Following my disaster last Friday, I spent a four-hour pre-weekend train journey in a crowded and uncomfortable cross-country carriage, retrieving from my memory, and retyping as much as I could of my reactions to the agenda/CEO report prepared for next Friday’s Southern Health Trust Board meeting (28/03/14 – although the agenda claims, confusingly, that this is a Thursday).
I’m going to be VERY interested in the minutes of that meeting, whenever it is*. Here’s why:
Paragraph 1.1 of the CEO’s report mentions that the ‘external, independent review that the Trust commissioned’ into Connor Sparrowhawk’s death, ‘was published on Monday 24 February 2014′ – neatly glossing over the facts that (a) the report wasn’t commissioned until the Trust had no option but to make such a report, (b) it wasn’t completed within anything resembling an appropriate timeframe (c) the Trust did everything possible to exclude Connor’s family from the investigation process, forcing them to fund expensive legal representation to enable family advocacy for Connor and (d) the Trust tried right up until the last gasp to prevent or delay publication of the report, constantly moving the goalposts.
It also characterises Connor’s death as ‘tragic’; and that is a crassly unacceptable evasion of responsibility. I’m going to have to assume that English Literature didn’t feature in the education of Sloven’s Chief Executive, because, as every GCSE student of Shakespeare knows, the essence of tragedy is that the tragic event is fated. Inevitable, written in the stars, unavoidable. An unbreakable thread of destiny created by Clotho, allotted by Lachesis, enforced by Atropos, beyond mortal control. Not the case here. Connor’s death was preventable and was due to human malignity and carelessness, not to divine intervention. Connor’s death wasn’t a tragedy, but something far worse. It was a disaster; a preventable disaster. That’s not a tragedy, that’s an outrage. And a disgrace.
1.2. The Trust immediately indicated publicly that it fully accepted all the findings of the report and once again apologised to Connor’s family and friends for its failings in respect of Connor’s death.
Mmn, shall we just forget that until publication was forced on the Trust, it determinedly peddled the line that there was nothing to get fashed about; no prob, Bob; just natural causes? No, we won’t. It must have been bloody obvious, from fairly early on, which way the report was going to have to go; why not ‘fess up as soon as the problem becomes visible, instead of waiting until everyone can see that you don’t have a leg to stand on?
Let’s also give that ‘once again’ a round of sarcastic applause, too, with its overtones of “We’d already bust a gut to say sorry, how much more do these unreasonable people want from us, ffs?” After all, Connor’s family and friends have only lost one person. There’s only so much sorry-saying anybody could do about that, isn’t there?
1.3. Connor Sparrowhawk .. was found submerged in the bath on the unit and died in hospital shortly afterwards. Post-mortem findings showed that he died as a result of drowning, likely to have been caused by an epileptic seizure.
Connor was pronounced dead at the hospital, after artificial life-support was switched off. But he had already died in the unit. After he was removed from the bath, he could not be revived. He did not breathe independently, his heart had stopped beating spontaneously.
The post-mortem that showed the epilepsy findings was not the initial, official one. The crucial information came from a subsequent PM requested by the family. Within a few days of Connor’s death, they were having to read up on post-mortems involving epilepsy, spot missed procedures, arrange for omissions to be rectified, and appoint legal representatives to ensure that this time, things were done properly. The Trust, meanwhile, was stating in public and in print that Connor had died of ‘natural causes’. Drowning is not a natural death.
Finally, the drowning was not ’caused by’ the epileptic seizure. That’s an elision of cause and effect to exculpate the Unit. The presumed seizure is likely what caused Connor to become submerged, but that submersion would not have drowned him had there been someone there to pull him above the surface or drain the water away immediately. There should have been someone there. Connor’s death by drowning was caused by a failure properly to care for him and his epilepsy, not by the epilepsy per se.
1.4. Since publication of the independent investigation report, the Trust has sought to be open, transparent and candid about this matter and has been open to approaches by the media.
Yup, transparent to the tune of maintaining radio silence for the best part of a week (including temporarily closing down its Twitter account and barring #JusticeforLB) after the report came out, only have its staff primed to spout nothing but evasive PR gobbledegook when interviews could no longer be avoided. The only thing that came across as sincere was the unfortunate phrase of the Trust’s Chief Medical Officer, saying that she and her colleagues wanted to help Connor’s mother to ‘move on’. As in, ‘move on, nothing to see here’, huh? Betcha do. Bad luck for Sloven that it was never going to happen.
And Sloven needn’t kid themselves that their previous seven-and-a-half months of obfuscation, opacity and secrecy went unremarked, or will be either forgotten or forgiven.
1.5. Following Connor’s death the Trust has, of course, made a number of improvements to services
Of course? OF COURSE? So ‘of course’ that when the Care Quality Commission inspected Slade House, eight weeks after Connor’s death, it failed on all ten areas inspected, and the only change to practice seemed to be that staff now ‘discreetly observed’ bathing patients (in line with some unelucidated, and apparently undocumented protocol)? Absolutely no mucking ‘of course’ about it. Bloody shysters.
1.6. In addition the Trust has been in contact with Connor’s parents.
Mostly, let it be noted, to say some variation of ‘No’ to them or put pressure on them to stop creating trouble for the Trust.
Staff expressed their condolences at the time of Connor’s death and the Trust has made contact with Connor’s mother (Sara Ryan) on a number of occasions.
As far as anyone knows, Connor’s mother has never invited the Trust, or otherwise given them permission, to address her or speak about her using her given name. Calling someone by their given name rather than their title and surname is familiar, in this case disrespectfully familiar. Sloven should have extended her the courtesy of using her formal appellation of Dr. Ryan.
