Pre-inquest life and ‘whistle blowing’

I’ve written various posts in the last week or so, consigning them to the saved draft folder because of the Contempt of Court Act 1981. Clearly stated here about the ongoing Hillsborough inquests:

The Attorney General wishes to draw attention to the risk of publishing material, including online, which could create a substantial risk that the course of justice in the inquests may be seriously impeded or prejudiced, particularly as this inquest involves a jury.

We’ve been given (or taken) a good run for our money on this really. As a sociologist I’m all for making visible typically invisible practices. And we’ve discovered way too many dark and shady public sector corners and deep holes in the last two years or so, documented on these pages and at At the same time, despite clearly identified failings in the coronial process, we have to sit back and hope that there will be #JusticeforLB.

On a related note, a lengthy document was shared with us, indirectly, this week. This document, a letter, involves some tooth enamel removing content. An extraordinary mix of truth/untruth, viciousness and hysteria. And a depressingly weighty dose of mother blame. It was her wot dunnit type stuff.

Deep thanks and respect to the person who shared this document with relevant people/legal teams. For their integrity and commitment to transparency. To making visible the stories/accounts circulating behind closed and armoured (public sector body) doors.

With a ladleful of irony, I won’t be tweeting or blogging as openly or transparently for the next two weeks. Here’s a photo of an extraordinary band who blasted some joy into the everyday lives of people passing by in Oxford city centre yesterday. A bit of light in our fucking foul lives right now.L1016172-3

Maladministration malarky


Blimey. Six months ago now that Oxfordshire County Council’s (OCC) secret ‘independent’, ‘internal’, ‘review’ arrived in my inbox first thing one Monday morning. Without warning. Six months ?? I’ve written about this a lot because we’ve been so distressed, incensed, baffled and depressed that a local authority could act in this way. Without apparent remorse. LB died. In ‘care’ they commissioned…

It turns out they can’t behave like this.

We’re fortunate. Lucky? [I don’t know what the right word is here…] Just bloody grateful to have pro bono support from someone I can only describe as a tornado of human rights expertise, action, commitment and sense. A remarkably detailed 27 page letter was sent to the Legal Officers at OCC. Carefully documenting the wrongness of their actions and why.

Some lowlights from this letter [my flaky lay interpretation]:

You can’t conduct a review into support offered to a family without involving the family in the review. You can’t treat local authority records as a definitive record of what happened when they are clearly flawed. Inadequate record keeping and inappropriate records (describing people disparagingly) is wrong. You can’t offer contradictory explanations why a review is commissioned and proceeded. You can’t circulate an internal report to external people. You can’t deny pre-publication right of reply to one individual/family. You shouldn’t share people’s personal data without requesting consent or informing them. You shouldn’t spring a review on people without warning. Meaningless apologies are meaningless. You can’t make vague reference to stuff (like changing practices in the future) and not follow it up. You can’t defame people and present them in a particular light that is offensive and untrue. Circulating such a review is a breach of a person’s (human) right to a private and family life…

And so it goes on. Issues raised around maladministration, defamation, data sharing and the processing of personal data.

I sent the letter to Agent T (big sis) earlier. She replied; “Just realised my jaw has been really clenched for the last half an hour just throughout rereading that letter…”

I’ve given this post a bit of a flippant title. I don’t know why. Maybe I’m sick of being such a consistent harbinger of public sector related misery. Sadly there seems to be no end to this position.

We’re expecting a response from OCC by 4pm tomorrow.

LB died. 

The final frontier

L1016083-2These last few weeks have been (particularly) battering. Sloven have revealed ‘their hand’ as documentation is circulated in advance of LB’s inquest. Despite glossy (meaningless) words in the Independent on Sunday, they continue to hold their (battle) ground.

Six members of staff now have separate legal representation. Six? Four of these are currently ‘properly interested parties’ along with Sloven and us. Interested parties can ask questions during the inquest. There will be eight sets of legal bods present. Wow. How will the tiny, wooden courtroom, described by John Lish, accommodate everyone?

I pretty much stopped working today. Sadly. It’s impossible to read the reports/interviews/documentation and continue to ‘work’. The emotional distress is too intense. We’ve been catapulted back to that space between LB’s death and his do. A space that defies words. This afternoon I slept. This morning we talked with a journalist. Re-living horror. And hearing further horror. Learning disabled people are simply treated with unchallenged (and accepted) contempt. Over and over again.

Our experience over the past two years can be summarised as harrowing grief, devastation, disbelief and destruction with repeated, unremitting and remorseless (hobnailed) booting by Sloven/OCC. Neither body has expressed a drop of positive action, candour or transparency. Fake apologies and dirty actions. Remarkable really.

