Had a day off today and had a lovely lunch with lil sis, Sam. Once she’d gone, the latest FOI pinged into my inbox. More stuff from the County Council about STATT. This includes a second (in addition to the November 2012 quality review) Quality and Safety Assurance Review of the Oxfordshire Learning Disability NHS Trust (OLDT), just before the Sloven takeover, commissioned in September 2012 by NHS South of England. Conducted by an external consultancy.

The review states that the impending acquisition, issues arising from Winterbourne View and those relating to an inpatient client led to a renewed intensity of interest and scrutiny on OLDT by the Strategic Health Authority. It discovered an insular organisation, with high levels of restraint, a culture in which a casualness ‘about strict process’ had been allowed, variable (even ‘dysfunctional’) relationships with commissioners and a complacency of attitude that was characterised as a lack of awareness and transparency. The review concludes that the culture can ‘best be characterised as a combination of defensiveness and complacency in respect of quality, safety and risk‘.

It recommends that Sloven swiftly act to ask the right questions of senior managers and ‘gain more robust assurance about incidents, actions and outcomes’. It also recommends that Sloven review staff training requirements and work to reduce restraint use.

Nearly 11 months before LB died. Everything that needed to be known about STATT was known. Documented, stamped and signed. A legitimated torture chamber. Post Winterbourne View.

We, knowing none of this, drove our beautiful and beyond loved boy, a couple of miles along the Slade, that cold, dark March evening. To his death. A death that could not have been more clearly written on the walls of Sloven Health and others.

You absolute bunch of fucking bastards.

Reading the emails from Oxon county council and clinical commissioning group, I’m struck (again) by the astonishing arrogance of Sloven Health. I’d already heard that when they did their royal tour of Oxon to smooth over the ripples caused by LB’s death, the failed CQC inspections and Verita’s damning report, they came across appallingly. Gail Hanrahan describes one such meeting brilliantly.

I’ve only heard Sloven senior team members talk on the radio/TV news but it’s a throwback to past decades to hear people clearly lacking any understanding about learning disability talk nonsense about ‘the modern way’ and ‘false positives’.

This arrogance is also captured in the Oxon email exchanges about this tour. In one meeting they were apparently concerned that the focus on learning disability in “the north of our patch” was impacting on other services they deliver, and they appeared offended to be asked for a copy of their ‘detailed action plan’. The too big to fail monster clearly in action.

The letter KP wrote to us a month or so ago is another example of this. A letter steeped in ‘I’m absolutely right’ statements and worse. A document  that will surely become an exemplar in ‘How not to engage with families of patients who have died through  a dereliction of duty of care’ events in the future.

The story leaping out from the (hundreds of) pages of emails, reports, minutes from across the board, is that Sloven took over crap provision, did nothing to sort it and are pretty irked that the likes of the CQC and Monitor are now breathing down their necks.

Something is badly wrong when an NHS Trust demonstrates what we’ve seen and continue to see in last 15 months.  NHS provision should surely be about continually trying to enhance and improve care provided. What else does it exist to do? (Obviously we have views on this but here we’re talking about what they ought and are funded to do).

Meanwhile, Sloven merrily collect HSJ awards while the police continue their investigation into LB’s death.

I suspect part of this arrogance comes from having apparently unlimited funds to try to make ‘problems’ disappear. Unlimited funding to chuck at legal teams to outmanoeuvre the odd family who are able (in a beyond unequal playing field) to avoid being crushed in the early days and just about drag themselves to the finish line years later.

A barbaric, inhumane situation. Seemingly condoned by those who must have the power to stand up and say “This ain’t right.  It stops now,” and don’t.

Mid afternoon yesterday an unnamed person turned up at work, managed to find our office, handed over a memory stick, read out the password for me to unencrypt (disencrypt?) the files on it, checked they could be opened, got me to sign a letter and left. All very secret squirrel.

I was left with three heaving PDFs. Communications from Oxfordshire County Council and Clinical Commissioning Group mentioning me and/or LB between March 2013 to 27 July 2014.

I’ve only glanced through this stuff. Hundreds of pages. So just wanted to jot down my initial thoughts. In no particular order. And ignoring the stuff of ongoing police investigations.

There is pretty much no recognition/acknowledgement or reflection a young man died and he shouldn’t have done. No surprise now really. It’s largely about blame, self protection, reputation and process.

The pages are littered with mentions of ‘mum’. Please ditch the ‘mum’ stuff. It’s so blinking patronising and degrading.

The records start in September 2013. A six month chunk is missing. More carelessness or incompetence (or worse). Either way, not acceptable. Simply unacceptable.

Redactions are reasonable. Mostly names and occasional small sections of text blacked out.

