingham confounder was the Community Care Live gig last month. When I wrote and forgot about this post. About the expert witness report:

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I received the epilepsy expert witness report this lunchtime, ahead of the pre-inquest review meeting next Tuesday. I was in the Speakers Lounge at the ICC (dunno what ICC stands for but something Conference related), Birmingham, at the Community Care Live event. It sounds pretty posh and not something I’ve sat in before. But it was just a space. A bit scruffy. With lukewarm tea, coffee and biscuits.

Various people I ‘know’ through twitter were around though. Which was kind of cool.

I vaguely grazed the report, half thinking about my talk, half listening to/joining in conversations around the table. The emotions involved in reading such a report are indescribable really. Deeply, sadly intense with no space to go. Certainly not at the ICC. In the Speakers Lounge.

On the train home, a few hours later, a woman was on the platform with her young daughter and a big case. She coached her daughter carefully and repeatedly about the steps they would take when the train arrived.

“You get on first and I’ll be right behind you because I want to make sure you’re safe”, she kept saying.

I got home this evening and read through the report again. Properly. With a flickering home movie stream in my mind. Constant moments of watching, coaching and doing the extreme safety parent thing. Interspersed with silent howls.

And bizarrely (or maybe not) I thought ‘Thank you for calling him by his name’.

Space, place and managing snow

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Just under two days in Tromso this week. Midnight sun land. Well not much sun but spectacular sights. And so much daylight. Which was strangely mesmerising. I learned a lot from colleagues about life in northern Norway. Including snow management techniques. The importance of building capacity to allow space for snow. Built on an understanding that the snow ain’t going anywhere fast and everyday life needs to continue.

Sloven and OCC don’t seem to understand the need for this space when it comes to grief and families. Instead they just shovel, or try to. A process that’s destructive, counter-productive and hugely damaging.

There are policies that try to create space for grief within the NHS. The sensible and straightforward Being Open framework, for example. But policies are just words if they’re ignored. As meaningless as the non-apologies identified by Ally, LB’s cousin, in her recent dissertation on Sloven communications.

There are obvious differences between heavy and sustained snowfall and grief. But I find it hard to understand how the grief stuff, something so agonisingly accessible – most people can, if they can bear to go there, have the beginnings of imagining what such grief feels like – is dismissed or ignored. Intensely human, deeply emotional and gut wrenchingly awful experience is trampled over, ignored or worse, by the public bodies responsible.

How do we get it so blinking wrong?

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Defam, flimflam and OCC

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.

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Extreme spaces and a touch of Marge Simpson

Another full on week. Thursday morning, the Private Members’ Bill ballot. Thursday afternoon, there was a meeting of the Expert Reference Group for the ongoing Mazars death review. This review, commissioned by the Real David Nicholson before his retirement from NHS England, was viewed as a tick box exercise by some. Sigh.

Friday morning we had an intense and, in places, deeply sad meeting in London talking through legal stuff. There was a bit of swearing, a box of tissues and a shedload of sensitivity.

Tonight we went for some nosh to celebrate Rosie moving to Bristol before starting her first full time job. On the way home, she was chuckling about the time I dipped back into the St Giles fair on my way back from a meeting a few years ago to have another cheeky go on the coin pushing machine. Apparently Tom texted me asking where I was and what was for tea, sending me into a spin about being a rubbish mother.

“You did what?” said Rich. “I didn’t know about that! Marge Simpson is a secret gambler…”

Setting aside what OCC would have made of this story in their craphole review, I just want to say; Good on yer, Rosie. It’s a fab job, brilliant opportunity and you bloody deserve it.

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June 4th and the #LBBill

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It’s been about 8 months now since the idea for the #LBBill was hatched. Sparked by a tweet by Mark Neary. Acted on with a remarkable combination of expertise, cheek, experience, knowledge, rage, good cheer, humour, collectivity and common sense. What could have been a throwaway comment became something more substantial. Talk turned to action. And gained layers of substance through a chaotically (un)organised campaign of crowd sourced feedback.

Details were thrashed through with meticulous attention by people, disabled people’s organisations, self advocates, carers, professionals and others. This collective focus enabled a remarkable measure of sense to be brought to version 2. Groan dimensions accompanying much legislation/social policy erased by strong statements by those who know.

On June 4th, the ballot will be held to select MPs who will have the opportunity to apply for a Private Members Bill (PMB). We really need to encourage all MPs to get on board with the Bill and, if they’re selected high up in the ballot, lobby the socks off them.

I don’t know much about PMBs. I do know that the #LBBill is the outcome of remarkable endeavour, commitment, love and determination. I can’t imagine there are many better prepared bills in terms of whatever you want to call public involvement/engagement/co-production or just getting on with it, together. Or bills that are such a remarkable expression of joy and celebration of lives too often dismissed and ignored.

I’d champion it if I was an MP. Without hesitation.

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Blatter, schmatter and candour

I came across Sloven’s 2013/4 Annual Report today in which they make the extraordinary claim that they are 100% compliant with Duty of Candour obligations (p121).

candour100% compliance? Eh? How can claiming LB died from natural causes in July 13, failing to disclose his full medical records until November 14 (via the coroner), accepting that his death was preventable in February 14 and then claiming again he died through natural causes in November 15, fit with duty of candour compliance? How can not sharing how Nico Reed died with his family for nearly two years be candour compliant? Or do learning disability related incidents stand outside this indicator?

Up until the last couple of months, I’d probably have written to the Board chair asking for some clarification on this. Not any more. The OCC report (OCCRAP) and their response to my obvious and fully justified distress about this report, on top of the various brain melt communications we’ve had with the now ex-Sloven Board chair/still-in-post CEO documented on these pages, have demonstrated that they have the power to do what they want. Including telling the most fanciful of lies and sticking them.

It’s simply one fucked up, archaic and sometimes corrupt system.

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Critical questions

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This afternoon, stuck on the Oxford Tube coming out of London, I was reading negative academic related stuff on my twitter timeline. Then my niece forwarded her undergraduate dissertation. She’s just completed a degree in linguistics at Leeds. For her dissertation she did a critical discourse analysis of four documents; Sloven’s public statement on the publication of the Verita report, their briefing document to Monitor, and letters from the CEO and Board Chair to us.

ally

I still don’t fully understand what transitivity is but non-apologies are pretty straightforward. In a kind of a random shambles; human, mother, (proud) aunt, campaigner, academic, raging woman, Oxford Tube captive and probably other identities, I read this dissertation. Between Hillingdon and Lewknor.

I was struck, in particular, by three things. First, it’s an example of an undergraduate dissertation that’s robust, rigorous, relevant and political. I’m impressed by both Ally’s work/focus and the encouragement and support she was obviously given by Leeds.

Second, (and I won’t say much about the content right now) the conclusions are clear, carefully evidenced and show that Sloven (and probably other NHS Foundation Trusts/local authorities) don’t operate anything approaching a whiff of candour, openness and transparency.

Third, if an undergraduate student can produce a clear, critical and well evidenced piece of research demonstrating this, why is so much meaningless talk still being talked?