In contrast, people have collectively recognised, rallied, raged and stepped up. A sort of maelstrom of creativity, colour, brightness, spontaneity, humour, life and humanity. Even more remarkable. [Thank goodness]

I hope we manage to retain some ‘sanity’ during the unfolding of this long awaited and deeply dreaded process. We’ve nothing to gain in many ways. LB is dead. That ain’t going to change. Answers? Within the boxes of documentation/reviews stacking up it’s pretty clear what happened and why. There’s no need for the inquest to be adversarial. With eight legal teams and the rows of ducks lined up, I can’t see it being anything else.

The biggest bundle in the bundle box

L1015872We received two weighty boxes of inquest bundles on Friday. (Bundles are lever arch files of well organised, numbered documents.) The ‘medical records’ bundle contains records we ain’t seen before. Despite requesting all of LB’s records in July 2013.

Our solicitor repeatedly requested missing records during those early months. Documents dribbled in. Peppered with ‘Oh yes we have!‘…and then  ‘Er, missing docs attached’ type responses. In February 2014 came the extraordinary realisation that none of the unit records we had were complete. We’d never received full copies of unit meeting minutes before or after LB died. Leaving us unaware that his seizure activity was disputed and dismissed.

Disputed… Dismissed???

[Howl.] [Can you imagine?]

Katrina Percy wrote to us in Feb 2014 apologising for this evidence of her piss poor leadership. A letter sent the day the first Verita report was published. [She didn’t mention the words piss poor or leadership but that’s what it was. The odd mistake may be ‘explained’ away as an error. When mistakes start stacking, up as they have and continue to do so, it can only be piss poor leadership.]

He died.

LB drowned.

In November 2014 the coroner sent us copies of the Initial Management Assessment (IMA) [I think that’s what it stands for] report and 72 hour SIRI document, neither of which we’d received. Over a year after LB died. More key documents slipping through the flakey Sloven disclosure net.

And yesterday, even more unseen footage…

We simply don’t understand how an NHS Trust can get away with such blatant disregard of candour and transparency. Without censure. We don’t understand how it’s acceptable that families have to, if they can scrape themselves off the floor long enough and have the resources to do so, police this stuff. We have excellent legal representation, costs covered by remarkable fundraising actions of all sorts of people and pro bono support.  We’ve also research skills that enable us to wade through this shite and identify omissions, crap and dishonesty. A lot of people don’t.

I’ve lost count of how many times we’ve (repeatedly) said These are public bodies… How can this be? How often we’ve been let down by people who must know the implications and consequences of their actions. They may have particular job titles/authority but they’re still human at the end of the day.  Just baffling. With an icey core.

Back to the bundles. No surprise that the biggest bundle in the bundle box is the ‘Sloven Policy bundle’. A remarkable 1030 pages of policies and procedures.

Nothing slipping through the net here of course. Nah. I won’t bother checking.


Jury bundles, floor plans and photos

L1015667A full on few weeks. Writing witness statements for the coroner a hideous task. Reliving everything that happened. Again. He died? While having to discard what we now know [unit records/CQC inspections seared into my brain/eyelids]. So blinking painful. Then a week or so later, receiving Sloven witness statements. Piercingly painful, sometimes enraging reading.

More reading as both big reviews commissioned by NHS England around LB’s death pitched up. The broader Verita review building on their original review which found LB’s death preventable. And the Mazars review into deaths in Sloven’s mental health and learning disability provision since 2011. These have been circulated for ‘factual accuracy checking’ (just drips off my tongue these days) and won’t be published now until after LB’s inquest. Around 500 pages that must be generating agitational agitations at top Sloven towers level. As it fucking should.

Yesterday was the fourth pre-inquest review hearing at Oxford County Hall. My Life My Choice turned up in force. It makes a difference to see family/ friends/campaigners in the public gallery. Sort of counteracting the apparent ease with which LB’s life seemed to be treated in a ‘deleted/trash emptied’ way. Like so many other people. George Julian brilliantly tweeted much of what was discussed on a new dedicated campaign account; LB’s inquest.

It was just incredibly sad. I don’t know. Maybe more so than the previous three meetings (if that’s possible). Earlier hearings involved thrashing out issues around whether or not the inquest should be an Article 2 inquest with a jury. This related to LB’s human rights – something he was always so (rightly) hot on – under the European Convention on Human Rights. How the state has a duty to protect life.

