The independent Mazars death review, just by way of a speedy update, was commissioned by NHS England to examine all deaths in Sloven’s learning disability/mental health provision from 2011-2015. The review is in apparently indefinite quarantine by NHS England under challenge by pretty much everyone and their dog.
[Well apart from Chunky Stan. Who, asleep on my feet is pouring his energies into extreme comfort using an almost winning combo of warm fur, being Chunky Stan and a snooze mechanism involving occasional deep/contented sighing…]
It turns out that Sloven made nearly 300 challenges/criticisms to the original draft of the Mazars (independent) review. Wow. 300 challenges? Unprecedented focus/scrutiny by the Sloves who, a week or so after LB’s death, publicly announced he died of natural causes and circulated a briefing about the risk my blog posed to their reputation…
Sloven Board minutes. 23.7.13
[Someone recently said that Sloven made a big error in their early responses to LB’s death. Sort of suggesting the pesky mess our meddling campaign has uncovered could have been left untouched if Sloven had behaved better. I’m not sure how to begin to make sense of this so I’ll stick to what we know for now.]
Publication of the Mazars death review was delayed on the basis of Sloven’s challenge and an academic review into the independent review methodology was commissioned by NHS England. [I know]. NHS England also got an internal dataset expert to review the, er, data. [I know]. Neither reviews of the review have turned up anything changing the findings/recommendations of the original report beyond the odd tweaking.
We found out this morning that Sloven have commissioned their own review into the review. Hahahahahahaha. No. Stoppit. You what?…. Taking marking your own homework in the brave new NHS (fake) world of transparency and candour to unprecedented lows. Really??
This postcard on our fridge repeatedly catches my eye as I reach for wine milk. We’re in a space of absurdities. A space unrecognised by Sloven, Oxfordshire County Council, NHS England, the Care Quality Commission, Monitor or the Department of Health. Evidenced by silence and in(non)action. A tumbleweed collective.
Erving Goffman talked about how much work is involved in awakening people to their true interests because their sleep is very deep.
Two and a half years since LB’s death and we clearly ain’t disturbing the slumber of anyone with any power to do anything. We can continue to try to ground the absurd though. Ground it in the human.
Here’s LB. Keeping watch on a Scottish holiday. No hint there may be trouble ahead. And why would/should he?
mydaftlife 
Is it any comfort to know how desperate they are to silence the report?
Reblogged this on danutag57.
Have you seen the front page of the Daily mail. The person in charge of PHSO thinks relatives of people that died whilst in the care of the NHS are being fobbed off by Trusts and medics investigating their own mistakes. What a shock!!! Is the truth finally going to emerge. Will someone in authority take note and do something now. Publish the Mazars report.
The Daily Mail article is a case of pot … kettle … black – and you don’t have to believe me. Go to the Patients Association web site and search for their paper, ‘Parliamentary and Health Service Ombudsman The ‘Peoples’ Ombudsman – How it Failed us.’
It concludes amongst other things:
“We need an Ombudsman that adopts the same set of principles it expects NHS Trusts to adopt when handling complaints.”
“If it is wrong at the top of the complaints process, it will be wrong all the way through the system. ”
We cannot expect Trust’s to handle complaints appropriately, when they know the PHSO are unlikely to carry out thorough investigations and therefore find failings.”
“The evidence we have gathered gives a public perception of the PHSO as lacklustre, weak, secretive, unaccountable, untouchable and ineffective.”
My experience supports the Patients Association’s views, especially on secrecy. Dame Julie Mellor should put her own house in order first – then she might be more effective in investigating complaints and encouraging improvements in the NHS.
Incidentally, the Patients Association paper also details another awful experience of the family of a deceased Southern Health patient (Jo Deering) and another disabled child (Child B – Trust unnamed).
within the collective there will be people that need to slacken the belt around their minds,hearts and souls. It is an incredibly small world, people talk, talk face to face. Nothing pus filled stays hidden for ever.
Ask your solicitors to request the Root Cause Analysis report into the death of a patient earlier this year in House 2, the slade site.
Wendy – do you have any more details of the death of a patient earlier this year in House 2 – such as a link to a media report. If so, perhaps you could post a link here? I have supplied a report on the Trust to several authorities but may have missed this one.
The death was expected but came at a time when management changes were poorly managed and supported by sloven. The investigation is looking at possible factors that may have contributed to the death. Sloven weren’t monitoring the management of services in Oxfordshire or providing sufficient support leading to services declining.
An independent review of the deaths of the people that Southern Health supported with a Learning Disability or Mental Health need from April 2011 to March 2015
You will all be aware of the inquest that looked into the preventable death of Connor Sparrowhawk, a patient at one of our former inpatient units in Oxford. As a result of Connor’s death, the Trust has made extensive changes to the way we provide our Learning Disabilities services across the Trust.
NHS England commissioned an organisation called Mazars to carry out a review of all deaths of people who used Southern Health services for Learning Disabilities and Mental Health in a four-year period. The report of which has not yet been finalised.
However, it has come to our attention the report has been leaked to the media, despite it not being finalised. We would not usually comment on a leaked draft report, but we are concerned this coverage may cause undue anxiety, especially amongst people who use our services and their families, and it prevents us from providing a comprehensive response at this time.
There are also serious concerns about the draft report’s interpretation of the evidence.
We fully accept that our reporting processes following a patient death have not always been good enough. We have taken considerable measures to strengthen our investigation and learning from deaths including increased monitoring and scrutiny. These include:
The launch of a new Procedure for Reporting and Investigating Deaths
The establishment of a central investigation team which is working to improve the quality of investigations
Increased executive oversight of the entire reporting process.
