Shiny new policies, ducks and ‘learning lessons’

The ‘learning lessons’ tripe regularly spouted by NHS Trust representatives in the wake of a negative report, inquest or otherwise (typically not in response to the harm caused to a person and their families) really naffs me off. We learn all the time. LB’s death wasn’t a ‘lesson’ to be learned from. He shouldn’t have died. Simple as. A point brilliantly made by AnneMarie Cunningham yesterday in a talk to a group of psychiatrists. To use ‘lessons learned’ in this context trivialises and further dehumanises LB (and everyone else who has died or experienced serious harm). Particularly when crap all is actually learned.

After the first review into LB’s death (Verita 1) was published, back in the day it made several recommendations around epilepsy care. 18 months later, during LB’s inquest, it was clear that Sloven staff members giving evidence had learned little about epilepsy. This didn’t stop Sloven’s Medical Director talking the talk about shiny new epilepsy policies and toolkits at the end of two weeks of harrowing evidence.

Similarly, when Sloven (eventually) realised that they were in a teensy bit of trouble around their response to deaths in their learning disability/mental health provision (a good 16 months after they knew an independent investigation was commissioned by NHS England), they started talking the talk about their mortality policies and processes. The Sept and Oct 2015 board papers include 65 and 70 mentions of SIRIs (Serious Investigations Requiring Investigation) and mortality respectively. There were 8 mentions in the June and July papers.

Wow. That’s good. They are taking the Mazars review seriously,’ you may be thinking.

Mmm. They are clearly taking it seriously. But I suspect the it is an unprecedented threat to their reputation. Evidenced by remarkable challenges to the content/publication of this review which remains under wraps somewhere in NHS England. If Sloven can’t bury or somehow influence the review, they will want to line their ducks up to try to distract attention from the brutality of their practice up to now.

Various changes – a central investigation team will now oversee investigation and learning, training and implementation of a new electronic investigation system continues, 50 investigators attended a 2 day investigation training course in November, so on and so on – must be in place and operational by the time the shit hits the fan. [On my more cynical days I can’t help thinking this delay is enabling these ducks to be better placed for buffing and final shiny distraction attempts. Easing the inevitable discomfort felt by pretty much every organisation involved in this scandalous and inhumane tale].

But hey ho. Sloven remain all talk and little real action. The December Board papers record that an inquest into a patient who used their mental health services was adjourned on Nov 11th until January 26th 2016. The quality of the SIRI reports provided by Sloven and Hampshire County Council were [still] not good enough. Another family facing the torture of further delay – across Christmas – caused by Sloven (and local authority) disregard and carelessness.

Their shiny new focus on SIRIs, candour and involving families can be tossed in the nearest skip. It doesn’t translate into action and they don’t give a shit about what really matters.


That old devil called Mazars again

Heard this afternoon that there is more delay around the publication of the Mazars death review because now the completeness of the data the investigation team used is being questioned. There has already been an independent academic review of the methodology used but this review didn’t cover the completeness of the data. Ho hum.

Three or four weeks ago I wrote about the completely different treatment NHS England have meted out to the second review they commissioned, Verita 2, which had holes in its methodology you could post a tanker through (and, not surprisingly, uncontroversial conclusions depending on which side of the professional divide you sit). That review was published in a blink with minimal apparent scrutiny.

The Mazars review (unless a whole new set of data is suddenly found in some dark and dusty corner somewhere) has far reaching, harrowing and deeply serious implications and will (or certainly should) lead to swift and urgent action. It shines a light on beyond shameful practices and beyond the walls of the Sloven empire clearly demonstrates how the government response so far to the evidence we have of the premature deaths of a certain group of people is insubstantial frippery. Just tinkering round the edges while people continue to die and are swept aside. Carelessly.

It also shows how buckets full of courage are needed to effectively challenge systemic crap and that Mazars may be that rare beast. An independent organisation conducting truly independent, independent reviews.


The birds eye view from an Oxon Commissioner

Summary of a 4615 word letter about what happened to LB below sent [to anon] by an Oxon Commissioner in 2014, forwarded to our legal team just before LB’s inquest. Beware the wrath of middling/senior public sector figures if you want to publicly document your experience of public sector provision is clearly the message here. An illustration of the toxicity of local authority/CCG practice. [Rage warning.]


A tale of mother blame.

