Oh dear. It really is Captain Bringdown time tonight. And I ain’t even going to apologise for the washing drying in the background. So much so wrong and no end in sight.
A despondent despatch from the Justice Shed
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OCC, ‘the BLOG’ and power
Bit of a ragbag ramble this evening. Including some tips for social care bods. I had a bit of a sort out today and a few choice docs from Oxfordshire County Council (OCC) popped up. Now OCC are doing a seriously cracking job at keeping their heads down so far, despite clearly being concerned that their involvement in what happened might come under the spotlight at some point. A lot of their exchanges are fuelled by this blog (or “the BLOG” as they call it).
The Director for Social and Community Services didn’t write to us after LB died. Or after the CQC found appalling failings at STATT in a report published in November 2013. Or after the Verita report found LB’s death preventable in February 2014. Nope. He wrote on April 2nd (saying sorry ‘about the death of’ LB) in response to comments I’d written about OCC. [Tip 1. Write to families straight away if someone dies an unexpected death in provision you commission. Not just when you feel publicly threatened]. OCC also declined to attend the pre-inquest review meeting recently (‘nothing to do with us guv’) even though the coroner’s court is in their building [Tip 2. Send someone to inquest meetings when the person’s death was preventable].
There’s a long list of things we think OCC did wrong. Not least giving STATT a green light in their quality review at the end of 2012. A month or so before a Winterbourne View JIP team of three (including an Oxon commissioner) visited and thought the place was a shithole. The commissioner put in a decorating chit (and now says no crap other than shabby detected) while the other two assumed the commissioner would do something about the place. Other than a lick of paint.
OCC self preservation workings are very apparent in docs disclosed to us. For example, in response to a request from the Clinical Commissioning Group (CCG) to offer us a meeting (as I seemed to be softening on my blog. Yes, really), a senior OCC official’s response was What if she brings her solicitor along with her? I think we need to do a bit more thinking before offering a meeting out of the blue. S/he then decides if the meeting goes ahead an OCC person should attend too in order to know what the CCG geezer is saying. Wow. [Tip 4. Second guessing responses and back watching suggests a right old toxic culture which needs urgent attention/disinfectant].
This blog seems to have evened out (only slightly mind) the power differential between families and health/social care organisations. It features in so many exchanges in disclosed documents often with links to posts. Slovens solicitors wrote a pretty steaming letter to us a couple of weeks ago (copying the coroner in) because I’d made an error on a recent post (now corrected).
I was a bit mortified at the time as I’ve tried to be accurate throughout. But given the amount of ‘errors’ cough cough the Sloves have made throughout this foul process (and the slimy, smearing Briefing document they circulated to fuck knows who else in addition to NHS England, Monitor), one error is pretty remarkable really. In the circumstances.
What a murky, murky little biz.
Stay classy, y’all.
Another sordid Sloven tale
When LB was in the unit there was a patient (one of five) who didn’t look brilliant. I only saw him/her dressed once. Most of the time we visited s/he was in a dressing gown and didn’t seem to go out much. S/he had a bit of a wry sense of humour and chatted away, like really chatted away. A bit like LB really.
I read months later that a patient died of cancer days after LB died. Eh? What? How could someone so close to the end of their life through terminal illness be in a secure unit days before their death [howl]. And why was this discussed in a document reflecting on the additional distress her/his death caused staff. No apparent consideration for other patients. Again.
In the 107 days LB was in the unit, we saw how the inmates (let’s not dress it up) connected with each other and had a sometimes uneasy, occasionally hilarious but a recognisably collective sense of being there. How the three living (remaining?) patients have dealt with the trauma they experienced during that hot, hot July, without specialist support (no post-Winterbourne View/JIP related, apparently gold plated, support here) is unimaginable. Were they able to attend this second funeral if nothing else?
I heard this week, through another dicky bird (the scourge of the candour duty obliterators) that some staff had been concerned about the wellbeing of this patient over some time. [Good]. These concerns were not really listened to. Allegedly, through the whistle blowing process, Sloven have only recently started an internal (that is, chocolate teapot jobby like) investigation into this person’s death. Over a year and a half later.
