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Monthly Archives: Dec 2015

The Wood And The Trees.

29 Tue Dec 2015

Posted by Kara Chrome in Uncategorized

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#justiceforallthedudes, #Mazars, NHS, Sloven Health



I still haven’t got my head around the Mazars review. Partly because it takes even me some time to read 254 pages of dense text packed with excruciatingly painful stories behind each digit in the statistical content, but mostly because – as NHSE and Sloven no doubt calculated, by releasing it at the very last gasp before Parliament rose for Christmas – most people, including me, have had one or two other things to occupy our minds for the last 10 days or so.

Because the report wasn’t available in its final form until after the House of Commons had closed for the holidays, it has gone into limbo until Tuesday 5 January 2016 at the earliest.  I hope it gets picked up and thoroughly aired as soon as possible thereafter, floods notwithstanding.  Meantime, there are a quite few things from the Urgent Question on the leaked report that I have filed for future reference and review. In no particular order:

  • ‘Parity of esteem’ there is not, even within lowly mental health services: 30% of working-age adult deaths were investigated, but only 1% Learning Disability deaths, and an even smaller proportion of deaths among people above retirement age.
  • There needs to be a focus on Southern Health’s particular failings but, as noted by the MP for Stafford, the findings have implications for the wider Health Service in relation to mental health and learning disability services.
  • The lack of family involvement was shocking.  The full report cites families who were not merely ‘not involved’ but were actively excluded from investigations.  I suspect that this is a function of power and control.  The patients were not seen as real people with a context, but as mere ‘cases’, so their families could be readily dismissed; and this view also played to Southern Health’s narrative whereby the service was the sole repository of knowledge about the person and their condition, the sole possessor of wisdom as to how to manage them, and the sole wielder of the power to treat and cure.
  • A Public Enquiry along the lines of the Francis enquiry is warranted, although “Fast action to change culture now” is also needed.  The conclusions of the Francis enquiry, if implemented immediately at Southern Health, could do no harm and could potentially do much good.
  • The scrutiny of Southern Health needs to be ‘intense & ongoing’.
  • The Secretary of State placed an inappropriate emphasis on clinicians as the main actors in the present state of things at Southern.  At the root of problems at Southern Health was a massive, protracted and embedded failure to manage.  Facilitating whistleblowing by individuals is only a partial solution of the problem.  It can make no difference until senior management & Boards are held to account for their response to problems.
  • That the problem with inquests whereby interested public bodies are entitled to unlimited state funding, but the dead person’s relatives have personally to fund their relative’s representation, has been noted, with 2 MPs asking about it. The Secretary of State replied as though the crowdfunding was a matter of relatives’ choice or was to fund civil litigation for pecuniary compensation, but of course this was not true.  Inquests are not non-adversarial proceedings in practice, whatever they may be in theory, and the question of funding for families at inquests should be put to the Secretary of State for Justice, Michael Gove.  In turn, the unfair and invidious position of families at inquests raises wider questions about legal aid and access to justice.
  • A system of independent medical examiners could do much to assist with transparency and openness.  Oddly enough, the creator of probably the best-known fictional Medical Examiner, the author Patricia Cornwell, was on the radio in the week before Christmas, talking about how her Kay Scarpetta character, like the real ME who inspired her creation, views the bodies she examines as patients: real people who are just as entitled to proper care postmortem as they should have been in life.
  • That there are questions to be asked of organisations beyond Southern Health about people’s care as patients, but also questions to be asked beyond the NHS about how to support people with mental ill-health or with learning disabilities to make a life.  Alongside the Health Secretary and the Justice Secretary, the Secretary of State for Work and Pensions also needs to be put firmly on the spot, over the closure of the Independent Living Fund, the reduction of Employment and Support Allowance paid to people in the ‘Work Related Activity Group’ (that is, people who are unwell or disabled but have the potential to move towards work, with proper support), the reduction of support to Local Authorities which in turn has meant the cutting of social care budgets, and the forthcoming transfer of Attendance Allowance to local authorities, which is likely further to reduce the support available to older people.

