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?”
“Can you just hold 350 in your head, please?”
“And add 10 to it?”
“And add 3?”
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?
Rosi’s blog on the report and its aftermath, ‘The 1%’ is here