Deference to a bereaved mother means that she has been able to tell a partial story.  This is frustrating. I know through inside information that not all that’s written on the blog is accurate. I mean LB’s recent diagnosis of epilepsy was the least of the family’s worries. The children’s team told me this. His mother  often rejected support only to come back wanting it immediately. She accused social services of harassment and told the social care manager she should have read her Facebook page to know she wasn’t coping.

It’s my understanding that his mother was the one who pushed for admission. She didn’t want LB home and was pushing for a supported living service that can’t be magicked up in a few weeks. [Christ]. She refused an increase in LB’s direct payment package and never made a complaint which was obviously the sensible thing to do. 

It was clearly a difficult time if you read her blog however not everything she reported was accurate. She frequently took lines out of emails people sent her out of context and posted them. And wrote things staff disputed. A colleague was trying to get LB out of STATT but because Sara Ryan didn’t want him home, they didn’t push it. In hindsight, they should have just discharged him.

I’ve read the minutes of the Care Programme Approach meeting where bathing was discussed. There were no minuted objections from the family to the idea that he should be left alone in the bath. He hadn’t had a seizure for a year so although in retrospect, 15 minute checks look unsafe, it may have been a reasonable risk assessment at the time. His mother and her friends tried to make the CPA meeting person centred and this was why vital things could have been missed. You can’t really have person centred planning fitting with clinical health processes. [Tsk].

I know that Sara Ryan doesn’t think this but the majority of STATT staff are very caring. People cried all weekend after LB died and still people are shaken and upset by it. The huge amount of negative publicity that has been generated continues to cause them immense stress. Sara refused to speak to anyone except via her sister and has made it difficult for open honest communication.

Once STATT was closed, and SR was banging on in social media land about stuff, we’ve been unable to do our jobs properly. Patients have nowhere to go and we’re too scared to say anything because of that pesky blog. I still believe that the worst services were always outside of Oxfordshire. The trouble is that SR’s anger is unproductive and her blog is causing problems. She names and shames people and causes illness. One friend was off work sick for two days as a result of one post.  I believe her campaigning has done a lot of damage.

I originally thought LB could have died anywhere but I now know [after publication of the original Verita review] that Sloven were responsible for his death. Despite SR refusing to speak to anyone, Sloven did themselves no favours by retreating. We usually do a quality visit after an unexplained death but the police and HSE were investigating. We asked the local NHS England team for the highest level of investigation but it wasn’t until SR spoke to David Nicholson that Verita were appointed. We argued for a family advocate but weren’t listened to. We didn’t visit STATT ourselves because a lot was going on and before we were able to review the unit the [pesky] CQC pitched up. They used a new form of investigation looking at stuff they wouldn’t usually look at (medication storage, clinical waste, batteries in defibrillators and so on). The CQC inspector gave us mixed messages and I certainly felt there were some wider politics going on.

I was really shocked by the Verita findings and had no idea that LB was experiencing increasing seizure activity or that risk assessments weren’t being conducted. I believe we at OCC had no way of knowing that we weren’t being told the truth by STATT staff or that Sloven weren’t checking on things. It’s the STATT team who will have to live with LB’s death for the rest of their lives. 

I do think in hindsight we could have perhaps followed up on the blog  and done some more checks in recognition of the fact a new organisation was taking over, but we were so stretched, I don’t think we could have done much more than that.

I know LB’s death was horrific and upsetting and I know his mother will never get over it. But you can never guarantee 100% safety and it’s not good for people to be continually checked. I’m fairly confident we’d have picked up STATT’s deterioration at our next visit (we do it all the time) but sadly it was too late.

I feel immensely sorry for Sara Ryan, it is terrible she has lost her son. However, I believe bloggers have a duty to be honest, and accurate; and some of the effect of her campaigning has made things difficult not just for professionals but for other service users and families. My hope is that she can find some kind of peace with this, and that one day, she might be able to move on.

Oh fuck right off.

[I’ve never met this person].

Being free and frank (Spencer)

My incredulity barometer has crashed this afternoon. Revisiting Sloven actions since LB’s death. A letter from Katrina Percy dated 5.12.13. Freshly back from maternity leave as she sensitively mentioned. Assuring us that the investigation into LB’s death (by Verita) will be thorough and transparent and the findings openly shared with us.

Fast forward a few weeks to discussion about publication of the Verita review. Transparency my arse. The report was not to be published. Reasons? To avoid a breach of Connor’s confidentiality, to protect staff, to not prejudice ongoing staff disciplinary actions and to not prejudice future investigations because staff wouldn’t be so “free and frank” in providing their views if they’d known the report would be published. The email from Sloven’s solicitor detailing all this ends with the classic statement:

Notwithstanding the above, the Trust is conscious of its duties to be open, frank and candid [hahahahahaha]. It does recognise that there is some public interest in ensuring that serious incidents are investigated and lessons are learned. [Gnaw…] To this end, the Trust proposes to prepare a summary of the investigation findings that will be published on its website.

