Meeting the Mazars

Tomorrow we have a meeting with the Mazars who have been commissioned by NHS England to undertake the review into all deaths in Sloven mental health and learning disability provision since 2011.

It’s probably worth flagging up some of the CIPOLD findings because they are so off the scale shocking. On average learning disabled women die 20 years sooner, and men 13 years sooner, than the general population. 22% of the sample were under 50 when they died.

Astonishing statistics. And then this:

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Despite 43% of the deaths being unexpected, they were nearly 10% less likely to be reported to the coroner. Wow. Howl.

A bit of historical context

I suppose it ain’t rocket science to work out why learning disabled people die earlier or why their deaths seem to be of less consequence than the deaths of others. In 1952, A.F.Tredgold wrote this in his cheerily named Handbook of Mental Deficiency  only a few years after the end of WW2;

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(Taken from David Race’s Learning Disability – A Social Approach.)

Forty years earlier, University College London set up a Laboratory of National Eugenics part funded by Francis Galton. Galton, who coined the term eugenics, wasn’t alone in his concern about the ‘feebleminded’ breeding like rabbits and decimating national fitness. A genuine fear of gene pool dilution (Wellcome have a fab digi-archive of The Eugenics Society documents which are kind of breathtaking). It was an influential movement for some time (and arguably still is, albeit less explicitly with that pesky term carefully hidden behind layers of more ‘acceptable’ language) involving a range of public figures including Beatrice and Sidney Webb, HG Wells, William Beveridge, George Bernard Shaw and John Maynard Keynes.

We’ve never really moved beyond this perception of learning disabled people as deficient, worthless, burdensome and a problem. Despite a steady stream of policy making and legislative change. It doesn’t matter that there are small pockets of brilliance dotted about the country if most learning disabled people lead constrained, contained and impoverished lives. Waiting for an inevitably premature death. With little accountability. And no imagined future.

So. A meeting tomorrow with the Mazars. Maybe another step forwards in making visible (unconscious?) practices that demonstrate the dismissal of some lives as relevant or human.

Leading to meaningful change? Nah. Why would it?

So wrong

Tonight I heard the saddest news. It took me back to a train journey. From Canterbury to Oxford over three years now. When I heard that LB’s classmate had been sectioned and taken out of county to a unit miles away. Aged 16. I had a right old blub on that train. It seemed so brutal. So wrong. My heart broke for the cute tot who had legendary status in our family folklore. And his family. How could these kids be failed so badly? Despite the gargantuan efforts of parents?

And then LB went into a unit. With an unimaginable outcome.

LB died 17 months ago now. And there is still no effective support. Services/professionals miss the point, don’t have the knowledge, skills or ability to read the writing on the wall, or respond to it.

Time to call it as it is. Surely?

Timidity and the Yellow Brick Road

Been chewing over stuff this week, given the pre-inquest review (howl), launch of the Bubb report, accompanying media coverage and commentary. (See Chris Hatton, Matthew Smith and Rob Greig and ace coverage by Saba Salman on her blog and in the Guardian.) It was also the CQC 3 Lives* follow up meeting.

Relentlessly unchallenged crap practice and helplessness consistently crop up. We know that ATUs/some supported living settings are spaces that leave human rights on the doorstep. Containing people for years in hideous ways the public only find out about when something goes wrong. Those in the know know, of course. The frontline staff delivering nosh, medication and often little else, clinicians signing forms, local authorities/commissioners/NHS England shelling out small fortunes, and tribunal members. They all know. We all know really. But only give it some thought when the next catastrophic event crops up.

And then what happens? Talk, as always. Lengthy, wordy, jargon filled reports and meetings with the same old suspects, many of whom have screaming conflicts of interest. 

I had a quick shufty at a couple of charity accounts this morning. Again, a whole PhD to be had exposing the pomp and self congratulation around commitment and involvement to the Winterbourne Concordat by various organisation in the past coupla years. Quick to grab their moment in the brief sunshine of planet Concordat.  I wonder how many charities will record in the 2014 accounts that it was an almighty failure. And their commitment amounted to, er, nothing.

In among my rambling, exhausted thoughts, timidity kept cropping up. And that bloody lion in The Wizard of Oz. Tom was in a school performance of this a couple of years ago. LB, generally a big fan of any type of production and extravaganza, took offence to the constant repetition of the chorus.

“Not that fucking yellow brick road AGAIN!!!” he roared. Before Rich took him home in the interval.

Timidity is a kind way of characterising all I see, hear and read around learning disability provision these days. Timidity underpinned variously by:

    • a lack of understanding of how to make change/what to do
    • a lack of interest/commitment
    • incompetence
    • conflicts of interest
    • concerns about self preservation/future career paths

Well timidity, for whatever reason, is going to change fuck all. And until people with some influence and power grow some, we might as well all give up, creep back to our respective holes and get on with the lives we are lucky enough (or otherwise) to have.

