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For nearly two years, since the preventable death of Connor Sparrowhawk, (aka ‘LB’) the organisation under whose ‘care’ he died – Southern Health NHS Foundation Trust – has been making responses of quite monstrous carelessness and crassness.  Its actions have earned the central organisation of the Trust the richly deserved nickname of ‘Sloven Towers’.

Sloven two

There really is a tower!

It started by immediately categorising LB’s drowning in a hospital bath as a ‘natural death’; continued with failure to ensure that remaining patients were safe (two months after he died, the Care Quality Commission failed the unit where LB died on all ten heads of inspection); moved on to putting pressure on LB’s family to stop causing trouble for the Trust; invented a slew of (specious) obstacles to further investigations; scrabbled around for last-minute ways to delay publication of the independent report that found LB’s death was preventable; tried to bully LB’s mother into compliance with Trust preferences and employed smear tactics against her; and most recently, stuck a barrister up in front of the coroner at the pre-inquest meeting, to repeat the long-discredited ‘natural death’ canard and argue that there was therefore no need for a jury.

The coroner, commendably, gave the Trust’s arguments short shrift, and a jury inquest is expected in October.

However, while Sloven is front and centre in the responsibility frame for failing to prevent LB’s death, they are not alone.

LB was admitted to the NHS hospital where he died – an Assessment and Treatment Unit or ‘ATU’ called Slade House, which has since been closed down – because there was not enough support available for him to stay at home safely.  LB, who had autism and learning disabilities, had seemed unsettled in the months before his admission, and his unhappiness had resulted in escalating episodes of behaviour that was dangerous to himself and others.  His mother hoped and expected that the ATU would be able to find out the underlying causes of LB’s behaviour, and help him learn ways to manage his stressors in everyday life.  She also hoped that LB’s time in the ATU would provide an opportunity for Oxfordshire County Council, the body responsible for providing suitable community support to LB, to come up with meaningful help for his return to the outside world.  What little service had previously been offered for LB was not adapted to his needs, and the only alternative offered was the Direct Payments scheme.  The DPs had proved as useless as the Council support, providing money that was unusable, since services or support of a kind that would be helpful to LB were simply not available for purchase by families.  If, when LB’s mother pleaded with them to put something more appropriate in place, OCC had provided the services that would have enabled LB to stay at home, his mother would have continued to ensure his bathing was supervised for safety.  He would not have drowned.

But OCC are also responsible in other respects.  The Council, through its Director of Social and Community Services, was part of the Oxfordshire Clinical Commissioning Group.  The CCG was the body that awarded to Sloven Health the contract to provide learning disability and mental health services.  If Sloven were providing an inadequate service, then it was partly the responsibility of the Commissioning Group for failing properly to scrutinise and monitor the contract.  Let’s not forget that according to the CQC, services at Slade House two months after LB’s death were still so grossly inadequate as to be immediately dangerous to the remaining patients.  But it was worse than that: the CCG had been aware since January 2013 that Slade House wasn’t up to scratch.  It was just that nobody had done anything about it.

OCC also had responsibility for LB’s safety through its membership of the Oxfordshire Safeguarding Adults Board.  The Safeguarding Board should have applied the Deprivation of Liberty Safeguards procedure to LB once he was no longer ‘sectioned’ but was still being held behind a locked door.  It didn’t.

Finally, OCC had the duty to assess LB’s needs and provide the services that would enable him to be safe when he came home.  After a very short time in the ATU, it became evident that being there was not helpful to LB; he was losing motivation and skills; he wasn’t getting any helpful therapy, and he wanted to come home.  But if he came home before the right support was in place, he and his family would find themselves back in exactly the same situation as they had been in prior to his admission.  OCC’s Adult Social Care foot-dragged over assessing and organising support, meaning LB’s discharge was delayed… and delayed.  And while ASC faffed around doing not a lot, LB was trapped in an environment that was so unsafe, he ended up dying there.

So Oxfordshire County Council has responsibility for three areas of failure that led to LB’s death: the inadequate provision of social care which led to him needing admission to the Sloven facility in the first place; the failure of the joint bodies of which the Council was part to provide proper oversight or safeguarding; and the continuing failure to organise suitable social care in the community that inordinately delayed LB’s discharge and left him exposed to unnecessary, and ultimately fatal, risk.

Up until recently, OCC has been very quiet.  Then at the end of March, out of the blue, the Director of Adult Social Services sent LB’s mother a copy of an ‘independent’ review that Oxfordshire had commissioned from a social care consultant.  The council had not told LB’s family that the review was underway or asked for information from them.  It had instead, without family consent or even knowledge, allowed its ‘independent’ reviewer full access to LB’s confidential social services records. The DASS finished by telling LB’s mother that the report – about her own son – was ‘confidential’ to the Council and must not be shared beyond her immediate family without written permission of the said Council.  Dr. Ryan didn’t share the report’s contents at that stage, but she did share the fact of its existence – and also shared the menaces that had accompanied its disclosure.

However, Dr. Ryan’s day-to-day blogging of her interactions with various organisations involved in LB’s (non-)care make it difficult to believe there could be much in the report that isn’t already in the public domain.  Someone commented, ‘I found a copy of the OCC report just lying by the side of the track’ – and added a picture to prove it.

OCC report

The commenter was quite right.  The threatening tone about breaching confidentiality was, of course, so much spurious claptrap, but when Dr. Ryan protested about the way the report had been created and communicated, she was given more condescending and inaccurate manure.  At one point, the Council tried to explain away the breach of confidence with regard to LB’s records by saying that when preparing the report, the consultant was within the circle of confidentiality because they were working for the Council – thereby blowing their own ‘independence’ argument out of the water.  And the reliability of the finished product was equally bogus.

The report itself proved to be a confection of irrelevance, self-serving half-truths and flat-out lies.  Besides omitting directly to contact LB’s mother Dr. Ryan, the reviewer had also failed to make use of relevant non-OCC documentation that was in the public domain, in particular  Dr. Ryan’s blog, which covered the entire period.  Instead, it seems, the reviewer had taken OCC’s apparently somewhat sloppily compiled records and treated them as though they were in themselves complete and impartial.  A initial trawl through the review showed a number of glaring errors, but in order that this misrepresentation should not come to be treated as a definitive statement of what happened with LB and social care, Dr. Ryan has had to go fine-tooth-combing through the statement, her correspondence and her writing from 2013, to find documentation for a line-by-line rebuttal of the errors.  It has been a time-consuming and soul-wrenching process.  In 23 pages of supposedly independent and impartial reporting, there were 61 examples of provable factual error, opinion presented as fact, or tendentious commentary.

These 61 perversions of fact and truth could have been avoided if Oxfordshire had undertaken a transparent process, or put the report compilation out, with LB’s family’s agreement, to someone truly independent who would have taken account of more than the defensive accounts given by Local Authority officers desperate to cover their backs.  What was produced instead was worse than manure, an unspeakably stinking slurry of shitespeak, smear, and innuendo.  It was textbook Sloven, raised to the nth power: arse-covering untruths, broadcast at random without a thought or a care for the terrible additional damage they would do to an already pulverised family.

Oxfordshire County Hall is an unprepossessing lump of a building: a quadruple-decker sandwich of grubby concrete and dark glass.  For administrative as well as architectural reasons, it will evermore be for me,

Ordure Hall.

Ordure Hall