A dense and extensive forest of thorny problems, and just to add to the thickets of unpleasant underbrush, there is the matter of Winterbourne View and the Joint Improvement Programme, which seems to have died  the death with no results.  The number of people spending long periods of time in supposedly short-term Assessment and Treatment Units has reduced only marginally; around half of the current inmates are people who were also incarcerated a year ago.  The biggest difference is that the average distance between home and place of stay has increased.  There are many reasons to worry that the whole Mazars review could follow Winterbourne view into the long grass and the wilderness, even though, unlike at Sloven, at Winterbourne View nobody actually died as a result of the non-care and neglect.

As I say, much of this got lost for a few days in the Christmas run-up.  Lots to do, and we miss my Dad especially at this time of year.  My parents were married just a few days before Christmas, so it was an extra-special festival in our family.  Dad always did the cake, with his special home-made marzipan that is a million times nicer than anything that ever came out of a shop.  On Christmas Eve, after we went to bed, he would arrange some of Frederik Bramming’s cardboard Kravlenisser, which he and Mum had purchased in Denmark on the way back from a snowy Scandinavian honeymoon, on the curtain rails and picture frames. There they would sit, laughing at us and each other, for the full Twelve Days.

Kravlenisser tabs

Without Dad, it’s difficult.  As it is for lots of people, whether because they have lost someone, or are alone, or are ill, or don’t celebrate for other reasons.  It’s a time when it’s easy to feel excluded or overwhelmed.  After she posted this, I sent Nico’s mother a picture of a tree decorated with sunflowers.

sunflower full view (1)

It wasn’t ideal  as Nico’s sunflower-tree, as it didn’t have all the right colours on it; but it was the best I could do in limited time.  We were due to gather at my youngest brother’s house, on Christmas Day, and there had been much to-ing and fro-ing over the wires and airwaves about who was getting what for whom, whether we were buying presents for the adults or only for the kids, who was contributing which component of the food, and what the theme was for the present-wrapping this year.  My sister is the queen of fabulous wrapping.  Each year she takes a theme and wraps to suit.  One year we all got parcels wrapped in brown paper and tied with buff raffia, with a trail of glitter-frosted ivy leaves wrapped around the string.  Another year, she had paper printed with sleighs and big jingle bells on top of each present.  The year my brother-in-law decorated the tree with peacock-feather baubles, she found silver bird tree-decorations to perch on the parcels and gave each one a peacock-eye tailfeather.

This year, however, Youngest Uncle and his other half had outdone themselves by completing a tree each.  Uncle’s, in the study/library, was all silver and crystal, with a few deep-red baubles as contrast, while his partner had gone for a multicoloured Victorian theme in the sitting room.  I had found some Victorian-looking cream paper printed with holly leaves for the presents from us, while my sister had wrapped this year’s parcels in metallic paper, with crystal snowflakes dangling from sequinned yarn.  Looking at the two contrasting trees, and with Nico’s sunflower tree still occupying one corner of my mind, I suddenly had a vision of a Justice Christmas Tree Festival.

I am pretty certain is is taking place somewhere in Oxford, although I’m not sure of the exact location – I didn’t really notice the sign at the entrance because I was looking at the Justice Shed banner.  It’s not a shed, anyway, it’s a big, stone-built hall, with narrow windows that allow the trees to be displayed against the walls. You might think it looks a bit like the Great Hall in the Harry Potter films.

First to greet us at the entrance is the tree that inspired the occasion: Nico Reed’s.  It is a blue spruce, decorated with, of course, wide-open sunflowers.  Their petals are edged with gold and their centres brushed with bright copper.  Copper-coloured tinsel winds round the branches, and between the sunflowers there are glittery pale-blue snowflakes as bright as Nico’s eyes, reflecting the pale blue and gold lights. At the top is the face of Nico himself, wearing his fur-trimmed red hat, a particularly beautiful nisse.

Next to it, against the north wall, stands Connor’s dark-needled fir tree, hung with a traditional red-and-green theme of untraditional miniature London buses and big shamrocks.  At the pinnacle, a huge multifaceted crystal casts rainbow splinters of light into every corner of the room, and showering down from it are many smaller drops of brilliance, each throwing out its own shards of colour, which intensify as the sun moves across the south windows, until all the out-of-the-way corners, for so long dark and unnoticed, are filled with light.

The #JusticeforLB tree has ribbons in blue, yellow and red; and crowdsourced padded fabric bauble shapes, each one appliqué’d with a George-Julian-style embroidered quotation.  In place of the fairy, a model of blind Justice flourishes her sword and scales.