The review has not assessed the quality of care provided by the Trust. Instead it looked at the way in which the Trust recorded and investigated the deaths of people with whom we had one or more contacts in the preceding 12 months. In almost all cases referred to in the report, the Trust was not the main provider of care.
We would stress the draft report contains no evidence of more deaths than expected in the last four years of people with mental health needs or learning disabilities for the size and age of the population we serve.
When the final report is published by NHS England we will review the recommendations and make any further changes necessary to ensure the processes through which we report, investigate and learn from deaths are of the highest possible standard.
We are aware this is likely to attract a high level of media attention from the press and on social media. As a result there may be national and local media on the Tatchbury site. We would like to remind you that if you are approached by anyone from the media, please refer them to the Communications Team via 023 8087 4666 (OOH: 07017029238).
We would like to emphasise that we are extremely proud of all our hardworking staff and many of the recommendations that have been made in this draft report are already taking place. As a Trust we pride ourselves on providing the highest quality of care to everyone we support.
We understand that this may be a difficult time for some of you. If you are affected by any of the content within the leaked report or by anything that may be reported in the media, please make sure you speak to your manager or please contact Work Place Options .
To download a copy of our frequently asked questions, please visit our intranet page (login required).
Seriously……. ????
Having through the 2 week inquest into Connors death, it reinforced all my fears it focused on his preventable death drowning in the bath ,no epilepsy care plan, ignoring his mothers concerns..The inquest could not address the general provision of care that should have been provided during 107 days.At the end of Inquest the Medical Director was given the opportunity to talk about the extensive changes made to improve the services including her praise of gold service epilepsy care provision put in place,alas she was unable to clarify some points asked by the coroner notdid not having the policy to hand,had she not read it inside out before inquest or even during the two weeks she sat there and listened to the shambles unraveling ??? ,
QC for the family did have a copy to hand and was able to assist ..
As a parent of a service user/ patient (much loved family member)who has had 3 admissions to ATU ‘s two with SH since Connors death the changes are not evident on the coal face, as ever some individuals stand out but the core staff on the ground appear demoralised ,afraid ,lack any proper training in managing distressed behaviours displayed by the most vulnerable individuals a provision where they should be highly skilled and valued, perhaps these policies and training documents are stuck in the tower with the gold service epilepsy policy or maybe with Katrina Percy’s award accepted on their behalf a few years back
Wow!
Why have southern health named themselves as ‘sloven’ on their avatar?
What a crock of **** Southern
What a crock of **** from Slovenia. Again.
This is all beyond incredible but I just wanted to say that I love the photo of Connor.
Sara
Your innate dignity and your love for your beautiful boy shone bright this morning. In spite of all done to you and your family. You are a light shining into very dark and murky places.
Bless you.
Yes i second that, bless you Sara x
This must be a bitter-sweet moment for Sara and her supporters. I have been saying for over 3 years that (from my own experience) Sloven is a Mid Staffs scandal waiting to happen but no-one in authority has believed me, save for those that did believe me but failed to take action. I take little pleasure in being proved right.
Did Sloven management really post (what is clearly) a staff circular on Sara’s blog – or has someone leaked it? I find the following especially offensive:
“We would not usually comment on a leaked draft report, but we are concerned this coverage
may cause undue anxiety, especially amongst people who use our services and their families.”
Nonsense – if that were the case, why was the report not published officially weeks ago?
Their only concern is about limiting the damage to their reputation – what’s left of it.
The minimum requirement now is for Katrina Percy and Dr Leslie Stevens to be suspended immediately, pending a disciplinary process. There might be a view that they should be summarily dismissed – but such pre-emptive action resulted in Sharon Shoesmith in the ‘Baby P’ case walking off with an indecent sum of money – which would be even more insulting for the families.
Duty of candour.
(Leaked it)
deeply sorry for the families who must have been devastated by the shocking headlining news coming out of the blue. Greatest admiration for the beautiful souls who leaked the draft , in doing so they are keeping faith with each and every one of the hundreds whose lives are lost .
I agree with you nic. Thank god for the people who have integrity. Too bad Sloven does not know what the word means.
Has there been any investigation into the role of the LA’s who placed vulnerable people into the ‘care’ of Sloven? Did they monitor their decision to place, and their statutory responsibilities/duty of care? Did they listen to concerns by families? How well did they treat the families who raised issues? Did they follow up the concerns raised by families, with Sloven? If so what actions did they take to keep people safe, if any?
I have no evidence of the LAs doing anything. Hampshire CC simply did not want to hear from me and Southampton CC were engaged with Sloven in covering up my case. You might ask also what West Hampshire Clinical Commissioning Group (they are Lead CCG for Sloven) – clearly, they were ‘asleep on the job’ too. Someone there should be suspended and ultimately fired too.
Did LA’s walk away clean of any responsibility, from Winterbourne? Was any one fired?
The Long Care families fought for years for some justice, for the years long shocking sexual and otherwise abuse of their family members; the most vulnerable of people. There was a criminal trial and sentencing of managers and staff, but the LA allegedly took the families right to the court door before they acknowledged any responsibility. Was any one fired from the LA?
I believe that the Department of Health should be commissioning a full inquiry by Sir Richard Francis QC and it should not be limited to Sloven. It’s Mid Staffs all-over again. New questions include:
What has to be asked now is:
Why were local authorities’ social services departments asleep on the job?
Why was Monitor asleep on the job?
Why was the CQC asleep on the job?
Why were Clinical Commissioning Groups asleep on the job (especially Sloven’s Lead CCG – West Hampshire CCG?
Why was NHS England asleep on the job?
I know that all these authorities turned a blind eye to my experience and research.
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