Tag Archives: inquests

Come again?

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Another day, another inquest. George Julian in court in Woking. Her commitment to shedding light on the horrors embedded within our health and social care systems is extraordinary. This week, it’s 41 year old Daniel. Daniel was living in a 16 ‘bed’ place called Ballater House. He died of choking.

Yesterday the witnesses included two nurses and a support worker. The evidence was woeful. Nobody could say anything about Daniel other than he liked folding clothes and trainers. Trainers were used to bribe him to eat. What was that? To bribe him to eat? Yep. He was told he could see pictures of trainers if he ate his food.

Bribing. Connor was told he could go home if he attended a social group in the unit.

For some months before he died, Daniel made noises at meal times. This definitely was not related to swallowing problems said the clinical lead nurse. Definitely not. Daniel was “nauseating”. And how do you know this, asked the coroner. Because it was nauseating.

Alongside the unusual retching type noises which definitely weren’t swallowing related, Daniel refused to eat anything other than sandwiches for a month before he died. Sandwiches for breakfast, lunch and tea. The nauseating continued and nobody cared enough to really do anything.

Virtual appointments were held with GPs, the hospital phoned the ‘home’ on four separate occasions about Daniel’s health. The calls went to a voice machine in the nurses office and no one bothered to listen back to them.

There was the usual lies and bullshit on show. The lead clinician demonstrated next to no knowledge about diabetes care and said he was not on duty the night Daniel died. He seemed to think he had no responsibility if he wasn’t in sight of Daniel. The absence of healthcare was nothing to do with him. He knew about diabetes from back in the day.

The coroner proved herself to be part of the collective (a loosely defined group of people who contribute to the impoverishment of people’s lives) I write about in my book. She slapped down the family barrister for asking the witnesses questions she’d asked. There were no answers though. No answers at all.

Each question was met with fumbled words generating more questions. More bafflement. More rage and more disgust at the shite that passes for care in this country at such a human cost (well and the ££££s these places charge). Local authorities and commissioners are slumbering or simply do not care. Containment is the name of the game here, as each inquest covered by George reveals. And if that containment is lacking in any basic care, so be it. Disrespect was also in the room. Witness phones ringing and a lack of listening to the questions.

Come again?

This is social murder.

Louis Cartwright and the absent blood tests

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Louis is the latest young person whose inquest was covered by George Julian. Her posts include family photos of a beautiful young cheeky chappy who looks like he’s on the cusp of taking on the world. Except he can’t. Because a dereliction of anything resembling “health care” led to his death before he could enjoy his 18th birthday trip to the US.

Louis’s inquest lasted one day. There were four witnesses; two doctors from the hospital, a GP and an expert witness. Louis was taken to A&E in January 2023 after being pale and out of sorts to an extent that alarmed his parents, Jackie and Ian. Once there, he was seen by Dr Morelli who was ‘unable’ to do a blood test as Louis did not cooperate. Given he’d sat for 5 hours on a chair in A&E clearly feeling like shite, this is no big surprise. Dr M arranged for him to go home and come back in the morning.

Louis was then seen by Dr Therabandu. He looked at Louis and made the judgement he didn’t look unwell. He did no observations other than ‘looking’ because Louis was sitting on the floor in the corridor. Quite some medical practice there; the monstering of Louis happening in full view and offered as an excuse for medical failings. Monstering underlined by Dr T referring to Louis’s ‘adult size’. It was time for Louis to go home (again) and get the blood sample done in the community.

We knew in Louis’s case many children or adults with learning difficulties, being out of their own surroundings is more harmful than good. 

Louis was very distressed, we were having to hold a big strong man.

Got to keep these people in the wild, in their own surroundings. Not in an emergency hospital department.

So, Dr T, asked the coroner. What would you say the cause of death was? Well natural causes of course. I have a lot of medical experience.

As witnesses were questioned, Jackie occasionally intervened with questions screaming in my head.

I don’t understand the blood tests should have happened, I know I’m just his mum, don’t have any legal background or medical background, but this is just common sense. I’m telling them he’s not well, these are consultants practically, they are very serious doctors. I’m sorry I’m ranting.

Hush now.

Next witness was Dr Ryba, a GP who did a home visit a few days after the failed blood tests. By now, Louis was not well enough to leave home. She described how;

He was placid, he was silent, he didn’t speak to me throughout my visit. He was docile and compliant and seemed at ease and not too anxious or distressed in any way.

Docile and compliant comments again pointing to monstering and fear. Dr R said Louis was “clinically stable” and off she went into the night. He was dead 12 hours later.

What do you think the cause of death was, asked the coroner. Difficult to say without a blood test, Dr R said. Anything else?

I’ve given it an enormous amount of thought, stress how difficult it must have been for his parents, would like to stress what a warm and loving environment he was being cared for in.