Christmas Tree Festivals are usually charity fundraising events, but I am not sure that charities have a place in this one (although that tree behind the door, with the dark-pink ribbons and shiny pink pigs, might belong to @Mishap_Charity).  But this festival is really for individuals, not organisations.

Steven Neary’s tree has metallic ornaments shaped like old-fashioned microphones and miniature EPs, with candy canes and brightly-coloured sweets all round them, and a cherry Bakewell in place of the star.  Grenouille’s is almost monochrome: silver tinsel, a few dark-blue matt-metal baubles, and many dangling strips striped in pearled white, iridescent black and silver, representing chromosomal conditions.  The star at the top is actually a starfish.

Here is Ollie’s tree, hung with horseshoes and bright with bunches of glowing colour-change  fibre-optic  filaments.  Here is Naomi’s, garlanded with cut-paper festoons and button-strings.

In pride of place, at the far end, and two or three times as tall as all the other trees, is the #JusticeForAllTheDudes tree.  You can’t really see what sort of tree it is, because is is covered, smothered, in – what else? – gingerbread people.

By next year, here’s to being able to see our way out of the wood and admire the trees.

The Unwritten Message.

16 Wed Dec 2015

Posted by Kara Chrome in Uncategorized

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Tags

#justiceforallthedudes, #justiceforLB, #Mazars

From: NHSE PRperson
Sent: 17 December 2015 14:01
To: Sloven_Health-ReputationMgr
Subject: Information Placement

! This message is High Priority

K

2016 NHS Mandate presented to HoC this morning before House rose for Christmas Recess.  Got fulsome commendations for tweaks to patient complaints system.  Sorted!

It’s now a very good day to get out anything we want to bury.  Mazars report?

J xx

Marking Time.

15 Tue Dec 2015

Posted by Kara Chrome in Uncategorized

≈ 3 Comments

Tags

#justiceforallthedudes, #justiceforLB, #Mazars, Sloven Health

Monday evening, 14 December 2015.  No sign of the Mazars report being published yet.

The Justice Shed has endured a hail of Sloven misinformation missiles and spin-stones.  The general feeling of besiegement – a curious mixture of boredom and tension – has been added to by a number of incoming hobby-horse half-bricks lobbed by various odd bods with axes to grind about NHS privatisation, Big Pharma and similar irrelevant bonnet-bees.

The “definition of ‘unexpected’ deaths” bee, first set in flight by my medical correspondent, proved to have surprisingly robust legs.  Roy Lilley, of nhsManagers.net, picked up on it and suggested that the Department of Health had leaked the report, in order to provide Jeremy Hunt with an excuse for (further) interference with the Health Service.  In his scenario, some sort of odd collusion between Katrina Percy and the Secretary of State for Health to produce poor analytics which would not prove that care at Southern Health was poor, had been foiled (or possibly facilitated) by the report being leaked by an impatient Mazars employee with a grudge.  I think.  It’s a bit hard to follow the line of the argument, especially since several of its basic premises are improbable assumptions, or just plain wrong.  Even after he had corrected his misapprehension that Prof. Mohammed Mohammed was the author of the Mazars report, Mr. Lilley was still propagating the Sloven/Mohammed suggestion that it was all about whether Sloven was an ‘outlier’ in terms of its death rates:

‘What is an ‘unexpected’ death? Broadly; a death which would not have occurred if the patient was in a similar Trust, with a similar social demographic – all things being equal.’

Meanwhile, Sloven was discovered to have been trying to minimise and explain away the Mazars figures to universities that place students within the Trust.

Chris Hatton’s magisterial blogpost on the subject expounds the CIPOLD definitions (which have got to be the most relevant for the circumstance) of unexpected, premature, avoidable, amenable and preventable deaths.  It also points out that even some ‘expected’ deaths may warrant investigation, and should have kicked the legs out from under the nonsense.  Here’s hoping.

George Julian has pointed out that the Mazars publication date was promised for ‘early’ this week, which “surely only leaves Tuesday, as Wednesday must be ‘midweek'”.  She is of course 100% right, but I am still not holding my breath.

Expected Unexpecteds.