This was pretty staggering at the time. A Sloven written summary of an independent investigation. The report was eventually published with all names and job titles redacted. Making for tricky reading in places.

Since then, of course, we’ve had LB’s inquest. In which those staff still represented by Sloven’s legal team (they were culled like flies as the inquest drew nearer) produced witness statements including sections about their ‘relationship with Dr Ryan’. [An astonishing erasure of all other family members]. For example;

I did not speak to her very much other than saying ‘hello’. I had seen Dr Ryan shouting at a consultant and I did not want to experience that. I was scared of her. She was a bit different.

These were distressing to read especially as I thought I’d got on well with these staff. The student nurse above always took time to fill us in on what LB had been doing and how he’d been. ‘Hello’?  Reassuringly staff were honest enough to simply bat away these questions during the inquest. Scared? Nah, I respected her. And so on.

We’re left feeling sickened and shocked to the core by these dirty dealings (by an NHS organisation…) An organisation whose actions point solely to a concern with reputation management. Fakery around staff protection. As for us, LB’s family. How did we feature in Sloven’s considerations? How did they try to make sure the process was sensitively and decently handled? To ease the inevitable pain and distress we would experience? Mmm. This can be captured by this extract from meeting notes in which I was mentioned. [A meeting to discuss publication of the Verita report that clearly showed that LB’s death was preventable…]


They didn’t even begin to try.

Nearly turning 21, magic and mopping up crapshite

Not a good time. LB’s 21st birthday on November 17th. Against a backdrop of global senselessness and horror. MargoJMilne posted a link to a wonderful version of Faure’s Cantique de Jean Racine yesterday. This sort of worked/distracted me for a bit.

Originally Rosie and I were going to be around on Tuesday and started to plan a ‘treat’ outing with some cracking suggestions via twitter (fab suggestions that will be squirrelled away for future enjoyment). Rich reorganised his work. It turns out Tom finishes lessons at noon that day. Will is coming home tomorrow for the week. Owen pitched up yesterday for the night, rearranged his university work and is staying till Tuesday. And the wondrous Molly and gang are coming round in the evening. Wow. We’ll muddle through with visits to the cemetery and Mansfield College to see the quilt, nosh, drink, memories and hopefully laughter.

I’m on leave tomorrow as well. After the dentist, another visit to the quilt, followed by lunch with big sis Tracey (Agent T) and our parents. It’s randomly spectacular that the quilt is in Oxford at this time and that Kevin the porter is so blinking helpful. [I think it will be on display till at least the weekend and will post the end date when it’s decided].

Several people have asked if things are pretty much sorted now the inquest is over. Here’s a brief summary of where we’re at (in no particular order):

  • The coroner has written a Prevention of Future Deaths report which Sloven have 56 days to respond to.
  • The Verita 2 report was published at some point in the last few weeks (tumbleweed).
  • The Mazars (draft) death review has undergone and survived severe challenge from Sloven (very long story). This should be published this week some time.
  • The Health and Safety Executive (HSE) continue to investigate LB’s death and should be drawing on evidence from the inquest. Of which there was plenty.
  • The General Medical Council (GMC) and Nursing and Midwifery Council (NMC) are investigating referred staff.
  • The Oxfordshire County Council maladministration/secret review shite is ongoing.
  • Norman Lamb’s Green Paper – No voice unheard, no right ignored – has shamefully been buried by the government (non) response published last week. The #LBBill is an ongoing endeavour.

On a slightly separate note, Norman Lamb deserves special mention for his consistent, dedicated and passionate attention to and knowledge about ongoing (howling) gaps and worse in learning disability and mental health provision. George Julian has gone on leave making clear her/our frustrations about the delays that seem be an unremarked upon part of this inhumane process.

It also became clear after an evening with mates on Friday that there was confusion over Dr Crapshite and Dr M. They all thought Dr M was Dr Crapshite. And Mr J, her barrister, made so much about this to defend her. Blimey. No. Sorry if that got lost in translation. Dr Crapshite was the community psychiatrist who saw LB once in Jan 2013 (and, as we heard during the inquest said she wouldn’t see him as a patient post discharge because I was toxic). Dr M was the unit psychiatrist who prescribed bonjela for LB’s bitten tongue post seizure and, erm, insisted (even during the inquest) that LB wasn’t having any seizure activity. Crapshite is as crapshite does but for the sake of clarity ‘Dr Crapshite’ is a different person to Dr M on these pages.

