Where has the rage gone? It’s still there, but seems to have transformed itself into a terrible calm, as though I had gone right through Dante’s icy lowest circle of Hell and discovered the place, the unreal universe, where there are temperatures colder than absolute zero and water doesn’t merely freeze, it anti-boils.
Backing up a little, this blog was originally set up because of the #JusticeforLB campaign. Since Connor Sparrowhawk, known as LB, drowned in an NHS bath in Oxford’s Slade House Assessment and Treatment Unit, his family has, through magnificently relentless digging, discovered that:
- the ‘care’ given at the Unit was inadequate to the point of negligence;
- there was a de facto four monkeys policy – hear, say, see and do nothing;
- the care offered for Connor after his death continued to be inadequate: the official post-mortem did not examine the possibility of epileptic activity leading to submersion;
- the organisation of which Slade House was part, Southern Health NHS Foundation Trust, was prepared to make public statements exculpating itself, on the basis of no facts;
- Southern Health was not prepared properly to investigate the circumstances of Connor’s death until it was forced to do so;
- Southern Health was prepared to make self-exculpatory statements that distorted or plain contradicted the facts that emerged.
So far, so bad. However, having ascended the (scavengers’ and parasites’) food chain from staff to management to provider, Connor’s family have moved on to the next link. Southern Health was not the final NHS arbiter of the ‘services’ provided by Slade House. The services required were detailed in a contract that Southern Health was awarded by Oxfordshire Clinical Commissioning Group, with which latter body the responsibility for specifying the services rests. As the contract-awarding body, the CCG is also responsible for monitoring the contract’s performance. It hasn’t made any formal comment about this in the nearly nine months since Connor died.
Giving the CCG the benefit of the doubt, it might have been plausible (though in no way excusable) that the commissioners had been fooled by the relentless PR-spin and management-speak of Southern Health. That the commissioners were well-meaning bumblers who lacked the capacity to realise that they were a weak link in the chain of safe healthcare.
No more. In the last week it has come to light that in 2013, a working group from the Winterbourne View Joint Improvement Programme went to look at examples of Assessment and Treatment Units which were documented as centres of good practice. One of the recommended centres was – Slade House. The WVJIP working group visited in company with an Oxfordshire CCG commissioner and everybody was horrified to find that actual practice was awful, nothing like the purported (documented) practice. The commissioner seemed as shocked as anybody.
And when was the WVJIP visit made? In January 2013, two months before Connor’s admission to Slade House, and six months before he died there. The commissioner knew, knew, had seen with his or her own eyes, that the ‘service’ offered through the Unit was atrocious. Had even, apparently, remarked that it just showed how important it was to visit in person rather than relying on reports. Yet it seems that the awfulness was insufficient to merit anything being done about it.
Why? Well, here’s an email from the back-end of 2013, sent by one of the commissioners: “It is evident however that the quality of the service at STATT, which had been person centred at the point of transfer to Southern Health in December 2012, deteriorated significantly over the period of time in question and I am very sorry that what was held to be an example of good practice had such a poor report from CQC.” CQC (Care Quality Commission) visited in September 2013, by which time the personal knowledge of the ‘deterioration’ acquired during the WVJIP visit was 9 months old. The email continues: “I’m afraid we have to hold Southern Health responsible for that deterioration although we don’t say so publicly as we don’t want to knock confidence in such a large provider.”
Now, I think I’ve proved I’m as much up for giving Southern Health a damn’ good kicking as the next reasonable person, but that assertion about responsibility doesn’t fall within my definition of ‘reasonable’. Even Southern Health, surely, would have been hard-put to it to cause a commissioner-shocking level of deterioration between December 2012 and January 2013? Mr. Commissioner can’t shuck off his organisation’s responsibility that easily. Another thing: Oxfordshire CCG have been taking credit to themselves for trying to set up contracts where payment depends on the outcome for patients rather than on having a notional level of service available. Not “knock(ing) confidence in … a provider”, however “large“, is, or bloody well should be, an irrelevance. If the email fairly represents the limit of the extent to which Oxon CCG – the flagbearer for outcome-dependent commissioning – is prepared to fight the vested interests of providers, then there’s no hope of change.
Worse yet, the CCG is not the last organisation deploying silence in the hope that it will Teflonise them against blame. Not a peep from the Adult Safeguarding Board, nary a syllable from the Adult Social Care people who should have provided the community care that would have allowed Connor to return to the safety of home – indeed, could have prevented the crisis that took him away from home in the first place.
So here’s the thing. I generally favour the cock-up theory of disasters. But such widespread collusion in silence and evasion of responsibility over the death of Connor, a person with learning disabilities and complex needs, looks remarkably like conspiracy. Something that permeates the whole health/care system, and in effect decides the life and death of people based on their perceived economic value (or cost). A chain of rotten links that is doing its best to strangle and crush Connor’s family, like Laocoön’s serpents*. Not Death by indifference, not 74 Deaths and counting, not even the killer 1200 avoidable deaths, but an unspoken policy of covert genocide dressed in rags of euthanasia.
From the day of Connor’s death, it seemed likely that negligence was a factor. I felt all along that a prosecution for corporate manslaughter should follow if negligence could be proved. But when negligence is so deliberate, so entrenched, is manslaughter really appropriate? Oh, legally, legally, manslaughter is the severest charge available. But morally? Looks to me terrifyingly like murder.
* (Laocoön – for anybody who’s forgotten the story and can’t be annoyed just now to Google it – was killed by constrictor snakes, along with his sons, as punishment for speaking an inconvenient truth. He was, as it happens, a priest of Poseidon, the god of the watery realm. How apposite.)