I’ve always thought LB was saying exactly what most people in that packed, hot hall thought that evening. He was just fearless enough to say it.

*Lisa is now shopping weekly at Tescos and been to Matalan.

The Sloven Book of Dirty Tricks

Pre-Inquest Hearing yesterday. And Sloven added a new chapter to their Book of Dirty Tricks. Delay, as always, was a Sloven feature. They circulated their submission 3.5 hours before the meeting started. Classy little technique. Reading it at home, and weeping, I thought back to the meeting we had with David Nicholson where he said something about the Trust not contesting LB’s death (I mean how can you, really?)

How can you? Well Sloven, turning up en masse with a barrister, a solicitor, their in house legal person and the now too familiar medical director, gave it a go. In an obscenely offensive move. They argued that there should not be a jury at the inquest because LB’s death wasn’t – wait for it – violent or unnatural.

Yep. I ain’t joking.

It’s indescribable how awful it is to read such dirty little, lying, contradictory, game playing, rubbish about the death of your child. This is the NHS?

Note to Sloven and team. If you fully accept the findings of a report stating that a patient died a preventable death, don’t pitch up in a courtroom setting six months later and claim he died of natural causes.

Complete scum of the earth stuff.

The coroner dismissed it straightaway.

The Pre-Inquest Review

Seventeen months after LB’s death, the pre-inquest review hearing is taking place tomorrow afternoon. In a room in County Hall, Oxford. The building where I used to attend meetings about provision for disabled kids in Oxford. Transport issues and cuts. The Parents Advisory Group.

There’s not much to say at this point. I’ve said it all on these pages. In various ways. Pretty relentlessly.

A tiny part of me still thinks ‘Really? The NHS? Behaving like a bunch of bullyboy thugs? Nah. Our beautiful dude died. He was young, fit and had his adult life ahead of him… Such a terrible, terrible preventable death would lead to care and concern, not cover up, delay, crap and deceit. Surely?’

A tiny part the size of a pin head now.

Tonight, we’ll be thinking about LB. In all his legendary awesomeness. And the comfort he felt in doing things his own way. Before he grew older and stuck his toe in a new and empty world of ‘adult services’. Where one size fits all and he wasn’t allowed to be.

Like so many young people like him.

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I bloody love and miss you. xxxxxxxx

The week that was

Seems wrong to end this last week with a rant (see previous post) so will do a quick summary of what was, considering all things, a pretty fab week. Monday was LB’s 20th birthday. Hoping that life won’t become a series of ticking off his birth day in a desperately desperate way, we managed to pull it out of the bag accidentally. The kids (and Jack, Rosie’s bf) all pitched up for a nosh up on Sunday. I probably bored them shitless with my teary ‘if there’s any day in a year that it would be bloody cool to see you all it’s LB’s birthday’ ramblings. We also got to hang out with the cutest little kids on the block in the afternoon.

On LB’s birthday, Rosie, Owen and I went to see the remaining poppies at the Tower of London.

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You can’t really call things like what to do on your dead child’s birthday (sorry). It’s so unknown and beyond distressing but, like last year, this was a cracking choice.

LB loved the Tower of London. It was the scene of one of his most memorable birthday outings and the poppies were gravely moving and powerful. A strangely comforting setting.
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We had a good time. The sun came out. And it was lovely to see Rosie and Owen bantering about. We recreated the iconic photo from that day. Then piled into the gift shop to buy bus stuff. We got Rich a bus tie to wear to the inquest (a grower, hopefully) and a brilliant London bus decoration (to be unveiled during the #justiceforLB advent calendar).

Phew.

On Wednesday morning we had a meeting with Norman Lamb about the #LBBill. It was a 9am kick off which we stupidly spiced up with some rush hour risks.
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But we all got there on time and Norman Lamb (or Lamp as the Aspland kids called him this evening) was a delight. Committed and trying to find a way through the seemingly concrete barriers to change.
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Friday, another trip to London for more #LBBill chat with Disabled People’s Organisations. We kind of expected, and were prepared for, some challenge about our motivations and actions. As it was, we were just a bunch of people, all wanting similar things, discussing what these things were and how to make them happen. Supported by crowdsourced drops of brilliance.
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“Errors, omissions, distortions and false claims”

Sloven board meeting papers were published this week. Ahead of the next meeting on November 25th. (Same day as our pre-inquest review meeting). Jaw dropping nuggets. As ever. This bunch of festering toe rags never fail to deliver.

First, the off the scale of inappropriate powerpoint that surfaced a few weeks ago – Could it happen here – is actually a quality improvement toolkit. Developed in response to ‘the risk of not learning from incidents’. Yes. I know. Personally this would be enough for me to whip their licence to kill operate away right now but we know there is no straightforward route to accountability.

crap

The ‘owner’ of this risk in Sloven Towers is the aptly named Medical Director (Quality), Martyn Diaper. The ‘toolkit’ uses what happened to LB in a tasteless and completely pointless way (there ain’t an awful lot to learn about people with epilepsy and the dangers of bathing after all) and is crap throughout. But hey ho. It’s going to be launched at the Sloven quality conference in December….