Wow. If nothing else, the shite that continues to become visible is, er, consistently, shite.
One of our campaign aims was a review into the deaths of all patients in Sloven learning disability and mental health provision since 2011. This was commissioned by David Nicholson last spring.The Death Review got off to a shaky start given nonsense about having Sloven and local CCGs on the expert advisory panel. It looks like this has been resolved but here’s hoping the review gets to the heart of the rotten core. It isn’t about number of deaths but about the response to these deaths. Not only are people denied humanity in life but also in death.
Chilling and unforgivable.
Newsnight. Yep.
The National Audit Office yesterday reported an unacceptable fail on the part of ‘The Department’, NHS England (and the 51 organisations who signed up to the Concordat back in the day) to move people out of ATUs.
We published our own audit from the Justice Shed on the same day. Makes for an interesting read.
And Newsnight came round. And did a cracking job.
LB made national TV 20 months after drowning in a bath in hospital. Astonishing.
Reflections on reflections
Oh dear. Some despondency reached the Justice Shed today. There were a few twitter threads of discussion around the fact that no disabled people were on the #LBBill panel at the Humanities gig at Manchester University.
Nope. There weren’t. Should there have been? Good question.
#JusticeforLB and the #LBBill have been organic, unscripted, slightly disorganised campaigns. Everyone involved is a volunteer. There’s no structure, no resources (other than goodwill which has been available by the shedload) and no agenda (other than effective change). Most importantly perhaps there are no vested interests.
Many #JusticeforLB campaigners are disabled. People have contributed in all sorts of ways. An open and transparent campaign. Anything and everything goes (just browse #107days to delight in this). A mix of determination, commitment, passion, humour, fear and fearlessness, and a refusal to be drawn into meaningless, empty and fake talk about what is about to change. The amount of hours and (crowd sourced) skills and support provided for free impossible to count.
This is in contrast to the spectacular failure of other efforts to make life better for learning disabled people. The National Audit Office are publishing their investigation into the ‘dread to think’ sums of money squandered on the Winterbourne View Joint (Non) Improvement Programme on Wednesday. This should make for an interesting – finger nails on the blackboard – type read. Big charities and other organisations have also talked the talk at length, across the last three or four years, within the stifling constraints of existing structures, organisational layers, an eye on salaries and the awkward position of being both campaigner and provider. Tripping over in jargon alley, distanced from the experiences and engagement of learning disabled people and their families, apart from the often tokenistic involvement of one or two disabled people, hands over ears to avoid properly listening.
So should there have been a disabled person on the panel on Monday? Of course there should. We’ve met with disabled people’s organisations. Cracking easy read bill resources are available. There have been events organised across the country focused on getting feedback from learning disabled people. Passion, commitment and effort have generated a mountain of feedback waiting to be analysed and fed into the next version of the Bill.
That the panel didn’t include a disabled person shouldn’t be a negative reflection on the campaign. It should raise questions, discussion and reflection on how meaningful involvement can happen within the context of no resources, little time (or structured organisation?) and an antipathy to tokenism. And what this means about ‘inclusion’ more generally.
As well as a shared commitment to making things different.
The roadshow
Bit of a #justiceforLB flurry this week with a workshop on Monday afternoon and evening talk at Manchester Met (see Mark Neary and Steve Broach), and a talk/workshop at the NDTi conference the next day. This generated loads of positive stuff which is ace. Meeting up with fellow justice campaigners ‘in real life’ is fab and hearing how the campaign is energising, moving, challenging and clearly being a collective pain in the arse, is heartening.
It’s pretty hard, odd, awkward, I don’t know, just off the page of sad really, publicly talking about your child who has died. Especially (I’m guessing) when her or his death just screams wrong on so many levels. On Monday and Tuesday I showed a slightly edited version of the film Rosie and I made in the days after LB died, for his do. I remember us sitting at the kitchen table in the early hours (because there were no day and night rules in that nothing (but hellish) space between death and burial/cremation), going through photos and home movies and stuff that captured LB. [Howl]. We paid meticulous detail to the content and arrangement of the short film. The magical part of Pure Imagination had to fit with the pic of LB being showered in confetti at a friend’s wedding, for example. A detail lost on others I’m sure (understandably), but of crucial importance to us in our tear sodden, bewildered and devastated states.