11 Fri Dec 2015

Posted by Kara Chrome in Uncategorized

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Tags

#justiceforallthedudes, #justiceforLB, #justiceforNico, #Mazars, Sloven Health

At the time of writing, the Mazars report into the deaths of patients of Southern Health NHS Foundation Trust, although ready to go, is still unpublished. The BBC news stories on Wednesday 9 December were based on a copy of the final draft of the report, leaked to them by person or persons unknown to #JusticeforLB.  The House of Commons Urgent Question to the Secretary of State for Health, on Thursday 9 December, was based on the same unpublished final draft.

As a general rule, I find televised Parliamentary proceedings an irritating bore, epitomised by that baying bearpit of ritualised smuggery and yah-boo-sucks non-addressing of the issues, that is Prime Minister’s Questions.  The UQ was very different: sober, even appropriately sombre.

Heidi Alexander (Lab., Lewisham East, Shadow Health Secretary) was suitably urgent in putting the question: “To ask the Secretary of State for Health if he will make a statement on the report of the investigation into deaths at Southern Health NHS Foundation Trust. “

Health Secretary Jeremy Hunt (Con., South West Surrey) would, at length.  He is obviously a bright boy.  He realised long ago – as soon as Verita 1 came out in early 2014 – that any attempt to dig a bomb-proof shelter on this issue would simply end up with him in a massively embarrassing hole, and he promptly came out with his hands up.  He adopted the same approach for the UQ, displaying cast-iron courtesy and resisting the temptation to yield to snark, even when asked awkward questions several times over.  Indeed, his responses were so cordial as to take on a slightly surreal air, as Members on all sides of the House heard the Minister telling them that they were ‘absolutely right’ ‘quite right’ and ‘completely on the same page’.  There were, of course, several places where he failed to answer the question despite replying at some length.  He is, after all, a politician.  Although the Mazars report states clearly that Southern’s major problem was a dreadful lack of adequate Board-level leadership, Mr. Hunt diverted to issues around individual health professionals and whistleblowing.  He did at least have the decency to look faintly embarrassed by his own equivocations, and at other times a slight hoarseness in his voice betrayed either a consummate actor, or else genuine feeling behind his words.  Watching him through the dispassionate microscope of television, the latter seemed more probable.

Ms. Alexander and many of the other MPs present also did themselves credit.  They had grasped that the point of the report was not the number of unexpected deaths, but that the overwhelming majority of the unexpected deaths had not been investigated.  They asked pertinent questions about informatics, mortality statistics and the prospect of independent Medical Examiners.  They pressed the Minister on when the finalised report would be published and pushed for it to be while the House was still sitting.  Mr. Hunt said NHSE had promised ‘before Christmas’, but not ‘before the Christmas Recess’.  (The Justice Shed promptly debated when actual publication would be.  Consensus was definitely in favour of 24 December, but 4pm or 5pm?)  Nobody in the Chamber was questioning the general validity of the Mazars findings, but outside, things were otherwise.

Health Service Journal (which named Katrina Percy, Southern Health’s CEO, ‘NHS Chief Executive of the Year 2012’ at one of their glitzy, pricy awards dinners) followed the line of a part-disclosed Southern-Health-commissioned review-of-the-Mazars-review (do keep up at the back there!) in dissing the Mazars findings by trash-talking their methodology.  The review review, written by Mohammed Mohammed, Bradford University Professor of Healthcare Quality and Effectiveness, picked out two items from page 5 and page 26 of the Mazars report and focussed on these as though they were the main thrust of Mazars findings.

The other query that came up was on the definition of ‘unexpected’.  I had already heard my Dad’s voice in my mind’s ear, asking, ‘What is meant by unexpected?  What constitutes a sufficient investigation?”, so I paid attention to these questions.

NHSE’s Serious Incident Framework says an unexpected death is one ‘where natural causes are not suspected.’  Posting that definition online got a near-apoplectic response from a medical practitioner, who said the definition should be ‘where unnatural causes are suspected’.  Initially, it sounded reasonable, but I could feel a niggle.  What if there was no reason to expect a person to die, but equally nothing to instantly give rise to suspicion of unnatural death?  Would those deaths just go into a limbo? Could they be classified as ‘nothing obvious’?

The BMA guidance to doctors issuing a Medical Certificate of Cause of Death (MCCD) suggests that an ‘expected death’ is one where the person has a current illness or condition from which they have been unable to recover despite appropriate treatment.  Other deaths are called ‘sudden or unexpected’ and fall into two categories: those where there is prima facie (obvious) evidence of violence or other unnatural causes, and those where despite the death being sudden or unexpected, there is no such prima facie evidence of unnatural cause.  The BMA adds that doctors

“are advised to be cautious in making or attempting to make this distinction unless they are forensically trained and experienced in clinical forensic medicine. It is too easy to wrongly classify a sudden or unexpected death.”