The Trust repeatedly apologised for its failings in respect of Connor’s death and sought to meet with Sara Ryan but to date Ms Ryan has declined all invitations to meet with the Trust Chief Executive or indeed any other Trust representative.
That’s Dr. Ryan’s privilege. She is under no obligation to exculpate the Trust, assist it to improve, or indeed do anything for anybody unless she feels like it. No blame attaches to Dr. Ryan for preferring to avoid representatives of the organisation that not only failed to keep her son alive, but subsequently refused to communicate amicably with her until talk became advantageous for the covering of the organisation’s own arse.
1.7. We are very keen to meet with and engage with Ms Ryan. We understand that she is currently going through a painful, grieving process.
Personally, I’d question the level of understanding when a report-writer considers that the word ‘painful’ is a necessary, rather than superfluous, adjunct to the phrase ‘grieving process’. And ‘process’ has an aura of finiteness about it. But nobody ever comes to the end of grieving for the death of a dearly loved person. You don’t at some point definitively emerge from grief, all shiny and new like a butterfly leaving its chrysalis. After a considerable lapse of time, a person may manage to move away from their grief for a while, at intervals, but the pull of loss always, always brings one back around again. The loss becomes a centre around which the rest of life revolves, the focal point of the locus of the future. Loss acts like the central star in a solar system of grief. Just as comets, however far-travelling, cannot escape the gravitational pull of the sun, so a grieving person never leaves their loss behind. Understand that.
On the basis of professional advice we have decided that it would be unhelpful to seek to engage with Sara through social media channels so we will continue to seek a face to face meeting whenever she feels that is appropriate and helpful.
Now, given the healthcare context of this report, that phrase ‘professional advice’ has a reassuring, doctorly sound to it, doesn’t it? A flavour of first do no harm, patient’s or client’s best interest, informed decision-making? Wrong. This advice comes from a legal professional and the best interests are not those of Connor’s family. The advice is not designed to be helpful to those missing and mourning him. It is a legal opinion, aimed at protecting Sloven from further exposing their shiteness to public view.
But note that juxtaposition of ‘professional advice’ with another (uninvited) use of Connor’s mother’s given name. It would be minimally courteous to use the mode of address to which she is entitled as a senior academic. Calling her by her given name alone is worse than patronising here, it’s infantilising. It gives the impression that that a healthcare professional’s opinion has been sought as to Dr Ryan’s psychological situation and it has been discovered that she is too immature and fragile with grief to cope. (Any mental health professional who wanted and merited to keep their licence to practise would refuse to disclose such an opinion in such circumstances, even if they felt themselves in a position to have formed it in the first place).
It never happened. The ‘professional’ opinion is again a legal/PR one, that social media engagement is not helpful to the Trust. But it’s left a monstrously false impression that Connor’s mother has been certified a grief-maddened, unstable nutcase, shouting randomly at strangers as she staggers through the social-media marketplace.
The apotheosis of shitespeak.
1.8. Meanwhile, I would once again wish to express my deepest condolences to Connor’s family and friends and to say how sorry I am that we failed Connor.
Yeah, yeah. Weren’t so sorry when you thought you would get away with keeping it quiet, were you?
1.9. The Trust began an important journey when it took over learning disability services that had previously been delivered by the Ridgeway Trust.
Then why the blue blistering blazes didn’t Sloven notice when Slade House set off on its ‘journey’ at a full 180 degrees to the required direction of travel? Under Ridgeway Trust management, the Unit was by all accounts no shining beacon of good practice, but at least it had begun improving how it sought and recorded family carers’ information, following a previous untoward incident. Why was that ‘learning’ not preserved and built upon?
We clearly have more to do to improve these services
What can anyone say, except, “No shit, Sherlock”? (Apart, maybe, from “No fucking shit, Sherlock.”?)
and our overall plan for the modernisation of Learning Disability care for the people of Oxfordshire and Buckinghamshire is covered elsewhere on the agenda.
I had begun deconstructing this part of the agenda as well, but got so bogged down in a morass of ‘key activities and deliverables’, ‘additional external resource’, ‘operational and clinical leadership’ (what?? where?) ‘alternative recruitment and retention incentives’ ‘triangulation’, ‘LD pathways’ and ‘agency fill rates’ that I decided that I had neither time nor will-to-live-serum enough to get me to the end of it.
Read it for yourself, if you think you can (and you’ll be a better woman than I am, Gunga Din), here.
Two brief final observations:
Firstly, nowhere in all 52 pages of the agenda, looked I never so hard, did I find a sentence saying anything remotely like, ‘By such-and-such a date, we will have put in place an admissions procedure that will prompt admitting staff to seek full information on a new patient’s medical conditions, treatments, day-to-day care, communication needs and relevant information as listed at… from family or other usual carers, as well as from treating Health and involved Social Care professionals.’ (That would be a S.M.A.R.T undertaking – remember SMART? From Management-speak for Beginners?)
Secondly, in Section 10, the section on Learning Disabilities, there are three paragraphs.
The first announces, in a welter of acronyms, that the ‘(LD) plan’ will be presented at the meeting.
The second details concerns about staffing.
The third is about the ‘financial underachievement’ as ‘a result of quality issues and mitigation plans in the LD Services provided in Oxford, Swindon, Wiltshire and Buckinghamshire’ that ‘creates a significant risk for the Trust’.
Now, which of those three items would you consider ought to be the most important and therefore merit the longest paragraph? Hmmn? And which do you think actually is the longest?
Want a clue?
(It isn’t 10.1. Or 10.2.)
* Turns out the meeting was over before I posted this – it actually took place on Tuesday 25 March 2014. Any members of the public wishing to exercise their right to attend, and relying on the information published on Sloven’s website, would have arrived two or three days too late. Very, very poor, Slove-chaps. But par for the course, I suppose.