More intense reading this week. The CQC inspection. Back in September. More evidence that LB’s death [howl] had the impact of slightly sour milk being poured down the sink. The Oxon Commissioning Group at a meeting in County Hall (less than 100 metres from where I’d just returned to work in September last year) minuted that STATT had been given a green light in January 2013 (due to the “positive engagement” with Sloven). Wow.

And then, a planned visit to the unit in the summer didn’t happen because of ‘the death of a service user in the unit’.

Wow.

A dead donkey.

The visit didn’t happen? After someone died there? Am I missing something?

The content of the CQC inspection of STATT needs no revisiting. Assessment and treatment had long gone (if ever present). It was a site of malaise and perceived bullying/overly process driven and ignorant/detached management. The spread of this toxic mixture was apparent in the observations of the inspection team. A damning and shameful account.

LB was kind of caught up in this. His death wasn’t a focus of the inspection. But he’s there. Part of the space, the story, the life (and death) of the unit. Epilepsy non-management, family non-involvement, non-choices and flaky capacity decisions. Hideous.

Sloven had waded in to bid for the Oxfordshire contract with a campaign worthy of whatever it cost. They talked the talk impressively enough to win the gig. KP filmed her message for Ridgeway. Then did little else and got caught out. Big time. Three failed CQC inspections in Oxfordshire in a matter of months. A complacency born of ‘too big to fail’ syndrome. A focus driven by sponds rather than patients.

Bizarrely, nothing has happened to the Sloves. They seem to be able to act without sanction (nonsensical redactions, undisclosed medical records, ongoing (into infinity) staff disciplinary procedures, letters sent to wrong recipients or dead patients, sacking advocates, veiled accusations of me trolling and hacking into their staff twitter accounts, blocking JusticeforLB supporters, etc etc etc).

In another set of heavily redacted emails I was sent yesterday, someone (redacted) emailed KP;

This is clearly a very painful period and one that is not made any easier by Sara Ryan’s unwillingness to engage with you. I feel you and your colleagues are continuing to deal with this in as sensitive and professional way as you possibly can

Are we living in a parallel universe? Here is a copy of the briefing they produced for Monitor. The world according to Sloven; 20140515094441957. It contains this note at the end:

Accurately my arse. It seems impossible to understand how such high level professionals could mistake two completely different phrases which have completely different meaning. When did the police start deciding cause of death? And the police were conducting an investigation at that point (and still are) so the whole statement is a fabrication to try to wriggle out of such a damning response to LB’s death. In an official briefing document?

It should be a concern to everyone that something as serious as death [he died?] can be treated so carelessly or worse. Not to the Slovens though. In their May board minutes (page 16, item 7.7)  they proposed for closure the independent review, commissioned by NHS England, that is being undertaken into the deaths in their mental health/learning disability services since 2011. We asked for this review because we were concerned that the ‘natural cause’ label had been slapped on other patients in the past. And appreciated David Nicholson actioning it so straightforwardly.

It’s not Sloven’s review to close, as they then report in their June board minutes (and it certainly ain’t complete) but they are arrogant enough and, apparently, untouchable enough, to do and say what they like.

Astonishing. Are they living in an imaginary world? Is the Board complicit in this or completely in the dark? Are Monitor/the CQC/NHS England/Jezza Hunt/Norman Lamb, etc etc not concerned about their actions?

Why is any of this?

On Thursday I received an email in response to my ‘access to records’ request to Oxfordshire CCG and local authority:

I would be grateful if you could provide me with proof of your identity; a photocopy of the relevant page of your passport or driving licence and a recent utilities bill would be acceptable. I would also need consent from or proof that you are the personal representative of Connor Sparrowhawk to allow us to be able to release the above details. Please let me know if this causes any difficulties.

The rest of the day, in between the Oxford Mail photographer pitching up (twice) for a ‘sad’ photo shoot (picking among the dog shit in the back garden), a shortened chat with a BBC Ouch journalist, and a visit from the NHS England chosen lay representative on the Serious Case Review, was spent raging/howling on the phone to the NHS Central Southern Commissioning Support Unit about this request.

“You’re all (fucking) NHS at the end of the day? Why can’t you join the dots?” I raged. [Without the swearing].

I tried to explain my distress;

Our son with epilepsy was left to drown [howl] in the bath in a heavily staffed, hugely expensive, specialist unit over a year ago…

Nothing has happened in response to this. Despite an independent investigation and CQC inspection providing evidence that the place was appallingly run…

… and no. I am not prepared to go to a solicitors office and get an affidavit to ‘prove’ I’m his mum [their suggestion] to send with our leccy bill to release these documents.

Meanwhile, in the sunshine world of the NHS (according to all things Bubb) we received the response to a collective letter written to the chair of a Royal College of General Practitioners (RCGP) Inquiry into person centred care in the 21st century. We’d written to say that the inclusion of the Chief Executive Officer (CEO) of Sloven on this panel (I know) was questionable given the ongoing investigation into LB’s death.

At a fairly basic level, if you are putting together a panel of experts, why include someone who is in charge of an organisation with an unfolding of set of failures around learning disability provision? Especially when the pool you could choose from ain’t that small.

Katrina Percy, CEO, didn’t have to account for herself in this exchange. There were no demands for utility bills. Or broader questions around legitimacy/credentials. Instead, a shutting down of any discussion;

The incident took place less than a year after Katrina took over responsibility for the service – and during a period when she was in fact on maternity leave.