Back in the day, these were important points to us and we were worried Sloven would derail them. Yesterday it was confirmed that LB’s inquest will start on October 5th for up to two weeks. Discussion turned to witnesses, jury bundles, floor plans and photos.

old pics (8)

Fordingbridge, Cillit Bang and eight notes

[The first of a (maybe one, a few or too many) detailed, dull, note heavy, contextual posts leading up to LB’s inquest. Sorry. It’s too important not to document...]

I’m pretty sure I’ve previously mentioned the original Verita investigation (V2008) into the beyond crap services provided at Fordingbridge Hospital in 2007/8 (rehabilitation and palliative care services).  Fordingbridge Hospital was run by the Hampshire Primary Care Trust which eventually became Southern Health NHS Foundation Trust (Sloven), absorbing Hampshire Community Health Care services (HCHC). [I know. Layers of tedious detail. Stick with it if you can bear too? to? to eurgh.]

[Note 1. Mike Petter, Hampshire PCT Non Exec Director during V2008, constant non exec board member across the years, is now Sloven board chair (announced August 2015).] 

The V2008 report can be read, heavily redacted, here (courtesy of the Daily Echo). Sue Harriman, then Director of Clinical Excellence, originally produced a summary document – the Fordingbridge public paper – in lieu of publication of the full report. [Note 2. Sue Harriman was acting Sloven CEO when LB died.] The full report couldn’t be published apparently because it included names of patients and staff. The Fordingbridge public paper, which reduced V2008 from 84 pages to 7, largely summarises the sterling work Hampshire PCT had conducted to improve the Fordingbridge service in the wake of the (almost) scandal. Recommendations from V2008 were included as an appendix. The paper concludes; 

A full review of all HCHC/Care Services inpatient facilities across Hampshire was conducted based on the findings from this investigation. The HCHC /Care Services Board was assured that the issues identified at Fordingbridge were not replicated elsewhere.

However, a Director-led strategic ‘Community Hospitals Action Plan’ was established to ensure our patients received the best possible experience with optimal outcomes.”

So the Hampshire Community Health Care services were all good apart from Fordingbridge and a strategic plan covered all other bases. A sort of Cillit Bang type approach to the emergence of failing services. An approach involving the following steps: i) Neutralise criticism by focusing on actions taken. ii) Isolate ‘germs’ and make it clear they are contained. iii) Add a layer of something wordy/fanciful to oil the ‘moving on’

[Note 3. iii) can often involve bringing in outside agencies at considerable expense (to the taxpayer) adding more oil/speed to ‘moving on’ talk.]

There are 29 recommendations in V2008. [Note 4. The Fordingbridge Public Paper lists 28. 5. At the time of V2008, Katrina Percy, current Sloven CEO, was managing director of providing organisations. Not sure what this means. 6. Sandra Grant, current Sloven director of people and communications, was human resources director.]

Of the 28 or 29 recommendations in V2008 over half – R5 (staff training), R6 (patient information/involvement), R8-10 (care planning), R11 (environment), R14-16 (dignity and respect), R17 (staffing levels/continuity of care), R22-25/29 (leadership) – easily ticked fail boxes in the subsequent series of CQC inspections across Sloven’s Oxfordshire provision that took place in 2013/14.

This stuff just wasn’t new to them.

Acquiring a whole new set of services in Oxfordshire in their (potentially lucrative) takeover of Ridgeway services four years after their Fordingbridge experience and no learning was drawn on to make sure these services were run properly. Despite the continuity of senior staff involved. Maybe NHS reorganisation give (senior) staff ‘get out of jail free cards’? Allowing them to toss aside existing knowledge while holding onto inflated salaries, status and sturdy, award holding, shelves.

Verita pinged up again in Sloven history, investigating crap provision after LB’s death in 2013. An investigation focusing on the unit LB died in; the Short Term Assessment and Treatment Unit (STATT) based at Slade House in Oxford. Sloven tried to avoid publication of V2014 using the same tactics they’d used with V2008. They don’t forget some things. Three weeks before V2014 was due to be published, they announced they’d publish a summary of the report on their website. To protect staff, protect LB’s confidentiality, stop the identification of staff and ensure the continuing ‘free and frank’ accounts of staff in such investigations. More trumped up rubbish.  

V2014 was eventually published with the names and job titles of staff redacted.

Research funding is dependent on demonstrating that you understand and are able to evaluate and summarise what is already known about a particular topic. That you will draw on this knowledge throughout the ensuing research. And that this research will have impact. Academic research isn’t without criticism. Quite the opposite. But I’m struck by how limited the lack dot joining is in health and social care reviews/investigations. Rich Watts here details another (stark) example of this.