I dug out this film this week because I kind of feel that who LB is has shifted. He’s gained notoriety. (A bloody hard fought one, mind). And in death, everything he would have wanted in life – buses and a truck named after him, a collective focus on buses and Eddie Stobart, a top notch legal team fighting his corner, a police investigation – has been achieved. He only needs Emma Watson to champion #justiceforLB and all boxes would be ticked.
Stripping all that back. He was a dude. A six form student with his adult life (though you can fuck right off with this adulthood at 12.01am on the 18th year of your birth rubbish) ahead of him. That he died after 18 years of barely getting a scratch (love him) at home, in ‘specialist provision’ that cost £3,500 per week (£14,000 per month???) with a staff to patient ratio of 4:5 is incomprehensible still. I’m not sure we’ll ever make sense of it.
But the campaign is keeping LB alive in a kind of cheesy old way. I suppose that’s why it’s a fairly typical response by families. And we seem to be getting somewhere. Almost.
As Stevie B says:
Too bloody right.
Inaccurate submissions
At that first pre-inquest review meeting, back in the day, Sloven’s legal team tried to narrow the focus of LB’s inquest with their infamous natural death statement. In addition, they argued the various ongoing reviews into what happened meant that broader issues were being investigated.
This list of reviews included (quote):
Investigations by a number of professional regulators, including the GMC and NMC, following referrals from a number of sources.
Wowsers, we thought. Have Sloven souped up the slowest staff disciplinary process on record? (19 months and still waiting…*) A number of sources? Who? We referred one staff member but other sources?
We found out eventually (today, nearly two months later) that, er, it was just the one two professional regulators. And one two staff members. One referred by us and one (a member of staff who had left) referred by Sloven. Blinky blonky blimey. Really? Trusts and their trusty, publicly funded, legal teams can submit made up rubbish to coroners? How the fuck does that work?
Well clearly in direct contradiction to Simon Hughes’ nonsensical argument on Radio 4 last week that inquests are family friendly, cuddly, inquisitorial gigs. And families most definitely need no legal representation. Tsk. ‘No no no‘ says Mr Hughes. Waggling his finger vigorously at bereaved families.
It turns out that Bevan Brittan, Sloven’s solicitors, openly promote their expertise in ‘inquest management’. They’ve even got a handy little ‘Avoiding a Coroner’s Rule 43 report at an inquest‘** article allegedly aimed at beleaguered Trusts caught on the hop letting pesky patients experience serious harm or worse on their watch.
An extract from their website:
Inquest management. Managing witnesses. Statement taking. Management at the inquest.
My brain (what’s left after 19 months of intense and unremitting grief and a full on battering by everything I naively/stupidly held to be ‘good’), kind of melts at this point. How can an inquisitorial process need management by an ‘Interested Party’?
LB died. He drowned in a bath. In a place in which he should, if nothing else (because there was nothing else) have been safe.
As simple as.
That we are being forced, seemingly deliberately slowly through a shite coated, beyond unfair and punitive system, is inhumane. To discover that Sloven’s legal team can apparently trot out lies, in a public hearing, without sanction, is…?
Dunno. We’re out of words.
*For a Trust that has consistently positioned the well being of their staff over us and other patients at the unit, they don’t half treat them like shit too.
**A serious and reputation damaging knuckle rapping report.
[Update 27.1.15 I made an error in that Sloven had referred a member of staff, but not sure this changes much of the above].
British (in)justice and Simon Hughes
No answer yet to my letter to the Ministry of (or for?) Justice but I remain baffled after this week. A week in which we had a second pre-inquest review (PIR) meeting and Simon Hughes, the Minister of State for Justice and and Civil Liberties was interviewed on You and Yours responding to Nico Reed’s mum, Rosi.