I’ll finish this post with two magical things.

A beautiful photo of LB I’d not seen before.

image (15)

And David Harling’s second animation. His first, equally spectacular work (or love), can be watched here.

Gotta keep fighting dark with light/colour. And remarkably (thank fuck) the light keeps coming.


Drafting stuff and Mansfield College magic

I’ve numerous draft posts that remain tucked away in the admin pages of this blog. These draft posts are largely those that led nowhere. Started too late in the evening, lacking meaning/welly/point/direction or those that were superseded in a good (or occasionally bad) way by some other development or unfolding.

I became interested in these draft posts during LB’s inquest when the blog became a source of contemporaneous (existing back in the day) evidence. It’s over two years since LB died [howl] and there is so much I’d forgotten. (Draft) blog posts record stuff. Written, saved, revised and date stamped.

On Sunday evening I started to write about the Sloven witness coaching apparent during LB’s inquest. It was pretty upsetting to read the witness statements of the (few) staff still represented by Sloven in advance of the inquest. The ‘Dick Dastardly tale of the incredibly difficult Dr Ryan‘ was pretty hard to make sense of (and hadn’t been apparent in the earlier Verita 1 staff interview statements).

While writing I received the draft of a new #JusticeforLB related development in artistry/wondrousness. Something so powerful and moving I immediately parked the staff coaching post. And cried. In a good way.

Yesterday I belatedly chased up the #JusticeforLB quilt. Displayed at the Yorkshire Sculpture Park (YSP) in September, Baroness Helena Kennedy, QC, had agreed to display the quilt at Mansfield college during LB’s inquest. Among the horror, maelstrom, chaos and everything else the quilt ball was dropped (by me). It turns out that YSP and Mansfield College were more than able to step up. The quilt was already on display in Mansfield College. Wow.


I called in on the way back from work this evening to have a look. The cheerful porter’s instructions:

“You follow the path round to the tower on the right hand side of the grass. Wait at the wooden doors, they open automatically. Turn left, walk down the corridor and there is it. It’s lovely.”


It is. And it’s possible to have a really good look at the different patches. It seems there is always something new to see. The college is open to the public, free of charge, Mon-Fri, 9-5pm. It’s wheelchair accessible and the porter in the lodge on the left as you come in from Mansfield Road will point you in the right direction. On display for the next week or so. Just wow.


With many thanks to Mansfield College for giving local people the opportunity to see the quilt.

(*long lost) Lawrence and looking for Dappy

I wrote about LB’s 18th birthday here. A day trip to London and a wish that Tulisa was his sister. Other birthday outings are dotted around this blog. Most involve London. Giving evidence (howl) during the inquest I talked about how we drove round Camden in June 2013 looking for Dappy. We didn’t find him.

Out of the hundreds of pages of damning/harrowing reports, records and staff interviews I read in the two years before the inquest, the odd thing made me smile. One was this family tree produced when LB was in the unit. I think a psychologist did it with him. LB, love him, disrupted the framework by telling her his family included Lawrence, Anne, Dappy and Tulisa. Anne was a mystery until a quick google tonight revealed Tulisa’s mum is called Ann. (Long lost) Lawrence remains a mystery.

family tree

It’s LB’s 21st birthday on November 17th. [Howl]. I don’t know what we’ll do. I sort of hope the Mazars death review is published that day. A review, generated by LB’s death, that will (surely) change the landscape of learning disability provision in the UK. A review that will mark a point in which chat about change is no longer acceptable.

The review examines deaths in Sloven’s learning disability and mental health ‘care’ between 2011-2015. The post Winterbourne View period. A period in which there has been so much talk about learning disability provision and no action. Huge amounts of dosh given to endeavours like the Winterbourne Joint Improvement Programme (since disappeared), Bubb’s breakfasts and the like. All the while actual people were being disappeared. In full view down Hampshire and Oxfordshire way*.

The publication date for the Mazars review seems to be ‘at some as yet undisclosed time in the future when a set of currently missing hoops have been found and gone through with a set of as yet unidentified really important people who may have run out of the necessary ink in their fountain pens to sign off publication. Ink which can only be produced from a rare vegetable that only grows once a year on a remote island off the island of Java.’