Wow. Championing Katrina. What a defence of the individual rather than the role. Astonishing. Maternity leave simply ain’t relevant here. And the introduction of that little known construct of ‘practice CEO’ when all bets are off in terms of accountability for a year after acquisition. Wow. The world of the NHS certainly works in mysterious, opaque and chummy ways.

And no, I ain’t sending a futility bill or proof of birth. I quipped on twitter I’d have to send a bit of umbilical cord and someone replied ‘umbilical cord and a bucket of tears’. Yeah. That just about captures it.

Been getting a bit weary in the last few weeks, partly because of this Bubb thang, partly because of Sloven delay. Delay has characterised the Sloven response this past year. And I know it’s been the same for Nico’s family. They take an age to do anything (other than pitch up for award ceremonies). Sloven delay;

about to or in the process of doing something with no end point in sight. And no whiff of urgency.

We are still waiting to hear the outcome of the staff disciplinary investigations. It’s over a year since LB died (he died?), and five months since the independent report was published (they had to wait for that, apparently). And still nothing. How long should this process take? What the fuck does it involve? And are six or seven members of staff really still suspended on full pay?

There is also a growing stench that any staff disciplining may only involve the Nursing and Midwifery Council. No whiff of a clinician or two getting a rap across the knuckles here. Nah, that ‘responsible clinician’ label is stuffed in a cupboard, next to the out of date oxygen tanks, quicker than you can say ‘HSJ Inspirational Leader’ when something goes seriously wrong.

Sloven have always paraded their staff as their main concern. Right from the get go. Patients schmaycents. No support for LB’s peers when he died such a nasty, preventable and public death. Being the non human types they were (and clearly still are). But oodles of concern about staff wellbeing. Same with the independent investigation. Layers of staff cosseting while we were left to wait. And wait. The final version of the report further delayed as the Slovens decided, at the last minute, to let staff comment on it. They delayed sending a full set of LB’s notes until two days before the report was due. They obstructed (may turn into delay when I get my arse together to complain about this) disclosing mention of me within Sloven towers by sending a set of black pages.

Delay is a quietly cruel and inhumane tool in this context. I can’t describe what this process is like because there are no words, but I do know it has been made so, so much worse because of these delays. Completely unacceptable but seemingly unmonitored.

In thinking about the treatment of family members when there has been a catastrophic incident resulting in serious harm or death, one of the simple actions NHS England? Monitor? CQC? Someone? could do is make sure there is no delay. Through effective sanctions.

As always, it really ain’t rocket science.

Under a Freedom of Information (FOI) request, we received the full file yesterday of the CQC inspection into Slade House last September. A delight to receive (largely) unredacted documents, unlike the pages of black received from Sloven. At the same time, a harrowing and distressing read. The published inspection report necessarily providing a precis of the appalling provision found there. How could they?

Among the 39 documents received, was a letter from Sloven to the CQC (Sept 24th) saying, amongst other shite, that they had “agreed with commissioners and the Local Areas Teams (NHS England) to upgrade the incident involving the death of a patient at STATT in July to a Level 2 SIRI“. (Becoming a bit of a dab translator of Sloven speak, I suspect this means they were told to change this grading.)

NHS guidelines around serious incidents can be found here. On p.23 it states;

• Initial incident grading should err on the side of caution, categorising and treating an incident as a serious incident if there is any possibility that it is.

Classy old Slovens went for the natural cause grading initially. Chucking err on the side of caution out with the defibrillator battery (and giving it a tick on the matron walkround sheet). Astonishing. They didn’t even deign to properly investigate the context of his death and the services being provided in STATT in July. Stating in the same minutes (23.7.23) that due processes were followed. Tick. (Bit like the local authority/commissioner visit to STATT in June last year where senior staff were asked about restraint; “Face down restraint Guv? Us? Nah. Never”. Tick.)

Level 1 investigations (p.37) are;

incidents involving No Harm and Low Harm and/or where circumstances are very similar to other previous incidents.

Now as LB died, the first two criteria don’t apply, and unless Sloven have a habit of letting patients drown in the bath in their provision, the latter isn’t relevant. So it seems extraordinary his death wasn’t judged to be worthy of a Level 2 investigation. I can only think, that, under a Sloven lens, any death of a learning disabled person is.. well a death of a learning disabled person. Kinda irrelevant really. Very similar to all those other deaths (4 in 10 learning disabled people die prematurely).

LB’s death finally became the serious incident it always was after a regulatory body found the unit he was in a shit hole and the commissioners/local authority stepped in. If this isn’t evidence enough that no NHS Trust should conduct an internal investigation into the unexpected death of a patient in their learning disability/mental health provision, I don’t know what is.

Footnote: I don’t know how much I have to spell out that not only was LB’s preventable death scandalous, but it is also completely unacceptable that we are having to nip at the heels of a sloppy, careless (or worse) and completely disregarding Trust (and other relevant bodies) to make all this shite visible and demand accountability. Every interaction with the Slovens has involved delay, prevarication and nonsense. And NOTHING has happened yet. Does Katrina Percy/senior management team have someone overseeing their actions or can they do what they like? [And on that note, if someone could bung this under the nose of Simon Waugh, Board Chair, that would be helpful. I don’t have time to write to every fucker who might actually have some influence to do something. Not after a whole year of this nightmare].