Simon Hughes stuck to the line that families don’t need legal representation at an inquest because it is (simply) an inquisitorial process. Such a blinkingly naive and ill informed response. He swerved the question about why public authorities can (and probably always do) have publicly funded legal representation. Typical slimeball stuff.
Here’s what could have happened if we’d had no legal representation at the PIR this week:
Coroner: Hello. Any questions from the family?
Family: We would like a jury at LB’s inquest please.
Coroner: I don’t think LB was detained so there is no basis to have a jury.
Family: He was. The unit door was locked.
Coroner: He could have asked for it to be unlocked. He wasn’t detained.
Family: Yes he was.
Coroner: I’m afraid I need more evidence. I remain unconvinced.
Family: He was.
Coroner: That isn’t evidence. It’s opinion.
Family: He just was.
Coroner: There will be no jury. Any other questions?
The British “justice” system clearly on fire when it comes to inquests.
“Yes to a jury…”
Wow. Not words I ever anticipated writing. Or tweeting. With a hint of triumph. There is no triumph. But then there is, kind of. In a pretty crap and thankless way. In the painstakingly laborious, relentless and distressing process of trying to get some sort of accountability for the preventable death of your child in a hospital bath [crumble].
The coroner agreed to a jury at LB’s inquest yesterday. At the second pre inquest review meeting. An article 2 inquest was already agreed. Whether or not there would be a jury was still to be decided. The decision hinged on whether or not LB was detained. Or not free to leave the unit. The unit with the locked door. And a care plan that stated that he was only to leave accompanied on a one to one basis. The dude who had never stepped outside without someone with him.
The discussion/arguments/submissions highlighted how coroners (and others) don’t necessarily understand how life is for some people. Why would they? With apparent good intentions the coroner tried to make sense of the evidence available to interpret LB’s ability/capacity/wherewithal to simply leave the unit as he chose. A locked door can be opened on request. He asked for evidence, for facts and not legal submissions, to underpin his ruling.
LB wouldn’t ask for a locked door to be opened. Particularly after being restrained face down for over 10 minutes in response to trying to come home on his first night in the unit. [Howl]. After such an inhumane and barbaric experience it kind of becomes irrelevant whether or not the unit door is locked. Simple power rules operate. And if staff had opened the door on LB’s request (which they never did), he would have waited for us to come and collect him.
He was detained. As simple as. Whatever way you want to try and interpret it. The coroner recognised this – after lengthy arguments (both legal and factual) from our legal team- and ruled in favour of a jury.
I was left wondering what would have happened if we hadn’t had legal representation.
The pre-inquest review meeting (2)
Second pre-inquest review meeting tomorrow afternoon. Here’s where we’re at:
- The coroner has agreed to an Article 2 inquest which is good but says no to a jury. Astonishingly Sloven have just said they think there should be a jury too. This will be decided tomorrow.
- The police will update on their investigation.
- The coroner will rule on whether Oxon County Council are an Interested Party. We think they should be for fairly obvious reasons.
- There may (or may not be) some discussion about potential witnesses.
- There may or may not be a date/length of inquest set (depending on the police investigation and number of potential witnesses).
- The coroner may or may not allow live tweeting.
Sloven (and the Bevan Brittans) have got a different barrister pitching up. Dunno if this was because Gerry Boyle’s photo was bounced around twitter by the wonderful Open Democracy peeps. Or because he looked totally sick to the stomach trying to argue (on either Sloven or Bevan Brittan’s instructions) that drowning is a natural death at the last meeting. Whatever, he’s replaced by Fiona Paterson.
We have the legendary Paul Bowen, QC, representing us (think that’s the right lingo). He, together with the equally legendary Caoilfhionn Gallagher and Charlotte Haworth Hird comprise a trio of human rights deliciousness that LB would have delighted in. Something that not only reassures us hugely but is also an antidote to some of the extremes we’ve experienced in this half world of unremitting uncertainty and unpleasantness.
Here’s to sense and integrity.
mydaftlife 