Not surprising really. The review implicates all the key players. Sloven, commissioners, NHS England, Monitor, the CQC and the Department of Health. The commissioning of a review into the methodology used in this (independent) review raises so many questions about what ‘independence’ in this context means my brain just freezes. The story seems to be that Sloven challenges to the methodology must be sorted pre-publication so as not to muddy the water. Eh? The findings are so controversial we need to dot the i’s and cross the t’s big time?  Producing a level of robust engagement not necessarily present in other independent reviews? Mmm.. that’s pretty awkward.

I’m kind of lost here for so many reasons. Not least the Verita 2 report that has findings and then a brief conclusion so off beam I was left wondering what magic dust had been sprinkled over these proceedings to allow such speedy publication (after a lamentably long and delayed production process). If the current examination of the Mazars methodology finds nothing untoward, will some other review into their processes be commissioned? Like did the investigatory team have the recommended five a day during the process? Or were any of the half arsed records they examined not treated with the necessary respect a piece of paper deserves?

We seem to be in a space of absurdity. Generated by a review that found the unthinkable.

*And elsewhere quite possibly…

A tale of two reviews (and an inquest)

For anyone managing to keep up with this dense (and often tediously frustrating and jargon laden) tale of trying to get accountability when your child dies a death in NHS ‘care’ (involving a dereliction of such basic care that defies understanding) well done.

To recap. A week or so ago, a second Verita review (V2) was published. This was commissioned in July 2014 to explore broader issues around why LB was admitted to the unit in which he died. A third review, the Mazars death review (M1), examining how Sloven responded to deaths in their learning disability and mental health provision since 2011, was commissioned on our request by David Nicholson shortly before he stepped down as NHS England CEO in March 2014. We thought this needed urgent investigation because of the ease with which Sloven dismissed LB’s death as natural causes. [Weep]. The contract was given to Mazars in November 2014. Another six month contract.

We fully expected both reviews to be published by June/July 2015. With the pesky general election as the big delay factor. But nah, they dragged on. M1 because the findings inevitably generated the need for further investigation. V2 because, er, it could. V2 was eventually circulated for factual accuracy on Aug 21th, M1 a couple of weeks later on Sept 9th.

During LB’s inquest the status of these two reports were continually contested. Sloven were determined to get V2 in front of the jury while chucking M1 into oblivion. We thought the coroner should have sight of M1 because the findings were relevant to a prevention of future deaths report. We found out, during this nasty piece of game playing in open court that V2 was complete. Nothing like being kept informed, sensitively. And then we were informed it wasn’t. What a mess. In a space that you’d kind of hope that the wellbeing of the family would be uppermost in the actions and thoughts of the NHS Trust involved and all related organisations. Family wellbeing? Eh? Nope. It’s all about reputation, reputation, reputation.

In the end, neither report was disclosed to the jury.

A week later, V2 was published. No further delay. Despite both lay reps (George Julian and Bill Love) disputing the findings. M1 continued to be challenged by the Sloves. NHS England took the criticisms of M1 seriously and commissioned an academic review of the methods used. [I know.]

Seems to be that an extra level of rigour is needed because the findings are so controversial. Yep. Make of that what you will. The NHS England plan for moving people out of of Assessment and Treatment Units was published last Friday. This was the subject of some criticism around resources, reach and expectation. To me it seemed to be well thought out, sensible plan particularly given the failures of everything that had gone before in the last 3/4 years (as long as the money followed the patients into the community and remained with them). It strikes me that the delay in the publication of M1 is a strategic move partly relating to last weeks news. We can’t have a report that drips death and darkness casting a shadow over shiny new plans.

The latest M1 delay news (the report of the methodology will take up to Nov 13th) came with the usual teeth jarring statement that NHS England know this will be ‘particularly disappointing for the family’. I don’t think NHS England know what this experience is like for us. I think it’s almost impossible for anyone to understand what it is like to have a child left to drown, alone, in an NHS hospital bath and then be forced to fight for over two years for accountability for his death. Please ditch the trite and meaningless statements.

Here’s a radical thought.You don’t need to wait for a written review on the methodology (you are choosing to). A telephone call with written confirmation to follow would do. Why not put this ‘grieving family’ at the centre of this vile and harrowing process for once and just publish the fucking report?

Is someone having a laugh?

Another failed CQC inspection for a unit on the Slade House site (across from the (now closed) Short Term Assessment and Treatment unit in which LB died) this week. Nah. 824* days after LB died and Sloven still can’t provide a service worthy of the (at least) £3500 per week they are paid to look after each of the four patients? Surely not.