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(Bit of an aside really, but judging from the programme and title, you’re doing pretty shit really. Not sure you need to set aside a day to discuss it.)

I assume Could it happen here is being ‘launched’ in the learning disability service user story session. Howl… how fucking dare you??? How fucking dare you?????? Sickening to think someone will stand up in front of an audience and present this pile of offensive crap. For so many reasons. Not least because LB wasn’t a ‘learning disability service user’. He was dearly loved young man with his whole life ahead of him.  And nothing went fucking well. How could you even begin to suggest it did?

Please don’t reduce him to some sub-standard, sloppy case study in a pretend learning exercise, in a shonky little day, top and tailed with yoga and footprints. 

Deep breath.

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Yep. The fuckers are actually thinking of putting in for a BMJ Award.

Setting to one side the seedy, commercial angle to the whole NHS award scam/industry, brilliantly captured this week by George Julian, how.the.hell can a Trust who allowed a fit and healthy young man to, er, die, and who continue to be the subject of a police investigation, even begin to think about awards?

Truly sickening.

Oh, and one last thing… The Patient Association published a cracking report about the role of the ombudsman andNHS complaints this week. And there, on page 17, (thanks @Minh Alexander) is a terrible story about a young woman let down by Sloven in 2011.

The account could be a word by word account of what we’ve experienced; insensitive and unsafe care, not listening to the family’s concerns and a response from Sloven containing ‘significant errors, omissions, distortions and false claims’.

More evidence of Sloven form. So much evidence of Sloven form. How they learn fuck all, cover up at any cost and crush families along the way.

Could it happen here, they ask.  Why wouldn’t it? Why wouldn’t it?

At least two rooms without a view

A bizarre bit of journalism popped up in the Sunday Times last weekend. About Lisa who was locked in a room for 9 years in an assessment and treatment unit (ATU) until she was ‘discovered’ by the Challenging Behaviour Foundation (CBF) ‘expert by experience’ on a CQC inspection. Much is made of the role of the CBF in this short piece. Not sure we need Viv Cooper, CBF CEO, to point out this is ‘deeply concerning and shocking’. It’s also a bit bizarre that the Sunday Times ‘can reveal’ this horrific story when it was published by the CQC last summer in their 3 Lives report.

But that ain’t all on the bizarre menu.

The story moves on to discuss Stephanie Bincliffe who died in an ATU (privately run by the Huntercombe Group) aged 25 and weighing almost 26 stone. Her inquest is ongoing. Why someone who died [died] and is (well should be) currently ‘news’ is mentioned after Lisa (who should have been but never was) is baffling.

But that ain’t all that is baffling.

Other than The Sunday Times, there has been no media coverage of Stephanie Bincliffe’s death despite the inquest being a public event. She was locked in a room for seven years (like Lisa). The Sunday Times reports:
Stephanie B

Two women. Two rooms. And media interest worthy of a local break-in in a disused warehouse in a disused retail park (earmarked for building a new, large scale, residential facility for learning disabled people perceived to be bothersome).

I can’t stop thinking about Lisa and Stephanie. I’ve really struggled with LB’s 107 days in STATT. 107 days. Howl. I battered Rich’s ear yesterday trying to remember what holidays we had in the 9 years before LB died. How could someone be locked in a room for years? In a health unit supposed to treat and assess? Howl.

Both Lisa and Stephanie had their ‘care’ commissioned. Both were sectioned which should involve a whole raft of built in processes/checks/regulation. Involving health and social care professionals and commissioners.

When I first heard Lisa’s chilling story at the CQC event back in February, David Harling who talked about it, used a photo to illustrate what a suite at the Ritz (or some other swanky London hotel) looked like at a cost of £12,600 per week.

I’ve googled and found this little baby for comparison:
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The money is irrelevant in many ways. We’re talking people’s lives. But it isn’t. The story woven around these bothersome patients who need ‘care packages’ so off the scale of expensive must involve collusion across a whole range of health and social professionals/NHS/private providers. £12,600 a week? Really?

And, ironically, the real cost of the (anti) care provided (a bit of hatch opening, pill pushing, hair brushing from a distance and a staffing ratio of .001? to 1) costs fuck all.

It stinks of a win win situation financially for the provider (NHS or private). A level of ignorance on the part of commissioners. A further battered health/social care budget for learning disability provision and a complete lack of care or interest across the board.

People who have committed no crime but are such a menace that locking them up for years is ok, even when they, er, die. Aged 25.

Moving quickly on because there really ain’t nothing to see in this room….

What role do key charities (in this case  those originally set up by families to improve the lives of their kids) actually play? And what do they actually do? And why?

Tumbleweed.

Or worse. Clearly.