In other words, where the death is sudden or unexpected, the decision about its ‘naturality’ is medico-legal and not purely medical.  The BMA says,

“English law, contrary to popular belief, does not, at present, place an obligation upon a doctor to report all sudden deaths to the Coroner. In practice, the wise practitioner will report a sudden death to the Coroner, normally through the agency of the local police… In all but very exceptional circumstances, even where there appear to be no suspicious circumstances, the doctor would be wise to notify the coroner.”

It appears that the principles around investigating deaths are of the precautionary variety – deaths are to be investigated, unless there is obvious good reason not to do so.  It’s a much lower bar than ‘investigate only if there are immediately obvious reasons to do so’.  It also means that it is reasonable to ‘expect’ some sudden or unexpected natural deaths to occur.  People do die suddenly, like the jogging guru Jim Fixx, who dropped dead at 52, but equally, they don’t die for no reason.  The causes of the death must be determined.  Mr. Fixx had a genetic predisposition to heart disease, possibly exacerbated by previous lifestyle factors.

Not until cause of death has been investigated, can the questions of preventability and accountability come into play.  And this is where Southern Health, despite their protestations, have failed.  They are not keen on accountability, particularly when it appears to be encroaching on the ivory towers of upper management.  In order to evade accountability for preventable deaths, they have avoided doing death investigations thoroughly, or at all.  They are complaining bitterly and loudly that people are conflating ‘unexpected’ deaths with ‘preventable’ deaths, that the Mazars report did not look at quality of patient care, and that it’s all so unfair.

It’s true that no-one can say that the uninvestigated deaths were all preventable.  Indeed, it’s certain that a proportion of them could not have been prevented by any efforts.  But there is equally no way of knowing whether that proportion was big or small, because Southern Health didn’t make any effort to find out.  They did not do the preliminary sifting to see what the causes of death were, or to see if those causes might be linked in any way to Southern Health’s care.  They are now pointing out the gaps in the data and saying ‘No evidence of wrongdoing’.  But an absence of evidence is not evidence of absence.  Other evidence – such as their eagerness to classify Connor’s death as ‘natural’, such as their treatment of the Reed family, and their attitude to the father of David West, suggest that some of the uninvestigated deaths might well have been preventable, and that a truly ‘learning organisation’ would have wanted to evaluate causes and circumstances of death, to see what could be done better in future.

We’ll never know.  Because Sloven couldn’t be bothered to look.

Less Than Human.

10 Thu Dec 2015

Posted by Kara Chrome in Uncategorized

≈ 2 Comments

Tags

#justiceforLB, #justiceforNico, #Mazars

It was Grenouille’s school Christmas Concert yesterday.  Always an utterly fab event.  The school has a very strong music department and runs an orchestra and two choirs.  G, love and bless, can’t carry a tune in a bucket, or remember all the words of a song in the correct sequence, but has been an enthusiastic and assiduous member of the choir from the word go.  The wonderful music teacher has given nothing but encouragement and praise for every effort, and has done wonders for G’s confidence and willingness to join in.

Attending the concert this year was tricky.  G had a healthcare monitoring appointment after school, so the afternoon schedule went: leave school; be driven along 10 miles of Rural Road to meet me at Healthcare Facility; get through (longish) appointment; go home; have early dinner; be driven back along 10 miles of Rural Road to Concert Venue in Schooltown; and all in three and a half hours.

The early part ran smoothly, and just before 5 p.m. I was in the kitchen, boiling water for spaghetti to go with the bolognese sauce I’d made earlier.  As always when I am cooking, my Radio 4 reflex kicked in, and I switched on in time for the start of ‘PM’.  And promptly forgot about spaghetti, and concerts, and anything, really, except what I was hearing.

The story at the top of the hour was about a review of deaths in a large Mental Health Trust.  My ears pricked up instantly.  Ever since LB’s inquest, and the publication of the incomprehensibly mangled Verita 2 report (might as well have been printed in whitewash, instead of ink) #JusticeForLB has been waiting for a second report.  This further report, commissioned by NHS England and being produced by a firm called Mazars, looked into all deaths in Southern Health in the period April 2011 to March 2015.