This was a re-inspection, the unit having failed to reach adequate standards in August 2014. And, on return, in August 2015, the inspectors found failings. Still. They found understaffing, inadequate record keeping, a lack of supervision and lack of leadership. The care provided was of a good standard, it’s the processes and leadership that are failing. One professional said;

as a service they seem very focused, but I don’t think they are helped by what goes on above them, it just doesn’t really seem to know what’s happening.

Nah. That couldn’t be clearer. Sloven are simply shite when it comes to learning disability provision. We all know that. It’s been demonstrated in the various investigations into LB’s death over the past two years. They are all PR, shiny awards, faddy nonsense and wasting big bucks on novelty crap.What’s it going to take for someone/organisation to step in and do something??

Meanwhile, Oxfordshire County Council (who couldn’t organise a piss up in a brewery clearly) have extended the contract for Sloven services in Oxfordshire for another two years. To enable a safe transition to new service providers. No idea what they were doing between early 2014 when they decided to pull the plug on the Sloven contract and now. Arsing around commissioning and responding to a craphole ‘independent’ report to contribute to the ‘toxic mother collective‘, led by Dr M, Dr Crapshite and Anon (ex-commissioner) perhaps.

Oxfordshire County Council are stumping up enormous sums of cash for flaky provision. My brain melted when I read that understaffing meant the on call staff member was up to 40 minutes away for emergency overnight medication provision but generic emergency services were nearby. £3500 a week?

Is it all just a joke? All talk, no improvement and a group of patients whose lives simply don’t matter? It doesn’t make any sense to me.

image (14)

*I counted the days this morning when I realised I’ve woken every morning since LB died thinking about him.

Screw face and skinning puppies

Still unable to make much meaningful sense of LB’s inquest but moments are surfacing. A few here. Again in no order. Toilet moments. The toilets were back from the courtroom, through the cafe towards the exit. A block of three cubicles for women. Despite strategically timed efforts (roughly aiming for the middle of break times) I always seemed to collide with a jury or Sloven staff member. So blinking awkward.There was only one woman advocate across the other seven legal teams so this was less of an issue [sigh]. I kind of went for a ‘make do and definitely don’t mend’ approach with jury members. This involved eyes firmly on the floor and the usual ‘thank you’ type acknowledgements around holding doors firmly parked.

The kids were upset and angry by the various interactional exchanges that occurred in the courtroom. Smirks, hints of excitement and puff and schmuff between various Sloven bods at the front of the courtroom. A ‘screw face’ technique was tried and tested across the two weeks to manage this.


Rosie also stepped up and explained what it was like to experience this behaviour to a senior Sloven staff member. Love her. Hopefully this has been passed to the Sloven senior team/board and will be incorporated into their inquest policy/engagement. Our and other families’ experiences suggest an over emphasis on staff coaching rather than any thought to what it must be like for family/friends in this setting.

Moments involving Dr M, the consultant psychiatrist, and her barrister, AJ, are sadly hard to forget. For so many reasons. Not least the efforts AJ made to work to a script seemingly derived from the various Disney/Pixar films LB both loved and got so upset about. Depicting me, ‘The mother’ [with extended dramatic pause], as a Cruella de vil type character. Skinning puppies for fur coats.

At one point Paul Bowen, QC, asked Dr M who was the best person to know what LB meant when he said something. This generated avoidance strategies reminiscent of childhood banter hanging out in the car outside pubs with my sisters. Coke, crisps and bickering/discussion with a backdrop of the Grease soundtrack. Dr M, not a child, prevaricated and twisted a knife that should have been removed over two years ago.

That is a very general question. It depends what being said and when it is being said, I cannot ask that question. It would have to be more specific.

[Howl]. There was worse to come. Almost luckily via video link as I’m not sure  what I would have done if she was present after this exchange.

Mr F: You heard Winnie Betsva admit that she had failed Connor, SR and the family, is there any matter relating to failures from your part?

Dr MIt was an act of tragedy. In hindsight, we could have made some different decisions but with the information we had at the time and balancing of pros and cons we made right decision at the time.

Mr FI asked ‘you’ not we.

Dr MI made the decision at the time with others weighing information we had at the time and no, I don’t believe there was a failure of care from my part.

An act of tragedy? No failure? Can you even begin to imagine? And this woman is a practicing psychiatrist in Cork having given up her licence here. The GMC still investigating her conduct… There is too much too wrong here. And our beautiful, funny, loving boy is dead.