Just a reminder, this is a 17 year old school boy, not a rescue chimp from Senegal. Anyway, over to questions from other interested parties:

SD [counsel for the family]: When you saw Louis did you see he was jaundiced?

PR: No.

Jackie: there was no light on.

SD: Did you see him with the light on?

PR: Yes, the bedroom light was on.

Jackie: It wasn’t the big light

The coroner said it was important not to confuse the witness.

This exchange highlights how the coroner leaned into medical witnesses across the day, dismissing Jackie’s expertise. Witnesses were protected while Jackie was left to flounder, trying to correct inaccuracies in evidence. The main light was not on. The GP could not see if Louis was jaundiced just as Dr T could not make informed judgements without formal observations. We are back in the familiar land of nonsense and absurdities. A weaving of a tale about the boy and impossible blood tests. Dr T’s next answer underlines this beautifully. She was asked about a photo showing Louis’s skin colour:

I wouldn’t make a diagnosis of jaundice from looking at those photographs.

And yet three medics made a range of judgements asserting Louis was well based on looking (in the dark).

Finally, expert witness. Dr Habibi. We reached the pinnacle of absurdity with Dr H’s evidence. Dr H stated blood tests would have offered an opportunity to explore why Louis was clearly unwell. He had been fit and well a few weeks before and there was nothing in his postmortem to suggest nasties that could not be recovered from. The absence of blood tests closed this avenue.

You can’t say that, Dr H. There were no blood tests. We cannot know what they would have shown! Er, well yes. Exactly. Without the blood tests we can only assume Louis died of natural causes, there is no other plausible reason. Yes. So blood tests should have been taken. But they weren’t and we’ve heard from three MEDICAL witnesses that Louis didn’t seem unwell.

We should start from the fact obviously tragically Louis did die. Final illness, even though it appeared not particularly concerning, it obviously was because it led to his illness in the end.

When you hear sense among the absurdity it is like watching a single raindrop on a spring bulb.

Louis died. He was clearly ill.

The coroner moved to submissions. Jackie had been told she could ask questions after witness evidence. She splurged a devastating ‘why?’ filling in the answers herself.

Why didn’t he get a blood test? Because he presented as difficult in different settings, have to remember all doctors said what they said because they don’t want to say what didn’t do. Lots of what was said was factually incorrect as we saw at the time. Dr Morelli made the decision to send him home, we did not want to leave. We wanted to stay in the hospital until, pointless going back and coming back, we knew would be more difficult next day to start the process again. It needed to be done. Hospital is the place where blood tests are done, nowhere else to go. […] I think that’s because Louis is boy with Down’s Syndrome, they couldn’t ask him questions, we had to present as best we could, hoping they’d listen to us. He was very, very unwell. Louis would rely on us as his parents, he trusted us more than anyone else. We were the people who he looked at and wanted to help him.

There was no answering these questions because the witnesses were released. The coroner concluded Louis died of unascertained and natural causes. Move on now, nothing to see here.

There was nowhere to take your beautiful and clearly unwell boy to keep him alive.

Imagine.

10 years, 10 points, 10 minutes

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Last night LDN Charity organised an event ‘Spotlight on the abuse of people with learning disabilities’ at the London Canal Museum. The panel, chaired by Simon Jarrett, consisted of Alexis Quinn, George Julian, Amanda Topps and me. Contributions from the audience were as powerful as the panel presentations and the sense of anger and commitment to change in the packed room was palpable. This is what I said:

Last week was the 10-year anniversary of our son Connor’s death in an NHS run ATU. He drowned in the bath while staff did an online Tesco order in the office next door. Ten years has allowed time to think about what unfolded and why, and in doing so different aspects have become more prominent. 

Given we each have 10 minutes to talk it seemed appropriate to produce 10 points of reflection about what happened to Connor (and others) and to think about what the lack of any real shift in the use of ATUs means.  

ONE. Connor was a beautiful, much loved, funny, talented and wonderfully complicated young man. He loved deeply and contributed so much to our family (and wider) that we are left with a chasm in our lives and hearts so full of love I can sometimes barely breathe.  

TWO. The day we had Connor admitted to the assessment and treatment unit (ATU) a mile or so from where we lived, I didn’t know Winterbourne View was an ATU. I didn’t know what an ATU was. I thought we were taking Connor to a specialist NHS hospital unit that would be staffed by uniformed and identifiable health professionals for a few weeks to understand why he had become so distressed and unpredictable. Connor had loved visiting his grandad at the JR hospital just weeks earlier. The locum medic who came to our home to assess Connor beforehand even said there would be a ward round that evening.  

I’m not sure what this not knowing, this ignorance means still. There was so much we didn’t know then. And so much people don’t know now.  

THREE. Connor was admitted on a Tuesday evening. The responsible clinician whose office was in a building across the car park from the unit, didn’t bother to walk across and see him the next day. Wednesday. Or on the Thursday or Friday. On Saturday, she went off on holiday for two weeks. Again, we had no idea. There was no ward round, no crisis specialist intervention, no urgency, information, interest. No nothing. Just our boy catapulted from his family home into a space that defies words. 