Hints of sensible thought are present which is refreshing. Reflections that the findings of the Verita report are awful and media coverage can only be negative, for example.

A stand out thing is surveillance. There are transcripts of the Phil Gayle show (in which the Gman shines through with his piercing questions) and twitter, this blog were a constant source of discussion and even information. Rich’s ‘Move on down the Bus’ song was circulated among the CCG. One commissioning bod found out about the ‘bath ban’ on these pages. (For info, apparently it was instigated by a ‘nervous’ consultant and was lifted on the day of the CQC inspection… Any news on the staff disciplinary actions I wonder?)

I tweeted yesterday that I was beginning to understand the viewing figures of this blog. It must be bookmarked across Sloven Towers, the local authority and CCG. And, I suppose, other organisations outside of Oxfordshire who may be following with a mix of fascination at the complete shiteness of the whole situation and relief that they ain’t involved/implicated.

Of course it doesn’t have to be surveillance. Social media has created a space that offers health/social care professionals alternative ways of gaining insight into the experiences of people/patients. And the consequences of their actions and the systems that underpin them. One or two people in these exchanges seem to get that.

The term ‘learned helplessness’ was new to me a few weeks ago. I still don’t know what it means. Other than a random excuse for the paucity of good care on offer at Slade House site (now known as chunkypoundland until the intricacies of potential land sales, profit taking and the like are laid bare).

The story of LB’s death and the subsequent damning CQC inspection (which Rich, barely containing his ire at the pre-Crimean levels of care identified regularly mutters ‘They found faeces on a chair?’) is documented in this blog. I recently acquired the quality review report that took place in November/December 2012. Four months before LB went into the unit. An internal inspection organised by the local authority/clinical commissioning group to make sure they were buying services fit for purpose.

It ain’t a pretty read.

What is astonishing is that the reviewer mentions clear concerns but didn’t mark them as actionable. And reader/s of the report obviously did nothing. The bar of what is acceptable is set so low I can’t help coming back to the ‘if this had been a dog home’ type thoughts. And they don’t see it. This isn’t learned helplessness, it’s ignorance. There’s no thought to what it must be like to experience living in the place. No reflection on the absolute powerlessness of the patients. Their ability to communicate hammered by medication dished out liberally, or crushed by brutality experienced at the hands of heavies in the name of ‘restraint’. And the possible/probable  distancing of families.

I know this blog is used in teaching health/social care students, but for those of you who have been working in this area for a long old time now, particularly if your job involves reading and responding to quality reviews (in a clean, warm, comfortable and safe environment, sitting cosily on a shedload of power/influence), here’s a quicky quiz to help you reflect on the level of your bar.

Based on a hypothetical quality review report. Just to mix it up at bit, let’s imagine that the provision is known to have problems and was recently acquired by an out of county Trust (one of those too big to fail jobbies).

• The design, decor and under utilisation of areas are identified as ‘specific problems’ and ‘too cold and clinical’. Do you a) do nothing b) act?
• Patients report that noise and other behaviours disturb them, make them uncomfortable and at times scare them. Do you a) do nothing b) act?
• Feedback suggests that discharge from the service has been variable. Do you a) do nothing b) act?
• It isn’t clear that patients are receiving therapies from their records, but the reviewer was ‘informed’ they do. Do you a) do nothing b) act?
• Feedback from patients and observations on the ward suggest that activities are minimal within the unit. Do you a) do nothing b) act?
• Observations show that staffing levels cause delays in allowing patients to be able to leave the unit for agreed periods of time. Do you a) do nothing b) act?

Quick totting up of scores: a = 0 points  b = 1

If you scored between:

0-1: back out of health or social care now. Do not pass Go.

2-3: you should take a long hard look at yourself and give your working practice  some full on critical reflection. Perhaps spend time in the provision you commission. Hang out with the patients and learn that they are actually, er, human, just like you. Oh and dust off your copy of the Mental Capacity Act and reacquaint yourself with basic human rights principles while you’re at it.

4-5: Ok. Follow above advice, keep following up on actions and make sure this focus doesn’t fall by the wayside.

6: Good on yer.

 

One final point. Almost funny but isn’t. Because none of this is. In the minutes/reports available online for this period, everyone (Sloves, CCG, LA)  dutifully report their Winterbourne JIP related actions. In detail. The same people, I assume who read and ignored the content of a report that provided clear indications (albeit couched in a flimflam language of ‘we were informed that stuff was happening’ even though it clearly wasn’t) that there were serious issues around what was being described as ‘care’ in ChunkyPoundland. Er, how does that work?

The level of blinkered stupidity is astounding. And we really should stop with the obsessive focus on Winterbourne View. It really ain’t helpful and I suspect may have created more harm than good at ground level in some places.