[Note 7. Rich regularly took the kids camping in the New Forest when they were young. One trip I remember, we went to Fordingbridge and the kids chose a book each in a small, local bookshop. It was the first time LB (still in junior school) surprised us with his book choice. It was something like a detailed log of types of Land Rovers in southern England. In black and white. With a lot of technical specification tables, chassis numbers and little else. It turned out to be the first in a series of nonfiction book choices that included David Bowie’s London spaces, the Red Cross First Aid manual, concurrent editions of the Yellow Pages (a cheap gig), the Eddie Stobart Story and much historical bus and London stuff. LB was never one for fiction.]

A potpourri* of learning, ‘craftivism’ and fun

One of those maelstrom twitter/social media type few days where all sorts of stuff cropped up. From different directions. A chunk of stuff about learning. We learned that the Health and Safety Executive are picking up the investigation into LB’s death from the police. [We sort of knew this but it was confirmed which is always good in our post 7/2013 experience]. And the interim board chair of Sloven is now the new board chair.  Mike Petter’s involvement with Katrina Percy pre-dates the creation of Southern Health, going back several years. Mmm. He now chairs a board that has, so far, demonstrated little engagement with what happened to LB (other than allowing continual obstruction and delay). And silence about the potential sale of the Slade House site. The original #107days included fab reflection by Amanda Reynolds on ‘What’s a board to do?’ I wonder if the Sloven Board ever asked themselves any of the questions she poses. Suspect not but they could always do it now.

Ho  hum.

One message I received the other day was for a question/s to challenge social workers/nurses who were going to be shown the Tale of Laughing Boy. The film is being used in several arenas to spark discussion among students/staff/senior teams in both health and social care. This is great. It’s a brilliantly produced film that captures love, humanity, common sense, crap and catastrophe. A lovely mate/legend told me recently it says everything she’s always banged on about person centred care in 15 minutes without any mention of ‘person centred care’.

So. Some suggested questions (relating to adult social care/in no particular order) for frank and open discussion in tandem with watching the film:

  • Do you ever/sometimes/often think parents are a pain in the arse, obstructive and make doing your job more difficult? If yes, what makes you think this? Why do you think they behave like this?
  • Have you/your team tried to find ways to resolve this tension and develop a productive relationship with families? If yes, how? What worked? If not, why not?
  • What would you think if a family member/person was blogging or tweeting about your service? What would you do? Do you think they should be ‘allowed’ to do this? What are your views about social media in the context of your work?
  • How often do you think about the aspirations/potential/value of the learning disabled adults you are involved with? Can you give some examples of how you’ve encouraged/enabled them realise their potential? Or things that have obstructed you doing this. If you don’t think about aspiration/potential why do you think this might be? 
  • How might health and social care work better together to ensure that what happened to LB (Nico Reed, Thomas Rawnsley and the many, many others ) doesn’t happen again?
  • Do you think the response of public bodies towards families after such catastrophic incidents is acceptable or reasonable? Can you identify the moments in which something different could have been done? Why do you think there is little apparent shift towards transparency and candour?

These points are just flung out in the hope of some productive discussion. Please add your own questions or reflections below. At some point, we’ll try to pull together some constructive thinking about what’s happened so the more thoughts the better.

More cheerful biz in the last few days involved the launch of the latest #JusticeforLB crowdsourcing request. New, deliciously creative, action to get involved in (details here).

I’ll sign off with my fave (I think) Chicago photo in this potpourri* of a post. Because it captures light, delight and fun.



*I bloody hate potpourri.

No permission necessary

More insight into how Oxfordshire County Council (OCC) treat the people/families they exist to serve while protecting their ‘own’. We raised numerous issues about the secret review OCC commissioned once we were aware of it. A review that clearly should be binned it was so deeply flawed.

Instead, the OCC social care director wrote to us in May stating ‘the report was prepared by someone independent to the Council and the appropriate course is for him to respond to your comments’.

Pretty pompous really. Particularly given that the director failed to mention that OCC would feed into the ‘independent person’s’ response with their own comments on each of the 61 points raised. A document included in the latest subject access information. I think we can probably all agree to ditch any claim to ‘independence’ at this point. The internal claim boat long since sailed given the circulation list. So, a review that is neither independent nor internal. Mmm.

The extract below covers points 5/6 of the OCC responses to the issues I raised written for the person who produced the review. Capturing so much in few words. And carefully placed dotted black ink.


The consultant, carefully shrouded in secrecy and protection. This is his personal information and we would need to seek his permission before sharing anything…

LB and our personal information?

No permission necessary.

[Postscript: In documenting these (what are, to us) chillingly, consistent accounts of crap practice and worse, I’m not suggesting that Sloven/OCC are monstrous providers/organisations. I suspect these practices are widespread.]