And this was apparently fine. 

FOUR. We met the lead paramedic who responded to the call that hot, sunny July morning before we moved from Oxford in May 2021. He was a friend of a friend of one of our children and asked to meet us. He said the ambulance overshot the turn for the unit that morning, There was no one outside directing it in. When they got to the unit, the door was locked and someone was painting the outside windows. He was bewildered by this lack of urgency and the absence of information from those present. He said his team had nothing to work with, nothing to base their treatment decisions on. The unit staff were literally clueless and said nothing. There is no pretence of healthcare, death care or any care in these places.  

And this is apparently fine. 

FIVE. After 2 years of health and local authority records being disclosed and 4 pre-inquest hearings Connor’s inquest was unexpectedly halted in the second week in October 2015. The responsible clinician’s barrister produced evidence that a patient, Henry, had died in the same bath a few years earlier. Photographs of the bathroom taken after Henry’s death were shared with us. Some of the same staff were on duty the day Henry died. The lack of disclosing Henry’s death for over two years is extraordinary. A second psychiatrist, present the day Connor died, looked at Henry and told the coroner by phone he died of natural causes. There was no postmortem and no inquest.  

When Connor’s inquest ended the coroner asked for Henry’s death to be investigated and the police took witness accounts from those present. The student nurse who was with Henry said he was told to leave the bathroom by professional X before the ambulance arrived. Professional X said he arrived at the unit after the ambulance. The coroner said it was long ago and there were bound to be contradictions. He dismissed Henry’s death again. 

And this is apparently fine. 

SIX. A death review commissioned by NHS England on our request was conducted by an international consultancy firm Mazars led by Marie Ann Bruce. It found only 2 out of 327 unexpected deaths of people with learning disabilities in the NHS Trust between 2011-2015 were investigated. Providing unassailable evidence you can punt human rights, regulatory procedures and processes off the nearest bridge when people with learning disabilities are involved. 

SEVEN. We don’t know how many people have died in assessment and treatment units. A Dispatches film by Alison Millar ‘Under Lock and Key’ shown in 2017 included the story of Bill who died in 2011. His parents then in their 70s were given what they called ‘blood money’ after an inquest found he died as an outcome of neglect.  

An early morning round table meeting was organised at Channel 4 the morning after the documentary was aired. An expectation that there would be an outcry Winterbourne View styley. No one really cared. We were coasting downwards by then, slowly and carefully unmaking scandals. I sat next to Bill’s parents who were pretty quiet. I wonder what they were thinking of this early morning shindig in central London that turned to nothing. Other than further evidence of bridge punting. 

EIGHT. There is no doubt that these places deprive people of their freedoms and rights. This deprivation manifests in myriad ways from being restrained, over medicated or secluded to being denied the basic opportunities to walk in nature, experience the wind on your face or have a drink with a mate.  Abuse, disrespect and devaluing profoundly erode wellbeing. We know this. Wiseman and Watson (2021) have written about the complex forms of violence experienced by people with learning disabilities and how these are critical to understanding the significant inequalities in health and wellbeing experienced by this group. And yet the numbers of those incarcerated in these places remain the same. 

NINE. The unmaking of this scandal, the greedy and self-interested actors that have jostled to drink at the fountain of self-serving opportunities and nosh on the plates of croissant crumbs, to line their pockets, seize media opportunities is grotesque. The stuffing of laminated photos of dead loved ones into the hands of bereaved and battered families… There has been no auditing of the money spent, contracts doshed out, time wasted, or individuals rewarded for no success.

We know these places are trauma generating and yet a paper published just this year found that just under 50% of 44 admissions and discharges from two ATUS from February 2019 to March 2022 were delayed. The most prevalent reasons for discharge delays were identification of a new placement, recruitment of care staff and building work (Gibson et al 2023). Two young men close to me have been in and out of ATUs over the past decade. One is currently back in an ATU while the other has been waiting years for the local authority to sort out a home for him. Both families have been the driving force at extraordinary emotional, financial and physical cost to try to get their boys a life worth living. 

This is apparently fine. 

TEN. I was struck by Simon Jarrett mentioning at a conference just yesterday that the exclusion of people with learning disabilities during the industrial revolution when enormous institutions were built was arbitrary, as many people could have worked in factories. There is a direct and remarkably enduring line from then to now where we have people formally incarcerated in ATUs, or in versions of ATUs dressed up as supported living or residential homes where people don’t even know their neighbours and their neighbours don’t know them.

All our lives are impoverished by the exclusion of a proportion of the population, and the way in which we, as a society, are failing people is something we should all take responsibility for. 

None of what we are talking about this evening is fine. None of it. Stop pretending it apparently is. 

Thank you.