I haven’t felt able to blog about the reviews/reports; it was just too depressing for words.  The Verita 2 report, commissioned and paid for by Southern Health, and published just after Connor’s inquest, showed every sign of having been subjected to extreme leaning-on by Sloven.  It set out a recognisable version of the facts, all pointing in one direction, then slewed round in its conclusion to come to findings that were at 90° to the whole line of the report up to that point.  Despite protests from the family’s advocate and the independent advocate on the report panel, Verita blandly refused to reconsider their findings and published the report as it stood.  Sloven gave it a smug welcome, but since the Inquest jury had already reached a verdict diametrically opposed to Verita’s, the report seemed a particularly ‘meh’ exercise of monumentally pointless hypocrisy.  It didn’t bode well, however, for how much notice Southern Health was likely to take of the Coroner’s Prevention of Future Deaths report, whenever that might be published.

The Mazars report, which had been ready at the same time as the Verita 2 report, dragged on.  Sloven were contesting the findings and asking for changes.  Lots of changes. About 300 of them, according to George Julian, the family advocate on both report panels.  Mazars rejected nearly all the proposed changes.  Southern Health started questioning the academic methodology of the report.  NHSE seemed to be cool with this.  The report publication date was put back, and put back.  George, who had postponed her holiday until after the expected publication date, went away worrying that it would come out while she was not there to support the family; but it was still unpublished when she returned.  Connor’s mother was becoming ill with the strain of waiting and not knowing what was happening.  NHSE called yet another discussion meeting for Friday 11 December.

But here we were, on Wednesday 9 December, and surely this report in the news had to be the Mazars report?  It was, and it was a shocker.  Out of 10,000+ deaths, there were 1,454 ‘unexpected deaths’ in Southern Health over the four-year period.  Of these, only 272 were investigated: 13% of all unexpected deaths, less than 1% of unexpected deaths of people with a learning disability and just 0.3% of unexpected deaths of people with a mental illness who were aged over 65.  How can Southern Health claim to have learned, I thought, when they haven’t studied?

I listened to the end of the piece, only semi-processing much of it; my mind was reeling. Then the pasta pan boiled over, with much steam and hissing, and I hastily returned my concentration to the evening’s preparations.

In the dark of the car an hour later, though, as my hands turned the steering wheel back and forth and my eyes checked the rises, dips, twists and turns of Rural Road, my mind went back over what I had heard.

“G, can you help me divide 1,454 by 4, please?”
“How?”
“Can you just hold 350 in your head, please?”
“OK”
“And add 10 to it?”
“360.”
“And add 3?”
“363.”

363.  Three hundred and sixty-three.  One a day, if you take a break on, say,  Christmas Day and Boxing Day.  There’s even a couple of spares left over for Leap Years, my inner cynic said, and I felt the saliva of disgust rise and flood my back teeth.  No wonder Southern Health were so swift to brush off Connor’s death; sudden or unexpected deaths are such a commonplace to them that they don’t even think about them unless forced to.  “There were no more unexpected deaths than were to be expected”, had said the Southern Health response, gnomically.

Concert Venue is a beautiful, old, mellow-stone building.  The atmosphere inside is equally mellow: warm and peaceful.  The concert was as wonderful as ever, but I couldn’t enjoy it.  I forced myself to concentrate on the pieces where G was taking part, drinking in the serious little face turned towards and wholly focussed on the conductor; but during the other items I remembered Connor’s mother mourning over his end of year assembly, and how Mark Neary can’t watch his son’s old school shows any more: not because Steven is gone, but because so many of his classmates are.  I thought of 1,453 other Southern Health families who, over the last four years, have suddenly found themselves in the parallel dimension of grief.  I felt like I needed to stay in touch with the Justice Shed.

So I did what I would have always sworn I would never, ever do in a concert or play: fished my phone out and scrolled through my twitter feed.  The horrified shock, sadness and hurt were palpable. Each tweet was like a blow to the chest.  Then there was a tweet from Nico Reed’s mother, Rosi, and it was as though my bruised heart broke:

” I cannot adequately put into words how I feel about that statement, ‘No more deaths than expected’. My son.”

The light on the stage blurred, shimmered, deformed.

How could, how COULD they?

Inhuman.

Rosi’s blog on the report and its aftermath, ‘The 1%’ is here

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